Treatment Plan for Mild Ileus
For mild ileus, begin with conservative management including bowel rest (NPO initially), isotonic IV fluid resuscitation to correct dehydration and electrolyte abnormalities (especially potassium and magnesium), early mobilization as soon as tolerated, and avoidance of medications that worsen gut motility—particularly opioids and anticholinergics. 1, 2
Initial Assessment and Supportive Care
Correct electrolyte abnormalities immediately, as hypokalemia and hypomagnesemia directly impair intestinal motility and are common contributors to ileus 1, 2. Address sodium depletion first, as hypokalemia is often secondary to hyperaldosteronism from volume depletion 2. Aggressive magnesium repletion with IV magnesium sulfate initially, then transition to oral magnesium oxide, is essential 2.
Administer isotonic IV fluids (lactated Ringer's or normal saline) to maintain euvolemia, but avoid fluid overload which worsens intestinal edema and prolongs ileus 1, 2, 3. The goal is to correct dehydration without causing weight gain exceeding 3 kg by day three 1.
Nasogastric tube placement should be reserved only for patients with severe abdominal distention, vomiting, or aspiration risk, and should be removed as early as possible since prolonged decompression paradoxically extends ileus duration 1, 2, 3. This is a critical pitfall—routine NG tube use worsens rather than improves outcomes 1, 2.
Mobilization and Nutrition
Encourage early mobilization immediately once the patient's condition allows, as ambulation directly stimulates bowel function and prevents complications of immobility 1, 2, 3. Early removal of urinary catheters facilitates mobilization 1, 2.
Resume oral intake early with small portions once bowel sounds return, particularly after small bowel procedures 1. Do not delay oral feeding based solely on absence of bowel sounds, as early feeding maintains intestinal function even during mild ileus 1. Start with clear liquids and advance as tolerated 2, 3.
If oral intake will be inadequate for more than 7 days, initiate enteral tube feeding within 24 hours 1. Parenteral nutrition is reserved only for cases where enteral feeding is completely contraindicated 1, 3.
Pharmacological Interventions
Implement opioid-sparing analgesia strategies, as opioids are a primary modifiable cause of prolonged ileus 1, 2. Consider multimodal analgesia with acetaminophen and NSAIDs (unless contraindicated), or regional techniques like TAP blocks 1.
Once oral intake resumes, administer oral laxatives: bisacodyl 10-15 mg daily to three times daily and magnesium oxide 1, 2, 3. These promote bowel function and are recommended by multiple guidelines 1, 2.
Consider metoclopramide 10-20 mg orally four times daily as a prokinetic agent for persistent mild ileus, though evidence for effectiveness is limited 1, 2, 3.
Chewing gum starting as soon as the patient is awake stimulates bowel function through cephalic-vagal stimulation and has shown benefit in multiple studies 1, 2, 3.
Medications to Avoid
Discontinue all nonessential medications that worsen ileus: anticholinergics, opioids (or minimize aggressively), antispasmodics, phenothiazines, and haloperidol 1, 2, 3. This is often overlooked but critical for resolution.
Special Considerations
For opioid-induced constipation contributing to ileus, methylnaltrexone 0.15 mg/kg subcutaneously every other day provides effective relief while preserving analgesia, though it should not be used in mechanical obstruction 1, 2.
Monitor for signs of progression to mechanical obstruction or complications requiring surgical intervention 2, 3. If ileus persists beyond 7 days despite optimal conservative management, diagnostic investigation is warranted to rule out mechanical obstruction 1.
Critical Pitfalls to Avoid
- Do not routinely place or maintain NG tubes—they prolong rather than shorten ileus 1, 2, 3
- Do not overload fluids—this is one of the most common and preventable causes of prolonged ileus 1, 2
- Do not continue high-dose opioids without considering alternatives 1, 2
- Do not delay mobilization or oral intake based solely on absence of bowel sounds 1