What is the treatment approach for ileus?

Treatment of Ileus

Treat ileus with judicious isotonic IV fluids (targeting <3 kg weight gain by day 3), opioid-sparing analgesia (preferably mid-thoracic epidural), early mobilization, and selective nasogastric decompression only for severe distention or vomiting—avoid routine NG tubes and fluid overload as these prolong rather than shorten ileus duration. 1, 2

Initial Resuscitation and Fluid Management

The cornerstone of initial management is careful fluid resuscitation without overloading:

• Administer isotonic IV fluids (lactated Ringer's or normal saline) to correct dehydration and electrolyte imbalances, but stop at euvolemia 1, 2
• Target weight gain of less than 3 kg by postoperative day three—exceeding this threshold causes intestinal edema that directly worsens and prolongs ileus 1, 3
• Correct electrolyte abnormalities immediately, particularly potassium and magnesium, as these directly impair intestinal motility 1, 3
• Continue IV fluids until pulse, perfusion, and mental status normalize and the patient shows no evidence of ongoing ileus 2

Critical pitfall: Fluid overloading is one of the most common and preventable causes of prolonged ileus—stop aggressive IV administration once euvolemia is achieved 1, 3

Nasogastric Tube Management

Use nasogastric tubes selectively, not routinely:

• Place a nasogastric tube only if the patient has severe abdominal distention, active vomiting, or aspiration risk 1, 2, 3
• Remove the NG tube as early as possible without prior clamping or contrast studies, as prolonged decompression paradoxically extends ileus duration 1, 3
• Do not use routine NG decompression—this is a major modifiable factor that worsens outcomes 1, 2, 3

Pain Management Strategy

Implement aggressive opioid-sparing analgesia from the outset:

• Use mid-thoracic epidural analgesia with low-dose local anesthetic combined with short-acting opiates as first-line pain management, particularly for postoperative ileus 1, 2, 3
• This approach is highly effective at both preventing and treating ileus compared to IV opioid analgesia 2, 3
• Consider alvimopan (a μ-opioid receptor antagonist) to accelerate gastrointestinal recovery when opioid analgesia cannot be avoided 1, 2
• For opioid-induced constipation contributing to ileus, use methylnaltrexone 0.15 mg/kg subcutaneously every other day 1

Critical pitfall: Opioids are a primary modifiable cause of prolonged ileus—do not continue high-dose opioids without considering alternatives or peripheral opioid antagonists 1, 3

Pharmacologic Interventions

Layer in prokinetic and bowel-stimulating agents systematically:

• Implement chewing gum starting as soon as the patient is awake—this stimulates bowel function through cephalic-vagal stimulation 1, 2, 3
• Administer oral laxatives once oral intake resumes: bisacodyl 10-15 mg daily to three times daily and magnesium oxide 1, 2, 3
• For persistent ileus unresponsive to initial measures, consider metoclopramide 10-20 mg orally four times daily as a prokinetic agent, though evidence is limited 1, 3
• For rescue therapy in refractory cases, consider water-soluble contrast agents or neostigmine 1, 3
• Avoid medications that worsen ileus: anticholinergics, antidiarrheals, and unnecessary opioids 1, 2

Early Mobilization

Begin mobilization immediately:

• Start ambulation as soon as the patient's condition allows—early mobilization stimulates bowel function and prevents complications of immobility 1, 2, 3
• Remove urinary catheters early to facilitate mobilization 1, 3
• Do not delay mobilization based solely on absence of bowel sounds 1, 3

Nutritional Support

Follow a stepwise approach to feeding:

• Maintain NPO status initially until bowel function begins to return 1
• Encourage early oral intake with small portions once bowel sounds return, particularly after right-sided resections and small-bowel anastomoses 1, 3
• Resume oral intake gradually: start with clear liquids and advance as tolerated 1, 2
• Initiate tube feeding within 24 hours if oral intake will be inadequate (<50% of caloric requirement) for more than 7 days 1, 3
• Provide early parenteral nutrition if enteral feeding is contraindicated due to intestinal obstruction, sepsis, intestinal ischemia, high-output fistulae, or severe gastrointestinal hemorrhage 1, 3
• Consider total parenteral nutrition from the 7th day without sufficient oral intake 4

Do not delay oral intake based solely on absence of bowel sounds—early feeding maintains intestinal function even in the presence of ileus 1, 3

Special Clinical Scenarios

For Fulminant C. difficile Infection with Ileus:

• Administer vancomycin 500 mg orally four times daily (or via NG tube if present) 1
• Add vancomycin 500 mg in 100 mL normal saline per rectum every 6 hours as a retention enema when ileus prevents adequate oral absorption 1
• Add IV metronidazole 500 mg every 8 hours together with oral or rectal vancomycin, particularly when ileus prevents adequate oral absorption 1, 2

For Neutropenic Enterocolitis with Ileus:

• Administer broad-spectrum antibiotics covering enteric gram-negative organisms, gram-positive organisms, and anaerobes 1, 2
• Strictly avoid anticholinergic, antidiarrheal, and opioid agents as they aggravate ileus in this setting 1, 2

For Bacterial Overgrowth Contributing to Ileus:

• Consider antibiotics such as rifaximin, amoxicillin-clavulanic acid, metronidazole, or ciprofloxacin 1
• Do not use repeated or prolonged courses of metronidazole due to risk of cumulative and potentially irreversible neurotoxicity 1

Monitoring for Return of Bowel Function

• Monitor for passage of flatus and return of bowel sounds as indicators of recovering bowel function 1
• If ileus persists beyond 7 days despite optimal conservative management, perform diagnostic investigation to rule out mechanical obstruction or other complications 3