Management of Small Bowel Ileus
Initial Management: Conservative Approach First
Non-operative management should always be attempted in patients with small bowel ileus unless there are signs of peritonitis, strangulation, or bowel ischemia. 1
The cornerstone of initial management includes:
- Nil per os (NPO status) 1
- Nasogastric tube decompression - effective in approximately 70-90% of patients with adhesive small bowel obstruction 1
- Intravenous fluid resuscitation and correction of electrolyte disturbances 1
- Nutritional support 1
- Prevention of aspiration 1
Imaging to Guide Decision-Making
CT scan is the preferred imaging technique to differentiate between complete obstruction and facilitate the decision for non-operative versus operative management 1. CT helps identify:
- Signs of closed loop obstruction 1
- Bowel ischemia 1
- Free fluid (suggesting need for urgent surgery) 1
- Location of obstruction (high jejunum versus deep pelvis) 1
Duration of Conservative Management
A 72-hour trial of non-operative management is considered safe and appropriate 1. Evidence shows:
- Most patients who respond to conservative treatment resolve within a mean of 22 hours and maximum of 5 days 2
- Delays in surgery beyond 72 hours increase morbidity and mortality 1
- Conservative trials beyond 5 days prove ineffective 2
- 64-79% of patients with partial obstruction resolve without surgery 2, 3
Indications for Immediate Surgery
Proceed directly to surgery without delay if any of the following are present:
- Signs of peritonitis 1
- Clinical evidence of strangulation 1
- Bowel ischemia on imaging 1
- Free perforation 1
- Signs of closed loop obstruction on CT 1
Nasogastric Tube Considerations
While both nasogastric tubes and long intestinal tubes can be used, standard nasogastric tube decompression is appropriate for most patients 1. Long trilumen tubes showed lower failure rates (10.4% vs 53.3%) in one trial but require endoscopic placement, and the high failure rate for NG tubes in that study was atypical compared to other literature 1.
Prokinetic Agents
Metoclopramide 10 mg IV (administered slowly over 1-2 minutes) may be used to facilitate small bowel transit in cases where delayed gastric emptying interferes with resolution 4. This is FDA-approved for facilitating small bowel intubation and stimulating gastric emptying 4.
Monitoring During Conservative Management
Daily clinical assessment must include:
- Nasogastric tube output volume 1
- Abdominal examination for peritoneal signs 1
- Vital signs and hemodynamic status 1
- Electrolyte monitoring and correction 1
- Assessment for dehydration and kidney injury 1
When to Abandon Conservative Management
Convert to surgical management if:
- No improvement after 72 hours of conservative treatment 1
- Persistent high nasogastric output with clinical deterioration 1
- Development of peritoneal signs 1
- Worsening abdominal distension or pain 1
- Hemodynamic instability 1
Common Pitfalls to Avoid
Do not delay surgery in high-risk scenarios: Emergency surgical exploration carries high morbidity with considerable risk for bowel injury, but delaying necessary surgery increases mortality 1. The key is distinguishing patients who will benefit from conservative management from those requiring urgent intervention.
Avoid prolonged conservative trials beyond 72 hours unless the patient shows clear clinical improvement with only persistent high NG output but no other signs of deterioration 1.
Monitor for common medical complications: dehydration with kidney injury, electrolyte disturbances, malnutrition, and aspiration 1.
Special Considerations for Chronic Dysmotility
In patients with chronic small intestinal dysmotility presenting with ileus-like symptoms:
- Exclude mechanical obstruction first - occasionally requires trial of low-fiber or liquid diet if radiology is inconclusive 1
- Consider drug effects - especially opioids and anticholinergics 1
- Multidisciplinary team management is essential, including gastroenterology, surgery, nutrition, and pain management 1
- Avoid unnecessary surgery and early medicalization 1