From the Guidelines
Ileus management should start with conservative measures, including bowel rest, nasogastric tube decompression, and intravenous fluid resuscitation with balanced crystalloids, as recommended by the most recent evidence 1. The initial approach to managing ileus involves a stepwise strategy, beginning with supportive care to alleviate symptoms and prevent complications.
Key Components of Initial Management
- Bowel rest with NPO status to reduce bowel workload
- Nasogastric tube decompression to relieve distension and prevent vomiting, as noted in 1
- Intravenous fluid resuscitation with balanced crystalloids, such as isotonic dextrose-saline or balanced isotonic crystalloid replacement fluids containing supplemental potassium, to correct electrolyte abnormalities and maintain hydration 1
- Pain management using non-opioid analgesics like acetaminophen and NSAIDs, as opioids can exacerbate ileus
- Early ambulation to stimulate bowel function
Pharmacologic Management
For pharmacologic management, prokinetic agents may be considered, including:
- Metoclopramide (10mg IV every 6 hours)
- Erythromycin (250mg IV every 6 hours)
- Alvimopan (12mg orally twice daily for up to 7 days) for postoperative ileus Neostigmine (2mg IV over 3-5 minutes) can be used in refractory cases under cardiac monitoring.
Decision-Making
The decision about specific interventions should be made in a multidisciplinary setting, taking into account the characteristics of the obstruction, patient’s expectations, prognosis, expected subsequent therapies, and functional status, as recommended by 1. Surgical intervention is reserved for cases with mechanical obstruction, perforation, or ischemia. Resolution is typically monitored by return of bowel sounds, passage of flatus or stool, and tolerance of oral intake, which should be reintroduced gradually starting with clear liquids and advancing as tolerated.
From the Research
Ileus Management Overview
- Ileus is a common challenge in adult surgical patients, with an estimated incidence of 17% to 80% 2
- The main mechanisms of postoperative ileus pathophysiology include fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch, and inflammation 2
Treatment Options
- Methylnaltrexone, a peripheral opioid antagonist, has been studied as a potential treatment for postoperative ileus, but its efficacy is uncertain 3, 4, 5, 6
- Early enteral nutrition (EEN) has been shown to facilitate return of normal bowel function, achieve enteral nutrition goals, and reduce hospital length of stay in patients who have undergone abdominal surgery 2
- Metoclopramide and erythromycin, two promotility agents, have not been found to be effective in expediting the resolution of ileus 2
- Alvimopan, another peripherally active mu-opioid receptor antagonist, has been approved in the US for the treatment of postoperative ileus after abdominal surgery with bowel resection 6
Safety and Efficacy
- Methylnaltrexone has been found to be safe and well-tolerated in postcolectomy patients, but its efficacy in reducing the duration of postoperative ileus has not been demonstrated 3, 5
- The most commonly observed adverse events associated with methylnaltrexone are nausea, pyrexia, and vomiting 5
- Further analyses of clinical trial data and designs are necessary to determine the potential role of methylnaltrexone in the treatment of postoperative ileus 6