What is the initial approach to treating ileus?

Initial Management of Ileus

Keep the patient strictly nothing by mouth (NPO) and begin immediate intravenous rehydration with isotonic crystalloids while correcting electrolyte abnormalities and discontinuing all medications that worsen ileus, particularly opioids and anticholinergics. 1

Immediate Resuscitation and Stabilization

NPO Status and Gastric Decompression

• Maintain strict NPO status until ileus resolves, as oral feeding is contraindicated and will worsen abdominal distension 1
• Place a nasogastric tube for decompression only if there is significant abdominal distension, vomiting, or accumulation of gastric fluid 1
• Remove the nasogastric tube as early as possible once these indications resolve, as prolonged decompression paradoxically extends ileus duration 2, 3

Intravenous Fluid Resuscitation

• Administer isotonic crystalloid solutions (lactated Ringer's solution or normal saline) for rehydration 1, 4
• In severe dehydration or shock, give initial fluid boluses of 20 mL/kg 1
• Continue rehydration until pulse, perfusion, and mental status normalize and there is no evidence of ongoing ileus 1
• Critical pitfall to avoid: Do not overload fluids—aim to limit weight gain to <3 kg by postoperative day three, as fluid overload causes intestinal edema and worsens ileus 2, 3
• Monitor fluid balance targeting adequate central venous pressure and urine output >0.5 mL/kg/h 1

Electrolyte Correction

• Monitor and correct electrolyte abnormalities immediately, especially potassium, sodium, and magnesium 1, 5
• Check serum electrolytes regularly (every 24-48 hours in severe cases) 1
• Magnesium deficiency is particularly common with high-output stomas; use magnesium oxide as it causes fewer osmotic effects 1
• Concurrent potassium replacement is indicated in patients with potassium depletion, often secondary to hypomagnesemia 2, 1

Medication Management

Discontinue Offending Agents

• Immediately discontinue all agents that exacerbate ileus: antimotility agents, anticholinergic medications, antidiarrheal agents, and opioids 1
• In established ileus, avoid antidiarrheals and opioids completely 1
• Loperamide in high doses can cause paralytic ileus and requires careful monitoring 1

Implement Opioid-Sparing Analgesia

• Use multimodal analgesia including regular paracetamol, NSAIDs, and tramadol as needed 1, 3
• Mid-thoracic epidural analgesia with low-dose local anesthetic combined with short-acting opiates is highly effective for preventing and treating postoperative ileus 3

Monitoring and Assessment

Clinical Monitoring

• Monitor vital signs frequently (at least four times daily) 1
• Reassess hydration status after 2-4 hours 1, 4
• Evaluate for signs of return of intestinal function, particularly passage of flatus or stool 1
• Monitor abdominal distension and bowel sounds 1
• Maintain a stool chart to record number and character of bowel movements 1
• Obtain daily abdominal radiography if colonic dilatation is detected at presentation 1

Identify and Treat Underlying Causes

• Exclude intra-abdominal sepsis, partial/intermittent bowel obstruction, enteritis (Clostridium or Salmonella), recurrent disease (Crohn's disease or radiation enteritis), or abrupt cessation of steroids or opiates 2
• Consider bacterial overgrowth; antibiotics such as rifaximin, amoxicillin-clavulanic acid, metronidazole, or ciprofloxacin may be indicated 3

Early Mobilization and Nutritional Support

Mobilization

• Encourage early mobilization as soon as the patient's condition allows to stimulate bowel function 2, 1, 3
• Early removal of urinary catheters facilitates mobilization 3

Nutritional Strategy

• Once ileus resolves and the patient can tolerate oral feeding, initiate early enteral nutrition 1, 6
• For postoperative ileus: Encourage early oral intake with small portions once bowel sounds return, especially after right-sided resections and small-bowel anastomoses 2, 3
• If oral intake will be inadequate (<50% of caloric requirement) for more than 7 days, initiate early tube feeding within 24 hours 2
• If enteral feeding is contraindicated (intestinal obstruction, sepsis, intestinal ischemia, high-output fistulae, or severe gastrointestinal hemorrhage), provide early parenteral nutrition 2
• Enteral nutrition is strongly preferred over parenteral nutrition when the intestine is accessible and functional 1, 6

Pharmacological Adjuncts (Once Oral Intake Resumes)

• Administer oral laxatives such as bisacodyl (10-15 mg daily to TID) and magnesium oxide once oral intake is resumed 2, 3
• For persistent ileus unresponsive to initial measures, consider water-soluble contrast agents or neostigmine as rescue therapy 2, 3, 5
• Metoclopramide (10-20 mg orally four times daily) may be considered as a prokinetic agent, though evidence for effectiveness is limited 3

Critical Pitfalls to Avoid

• Do not routinely place nasogastric tubes—they prolong rather than shorten ileus duration unless there is severe distention, vomiting, or aspiration risk 2, 3
• Do not continue aggressive IV fluid administration beyond what is needed for euvolemia—fluid overload is a major preventable cause of prolonged ileus 2, 3
• 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, 3
• Do not continue high-dose opioids without considering opioid-sparing alternatives 3