Management of Paralytic Ileus with Persistent Vomiting
Patients with paralytic ileus and persistent vomiting require immediate NPO status, nasogastric decompression, IV fluid resuscitation, and withholding of oral antiemetics until bowel sounds return. 1, 2
Immediate Initial Management
Maintain strict NPO status until bowel function returns, as oral intake during paralytic ileus worsens gastric distension and aspiration risk. 2
Place a nasogastric tube for gastric decompression to relieve abdominal distension and prevent aspiration of gastric contents. 2 A venting gastrostomy (≥20 French gauge) may be considered if nasogastric drainage provides symptomatic relief but is needed long-term, though this carries risks of leakage and infection. 1
Initiate aggressive IV fluid resuscitation to correct fluid and electrolyte imbalances, particularly hypokalemia, hypochloremia, and metabolic alkalosis that result from persistent vomiting. 3, 2
Discontinue or minimize opioid medications immediately, as they are a primary cause of worsening ileus. 2
Critical Contraindication for Antiemetics
Do not administer antiemetics in the setting of paralytic ileus, as this can mask progressive ileus and gastric distension, potentially leading to bowel perforation. 3 This is the most important pitfall to avoid—antiemetics should only be considered after bowel sounds return and mechanical obstruction is excluded. 1
Pharmacologic Management After Bowel Function Returns
Once bowel sounds are audible and ileus begins resolving:
Consider metoclopramide 10 mg IV every 6 hours as a prokinetic agent to stimulate gastrointestinal motility and gastric emptying. 3, 2, 4 Metoclopramide is particularly effective for gastric stasis and can be titrated to maximum benefit. 3
For persistent vomiting after ileus resolution, add ondansetron 8-16 mg IV combined with dexamethasone 10-20 mg IV, as this combination provides superior antiemetic coverage through different receptor mechanisms. 3 However, monitor closely as ondansetron can increase constipation. 1, 3
Administer antiemetics on a scheduled basis rather than PRN, as prevention of vomiting is far easier than treating established emesis. 3
Consider alternative routes (IV, rectal, sublingual) if oral administration is not feasible due to ongoing vomiting. 3
Additional Supportive Measures
Encourage early mobilization as soon as the patient's condition allows to stimulate bowel motility. 2
Correct electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, which can perpetuate ileus. 3, 2
Consider antibiotics (rifaximin, metronidazole, or amoxicillin-clavulanic acid) if bacterial overgrowth is suspected in prolonged ileus. 2
For refractory cases, consider neostigmine for persistent paralytic ileus after conservative measures fail. 2
Monitoring and Progression
Assess daily for return of bowel sounds, passage of flatus, and bowel movements before advancing diet. 2
When reintroducing oral intake, start with clear liquids and progress to small, frequent meals with low-fat, low-fiber content. 2
If oral intake remains inadequate for >7 days, consider enteral nutrition via feeding tube or parenteral nutrition, preferring enteral when the gut is accessible. 2
Key Pitfalls to Avoid
- Never use antiemetics during active paralytic ileus 3
- Do not continue opioid medications 2
- Avoid premature oral intake before return of bowel function 2
- Do not use antidiarrheal medications (loperamide, diphenoxylate) which worsen ileus 2
- Monitor for extrapyramidal symptoms with metoclopramide and treat with diphenhydramine 50 mg IV if they occur 3, 4