What is the appropriate management for a patient with paralytic ileus?

Management of Paralytic Ileus

Patients with paralytic ileus require immediate NPO status, nasogastric decompression, intravenous fluid resuscitation, and discontinuation of opioids, with prokinetic agents reserved for persistent cases. 1, 2

Immediate Management Steps

NPO Status and Decompression

• Maintain strict NPO (nil per os) 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 1, 2
• Monitor for return of bowel sounds, passage of flatus, and bowel movements as indicators of resolution 1, 2

Fluid and Electrolyte Management

• Provide adequate intravenous fluid resuscitation with isotonic fluids (lactated Ringer's or normal saline) to correct dehydration and electrolyte imbalances 1, 2
• Avoid fluid overload by aiming for perioperative weight gain less than 2.5-3 kg and maintaining near-zero fluid balance 2
• In severe dehydration, continue IV rehydration until pulse, perfusion, and mental status normalize 2

Medication Review

• Immediately discontinue or minimize opioid medications, as they are the primary cause of worsening ileus 1, 2
• Avoid antidiarrheal medications (loperamide, diphenoxylate) as they exacerbate ileus 1, 2
• Anticholinergic drugs and narcotic analgesics antagonize the effects of prokinetic agents and should be avoided 3

Pharmacological Management

Prokinetic Agents

• Consider metoclopramide to stimulate gastrointestinal motility in persistent cases, though it only helps a minority of patients with generalized motility disorders 1, 2
• Be aware that metoclopramide carries risk of extrapyramidal symptoms (occurring in approximately 1 in 500 patients) and tardive dyskinesia with prolonged use beyond 12 weeks 3
• Metoclopramide should be administered slowly (1-2 minutes for 10 mg IV) to avoid transient anxiety and restlessness 3

Neostigmine

• Administer neostigmine for persistent paralytic ileus that does not respond to conservative measures 1, 2, 4
• This is particularly effective in cases of colonic pseudo-obstruction (Ogilvie's syndrome) 4

Antibiotics

• Consider antibiotics (rifaximin, metronidazole, or amoxicillin-clavulanic acid) if bacterial overgrowth is suspected in prolonged ileus 1, 2
• For complicated intra-abdominal infections with paralytic ileus, coverage for obligate anaerobic bacilli should be provided 5

Nutritional Support

Timing and Route

• Consider enteral nutrition via feeding tube or parenteral nutrition if oral intake remains inadequate for more than 7 days 1, 2
• Prefer enteral nutrition over parenteral nutrition when the gut is accessible and functioning 1, 2
• Reserve long-term parenteral nutrition for patients with significant malnutrition who cannot tolerate enteral nutrition 2

Reintroduction of Oral Feeding

• Start with clear liquids and progress to small, frequent meals with low-fat, low-fiber content when reintroducing oral feeding 1, 2
• Increase volume or change food type, but not both simultaneously, to assess tolerance 1
• Assess tolerance based on presence or absence of nausea, vomiting, abdominal distension, or diarrhea 1
• Liquid feeds may be better tolerated than solid meals 2

Vitamin Supplementation

• Monitor and supplement fat-soluble vitamins (Vitamin A 10,000 IU daily, Vitamin D 3000 IU daily, Vitamin E 100 IU daily, Vitamin K 300 μg daily) 2, 6

Supportive Measures

Early Mobilization

• Encourage early mobilization as soon as the patient's condition allows to stimulate bowel motility 1, 2, 7
• Early mobilization is particularly important in postoperative and trauma patients 7

Pain Management

• Consider thoracic epidural analgesia for pain management as an alternative to opioids in postoperative ileus 1, 2
• Avoid high-dose opioids as they worsen intestinal dysmotility and can lead to narcotic bowel syndrome 2

Monitoring and Reassessment

• Assess daily for return of bowel sounds, passage of flatus, and bowel movements 1, 2
• Reassess the effectiveness of therapy daily and adjust management accordingly 1, 2
• Be vigilant for complications including bowel perforation, ischemia, and aspiration 7, 8

Critical Pitfalls to Avoid

• Do not allow premature oral intake before return of bowel function, as this can worsen symptoms and delay recovery 1, 2
• Do not continue opioid medications, as they are the most common exacerbating factor 1, 2
• Do not use antidiarrheal agents (loperamide, diphenoxylate) as they worsen the condition 1, 2
• Do not pursue unnecessary surgery, as it can worsen intestinal function and lead to need for reoperation 2
• Do not allow thirsty patients with vomiting to drink large volumes ad libitum; instead administer small amounts via spoon or syringe 2
• Avoid enemas in patients with paralytic ileus, as they are contraindicated 5
• Be cautious when using prokinetic agents like metoclopramide, as theoretically they could put increased pressure on suture lines following gut anastomosis 3