What is the initial treatment for paralytic ileus?

Initial Treatment for Paralytic Ileus

The cornerstone of initial treatment is immediate NPO status, nasogastric decompression, intravenous fluid resuscitation, and discontinuation of opioids, with prokinetic agents reserved for persistent cases. 1, 2

Immediate Management Steps

The first priority is bowel rest and decompression:

• Keep the patient strictly NPO (nil per os) until bowel function returns, as oral intake is contraindicated due to impaired gastric emptying and intestinal transit 1, 2
• Place a nasogastric tube for gastric decompression to relieve abdominal distension and prevent aspiration 1, 2
• Provide adequate intravenous fluid resuscitation using isotonic fluids (lactated Ringer's or normal saline) to correct dehydration and electrolyte imbalances 1, 2
• Immediately discontinue or minimize opioid medications, as they are the primary cause of worsening ileus 1, 2

Fluid Management Specifics

Careful attention to fluid balance is critical:

• Avoid fluid overload by aiming for perioperative weight gain less than 2.5-3 kg and maintaining near-zero fluid balance 1, 2
• Continue IV rehydration in severe dehydration until pulse, perfusion, and mental status normalize 2

Pharmacological Management

Avoid antidiarrheal medications (loperamide, diphenoxylate) as they worsen ileus 1, 2

For persistent cases, consider escalating therapy:

• Metoclopramide may be used to stimulate gastrointestinal motility, though it only helps a minority of patients with generalized motility disorders 1, 2
• Neostigmine should be considered for persistent paralytic ileus that does not respond to conservative measures 1, 2
• Antibiotics (rifaximin, metronidazole, or amoxicillin-clavulanic acid) are indicated if bacterial overgrowth is suspected in prolonged ileus 1, 2

Supportive Measures

Encourage early mobilization as soon as the patient's condition allows to stimulate bowel motility 1, 2

For pain management:

• Consider thoracic epidural analgesia for postoperative ileus as an alternative to opioids 1, 2
• Avoid high-dose opioids as they worsen intestinal dysmotility and can lead to narcotic bowel syndrome 2

Nutritional Support

If ileus is prolonged:

• Consider enteral nutrition via feeding tube or parenteral nutrition if oral intake remains inadequate for more than 7 days 1, 2
• Prefer enteral nutrition over parenteral nutrition when the gut is accessible and functioning 1, 2
• When reintroducing oral feeding, start with clear liquids and progress to small, frequent meals with low-fat, low-fiber content 1, 2

Monitoring for Resolution

Assess daily for return of bowel sounds, passage of flatus, and bowel movements as indicators of resolution 1, 2

Reassess the effectiveness of therapy daily and adjust management accordingly 1, 2

Critical Pitfalls to Avoid

The most common errors that worsen outcomes:

• Do not allow premature oral intake before return of bowel function 1, 2
• Do not continue opioid medications, which are the most common exacerbating factor 1, 2
• Do not use antidiarrheal agents as they worsen the condition 2
• Do not pursue unnecessary surgery as it can worsen intestinal function and lead to need for reoperation 2
• Do not allow thirsty patients with vomiting to drink large volumes ad libitum; instead administer small amounts via spoon or syringe 2