What is the treatment approach for ileus?

Treatment of Ileus

Initiate treatment with isotonic intravenous fluids (lactated Ringer's or normal saline), maintain NPO status, correct electrolyte abnormalities (especially potassium and magnesium), minimize or eliminate opioid use, and encourage early mobilization as soon as the patient's condition allows. 1, 2

Initial Resuscitation and Stabilization

• Administer isotonic IV fluids (lactated Ringer's or normal saline) to correct dehydration and electrolyte imbalances, but avoid fluid overloading as this worsens intestinal edema and prolongs ileus 1, 2, 3

• Target weight gain of less than 3 kg by postoperative day three to prevent intestinal edema that exacerbates ileus 3

• Correct electrolyte abnormalities immediately, particularly potassium and magnesium, as these directly affect intestinal motility 1, 2, 3

• Place a nasogastric tube only if the patient has severe abdominal distention, active vomiting, or aspiration risk—not routinely 1, 2, 3

• Remove the nasogastric tube as early as possible without prior clamping or contrast studies, as prolonged decompression paradoxically extends ileus duration 2, 3, 4

Pain Management Strategy

• Implement opioid-sparing analgesia immediately, as opioids are a primary modifiable cause of prolonged ileus 1, 2, 3

• Use mid-thoracic epidural analgesia with low-dose local anesthetic combined with short-acting opiates as the cornerstone of pain management, particularly for postoperative ileus 1, 2, 3

• Consider alvimopan (a μ-opioid receptor antagonist) to accelerate gastrointestinal recovery when opioid analgesia cannot be avoided 1, 2

• For opioid-induced constipation contributing to ileus, consider methylnaltrexone (0.15 mg/kg subcutaneously every other day) 3

Pharmacologic Interventions

• Administer oral laxatives once oral intake resumes: bisacodyl (10-15 mg daily to three times daily) and magnesium oxide 1, 2, 3

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

• For persistent ileus unresponsive to initial measures, consider metoclopramide (10-20 mg orally four times daily) as a prokinetic agent, though evidence is limited 3

• For rescue therapy in refractory cases, consider water-soluble contrast agents or neostigmine 3

• Avoid medications that worsen ileus: anticholinergics, antidiarrheals, and unnecessary opioids 1, 2

Nutritional Support

• Maintain NPO status initially until bowel function begins to return 2

• Encourage early oral intake with small portions once bowel sounds return, particularly after right-sided resections and small-bowel anastomoses 3

• Resume oral intake gradually: start with clear liquids and advance as tolerated 1, 2

• Initiate tube feeding within 24 hours if oral intake will be inadequate (less than 50% of caloric requirement) for more than 7 days 3

• Provide early parenteral nutrition if enteral feeding is contraindicated due to intestinal obstruction, sepsis, intestinal ischemia, high-output fistulae, or severe gastrointestinal hemorrhage 3

Early Mobilization

• Begin mobilization immediately once the patient's condition allows, as early ambulation stimulates bowel function and prevents complications of immobility 1, 2, 3, 4

• Remove urinary catheters early to facilitate mobilization 2, 3

Special Considerations

For Fulminant C. difficile Infection with Ileus

• Administer vancomycin 500 mg orally four times daily (or via nasogastric tube if present) 5

• Add vancomycin 500 mg in 100 mL normal saline per rectum every 6 hours as a retention enema when ileus is present 5

• Administer intravenous metronidazole 500 mg every 8 hours together with oral or rectal vancomycin, particularly when ileus prevents adequate oral absorption 5

For Neutropenic Enterocolitis with Ileus

• Administer broad-spectrum antibiotics covering enteric gram-negative organisms, gram-positive organisms, and anaerobes 1

• Strictly avoid anticholinergic, antidiarrheal, and opioid agents as they aggravate ileus in this setting 1

For Bacterial Overgrowth Contributing to Ileus

• Consider antibiotics such as rifaximin, amoxicillin-clavulanic acid, metronidazole, or ciprofloxacin 3

Monitoring for Return of Bowel Function

• Monitor for passage of flatus and return of bowel sounds as indicators of recovering bowel function 2

• Do not delay mobilization or oral intake based solely on absence of bowel sounds, as early feeding maintains intestinal function even in the presence of ileus 3

Critical Pitfalls to Avoid

• Do not routinely place nasogastric tubes, as they prolong rather than shorten ileus duration 2, 3, 4

• Do not continue aggressive IV fluid administration beyond euvolemia, as fluid overload is a major preventable cause of prolonged ileus 2, 3

• Do not continue high-dose opioids without considering opioid-sparing alternatives or peripheral opioid antagonists 3

• Do not use repeated or prolonged courses of metronidazole due to risk of cumulative and potentially irreversible neurotoxicity 5