What are the initial management steps for ileus?

Initial Management of Ileus

Keep the patient strictly NPO, initiate IV isotonic crystalloid resuscitation, correct electrolyte abnormalities, immediately discontinue all opioids and antimotility agents, and consider nasogastric decompression if there is significant distension or vomiting. 1

Immediate Resuscitation and Stabilization

NPO Status and Gastric Decompression

• Maintain strict NPO status until ileus resolves, as oral feeding is contraindicated and will worsen abdominal distension 1
• Insert a nasogastric tube for decompression if the patient has significant abdominal distension, vomiting, or accumulation of gastric fluid 1
• This decompression helps reduce intraluminal pressure, which can compromise intestinal microcirculation when pressure exceeds 30 mmHg 2

Intravenous Fluid Resuscitation

• Administer isotonic crystalloid solutions (lactated Ringer's solution or normal saline) for IV rehydration 1, 3
• Continue rehydration until pulse, perfusion, and mental status normalize and there is no evidence of ileus 1
• In patients with severe dehydration or shock, give initial fluid boluses of 20 mL/kg 1
• Monitor fluid balance targeting adequate central venous pressure and urine output >0.5 mL/kg/h 1
• Avoid fluid overload: aim to limit weight gain to <3 kg by postoperative day three 4

The evidence strongly supports isotonic crystalloids over oral rehydration in the presence of ileus, as oral intake fails in this setting and worsens distension 3, 5.

Electrolyte Correction

• Monitor and correct electrolyte abnormalities, especially potassium, sodium, and magnesium 1, 6
• Provide concurrent potassium replacement in patients who have developed depletion 1
• Address magnesium deficiency, which is common especially with high-output stomas; magnesium oxide may cause fewer osmotic effects than other preparations 1
• Check serum electrolytes regularly (every 24-48 hours in severe cases) 4, 7

Medication Management

Discontinue Contributing Agents

• Immediately stop all agents that exacerbate ileus: antimotility agents, anticholinergic medications, antidiarrheal agents, and opioids 1
• Loperamide in high doses can cause paralytic ileus and must be avoided completely in established ileus 1
• In the presence of established ileus, antidiarrheals and opioids should be avoided completely 1

Analgesic Substitution

• Wean narcotics and substitute with regular paracetamol, regular NSAIDs if not contraindicated, and regular or as-required tramadol 7
• This opioid-sparing analgesia is a critical component of ileus prevention and management 4

Monitoring Parameters

Clinical Assessment

• Monitor vital signs frequently (at least four times daily, more often if deterioration noted) 4, 1
• Reassess hydration status after 2-4 hours 1, 3
• Monitor abdominal distension and bowel sounds 1
• Evaluate for signs of return of intestinal function, such as passage of flatus or stool 1
• Maintain a stool chart to record number and character of bowel movements 4

Laboratory Monitoring

• Measure FBC, ESR or CRP, serum electrolytes, serum albumin, and liver function tests every 24-48 hours 4
• Maintain hemoglobin >10 g/dL with blood transfusion if needed 4

Radiological Monitoring

• Obtain daily abdominal radiography if colonic dilatation (transverse colon diameter >5.5 cm) is detected at presentation 4
• Maintain a low threshold for further radiological assessment if clinical deterioration occurs 4

Additional Supportive Measures

Thromboprophylaxis

• Administer subcutaneous heparin to reduce the risk of thromboembolism 4
• This is particularly important given the increased risk of venous thromboembolism in patients with ileus and immobility 8

Early Mobilization

• Encourage regular ambulation as tolerated 4, 7
• Early mobilization decreases pulmonary complications, thromboembolism, and insulin resistance 4

Nutritional Support

• Once ileus resolves and the patient can tolerate oral feeding, initiate early enteral nutrition 1
• If ileus is prolonged and oral/enteral nutrition cannot be maintained, consider parenteral nutrition 1
• Enteral nutrition is preferred over parenteral nutrition when the intestine is accessible and functional 1
• For severely undernourished patients, preoperative nutritional support is mandatory 4
• If unable to tolerate adequate oral intake for more than 7 days postoperatively, initiate parenteral nutrition 7

Common Pitfalls to Avoid

• Do not attempt oral feeding during active ileus, as this worsens distension and delays resolution 1, 5
• Do not continue opioids or antimotility agents, even if pain control is challenging—find alternative analgesics 1, 7
• Do not delay fluid resuscitation while waiting for laboratory results; begin empiric isotonic crystalloid administration immediately 1
• Do not use prokinetic agents like metoclopramide routinely, as they carry significant risks including tardive dyskinesia and neuroleptic malignant syndrome, and their effectiveness in ileus is not well-established 9