What is the management for ileus?

Management of Ileus

Begin with isotonic intravenous fluid resuscitation to correct dehydration and electrolyte abnormalities, particularly potassium and magnesium, while strictly avoiding fluid overload that worsens intestinal edema. 1, 2

Initial Resuscitation and Stabilization

Fluid Management:

• Administer isotonic IV fluids to maintain euvolemia, targeting weight gain of less than 3 kg by postoperative day three—exceeding this threshold directly causes intestinal edema that prolongs ileus 1, 2
• Avoid fluid overloading as this is one of the most common and preventable causes of prolonged ileus 1, 3, 2

Electrolyte Correction:

• Immediately correct potassium and magnesium deficiencies, as these directly impair intestinal motility 1, 2
• Monitor and replace ongoing losses, particularly in patients with high-output stomas 4, 2

Nasogastric Decompression:

• Do NOT routinely place nasogastric tubes—they prolong rather than shorten ileus duration 1, 3, 2
• Place a nasogastric tube ONLY for severe abdominal distention, vomiting, or aspiration risk, and remove as early as possible 1, 3, 2

Pain Management Strategy

Opioid-Sparing Analgesia:

• Implement mid-thoracic epidural analgesia with local anesthetic as the single most effective intervention for preventing and treating ileus 1, 3, 2
• Minimize systemic opioids through multimodal analgesia, as opioids directly inhibit gastrointestinal motility and are a primary modifiable cause of prolonged ileus 1, 3, 2
• Consider alvimopan to accelerate gastrointestinal recovery when opioid analgesia is necessary 1

Early Mobilization and Nutrition

Mobilization:

• Begin ambulation immediately once the patient's condition allows—early mobilization stimulates bowel function and prevents complications 1, 3, 2
• 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 3, 2
• If oral intake will be inadequate (<50% of caloric requirement) for more than 7 days, initiate tube feeding within 24 hours 3, 2
• Provide early parenteral nutrition if enteral feeding is contraindicated due to intestinal obstruction, sepsis, ischemia, high-output fistulae, or severe hemorrhage 3, 2

Pharmacological Interventions

Laxatives and Prokinetics:

• Administer bisacodyl 10-15 mg orally daily to three times daily once oral intake resumes 1, 3, 2
• Give oral magnesium oxide to promote bowel function 1, 3, 2
• Consider metoclopramide 10-20 mg orally four times daily as a prokinetic agent for persistent ileus 3, 2

Rescue Therapy:

• For persistent ileus unresponsive to initial measures, consider water-soluble contrast agents or neostigmine 3, 2

Adjunctive Measures:

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

Special Considerations

Bacterial Overgrowth:

• If bacterial overgrowth is suspected (particularly in chronic intestinal dysmotility), consider antibiotics: rifaximin as first choice, or rotating courses of amoxicillin-clavulanic acid, metronidazole, ciprofloxacin, or doxycycline every 2-6 weeks 4
• Monitor for complications: peripheral neuropathy with long-term metronidazole, tendonitis with ciprofloxacin, and Clostridioides difficile infection 4

High-Output Stomas:

• Restrict oral hypotonic fluids to 500 ml/day and provide glucose/saline solution with sodium concentration of at least 90 mmol/L 1
• Use loperamide 2-8 mg to reduce motility 1
• Monitor fluid production and urinary sodium, adapting fluid intake accordingly 2

Postoperative Context:

• Prefer laparoscopic over open surgical approaches when feasible—minimally invasive surgery results in shorter ileus duration 1, 2

Critical Pitfalls to Avoid

• Do NOT continue high-dose opioids without considering opioid-sparing alternatives or peripheral opioid antagonists 3
• Do NOT maintain prolonged nasogastric decompression unless there is severe distention, vomiting, or aspiration risk 3, 2
• Do NOT delay mobilization or oral intake based solely on absence of bowel sounds—early feeding maintains intestinal function even in the presence of ileus 3
• Do NOT overload fluids—this impairs gastrointestinal function and worsens intestinal edema 3, 2

Monitoring and Escalation

• Monitor for signs of bowel function return, including passage of flatus and bowel sounds 1
• Resume oral intake gradually once bowel function returns, starting with clear liquids and advancing as tolerated 1
• Consider referral to specialized intestinal failure units for patients with chronic or refractory ileus requiring long-term parenteral nutrition 2
• Monitor for complications including lactic acidosis or hyperammonemia in patients with short bowel syndrome receiving monosaccharides 2