Does colonic ileus require surgical intervention?

From the Guidelines

Colonic ileus typically does not require surgery as initial treatment, and medical management with bowel rest, intravenous fluids, and discontinuation of medications that may worsen ileus should be prioritized. In cases of colonic ileus, particularly those caused by Clostridium difficile infection (CDI), treatment with vancomycin 125 mg orally four times daily for 10–14 days is recommended, and rectally administered vancomycin may be considered as an adjunctive therapy in the setting of ileus 1. However, surgery may be necessary in patients with complicated CDI, and prompt surgical evaluation should be obtained to reduce mortality 1. The decision to proceed with surgery should be based on the presence of signs of bowel ischemia or perforation, or if the condition fails to improve with conservative management.

Key Considerations

• Discontinuation of medications that may worsen ileus, such as opioids, anticholinergics, and calcium channel blockers
• Use of prokinetic agents like metoclopramide or erythromycin to stimulate bowel motility
• Close monitoring of vital signs, abdominal examination, and radiographic studies to detect complications requiring surgical management
• Consideration of subtotal or total colectomy with end ileostomy in patients with complicated CDI who require surgery 1

Treatment Approach

• Medical management should be prioritized, with surgery reserved for cases with mechanical obstruction, bowel ischemia or perforation, or failure to improve with conservative management
• Treatment of underlying cause of ileus, such as CDI, should be guided by evidence-based recommendations, including the use of vancomycin and consideration of rectal administration in the setting of ileus 1

From the Research

Colonic Ileus Treatment

• Colonic ileus, also known as acute colonic pseudo-obstruction, is a condition that can be treated with medication, as shown in a study published in 2000 2.
• Neostigmine, an acetylcholinesterase inhibitor, has been found to be a safe and effective treatment for acute colonic pseudo-obstruction, with complete clinical resolution of large bowel distention occurring in 26 of 28 patients 2.
• However, not all cases of colonic ileus can be treated with medication, and some may require surgical intervention, as seen in a patient with sigmoid cancer who required resection 2.

Surgical Intervention

• A study published in 2017 found that the diagnosis of ileus is one of the most common indications for an emergency laparotomy, with a perioperative lethality rate ranging from 5-15% 3.
• The study also noted that mechanical ileus, primary and secondary paralytic ileus, and postoperative ileus are important in the differential diagnosis, and a multimodal concept is required for successful treatment 3.
• Another study published in 2020 compared the safety and efficacy of intermittent bolus and continuous infusion neostigmine for acute colonic pseudo-obstruction, and found that while initial clinical response was similar between groups, continuous infusion neostigmine was associated with greater bowel diameter reduction at 24 hours 4.

Postoperative Ileus

• A systematic review published in 2018 found that postoperative ileus is a common condition with no established definition, aetiology, or treatment, but that minimally invasive surgery, protocol-driven recovery, and measures to avoid major inflammatory events may offer the best chances of reducing postoperative ileus 5.
• The review also noted that chewing gum, early enteral feeding, thoracic epidural analgesia, systemic lidocaine, and peripheral μ antagonists have been tested as interventions to prevent or reduce postoperative ileus, but that further investigation is needed to determine their safety and cost-effectiveness 5.
• A study published in 2019 found that early enteral nutrition facilitates return of normal bowel function, achieving enteral nutrition goals, and reducing hospital length of stay in patients who have undergone abdominal surgery, and strongly recommends early enteral nutrition to expedite resolution of ileus 6.