Management of Bowel Distention Due to Ileus
For a patient with bowel distention from ileus, immediately implement nasogastric decompression if there is severe distention or vomiting, correct electrolyte abnormalities (especially potassium and magnesium), maintain strict NPO status, provide isotonic IV fluids while avoiding overload, and discontinue all medications that worsen ileus including opioids and anticholinergics. 1, 2
Initial Assessment and Stabilization
Determine if mechanical obstruction is present before proceeding with ileus management, as mechanical obstruction requires surgical evaluation within 12 hours while functional ileus is managed conservatively. 3, 4
Immediate Interventions
Place a nasogastric tube for decompression only if the patient has severe abdominal distention, active vomiting, or risk of aspiration—not routinely, as prolonged nasogastric decompression paradoxically extends ileus duration. 5, 1, 2
Maintain strict NPO status until the ileus resolves, as oral feeding is contraindicated and worsens abdominal distension. 2
Administer isotonic crystalloid solutions (lactated Ringer's or normal saline) for rehydration, but critically avoid fluid overload—target weight gain <3 kg by postoperative day three to prevent intestinal edema that worsens ileus. 1, 6, 2
Measure intra-abdominal pressure (IAP) via trans-bladder technique when risk factors for intra-abdominal hypertension are present, as elevated IAP >20-25 mmHg with systemic consequences defines abdominal compartment syndrome requiring urgent decompressive laparotomy. 5, 7
Electrolyte Correction
Aggressively correct electrolyte abnormalities, as these directly impair intestinal motility and are frequently overlooked contributors to persistent ileus. 1, 2, 8
Correct hypokalemia after first addressing sodium depletion and hypomagnesemia, as low potassium is typically secondary to hyperaldosteronism from sodium depletion. 1
Correct hypomagnesemia with IV magnesium sulfate initially, then transition to oral magnesium oxide, checking levels every 1-2 days. 1, 2
Monitor serum creatinine, potassium, and magnesium every 24-48 hours in severe cases, with urinary sodium <10 mmol/L indicating sodium depletion requiring replacement. 1, 2
Medication Management
Immediately discontinue all agents that exacerbate ileus, as this is a critical and often overlooked step. 1, 2
Stop opioids completely if possible, as they are a primary modifiable cause of prolonged ileus and directly inhibit gastrointestinal motility. If the patient has been on long-term opioids, consider supervised withdrawal with pain specialist involvement for narcotic bowel syndrome. 5, 1, 2
Discontinue anticholinergics, antidiarrheals, antispasmodics, phenothiazines, and cyclizine, as these worsen intestinal dysmotility. 5, 1, 2
Avoid loperamide, as high doses can cause paralytic ileus. 2
Pain Management Strategy
Implement opioid-sparing analgesia as the cornerstone of treatment, since systemic opioids are a major cause of persistent ileus. 1, 6, 2
Use mid-thoracic epidural analgesia with local anesthetic as first-line for pain control, as this is highly effective at preventing and treating ileus compared to IV opioids. 1, 6
Employ multimodal analgesia including regular paracetamol, NSAIDs (unless contraindicated), and tramadol as needed. 1, 2
Consider abdominal wall blocks (such as TAP blocks) as adjuncts to reduce opioid consumption. 1
Decompression Strategies
For gastric distention, liberal use of nasogastric decompression is appropriate, but remove the tube as early as possible once symptoms improve. 5, 1
For colonic distention with established colonic ileus not responding to simple measures, consider neostigmine (an anticholinesterase) for pharmacologic colonic decompression. 5, 8
For small bowel distention, an ileus tube can be inserted via the nose under fluoroscopy into the obstructed small intestine, with the insertion depth adjusted based on imaging. 9
Pharmacological Interventions
Once oral intake resumes or for persistent ileus:
Administer oral laxatives: bisacodyl 10-15 mg daily to three times daily and magnesium oxide to promote bowel function. 1, 6
Consider metoclopramide 10-20 mg orally four times daily as a prokinetic agent for persistent ileus, though evidence for effectiveness is limited. 1, 10
For opioid-induced constipation contributing to ileus, consider methylnaltrexone 0.15 mg/kg subcutaneously every other day (maximum once daily), which provides relief while preserving analgesia—but avoid in mechanical bowel obstruction. 1, 6
For persistent ileus unresponsive to initial measures, consider water-soluble contrast agents or neostigmine as rescue therapy. 1
Early Mobilization
Encourage early ambulation as soon as the patient's condition allows, as this stimulates bowel function and prevents complications of immobility including thromboembolism. 1, 6, 2
Remove urinary catheters early to facilitate mobilization. 1
Administer subcutaneous heparin for thromboprophylaxis given the increased risk with immobility. 2
Nutritional Support
Once ileus resolves and bowel sounds return, encourage early oral intake with small portions, particularly after right-sided resections and small-bowel anastomoses. 1, 6
If oral intake will be inadequate (<50% of caloric requirement) for more than 7 days, initiate early tube feeding within 24 hours—start with nasojejunal tube, and if successful, consider endoscopic or surgical jejunostomy. 5, 1
If enteral feeding is contraindicated due to intestinal obstruction, sepsis, ischemia, high-output fistulae, or severe GI hemorrhage, provide early parenteral nutrition. 5, 1, 6
For patients with venting gastrostomy (ideally >20 French gauge), this may reduce vomiting by decompressing the stomach, though complications include leakage and infection. 5
Monitoring and Reassessment
Monitor vital signs frequently (at least four times daily) and reassess hydration status after 2-4 hours. 2
Evaluate for signs of return of intestinal function, such as passage of flatus or stool, and maintain a stool chart. 2
Obtain daily abdominal radiography if colonic dilatation is detected at presentation, with low threshold for further imaging if clinical deterioration occurs. 2
If ileus persists beyond 7 days despite optimal conservative management, perform diagnostic investigation to rule out mechanical obstruction or other complications. 1
Critical Pitfalls to Avoid
Do not overload fluids—this is one of the most common and preventable causes of prolonged ileus, as fluid overload impairs gastrointestinal function and causes intestinal edema. 1, 6, 2
Do not maintain prolonged nasogastric decompression unless there is severe distention, vomiting, or aspiration risk, as this worsens rather than shortens ileus. 1, 6, 2
Do not continue high-dose opioids without considering opioid-sparing alternatives or peripheral opioid antagonists. 1
Do not delay mobilization or oral intake based solely on absence of bowel sounds, as early feeding maintains intestinal function even in the presence of ileus. 1
Do not ignore intra-abdominal hypertension—if IAP exceeds 20-25 mmHg with systemic consequences (abdominal compartment syndrome), decompressive laparotomy is indicated. 5, 7