How should paralytic ileus be managed?

Management of Paralytic Ileus

Paralytic ileus requires immediate bowel rest (NPO status), intravenous fluid resuscitation with strict avoidance of overhydration (target weight gain <3 kg), aggressive opioid minimization with multimodal analgesia, early mobilization, and selective nasogastric decompression only for severe distention or vomiting risk. 1, 2, 3

Immediate Initial Management

Bowel Rest and Decompression

• Maintain strict NPO status until bowel function returns, as oral intake cannot be tolerated due to impaired gastric emptying and intestinal transit 1
• Place a nasogastric tube for decompression ONLY if the patient has severe abdominal distention, prominent vomiting, or aspiration risk—routine nasogastric tube placement prolongs rather than shortens ileus duration and should be avoided 1, 2, 3
• Remove the nasogastric tube as early as possible once symptoms improve 2, 3

Fluid and Electrolyte Management

• Administer isotonic intravenous crystalloids (preferably balanced solutions like Ringer's lactate) to maintain euvolemia, but strictly limit total fluid administration to prevent weight gain exceeding 3 kg—fluid overload causes intestinal edema that significantly worsens and prolongs ileus 2, 3
• Correct electrolyte abnormalities immediately, particularly potassium and magnesium, as these directly impair intestinal motility 2, 3
• Monitor serum electrolytes, creatinine, potassium, and magnesium every 1-2 days initially 3

Critical Medication Adjustments

• Immediately discontinue or minimize all medications that worsen ileus: opioids (highest priority), anticholinergics, antidepressants, antispasmodics, phenothiazines, cyclizine, and haloperidol 4, 3
• If the patient has been on long-term opioids, consider narcotic bowel syndrome and initiate gradual supervised opioid withdrawal with pain specialist involvement 4
• Implement opioid-sparing multimodal analgesia using regular acetaminophen, NSAIDs (if not contraindicated), and consider alvimopan (peripheral mu-receptor antagonist) if opioid analgesia is necessary 3
• Avoid antidiarrheal medications such as loperamide and diphenoxylate, which worsen ileus 1

Early Mobilization Strategy

• Begin mobilization immediately once the patient's condition allows—early ambulation is one of the most effective interventions for stimulating bowel function 4, 2, 3
• Remove urinary catheters early to facilitate mobilization 2, 3
• Implement chewing gum as soon as the patient is awake, as it stimulates bowel function through cephalic-vagal stimulation 3

Pharmacological Interventions

Prokinetic Agents

• Consider metoclopramide (10-20 mg orally four times daily) to stimulate gastrointestinal motility 1, 2
• For persistent ileus unresponsive to initial measures, consider neostigmine as rescue therapy 1, 2, 3

Laxatives

• Administer oral laxatives such as bisacodyl (10-15 mg daily to three times daily) and magnesium oxide once oral intake is resumed 2

Antibiotics for Bacterial Overgrowth

• If bacterial overgrowth is suspected in prolonged ileus, use rifaximin, metronidazole, amoxicillin-clavulanic acid, or ciprofloxacin 1, 3

Nutritional Support Algorithm

When Oral Intake Remains Inadequate

• If oral intake will be inadequate (<50% of caloric requirement) for more than 7 days, initiate early tube feeding within 24 hours 4, 1, 2
• Prefer enteral nutrition over parenteral nutrition when the gut is accessible—enteral feeding maintains gut mucosal structure and reduces complications 1
• Consider feeding jejunostomy with or without venting gastrostomy in carefully selected patients 4

Parenteral Nutrition Indications

• Reserve long-term parenteral nutrition for patients with significant malnutrition or electrolyte disturbance who cannot tolerate enteral nutrition 4, 3
• If enteral feeding is contraindicated, provide early parenteral nutrition to mitigate inadequate oral/enteral intake 4, 2
• Never use feeding lines to administer drugs due to high risk of catheter infection 4

Reintroducing Oral Feeding

• When reintroducing oral feeding, start with clear liquids and progress to small, frequent meals with low-fat, low-fiber content 1
• Increase either the volume OR the type of food, but never both simultaneously—this allows proper assessment of tolerance 1
• Assess tolerance based on presence or absence of nausea, vomiting, abdominal distension, or diarrhea 1

Rescue Therapy for Persistent Ileus

• For ileus persisting beyond 7 days despite optimal conservative management, consider water-soluble contrast agents or neostigmine as rescue therapy 2, 3
• Ileus lasting more than 7 days should prompt diagnostic investigation to rule out mechanical obstruction or other complications 3

Exclude Alternative Diagnoses

• Rule out mechanical obstruction, intra-abdominal sepsis, partial obstruction, infectious enteritis (Clostridium difficile, Salmonella), recurrent inflammatory disease, or medication effects before confirming paralytic ileus 3
• If C. difficile infection is suspected, administer appropriate antimicrobial therapy 3

Multidisciplinary Team Involvement

• Complex cases require multidisciplinary team management including gastroenterologist, gastrointestinal surgeon, pain team, psychiatrist/psychologist, dietitian, and specialist nurses 4
• Maintain vigilance for psychopathology and provide ongoing psychological support 4
• Consider referral to specialized intestinal failure units for chronic or refractory ileus requiring long-term parenteral nutrition 2

Critical Pitfalls to Avoid

• Do not overload fluids—this is one of the most common and preventable causes of prolonged ileus 2, 3
• Do not continue high-dose opioids without implementing opioid-sparing alternatives 3
• Do not maintain prolonged nasogastric decompression unless severe distention, vomiting, or aspiration risk exists 2, 3
• Do not prematurely initiate oral intake before return of bowel function 1
• Avoid unnecessary surgery in these high-risk patients—surgery should be reserved for judicious palliative intervention only when it can improve symptoms and quality of life 4