What is the best management approach for paralytic ileus?

Management of Paralytic Ileus

Immediately make the patient NPO, place a nasogastric tube for gastric decompression, discontinue all opioids, administer isotonic IV fluids while avoiding overload (target <2.5-3 kg weight gain), and begin early mobilization as soon as possible. 1

Immediate Initial Management

NPO Status and Gastric Decompression:

• Keep the patient strictly NPO until bowel function returns, as oral intake is contraindicated due to impaired gastric emptying and intestinal transit 1
• Place a nasogastric tube for gastric decompression to relieve abdominal distension and prevent aspiration 1, 2
• 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 1, 2
• Critical pitfall to avoid: Do not overload fluids—aim for perioperative weight gain less than 2.5-3 kg and maintain near-zero fluid balance, as fluid overload worsens intestinal edema and prolongs ileus 1, 3
• Correct electrolyte abnormalities, particularly potassium and magnesium, which directly affect intestinal motility 2, 3
• Continue IV rehydration until pulse, perfusion, and mental status normalize in severe dehydration 1

Pharmacological Management

Discontinue Offending Medications:

• Immediately discontinue or minimize opioid medications, as they are the primary cause of worsening ileus 1
• Avoid antidiarrheal medications (loperamide, diphenoxylate) as they exacerbate ileus 1
• Avoid anticholinergics which worsen ileus 2

Prokinetic and Pharmacologic Agents:

• Consider metoclopramide (10-20 mg PO QID) to stimulate gastrointestinal motility, though it only helps a minority of patients with generalized motility disorders 1, 3
• Administer neostigmine for persistent paralytic ileus that does not respond to conservative measures 1, 2
• Consider alvimopan to accelerate gastrointestinal recovery when opioid analgesia is necessary 2
• Once oral intake resumes, administer oral laxatives: bisacodyl (10 mg orally twice daily) and magnesium oxide to promote bowel function 2, 3
• Consider rifaximin or other antibiotics if bacterial overgrowth is suspected in prolonged ileus 1, 3

Pain Management Strategy

Opioid-Sparing Analgesia:

• Implement thoracic epidural analgesia (mid-thoracic) for pain management as an alternative to opioids 1, 2, 3
• Avoid high-dose opioids as they worsen intestinal dysmotility and can lead to narcotic bowel syndrome 1

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, 3
• Enteral nutrition is preferred over parenteral nutrition when the gut is accessible and functioning 1
• Reserve long-term parenteral nutrition for patients with significant malnutrition who cannot tolerate enteral nutrition 1

Reintroduction of Oral Intake:

• Introduce clear liquids and small, frequent meals with low-fat, low-fiber content gradually 1
• Liquid feeds may be better tolerated than solid meals 1
• Monitor and supplement fat-soluble vitamins (A, D, E, K) 1

Supportive Measures

Early Mobilization:

• Encourage early mobilization as soon as the patient's condition allows to stimulate bowel motility 1, 2, 3
• Early removal of urinary catheters facilitates mobilization 2, 3

Adjunctive Therapies:

• Consider chewing gum to stimulate bowel function through cephalic-vagal stimulation 2, 3
• Abdominal massage may be efficacious in reducing gastrointestinal symptoms, particularly in patients with concomitant neurogenic problems 4

Monitoring and Reassessment

• Reassess the effectiveness of therapy daily and adjust management accordingly 1
• Monitor for passage of flatus and bowel sounds as indicators of resolution 2
• Resume oral intake gradually once bowel function returns, starting with clear liquids and advancing as tolerated 2

Critical 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 1
• Do not use antidiarrheal agents as they worsen the condition 1
• Do not pursue unnecessary surgery as it can worsen intestinal function and lead to need for reoperation 1
• Do not allow thirsty patients with vomiting to drink large volumes ad libitum—instead administer small amounts via spoon or syringe 1
• Enemas are contraindicated in paralytic ileus, as well as in patients with neutropenia, thrombocytopenia, recent colorectal/gynecological surgery, recent anal/rectal trauma, severe colitis, toxic megacolon, or recent pelvic radiotherapy 4