What is the treatment approach for ileus?

Treatment of Ileus

Treat ileus with aggressive fluid resuscitation targeting euvolemia (weight gain <3 kg by postoperative day 3), opioid-sparing analgesia using mid-thoracic epidural when possible, early mobilization, early oral feeding once bowel sounds return, and oral laxatives (bisacodyl 10-15 mg daily to three times daily plus magnesium oxide), while avoiding routine nasogastric tube placement unless severe distention or vomiting is present. 1, 2, 3

Initial Resuscitation and Stabilization

Fluid Management:

• Administer isotonic IV fluids to correct dehydration and electrolyte imbalances, but strictly avoid fluid overloading as this worsens intestinal edema and directly prolongs ileus duration 1, 2, 3
• Target weight gain of less than 3 kg by postoperative day three—exceeding this threshold causes intestinal edema that extends ileus 1, 2, 3
• Monitor and replace ongoing losses, particularly in patients with high-output stomas 2

Electrolyte Correction:

• Immediately correct potassium and magnesium deficiencies, as these directly impair intestinal motility and are essential for bowel function recovery 1, 2, 3

Nasogastric Decompression:

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

Pain Management Strategy

This is the single most important modifiable intervention:

• Implement mid-thoracic epidural analgesia with low-dose local anesthetic combined with short-acting opiates as the cornerstone of pain management, particularly for postoperative ileus 1, 2, 3
• Minimize systemic opioids through multimodal analgesia, as opioids directly inhibit gastrointestinal motility and are a primary modifiable cause of prolonged ileus 1, 2, 3
• Consider alvimopan (a μ-opioid receptor antagonist) to accelerate gastrointestinal recovery when opioid analgesia cannot be avoided 1
• For opioid-induced constipation contributing to ileus, consider methylnaltrexone (0.15 mg/kg subcutaneously every other day) 1, 3

Pharmacologic Interventions

Laxatives (start once oral intake resumes):

• Administer bisacodyl 10-15 mg orally daily to three times daily 1, 2, 3
• Add magnesium oxide 1, 2, 3

Prokinetic Agents:

• For persistent ileus unresponsive to initial measures, consider metoclopramide 10-20 mg orally four times daily, though evidence for effectiveness is limited 1, 2, 3

Rescue Therapy:

• For refractory cases, consider water-soluble contrast agents or neostigmine 1, 3

Chewing Gum:

• Implement chewing gum starting as soon as the patient is awake, as this stimulates bowel function through cephalic-vagal stimulation 1, 3

Medications to Avoid:

• Strictly avoid anticholinergics, antidiarrheals, and unnecessary opioids as they worsen ileus 1, 3

Early Mobilization

• Begin mobilization immediately once the patient's condition allows, as early ambulation stimulates bowel function and prevents complications of immobility 1, 2, 3
• Remove urinary catheters early to facilitate mobilization 1, 3

Nutritional Support

Oral Intake:

• 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, 2, 3
• Resume oral intake gradually: start with clear liquids and advance as tolerated 1
• Do not delay oral intake based solely on absence of bowel sounds, as early feeding maintains intestinal function even in the presence of ileus 3

Enteral Feeding:

• Initiate tube feeding within 24 hours if oral intake will be inadequate (less than 50% of caloric requirement) for more than 7 days 1, 3

Parenteral Nutrition:

• 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 parenteral nutrition from the 7th day without sufficient oral intake 4

Special Clinical Scenarios

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 is present 1
• Administer intravenous metronidazole 500 mg every 8 hours together with oral or rectal vancomycin, particularly when ileus prevents adequate oral absorption 5, 1

Neutropenic Enterocolitis with Ileus:

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

Bacterial Overgrowth Contributing to Ileus:

• Consider antibiotics such as rifaximin (first choice), or rotating courses of amoxicillin-clavulanic acid, metronidazole, ciprofloxacin, or doxycycline every 2-6 weeks 1, 2, 3

Monitoring for Return of Bowel Function

• Monitor for passage of flatus and return of bowel sounds as indicators of recovering bowel function 1, 2
• If ileus persists beyond 7 days despite optimal conservative management, investigate for mechanical obstruction or other complications 3

Critical Pitfalls to Avoid

These are the most common errors that prolong ileus:

• Do not routinely place nasogastric tubes, as they prolong rather than shorten ileus duration 1, 2, 3
• Do not continue aggressive IV fluid administration beyond euvolemia, as fluid overload is a major preventable cause of prolonged ileus 1, 2, 3
• Do not continue high-dose opioids without considering opioid-sparing alternatives or peripheral opioid antagonists 1, 2, 3
• Do not use repeated or prolonged courses of metronidazole due to risk of cumulative and potentially irreversible neurotoxicity 1
• Do not delay mobilization or oral intake based solely on absence of bowel sounds 3

Surgical Considerations

• Prefer laparoscopic over open surgical approaches when surgery is necessary, as minimally invasive surgery results in shorter ileus duration 2, 3
• Surgery should be undertaken if complete mechanical obstruction or strangulation is suggested 6
• Before operation, restore fluid and electrolyte balance and institute decompression by means of a nasogastric tube 6