What is the treatment for paralytic ileus?

Treatment of Paralytic Ileus

The initial management of paralytic ileus requires maintaining NPO status, nasogastric decompression, intravenous fluid resuscitation, and immediate discontinuation of opioids, with prokinetic agents and neostigmine reserved for persistent cases. 1

Immediate Management Steps

NPO Status and Decompression:

• Keep the patient strictly NPO (nothing by mouth) until bowel function returns, as oral intake is contraindicated during paralytic ileus due to impaired gastric emptying and intestinal transit 1
• Place a nasogastric tube for gastric decompression to relieve abdominal distension and prevent aspiration 1
• Monitor for return of bowel sounds, passage of flatus, and bowel movements as indicators of resolution 1

Fluid and Electrolyte Management:

• Administer isotonic intravenous fluids (lactated Ringer's or normal saline) to correct dehydration and electrolyte imbalances 2, 1
• Avoid fluid overload—aim for perioperative weight gain less than 2.5-3 kg and maintain near-zero fluid balance 2, 1
• In severe dehydration, continue IV rehydration until pulse, perfusion, and mental status normalize 2

Medication Review:

• Immediately discontinue or minimize opioid medications, as they are a primary cause of worsening ileus 2, 1, 3
• Avoid antidiarrheal medications (loperamide, diphenoxylate) which can exacerbate ileus 1
• If the patient requires long-term opioids, involve a pain specialist for gradual supervised withdrawal 4

Pharmacological Management

Prokinetic Agents:

• Consider metoclopramide to stimulate gastrointestinal motility, though it helps only a minority of patients with generalized motility disorders 1, 4
• Alternative prokinetics include domperidone and erythromycin 4

Neostigmine for Persistent Cases:

• Administer neostigmine for persistent paralytic ileus that does not respond to conservative measures 1, 5
• This is particularly effective in acute colonic pseudo-obstruction (Ogilvie's syndrome) 5

Antibiotics for Bacterial Overgrowth:

• Use antibiotics if bacterial overgrowth is suspected in prolonged ileus (typically after 7 days) 1
• First-line: Rifaximin 550mg twice daily for 1-2 weeks due to favorable side effect profile 1, 6, 4
• Alternatives: Metronidazole, amoxicillin-clavulanic acid, ciprofloxacin, or cephalosporins 1, 6
• Rotate antibiotics in repeated courses every 2-6 weeks with 1-2 week antibiotic-free periods to prevent resistance 6

Nutritional Support

Timing and Route:

• Consider enteral nutrition via feeding tube or parenteral nutrition if oral intake remains inadequate for more than 7 days 1
• Prefer enteral nutrition over parenteral nutrition when the gut is accessible and functioning 1, 4
• Reserve long-term parenteral nutrition for patients with significant malnutrition who cannot tolerate enteral nutrition 2, 4

Reintroduction of Oral Feeding:

• Start with clear liquids and progress to small, frequent meals (4-6 per day) with low-fat, low-fiber content 1, 4
• Many patients tolerate liquid feeds better than solid meals 2, 4
• Separate liquids from solids by avoiding drinking 15 minutes before or 30 minutes after eating 6, 4

Micronutrient Supplementation:

• Monitor and supplement fat-soluble vitamins with water-miscible forms: Vitamin A (10,000 IU daily), Vitamin D (3,000 IU daily), Vitamin E (100 IU daily), Vitamin K (300 mcg daily) 6, 4
• Check vitamin B12, iron, and magnesium status regularly 2, 4

Supportive Measures

Early Mobilization:

• Encourage early mobilization as soon as the patient's condition allows to stimulate bowel motility 1
• This is particularly important in postoperative ileus, which is the single largest factor influencing length of hospital stay after bowel resection 7

Pain Management:

• Consider thoracic epidural analgesia for pain management in postoperative ileus as an alternative to opioids 1
• Avoid high-dose opioids which worsen intestinal dysmotility and can lead to narcotic bowel syndrome 4

Monitoring and Reassessment

• Reassess the effectiveness of therapy daily and adjust management accordingly 1
• Monitor for complications including bowel perforation, malnutrition, and prolonged hospital stay 3, 7
• Every additional day of hospitalization and delay in operation (if needed) increases mortality risk 8
• Advanced age, higher frailty index, and longer hospital length of stay are significant mortality risk factors 8

Common Pitfalls to Avoid

• Do not allow premature oral intake before return of bowel function 1
• Do not continue opioid medications, as they are the most common exacerbating factor 2, 1, 3
• Do not use antidiarrheal agents which worsen the condition 1
• Do not pursue unnecessary surgery, as it can worsen intestinal function and lead to need for reoperation 4
• Do not allow thirsty patients to drink large volumes ad libitum if vomiting is present—instead administer small amounts (5-10 mL) every 1-2 minutes via spoon or syringe 2