What is the treatment for dynamic ileus (small bowel obstruction)?

From the Guidelines

The treatment of dynamic ileus should focus on supportive care with intravenous crystalloids, anti-emetics, and bowel rest as soon as possible. This approach is crucial in managing the condition while addressing the underlying cause. The initial management should include:

• Intravenous administration of isotonic dextrose-saline crystalloid or balanced isotonic crystalloid replacement fluids containing supplemental potassium to correct electrolyte imbalances and replace lost volumes, as recommended by the study published in the World Journal of Emergency Surgery 1
• Bowel rest with nothing by mouth (NPO) to reduce bowel activity and allow for recovery
• Nasogastric suction for diagnostic and therapeutic purposes, such as analyzing gastric contents and preventing aspiration pneumonia by decompressing the proximal bowel
• Insertion of a Foley catheter to monitor urine output and ensure adequate hydration
• Pain management with non-opioid analgesics to avoid worsening the ileus
• Early ambulation to stimulate bowel function and promote recovery
• Discontinuation of medications that may contribute to ileus, such as anticholinergics and opioids, when possible
• Consideration of prokinetic agents or other medications in select cases, although evidence for their efficacy is limited, as noted in the study 1. The goal of treatment is to support the patient while allowing the bowel to recover from the underlying cause of the ileus, and most cases resolve within 2-3 days with conservative management.

From the FDA Drug Label

INDICATIONS & USAGE Diabetic Gastroparesis (Diabetic Gastric Stasis) Metoclopramide Injection (metoclopramide hydrochloride, USP) is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis The Prevention of Nausea and Vomiting Associated with Emetogenic Cancer Chemotherapy Metoclopramide Injection is indicated for the prophylaxis of vomiting associated with emetogenic cancer chemotherapy The Prevention of Postoperative Nausea and Vomiting Metoclopramide Injection is indicated for the prophylaxis of postoperative nausea and vomiting in those circumstances where nasogastric suction is undesirable Small Bowel Intubation Metoclopramide Injection may be used to facilitate small bowel intubation in adults and pediatric patients in whom the tube does not pass the pylorus with conventional maneuvers Radiological Examination Metoclopramide Injection may be used to stimulate gastric emptying and intestinal transit of barium in cases where delayed emptying interferes with radiological examination of the stomach and/or small intestine.

The treatment of dynamic ileus is not explicitly mentioned in the provided drug label for metoclopramide (IV) 2. However, the label does indicate that metoclopramide can be used to stimulate gastric emptying and intestinal transit, which may be beneficial in the treatment of dynamic ileus.

• The primary indications for metoclopramide (IV) are for the relief of symptoms associated with diabetic gastroparesis, the prevention of nausea and vomiting associated with emetogenic cancer chemotherapy and postoperative nausea and vomiting, and to facilitate small bowel intubation.
• There is no direct information in the label that supports the use of metoclopramide (IV) for the treatment of dynamic ileus. However, based on its effects on gastric emptying and intestinal transit, metoclopramide (IV) may be considered as a potential treatment option for dynamic ileus, but this would be an off-label use.

From the Research

Treatment Options for Dynamic Ileus

• The treatment of dynamic ileus involves addressing the underlying cause and providing supportive care 3.
• Multiple medical interventions have been proposed, but their effectiveness is uncertain 3.

Effectiveness of Promotility Agents

• Metoclopramide and erythromycin have been studied as potential treatments for ileus, but neither has been shown to be effective in expediting its resolution 3, 4, 5.
• Metoclopramide has been found to reduce nausea and emesis postoperatively, but its effect on postoperative ileus is limited 4.
• One study found that metoclopramide did not decrease the length of stay in the surgical intensive care unit or total hospital length of stay 5.

Early Enteral Nutrition (EEN)

• EEN has been shown to facilitate the return of normal bowel function, achieve enteral nutrition goals, and reduce hospital length of stay in patients who have undergone abdominal surgery 3.
• A systematic review and meta-analysis found that EEN is effective in expediting the resolution of ileus in adult surgical patients 3.

Other Treatment Options

• Methylnaltrexone, a peripheral opioid antagonist, has been studied as a potential treatment for postoperative ileus, but it did not significantly reduce the time to resolution of ileus or length of stay 6.
• Other treatment options, such as gum chewing and tube feeds, have been reviewed in the literature, but their effectiveness is uncertain 7.
• New and experimental drugs are currently in development, but more research is needed to determine their efficacy 7.