What is the management of ileus?

Management of Ileus

Initial Resuscitation and Stabilization

Keep the patient strictly NPO until ileus resolves, as oral feeding worsens abdominal distension and is contraindicated. 1

Fluid and Electrolyte Management

• Administer isotonic crystalloid solutions (lactated Ringer's or normal saline) for intravenous rehydration, continuing until pulse, perfusion, and mental status normalize 1
• In severe dehydration or shock, give initial fluid boluses of 20 mL/kg 1
• Critically important: Avoid fluid overload—limit weight gain to <3 kg by postoperative day three to prevent intestinal edema that worsens ileus 1, 2
• Target urine output >0.5 mL/kg/h and adequate central venous pressure 1

Electrolyte Correction

• Monitor and correct potassium, sodium, and magnesium abnormalities—check serum electrolytes every 24-48 hours in severe cases 1, 2
• Concurrent potassium replacement is essential in patients with depletion 1
• Magnesium deficiency is common, especially with high-output stomas; use magnesium oxide as it causes fewer osmotic effects 1
• Maintain hemoglobin >10 g/dL with transfusion if needed 1

Gastric Decompression

• Place a nasogastric tube only if there is significant abdominal distension, vomiting, or risk of aspiration 1, 2
• Remove the nasogastric tube as early as possible—prolonged decompression paradoxically extends ileus duration rather than shortening it 2, 3

Medication Management

Discontinue Offending Agents

Immediately stop all medications that exacerbate ileus: 1

• Antimotility agents
• Anticholinergic medications
• Antidiarrheal agents (including loperamide, which can cause paralytic ileus in high doses)
• Opioids—avoid completely in established ileus 1

Analgesia Strategy

• Implement opioid-sparing analgesia with regular paracetamol, regular NSAIDs (if not contraindicated), and regular or as-required tramadol 1, 4
• Mid-thoracic epidural analgesia with low-dose local anesthetic combined with short-acting opiates is the cornerstone for postoperative ileus prevention and treatment 2, 3

Prokinetic and Laxative Therapy

Once oral intake resumes:

• Administer oral magnesium oxide to promote bowel function 2, 3
• Give bisacodyl 10-15 mg daily to three times daily 2
• Consider metoclopramide 10-20 mg orally four times daily for persistent ileus, 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

Rescue Therapy

For persistent ileus unresponsive to initial measures, consider water-soluble contrast agents or neostigmine 2

Mobilization and Supportive Care

• Begin mobilization immediately once the patient's condition allows—early ambulation stimulates bowel function and prevents thromboembolism, pulmonary complications, and insulin resistance 1, 2
• Administer subcutaneous heparin for thromboprophylaxis in patients with prolonged immobility 1, 3
• Remove urinary catheters early to facilitate mobilization 3
• Maintain a stool chart to record number and character of bowel movements 1

Monitoring

• Monitor vital signs at least four times daily 1
• Reassess hydration status every 2-4 hours initially 1
• Evaluate for signs of return of intestinal function: passage of flatus or stool, bowel sounds 1, 3
• Monitor abdominal distension 1
• Obtain daily abdominal radiography if colonic dilatation is detected at presentation 1
• Maintain a low threshold for further radiological assessment if clinical deterioration occurs 1

Nutritional Support

• Encourage early oral intake with small portions once bowel sounds return, starting with clear liquids and advancing as tolerated 2, 3
• Chewing gum starting as soon as the patient is awake stimulates bowel function through cephalic-vagal stimulation 2, 3
• If oral intake will be inadequate (<50% of caloric requirement) for more than 7 days, initiate early tube feeding 2, 4
• If enteral feeding is contraindicated due to intestinal obstruction, sepsis, intestinal ischemia, high-output fistulae, or severe gastrointestinal hemorrhage, provide early parenteral nutrition 2, 3
• Enteral nutrition is preferred over parenteral nutrition when the intestine is accessible and functional 1

Special Considerations

For Bacterial Overgrowth

• Consider antibiotics such as rifaximin, amoxicillin-clavulanic acid, metronidazole, or ciprofloxacin if bacterial overgrowth is contributing to ileus 2

For High-Output Stomas

• Restrict oral hypotonic fluids to 500 mL/day 3
• Provide glucose/saline solution with sodium concentration of at least 90 mmol/L 3
• Use loperamide 2-8 mg to reduce motility 3

When to Investigate Further

If ileus persists beyond 7 days despite optimal conservative management, perform diagnostic investigation to rule out mechanical obstruction or other complications 2

Critical Pitfalls to Avoid

• Do not continue high-dose opioids without considering opioid-sparing alternatives 2
• Do not maintain prolonged nasogastric decompression unless severe distention, vomiting, or aspiration risk persists 2
• Do not continue aggressive IV fluid administration beyond euvolemia—fluid overload is a major preventable cause of prolonged ileus 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
• Do not routinely use nasogastric tubes, as they may prolong ileus duration 2, 3