What is the initial treatment for a patient with paralytic ileus?

Initial Treatment for Paralytic Ileus

The initial treatment for paralytic ileus consists of strict NPO status, nasogastric decompression for symptomatic patients, intravenous fluid resuscitation with isotonic crystalloids, and immediate discontinuation of opioids and other offending medications. 1, 2

Immediate Management Steps

The cornerstone of initial management involves four critical interventions that must be implemented simultaneously:

NPO Status and Gastric Decompression

• Maintain strict nil per os (NPO) status until bowel function returns, as oral intake is contraindicated due to impaired gastric emptying and intestinal transit 1, 2
• Place a nasogastric tube for gastric decompression to relieve abdominal distension and prevent aspiration, particularly in patients with severe distention, vomiting, or aspiration risk 1, 2
• Remove the nasogastric tube as early as possible once symptoms improve, as prolonged decompression can paradoxically extend ileus duration 3

Fluid and Electrolyte Management

• Administer isotonic intravenous fluids (lactated Ringer's or normal saline) to correct dehydration and electrolyte imbalances 1, 2
• Avoid fluid overload—aim for perioperative weight gain less than 2.5-3 kg and maintain near-zero fluid balance, as excessive fluids cause intestinal edema and worsen ileus 1, 3
• Correct electrolyte abnormalities aggressively, particularly hypokalemia and hypomagnesemia, which directly impair intestinal motility 3
• Address hypomagnesemia first with intravenous magnesium sulfate, then transition to oral magnesium oxide, as potassium correction is often ineffective without adequate magnesium 3

Medication Management

• Immediately discontinue or minimize opioid medications, as they are the primary pharmacologic cause of worsening ileus 1, 2, 3
• Avoid antidiarrheal medications (loperamide, diphenoxylate) and anticholinergics, which exacerbate ileus 1, 2, 3
• Review and discontinue all nonessential constipating medications including antidepressants, antispasmodics, phenothiazines, and haloperidol 3

Early Mobilization

• Encourage early mobilization as soon as the patient's condition allows to stimulate bowel motility and prevent complications of immobility 1, 2, 3
• Remove urinary catheters early to facilitate mobilization 3

Monitoring for Resolution

Assess daily for clinical indicators of ileus resolution:

• Return of bowel sounds (though their absence should not delay feeding once other criteria are met) 1, 3
• Passage of flatus 1, 2
• Bowel movements 1, 2
• Reduction in abdominal distension 1

Pharmacological Interventions for Persistent Cases

If conservative measures fail after 24-48 hours, consider escalating therapy:

Prokinetic Agents

• Metoclopramide 10-20 mg orally four times daily may be considered to stimulate gastrointestinal motility, though evidence for effectiveness is limited and it only helps a minority of patients 1, 2, 3
• Neostigmine may be administered for persistent paralytic ileus unresponsive to conservative measures 1, 2

Laxatives

• Oral magnesium oxide and bisacodyl (10-15 mg daily to three times daily) should be administered once oral intake resumes to promote bowel function 3

Antibiotics

• Consider rifaximin, metronidazole, or amoxicillin-clavulanic acid if bacterial overgrowth is suspected in prolonged ileus 2, 3

Pain Management Strategy

For postoperative ileus specifically:

• Implement opioid-sparing analgesia using multimodal approaches 3
• Mid-thoracic epidural analgesia with local anesthetic is the most effective pain management strategy for preventing and treating postoperative ileus 3
• Use NSAIDs and acetaminophen as adjuncts unless contraindicated 3
• Consider abdominal wall blocks (TAP blocks) to reduce opioid consumption 3

Nutritional Support

If ileus persists beyond initial conservative management:

• Consider enteral nutrition via feeding tube or parenteral nutrition if oral intake remains inadequate for more than 7 days 1, 2, 3
• Prefer enteral nutrition over parenteral nutrition when the gut is accessible and functioning 1, 2
• When reintroducing oral feeding, start with clear liquids and progress to small, frequent meals with low-fat, low-fiber content 2
• Increase volume or change food type, but not both simultaneously, to assess tolerance 2

Critical Pitfalls to Avoid

• Do not allow premature oral intake before return of bowel function, as this worsens symptoms 1, 2
• Do not continue opioid medications, as they are the most common exacerbating factor 1, 2, 3
• Do not use antidiarrheal agents, which worsen the condition 1, 2
• Do not maintain prolonged nasogastric decompression unless there is severe distention, vomiting, or aspiration risk 3
• Do not overload fluids—this is one of the most common and preventable causes of prolonged ileus 3
• Do not pursue unnecessary surgery, as it can worsen intestinal function 1
• Do not allow thirsty patients with vomiting to drink large volumes ad libitum—instead administer small amounts via spoon or syringe 1

Reassessment and Escalation

• Reassess the effectiveness of therapy daily and adjust management accordingly 1, 2
• If ileus persists beyond 7 days despite optimal conservative management, investigate for mechanical obstruction, intra-abdominal sepsis, or other complications 3
• Consider water-soluble contrast agents as rescue therapy for persistent cases 3