What is the treatment for ileus?

Treatment for Ileus

The cornerstone of ileus management is a structured approach prioritizing fluid resuscitation, electrolyte correction, nasogastric decompression only when necessary, opioid-sparing analgesia, early mobilization, and laxative administration once oral intake resumes. 1, 2

Initial Resuscitation and Supportive Care

Fluid and Electrolyte Management:

• Administer isotonic intravenous fluids (lactated Ringer's or normal saline) to correct dehydration and maintain euvolemia 2, 3
• Critically important: Limit weight gain to less than 3 kg by postoperative day three to prevent intestinal edema, which directly worsens ileus 1
• Correct potassium and magnesium deficiencies immediately, as these electrolyte abnormalities directly impair intestinal motility 1, 2
• Continue IV fluids until vital signs normalize and ileus resolves 2, 3

Nasogastric Decompression:

• Place a nasogastric tube ONLY in patients with severe abdominal distention, active vomiting, or aspiration risk 1, 2, 3
• Remove the nasogastric tube as early as possible—routine prolonged decompression paradoxically extends ileus duration rather than shortening it 1, 2
• No need for clamping trials or contrast studies before removal 4

Pharmacological Interventions

Analgesia Strategy:

• Implement mid-thoracic epidural analgesia as the preferred pain control method, as it is highly effective at preventing and treating postoperative ileus 1, 2, 3
• Use low-dose local anesthetic combined with short-acting opiates to minimize motor block 1
• Minimize or eliminate systemic opioids, which are a primary modifiable cause of prolonged ileus 1, 5

Laxatives and Prokinetics:

• Administer bisacodyl 10-15 mg orally daily to three times daily once oral intake resumes 1
• Give oral magnesium oxide to promote bowel function 1, 2, 3
• Consider metoclopramide 10-20 mg orally four times daily as a prokinetic agent for persistent ileus, though evidence is limited 1, 6
• For opioid-induced constipation contributing to ileus, consider methylnaltrexone 0.15 mg/kg subcutaneously every other day 1
• For postoperative ileus specifically, alvimopan (a μ-opioid receptor antagonist) can accelerate gastrointestinal recovery when opioid analgesia is necessary 2, 3

Rescue Therapy:

• For persistent ileus unresponsive to initial measures, consider water-soluble contrast agents or neostigmine 1

Medications to Avoid:

• Stop anticholinergics immediately, as they worsen ileus 1, 2
• Discontinue or minimize opioids 2, 4

Early Mobilization and Nutrition

Mobilization:

• Begin ambulation immediately once the patient's condition allows—early mobilization stimulates bowel function and prevents complications of immobility 1, 2, 3
• Remove urinary catheters early to facilitate mobilization 1, 2

Nutritional Support:

• Encourage early oral intake with small portions once bowel sounds return, particularly after right-sided resections and small-bowel anastomoses 1
• Do not delay oral intake based solely on absence of bowel sounds—early feeding maintains intestinal function even in the presence of ileus 1
• Start with clear liquids and advance as tolerated 2, 3
• If oral intake will be inadequate (<50% of caloric requirement) for more than 7 days, initiate tube feeding within 24 hours 1
• Provide early parenteral nutrition if enteral feeding is contraindicated (intestinal obstruction, sepsis, intestinal ischemia, high-output fistulae, or severe gastrointestinal hemorrhage) 1, 3
• Consider parenteral nutrition from day 7 if sufficient oral intake has not resumed 4

Adjunctive Measures:

• Implement chewing gum as soon as the patient is awake—it stimulates bowel function through cephalic-vagal stimulation 1, 2, 3

Special Considerations

Infection-Related Ileus:

• For ileus associated with Clostridium difficile infection, administer appropriate antimicrobial therapy; use intravenous metronidazole when oral administration is not possible 2, 3
• For neutropenic enterocolitis, give broad-spectrum antibiotics covering enteric gram-negative organisms, gram-positive organisms, and anaerobes 3
• Consider antibiotics (rifaximin, amoxicillin-clavulanic acid, metronidazole, or ciprofloxacin) for bacterial overgrowth contributing to ileus 1

Thromboembolism Prophylaxis:

• Administer subcutaneous heparin to reduce thromboembolism risk in patients with prolonged immobility 2

Critical Pitfalls to Avoid

• Do not overload fluids—this is one of the most common and preventable causes of prolonged ileus, causing intestinal edema and impaired gastrointestinal function 1, 2, 3
• Do not routinely place or maintain nasogastric tubes, as they prolong rather than shorten ileus duration 1, 2, 3
• Do not continue high-dose opioids without considering opioid-sparing alternatives or peripheral opioid antagonists 1, 4
• Do not delay mobilization or oral intake waiting for bowel sounds to return 1

Monitoring

• Monitor for signs of bowel function return: passage of flatus, bowel sounds, and tolerance of oral intake 2
• Exclude mechanical obstruction, intra-abdominal sepsis, partial obstruction, enteritis, or medication effects as alternative causes 2