What is the appropriate medical management for ileus?

Medical Management of Ileus

Initial Assessment and Fluid Management

Administer isotonic intravenous fluids (lactated Ringer's or normal saline) to correct dehydration while strictly avoiding fluid overload, as excessive fluid administration is one of the most common and preventable causes of prolonged ileus. 1, 2

• Target weight gain of less than 3 kg by postoperative day three to prevent intestinal edema that worsens ileus 1
• Continue IV rehydration until pulse, perfusion, and mental status normalize and there is no evidence of ileus 3, 4
• Avoid 0.9% saline due to risk of salt and fluid overload; prefer balanced crystalloids 1
• Monitor fluid balance closely, as fluid overloading impairs gastrointestinal function and significantly prolongs ileus duration 1, 2

Electrolyte Correction

Aggressively correct electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, as these directly impair intestinal motility. 1, 2

• Address sodium depletion and hypomagnesemia first before correcting potassium, as hypokalemia is typically secondary to hyperaldosteronism from sodium depletion 1
• Administer intravenous magnesium sulfate initially for severe hypomagnesemia, then transition to oral magnesium oxide 1
• Monitor serum creatinine, potassium, and magnesium every 1-2 days initially 1, 4

Nasogastric Decompression

Avoid routine nasogastric tube placement, as it paradoxically prolongs rather than shortens ileus duration. 1, 2

• Place nasogastric tube only for severe abdominal distention, vomiting, or risk of aspiration 1, 2
• Remove the nasogastric tube as early as possible once placed 1, 4

Pain Management Strategy

Implement opioid-sparing analgesia as the cornerstone of ileus management, since opioids directly inhibit gastrointestinal motility and are a primary modifiable cause of prolonged ileus. 1, 2

• Use mid-thoracic epidural analgesia with local anesthetic as the single most effective intervention for preventing and treating postoperative ileus 1
• Employ multimodal analgesia including regular paracetamol and regular NSAIDs (if not contraindicated) 1, 4
• Consider abdominal wall blocks (such as TAP blocks) as adjuncts to reduce opioid consumption 1
• Discontinue or minimize all opioid medications immediately 4, 5

Medication Review

Immediately discontinue all agents that exacerbate ileus. 4

• Stop antimotility agents (loperamide in high doses can cause paralytic ileus) 4
• Discontinue anticholinergic medications 1, 4
• Avoid antidiarrheal agents in the presence of established ileus 4

Pharmacological Interventions

Once oral intake resumes, administer oral laxatives including bisacodyl 10-15 mg daily to three times daily and magnesium oxide to promote bowel function. 1, 2

• Consider metoclopramide 10-20 mg orally four times daily as a prokinetic agent for persistent ileus, though evidence for effectiveness is limited 1, 2
• For opioid-induced constipation contributing to ileus, consider methylnaltrexone 0.15 mg/kg subcutaneously every other day (maximum once daily), except in postoperative ileus or mechanical bowel obstruction 1, 2
• For refractory colonic ileus, consider neostigmine administration to stimulate colonic motility 2
• Chewing gum starting as soon as the patient is awake stimulates bowel function through cephalic-vagal stimulation 1, 2

Early Mobilization and Nutrition

Encourage early mobilization immediately once the patient's condition allows, as ambulation stimulates bowel function and prevents complications of immobility. 1, 2

• Remove urinary catheters within 24 hours to facilitate early mobilization 1, 2
• Encourage early oral intake with small portions once bowel sounds return, particularly after right-sided resections and small-bowel anastomoses 1
• Do not delay feeding based solely on absence of bowel sounds 1
• If oral intake will be inadequate (<50% of caloric requirement) for more than 7 days, initiate early tube feeding 1, 5
• If enteral feeding is contraindicated, provide early parenteral nutrition 1, 2

Special Considerations for Persistent Ileus

For ileus persisting beyond 7 days despite optimal conservative management, investigate for mechanical obstruction, intra-abdominal sepsis, or other complications. 2

• Rule out mechanical obstruction, intra-abdominal sepsis, partial obstruction, enteritis (Clostridium, Salmonella), recurrent disease (Crohn's, radiation), or medication effects 1
• Consider water-soluble contrast agents or neostigmine as rescue therapy for persistent ileus 1
• For colonic dilation, consider rectal tube placement to achieve decompression 2
• Administer broad-spectrum antibiotics if there is concern for bacterial translocation or septic complications 1

Monitoring

Monitor vital signs frequently and assess for signs of return of intestinal function, including passage of flatus or stool. 2, 4

• Reevaluate hydration status after 2-4 hours 4
• Monitor abdominal distension and bowel sounds 4
• Maintain a stool chart to record number and character of bowel movements 4
• Obtain daily abdominal radiography if colonic dilatation is detected at presentation 4

Critical Pitfalls to Avoid

• Do not overload fluids—this is the most common and preventable cause of prolonged ileus 1, 2
• Do not continue high-dose opioids without considering opioid-sparing alternatives 1
• Do not maintain prolonged nasogastric decompression unless there is severe distention, vomiting, or aspiration risk 1
• Do not routinely place nasogastric tubes, as they prolong rather than shorten ileus 1, 2