How do you treat an ileus?

Treatment of Ileus

Maintain the patient strictly NPO, initiate isotonic IV fluid resuscitation with correction of electrolyte abnormalities (especially potassium and magnesium), discontinue all opioids and anticholinergic medications immediately, and implement early mobilization as the cornerstone of initial management. 1, 2

Initial Resuscitation and Stabilization

Fluid Management:

• Administer isotonic crystalloid solutions (lactated Ringer's or normal saline) for IV rehydration until pulse, perfusion, and mental status normalize 1, 2
• In severe dehydration or shock, give initial fluid boluses of 20 mL/kg 1
• Critical pitfall: Avoid fluid overload—limit weight gain to <3 kg by postoperative day 3, as excessive fluids cause intestinal edema and prolong ileus 3, 2
• Target adequate central venous pressure and urine output >0.5 mL/kg/h 1

Electrolyte Correction:

• Monitor and aggressively correct potassium, sodium, and magnesium abnormalities, checking levels every 24-48 hours in severe cases 1, 2
• Address sodium depletion and hypomagnesemia first before correcting hypokalemia, as low potassium is typically secondary to hyperaldosteronism from sodium depletion 2
• For hypomagnesemia, use IV magnesium sulfate initially, then transition to oral magnesium oxide 2

Gastrointestinal Decompression

Nasogastric Tube Placement:

• Place a nasogastric tube only in patients with severe abdominal distention, vomiting, or aspiration risk 1, 2
• Remove the NG tube as early as possible—prolonged nasogastric decompression paradoxically extends ileus duration rather than shortening it 3, 2
• Liberal use of rectal tubes for colonic decompression when the colon is dilated 4

Medication Management

Discontinue Offending Agents:

• Immediately stop all opioids, antimotility agents, anticholinergic medications, and antidiarrheal agents 1, 2
• Discontinue nonessential constipating medications including antidepressants, antispasmodics, phenothiazines, and haloperidol 3

Opioid-Sparing Analgesia:

• Implement multimodal pain control with regular paracetamol, NSAIDs, and tramadol as needed 1, 3
• For postoperative ileus, mid-thoracic epidural analgesia with local anesthetic is the single most effective intervention 3, 2

Pharmacological Interventions

Promotility and Laxative Therapy:

• Once oral intake resumes, administer oral laxatives: bisacodyl 10-15 mg daily to three times daily and magnesium oxide 1, 3, 2
• For established colonic ileus not responding to simple measures, use neostigmine 4, 5, 6
• Consider metoclopramide 10-20 mg orally four times daily as a prokinetic agent for persistent ileus, though evidence is limited 1, 3
• Chewing gum starting as soon as the patient is awake stimulates bowel function through cephalic-vagal stimulation 3, 2

For Opioid-Induced Ileus:

• Consider methylnaltrexone 0.15 mg/kg subcutaneously every other day (maximum once daily) for opioid-induced constipation, except in postoperative ileus or mechanical obstruction 3, 2

Supportive Care and Monitoring

Early Mobilization:

• Encourage early ambulation as soon as the patient's condition allows—this stimulates bowel function and prevents complications of immobility 1, 3, 2
• Remove urinary catheters within 24 hours to facilitate mobilization 3, 2

Monitoring:

• Monitor vital signs at least four times daily 1
• Evaluate for signs of return of intestinal function (passage of flatus or stool, bowel sounds) 1, 2
• Maintain a stool chart to record number and character of bowel movements 1
• Obtain daily abdominal radiography if colonic dilatation is detected at presentation 1

Thromboprophylaxis:

• Administer subcutaneous heparin to reduce risk of thromboembolism in patients with prolonged immobility 1, 2

Nutritional Support

Resumption of Feeding:

• Once ileus resolves and the patient can tolerate oral feeding, initiate early enteral nutrition 1, 2
• For postoperative patients, encourage early oral intake with small portions once bowel sounds return—do not delay feeding based solely on absence of bowel sounds 3
• For mild ileus, limit bowel rest to 24-48 hours maximum, then resume oral intake regardless of bowel sounds 3

Prolonged Ileus:

• If oral/enteral nutrition cannot be maintained for >7 days, initiate parenteral nutrition 1, 3
• Enteral nutrition is preferred over parenteral when the intestine is accessible and functional 1, 2

Special Considerations

Intra-Abdominal Hypertension:

• If ileus is associated with intra-abdominal hypertension, ensure optimal sedation and analgesia 4
• Consider brief trials of neuromuscular blockade as a temporizing measure 4
• Use a protocol to avoid positive cumulative fluid balance after acute resuscitation 4

Persistent Ileus:

• If ileus persists beyond 7 days despite optimal conservative management, investigate for mechanical obstruction, intra-abdominal sepsis, or other complications 3, 2
• For persistent colonic pseudo-obstruction with risk of rupture, consider neostigmine, endoscopic decompression, or cecostomy 6

Critical Pitfalls to Avoid

• Do not continue opioids—they are a primary modifiable cause of prolonged ileus 3, 2
• Do not maintain prolonged NG tube decompression unless severe distention, vomiting, or aspiration risk exists 3, 2
• Do not overload fluids—this is one of the most common and preventable causes of prolonged ileus 3, 2
• Do not delay mobilization or oral intake based solely on absence of bowel sounds 3