What is the treatment for ileus enteritis?

Treatment of Ileus

The cornerstone of ileus management is aggressive intravenous fluid resuscitation with isotonic crystalloids, correction of electrolyte abnormalities (particularly potassium and magnesium), nasogastric decompression only when clinically indicated, early mobilization, and avoidance of medications that impair gut motility—with surgery reserved only for mechanical obstruction or complications like perforation. 1, 2

Initial Resuscitation and Stabilization

The immediate priority is restoring intravascular volume and correcting metabolic derangements:

• Administer isotonic intravenous fluids (lactated Ringer's or normal saline) to correct dehydration and prevent hypovolemia, continuing until vital signs normalize and mental status clears 1, 2
• Correct electrolyte abnormalities aggressively, particularly potassium and magnesium deficiencies, as these directly impair intestinal smooth muscle contractility and prolong ileus 1, 2, 3
• Avoid fluid overloading, as excessive administration worsens intestinal wall edema and paradoxically prolongs ileus—target weight gain of less than 3 kg by postoperative day 3 if applicable 1, 3
• Administer subcutaneous low molecular weight heparin for thromboprophylaxis in patients with prolonged immobility 1, 4

Nasogastric Decompression: Use Selectively

A critical pitfall is routine nasogastric tube placement, which actually prolongs rather than shortens ileus duration:

• Place nasogastric tube only for severe abdominal distention, intractable vomiting, or aspiration risk—not routinely 1, 2, 3
• Remove the nasogastric tube as early as possible once symptoms improve, as prolonged decompression extends ileus 1, 3

Pharmacologic Interventions

Pain Management Strategy

• Implement opioid-sparing analgesia as opioids directly inhibit gastrointestinal motility and are a primary modifiable cause of prolonged ileus 1, 3
• Consider mid-thoracic epidural analgesia with low-dose local anesthetic and short-acting opiates, which is highly effective at preventing and treating postoperative ileus 1, 3
• Use alvimopan (a peripheral μ-opioid receptor antagonist) to accelerate gastrointestinal recovery when opioid analgesia is necessary 1, 2

Prokinetic and Laxative Agents

• Administer oral magnesium oxide once oral intake resumes to promote bowel function 1, 2, 3
• Give bisacodyl 10 mg orally twice daily to improve intestinal motility 1, 3
• Consider metoclopramide 10-20 mg orally four times daily as a prokinetic agent for persistent ileus, though evidence is limited 3
• Implement chewing gum starting as soon as the patient is awake, as this stimulates bowel function through cephalic-vagal stimulation 1, 2, 3

Medications to Avoid

• Discontinue anticholinergics, antidiarrheals, and opioids as these agents aggravate ileus 1, 2

Nutritional Support

The approach depends on ileus duration and severity:

• Maintain NPO status initially until bowel function shows signs of returning 1
• Resume oral intake gradually once flatus passes or bowel sounds return, starting with clear liquids and advancing as tolerated 1, 2
• Provide enteral nutrition (preferred route) if ileus is prolonged and oral intake will be inadequate for more than 7 days 1, 3
• Initiate total parenteral nutrition only when enteral feeding is contraindicated (signs of shock, intestinal ischemia, high-output fistula, severe hemorrhage) or in critically ill patients requiring emergency surgery 4, 1

Early Mobilization

• Encourage early ambulation as soon as the patient's condition allows, as mobilization stimulates bowel function and prevents complications of prolonged bed rest 1, 3
• Remove urinary catheters early to facilitate mobilization 1, 3

Special Clinical Scenarios

Intra-abdominal Abscess or Superinfection

When ileus occurs in the context of inflammatory bowel disease or suspected infection:

• Do not routinely administer antibiotics unless there is documented superinfection or intra-abdominal abscess 4
• For confirmed abscess or superinfection, provide broad-spectrum antimicrobial therapy covering gram-negative aerobic/facultative bacilli, gram-positive streptococci, and obligate anaerobic bacilli 4
• Use fluoroquinolones or third-generation cephalosporin plus metronidazole as empiric coverage, adjusting based on culture sensitivities 4
• Expect clinical improvement within 3-5 days of appropriate antibiotics; if no improvement, re-evaluate with repeat imaging 4

Postoperative Ileus

• Prefer laparoscopic over open surgical approaches when surgery is necessary, as minimally invasive techniques result in faster return of bowel function 1, 2, 3
• Implement enhanced recovery after surgery (ERAS) protocols incorporating multiple interventions: minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early feeding, laxatives, and avoidance of routine nasogastric tubes 3

Rescue Therapy for Persistent Ileus

• Consider water-soluble contrast agents or neostigmine as rescue therapy for ileus unresponsive to initial conservative measures 3
• Investigate for mechanical obstruction if ileus persists beyond 7 days despite optimal conservative management 3

Monitoring for Resolution

• Monitor for passage of flatus and return of bowel sounds as indicators of recovering bowel function 1
• Track stool frequency and character to assess resolution 4
• Measure inflammatory markers (C-reactive protein) if infection is suspected 4

Critical Pitfalls to Avoid

• Do not continue aggressive IV fluids beyond euvolemia, as fluid overload is a major preventable cause of prolonged ileus 1, 3
• Do not delay mobilization or oral intake based solely on absence of bowel sounds, as early feeding maintains intestinal function even during ileus 3
• Do not maintain prolonged nasogastric decompression unless there is ongoing severe distention or vomiting 1, 3
• Do not continue high-dose opioids without considering opioid-sparing alternatives or peripheral opioid antagonists 3