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 resolve ileus. 1, 2

Initial Resuscitation and Fluid Management

Fluid administration requires careful balance to avoid the most common preventable cause of prolonged ileus:

• Administer isotonic IV fluids (lactated Ringer's or normal saline) to correct dehydration and electrolyte imbalances 1, 2
• Strictly limit weight gain to less than 3 kg by postoperative day three, as fluid overload causes intestinal edema that directly worsens and prolongs ileus 1, 3
• Continue IV rehydration until pulse, perfusion, and mental status normalize 2
• Immediately correct electrolyte abnormalities, particularly potassium and magnesium, which directly impair intestinal motility 1, 3

Critical pitfall: Aggressive fluid administration beyond euvolemia is a major iatrogenic cause of prolonged ileus—stop fluids once the patient is adequately resuscitated 1, 3

Nasogastric Tube Management

The evidence strongly contradicts routine NG tube placement:

• Place nasogastric tubes only for severe abdominal distention, active vomiting, or aspiration risk—not routinely 1, 2, 3
• Remove the NG tube as early as possible, as prolonged decompression paradoxically extends ileus duration 1, 3
• Remove without prior clamping or contrast studies 1, 4

Pain Management Strategy

Opioids are a primary modifiable cause of prolonged ileus, making pain management strategy critical:

• Implement opioid-sparing analgesia immediately as the cornerstone of treatment 1, 2, 3
• 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
• Consider alvimopan (μ-opioid receptor antagonist) to accelerate gastrointestinal recovery when opioid analgesia cannot be avoided 1, 2
• For opioid-induced constipation contributing to ileus, consider methylnaltrexone 0.15 mg/kg subcutaneously every other day 1, 3

Pharmacologic Interventions

Once oral intake resumes, implement prokinetic measures:

• Administer oral laxatives: bisacodyl 10-15 mg daily to three times daily and magnesium oxide 1, 2, 3
• Implement chewing gum starting as soon as the patient is awake, as this stimulates bowel function through cephalic-vagal stimulation 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, 2, 3
• Strictly avoid medications that worsen ileus: anticholinergics, antidiarrheals, and unnecessary opioids 1, 2

Early Mobilization

Mobilization directly stimulates bowel function:

• Begin mobilization immediately once the patient's condition allows 1, 2, 3
• Remove urinary catheters early to facilitate mobilization 1, 3

Nutritional Support

Follow a stepwise approach based on duration and severity:

• 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

Important nuance: Do not delay mobilization or oral intake based solely on absence of bowel sounds, as 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 nasogastric 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 intravenous metronidazole 500 mg every 8 hours together with oral or rectal vancomycin 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, 3

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, investigate for mechanical obstruction or other complications 3

Critical Pitfalls Summary

Three major preventable errors prolong ileus:

1. Do not routinely place nasogastric tubes—they prolong rather than shorten ileus duration 1, 2, 3
2. Do not continue aggressive IV fluid administration beyond euvolemia—fluid overload is a major preventable cause of prolonged ileus 1, 2, 3
3. Do not continue high-dose opioids without considering opioid-sparing alternatives or peripheral opioid antagonists 1, 3