What is the best management approach for paralytic ileus?

Management of Paralytic Ileus

The cornerstone of paralytic ileus management is immediate NPO status, nasogastric decompression, aggressive IV fluid resuscitation, and discontinuation of all opioids, with prokinetic agents and neostigmine reserved only for persistent cases that fail conservative measures. 1, 2

Immediate Management Protocol

NPO Status and Decompression

• Keep patients strictly NPO until bowel function returns, as oral intake is absolutely contraindicated due to impaired gastric emptying and intestinal transit 1, 2
• Place a nasogastric tube for gastric decompression to relieve abdominal distension and prevent aspiration 1, 2
• Monitor continuously for return of bowel sounds, passage of flatus, and bowel movements as indicators of resolution 1, 2

Fluid and Electrolyte Management

• Administer isotonic IV fluids (lactated Ringer's or normal saline) to correct dehydration and electrolyte imbalances 1
• Avoid fluid overload—aim for perioperative weight gain less than 2.5-3 kg and maintain near-zero fluid balance, as excessive fluids worsen intestinal edema and prolong ileus 1, 3
• In severe dehydration, continue IV rehydration until pulse, perfusion, and mental status normalize 1
• Correct electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, which directly impair intestinal motility 3

Pharmacological Management

Medication Discontinuation (Critical)

• Immediately discontinue or minimize opioid medications, as they are the primary pharmacological cause of worsening ileus 1, 2, 3
• Stop all antidiarrheal medications (loperamide, diphenoxylate) as they exacerbate ileus 1, 2
• Review and discontinue other culprit medications including anticholinergics, clozapine, baclofen, phenytoin, and verapamil 3

Prokinetic Therapy (For Persistent Cases Only)

• Consider metoclopramide to stimulate gastrointestinal motility, though it helps only a minority of patients with generalized motility disorders 1, 2
• Be aware that metoclopramide carries risk of extrapyramidal symptoms (1 in 500 patients), tardive dyskinesia with prolonged use, and neuroleptic malignant syndrome, with acute dystonic reactions more common in patients under 30 years 4
• Administer neostigmine for persistent paralytic ileus unresponsive to conservative measures 1, 2
• Consider rifaximin, metronidazole, or amoxicillin-clavulanic acid if bacterial overgrowth is suspected in prolonged ileus 2

Nutritional Support Strategy

Timing and Route Selection

• If oral intake remains inadequate for more than 7 days, initiate enteral nutrition via feeding tube or parenteral nutrition 1, 2
• Prefer enteral nutrition over parenteral nutrition when the gut is accessible and functioning 1, 2
• Reserve long-term parenteral nutrition only for patients with significant malnutrition who cannot tolerate enteral nutrition 5, 1

Reintroduction of Oral Feeding

• Start with clear liquids and progress to small, frequent meals with low-fat, low-fiber content 1, 2
• Liquid feeds are generally better tolerated than solid meals in patients with impaired gastric motility 5, 1
• Monitor and supplement fat-soluble vitamins (A, D, E, K) as deficiencies are common 5, 1

Supportive Measures

Non-Pharmacological Interventions

• Encourage early mobilization as soon as the patient's condition allows to stimulate bowel motility 1, 2, 3
• Consider thoracic epidural analgesia for pain management in postoperative ileus as an alternative to systemic opioids 1, 2, 3
• Avoid high-dose opioids as they worsen intestinal dysmotility and can lead to narcotic bowel syndrome 1

Monitoring Protocol

• Reassess the effectiveness of therapy daily and adjust management accordingly 1, 2
• Monitor intra-abdominal pressure, especially when it exceeds 15 mmHg, to prevent abdominal compartment syndrome 3

Critical Pitfalls to Avoid

Do not allow premature oral intake before return of bowel function, as this will worsen symptoms and delay recovery 1, 2

Do not continue opioid medications, as they are the most common exacerbating factor and will perpetuate the ileus 1, 2, 3

Do not use antidiarrheal agents, as they directly worsen the condition by further impairing motility 1, 2

Do not pursue unnecessary surgery, as it can worsen intestinal function and lead to need for reoperation 1

Do not use rectal tubes as standard treatment, as they are not evidence-based for paralytic ileus management 3

Do not allow thirsty patients with vomiting to drink large volumes ad libitum—instead administer small amounts via spoon or syringe 1