Management of Ileus
Initial Resuscitation and Stabilization
Administer isotonic intravenous fluids (lactated Ringer's or normal saline) immediately to correct dehydration and electrolyte imbalances, continuing until vital signs normalize and there is no evidence of ileus. 1
Place a nasogastric tube for decompression only in patients with severe abdominal distention, vomiting, or aspiration risk—then remove it as early as possible since prolonged decompression paradoxically extends ileus duration. 2, 3, 4
Correct electrolyte abnormalities aggressively, particularly potassium and magnesium, which directly affect intestinal motility. 2, 3, 4
Maintain strict NPO status initially until bowel function returns. 3, 4
Avoid fluid overloading—target weight gain limited to <3 kg by postoperative day three to prevent intestinal edema that worsens ileus. 2, 4
Medication Management
Immediately discontinue all medications that exacerbate ileus: opioids, antimotility agents (loperamide), anticholinergics, and antidiarrheal agents. 3, 4
Implement opioid-sparing analgesia strategies as the cornerstone of management—mid-thoracic epidural analgesia with low-dose local anesthetic is highly effective at preventing and treating ileus. 2, 4
Once oral intake resumes, administer bisacodyl 10-15 mg orally twice daily and magnesium oxide to promote bowel function. 2, 4
For persistent ileus despite initial measures, consider metoclopramide 10-20 mg orally four times daily as a prokinetic agent, though evidence for effectiveness is limited. 2, 5
For opioid-induced constipation contributing to ileus, consider methylnaltrexone 0.15 mg/kg subcutaneously every other day. 2
For rescue therapy in refractory cases, consider water-soluble contrast agents or neostigmine. 2
Early Mobilization and Nutrition
Begin mobilization immediately once the patient's condition allows—early ambulation stimulates bowel function and prevents complications of immobility. 2, 4
Remove urinary catheters early to facilitate mobilization. 2, 4
Encourage chewing gum starting as soon as the patient is awake, as it stimulates bowel function through cephalic-vagal stimulation. 2, 4
Once bowel sounds return, encourage early oral intake with small portions, particularly after right-sided resections and small-bowel anastomoses. 2
If oral intake will be inadequate (<50% of caloric requirement) for more than 7 days, initiate early tube feeding within 24 hours. 2, 6
If enteral feeding is contraindicated (intestinal obstruction, sepsis, intestinal ischemia, high-output fistulae, severe GI hemorrhage), provide early parenteral nutrition from day 7. 2, 3, 6
Monitoring for Resolution
Monitor for signs of bowel function return: passage of flatus, bowel sounds, tolerance of oral intake, and reduction in abdominal distention. 3, 4
Continue intravenous rehydration until pulse, perfusion, and mental status normalize and there is no evidence of ileus. 1, 3
Once ileus resolves, resume oral intake gradually starting with clear liquids and advancing as tolerated. 4
Critical Pitfalls to Avoid
Do not routinely place or maintain nasogastric tubes—they prolong rather than shorten ileus duration unless there is severe distention, vomiting, or aspiration risk. 2, 4
Do not overload fluids during or after surgery—this is one of the most common and preventable causes of prolonged ileus due to intestinal edema. 2, 4
Do not continue high-dose opioids without considering opioid-sparing alternatives or peripheral opioid antagonists. 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. 2
Special Considerations
For postoperative ileus prevention, implement enhanced recovery after surgery (ERAS) protocols including minimally invasive surgery when possible, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission/early removal of nasogastric intubation. 2
For bacterial overgrowth contributing to ileus, consider antibiotics such as rifaximin, amoxicillin-clavulanic acid, metronidazole, or ciprofloxacin. 2