Initial Management of Obstructive Ileus
The initial management of obstructive ileus should be conservative with bowel rest (NPO), nasogastric decompression, intravenous fluid resuscitation with crystalloid, electrolyte monitoring and correction, and analgesia, unless there are signs of peritonitis, strangulation, or ischemia requiring emergency surgery. 1, 2
Immediate Assessment and Risk Stratification
The first priority is distinguishing between patients who require immediate surgery versus those suitable for conservative management:
Emergency Surgical Indications (Operate Immediately)
- Signs of peritonitis (diffuse tenderness, guarding, rebound) 1, 2, 3
- Suspected strangulation or intestinal ischemia - look for fever, tachycardia, continuous pain (not colicky), elevated lactate, leukocytosis with left shift 1, 3
- Closed-loop obstruction on CT imaging 1, 2
- Free perforation with pneumoperitoneum 3
- Hemodynamic instability/hypotension in the setting of bowel obstruction 1
Initial Diagnostic Workup
- Physical examination should specifically assess for abdominal distension, peritoneal signs, and examine all hernial orifices (inguinal, femoral, umbilical, incisional) 1, 3
- Laboratory tests: Complete blood count, C-reactive protein, lactate, electrolytes, BUN/creatinine, coagulation profile 1, 3
- CT scan with IV contrast is the preferred imaging modality with >90% diagnostic accuracy (far superior to plain radiographs at 50-60% sensitivity) 1, 3
Conservative Management Protocol
For patients without signs of strangulation or peritonitis, initiate the following:
Core Components
- Nil per os (NPO) - complete bowel rest 1, 3
- Nasogastric tube decompression - place immediately if active vomiting or significant gastric distension 2
- Intravenous crystalloid resuscitation - aggressive fluid replacement to correct dehydration 1, 3
- Electrolyte monitoring and correction - particularly potassium, sodium, and chloride 1, 3
- Foley catheter for urine output monitoring 1
- Analgesia for pain control 1
Water-Soluble Contrast Administration
- Administer 50-150 mL of Gastrografin once the stomach is adequately decompressed to avoid aspiration 2
- This serves both diagnostic and therapeutic purposes - reduces need for surgery by 70-90% in adhesive obstruction 1, 3
- Obtain plain abdominal X-ray at 24 hours after contrast administration 2
Timing of Surgical Intervention
The 72-Hour Rule
- Continue conservative management for up to 72 hours in stable patients without signs of ischemia 1, 2, 3
- Most obstructions resolve within 22 hours if they will resolve conservatively 4
- After 72 hours of persistent obstruction: Proceed to surgery, preferably starting with laparoscopic approach 2, 3
Monitoring During Conservative Management
- Serial abdominal examinations - watch for development of peritoneal signs 2
- Serial lactate and white blood cell counts - rising values suggest ischemia 2
- Maintain low threshold for surgical intervention if any clinical deterioration occurs 2, 3
Critical Pitfalls to Avoid
- Do not delay surgery in patients with peritoneal signs, rising lactate, or worsening leukocytosis - these indicate strangulation or ischemia 1, 2
- Water-soluble contrast can worsen dehydration due to high osmolarity shifting fluid into bowel lumen - ensure adequate IV hydration 1
- Do not continue conservative management beyond 72 hours in patients with persistent complete obstruction - this increases morbidity and mortality 2, 3
- Avoid antiemetics that increase GI motility (like metoclopramide) in complete obstruction - they can worsen the situation 3
Special Considerations
Malignant Bowel Obstruction
- Surgery after CT scan is primary treatment for patients with longer life expectancy (months to years) 1, 3
- Medical management (opioids, anticholinergics, octreotide, corticosteroids) is preferred for advanced disease or poor surgical candidates 3, 5