From the Guidelines
Ileus should be treated with a multifaceted approach including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission/early removal of nasogastric intubation, as recommended by the most recent guidelines 1.
Treatment Overview
The treatment of ileus involves addressing the underlying cause and providing supportive care to manage symptoms and prevent complications.
- Bowel rest by stopping oral intake (NPO status) is often recommended to reduce the workload on the bowel and allow it to recover.
- Nasogastric tube decompression can be used to relieve abdominal distension and prevent aspiration pneumonia, as noted in a study on bowel obstruction management 1.
- Intravenous fluid administration is crucial to maintain hydration and electrolyte balance, with a focus on correcting any electrolyte abnormalities, particularly potassium, magnesium, and phosphate.
- Pain management should be optimized, often avoiding opioids which can worsen ileus, and instead using alternative analgesics.
- Early ambulation is encouraged as movement helps stimulate bowel function.
- Medications that may contribute to decreased bowel motility should be discontinued when possible.
Specific Interventions
- Prokinetic agents like metoclopramide or erythromycin may be used in select cases, though evidence for their efficacy is limited.
- Alvimopan may be used for postoperative ileus, as it has been shown to be effective in reducing the duration of postoperative ileus.
- Nutritional support via parenteral nutrition should be considered if ileus persists beyond 5-7 days, as recommended by guidelines on palliative care 1.
- Surgery is rarely needed for uncomplicated ileus but may be necessary if there is an underlying mechanical obstruction or if the ileus is secondary to another condition requiring surgical intervention.
Recent Guidelines
The most recent guidelines from the ERAS society recommend a multifaceted approach to minimizing postoperative ileus, including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission/early removal of nasogastric intubation, with a strong recommendation grade 1.
- These guidelines also emphasize the importance of fluid optimization, aiming to have weight gain limited to < 3 kg at postoperative day three, as noted in a study on postoperative ileus minimization 1.
- Early oral intake should be encouraged to maintain intestinal function, and small portions should be offered initially, especially after right-sided resections and small-bowel anastomosis.
From the FDA Drug Label
INDICATIONS & USAGE Diabetic Gastroparesis (Diabetic Gastric Stasis) Metoclopramide Injection (metoclopramide hydrochloride, USP) is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis Small Bowel Intubation Metoclopramide Injection may be used to facilitate small bowel intubation in adults and pediatric patients in whom the tube does not pass the pylorus with conventional maneuvers Radiological Examination Metoclopramide Injection may be used to stimulate gastric emptying and intestinal transit of barium in cases where delayed emptying interferes with radiological examination of the stomach and/or small intestine.
The treatment of ileus is not directly addressed in the provided drug label for metoclopramide (IV) 2. However, metoclopramide can be used to stimulate gastric emptying and intestinal transit, which may be beneficial in some cases of ileus.
- Key points:
- Metoclopramide is indicated for diabetic gastroparesis, which is a related condition.
- It can be used to facilitate small bowel intubation and stimulate gastric emptying and intestinal transit. However, the FDA label does not explicitly state that metoclopramide is indicated for the treatment of ileus.
From the Research
Treatment of Ileus
- The treatment of ileus depends on the underlying cause, with mechanical ileus often requiring surgical intervention and functional ileus typically managed conservatively 3.
- Peripherally acting mu-opioid receptor antagonists, such as alvimopan and methylnaltrexone, have been shown to be effective in treating postoperative ileus by mitigating the deleterious effects of opioids on gastrointestinal motility 4, 5.
- Minimizing the use of opioids and replacing them with other drugs can help prevent postoperative ileus 6.
- Supportive measures, such as optimizing inpatient administration of opioids, can help prevent opioid use-related postoperative ileus and reduce hospital length of stay 7.
- A multimodal approach to managing postoperative ileus, including the use of peripherally acting mu-opioid receptor antagonists and opioid-sparing strategies, can help accelerate the recovery of gastrointestinal function after surgery 4, 6.
Management of Postoperative Ileus
- The use of opioids should be minimized to prevent postoperative ileus, and alternative drugs should be used when possible 6.
- Peripherally acting mu-opioid receptor antagonists can be used to treat postoperative ileus, but the evidence is inconsistent and of relatively low quality 5.
- The administration of more than 90 oral morphine equivalents per day of hospitalization is associated with a four times greater risk of developing postoperative ileus in opioid-naïve older patients 7.
- Developing postoperative ileus is associated with a significant increase in hospital length of stay, highlighting the importance of optimizing inpatient administration of opioids to prevent this complication 7.