What is the appropriate management of paralytic ileus?

Management of Paralytic Ileus

Immediate Initial Management

The cornerstone of paralytic ileus treatment is strict NPO status, nasogastric decompression (only if severe distention/vomiting present), intravenous fluid resuscitation with isotonic crystalloids, immediate discontinuation of opioids and other offending medications, correction of electrolyte abnormalities (especially potassium and magnesium), and early mobilization. 1, 2, 3

First 24 Hours: Remove Iatrogenic Factors

• Immediately discontinue or minimize opioid medications, as they are the single most common modifiable cause of prolonged ileus by directly inhibiting gastrointestinal motility 1, 2, 3
• Remove nasogastric tube as early as possible if one was placed—prolonged NG decompression paradoxically extends ileus duration rather than shortening it 1, 2
• Only place NG tube for decompression in patients with severe abdominal distention, vomiting, or aspiration risk, and remove as soon as these resolve 1, 2
• Stop all anticholinergics, antidiarrheals (loperamide, diphenoxylate), antidepressants, antispasmodics, phenothiazines, and haloperidol as these worsen ileus 2, 3

Fluid and Electrolyte Management

• Administer isotonic intravenous fluids (lactated Ringer's or balanced crystalloids) to correct dehydration while strictly avoiding fluid overload 1, 2, 3
• Avoid 0.9% saline due to risk of salt and fluid overload 1
• Target weight gain <3 kg by postoperative day 3 to prevent intestinal edema that worsens ileus 1, 2
• Aggressively correct hypokalemia and hypomagnesemia, as these directly impair intestinal motility 1
• For hypokalemia, first address sodium depletion and hypomagnesemia, as low potassium is typically secondary to hyperaldosteronism from sodium depletion 1
• Administer intravenous magnesium sulfate initially for severe hypomagnesemia, then transition to oral magnesium oxide 1

Pain Management Strategy

• Implement mid-thoracic epidural analgesia with local anesthetic as the single most effective intervention for preventing and treating ileus—this is superior to all other analgesic strategies 1, 2, 3
• Use low-dose local anesthetic combined with short-acting opiates to minimize motor block and hypotension 1
• Employ multimodal opioid-sparing analgesia including NSAIDs and acetaminophen (unless contraindicated) 1, 3
• Consider abdominal wall blocks (TAP blocks) as adjuncts to reduce opioid consumption 1

Early Mobilization and Nutrition

• Begin mobilization immediately once the patient's condition allows—early ambulation stimulates bowel function and prevents complications of immobility 1, 2, 3
• Remove urinary catheter within 24 hours to facilitate early mobilization 1
• Encourage early oral intake with small portions once bowel sounds return, particularly after right-sided resections and small-bowel anastomoses 1, 2
• Do not delay feeding based solely on absence of bowel sounds—early feeding maintains intestinal function even in the presence of ileus 1
• Start with clear liquids and progress to small, frequent meals with low-fat, low-fiber content 2, 3
• Liquid feeds may be better tolerated than solid meals in patients with impaired gastric motility 4, 3

Pharmacological Interventions

First-Line Laxatives (Once Oral Intake Resumes)

• Administer oral bisacodyl 10-15 mg daily to three times daily 1, 2, 3
• Add oral magnesium oxide to promote bowel function 1, 2, 3
• Implement chewing gum starting as soon as the patient is awake—this stimulates bowel function through cephalic-vagal stimulation 1, 2

Prokinetic Agents (For Persistent Ileus)

• Consider metoclopramide 10-20 mg orally four times daily as a prokinetic agent, though evidence for effectiveness is limited 1, 2, 3
• 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
• Alternative agents include naloxegol, lubiprostone, or linaclotide for refractory opioid-induced cases 1

Rescue Therapy (For Persistent Ileus Beyond 5-7 Days)

• Consider neostigmine for persistent paralytic ileus unresponsive to conservative measures 2, 3, 5
• Consider water-soluble contrast agents as rescue therapy 1
• If bacterial overgrowth is suspected in prolonged ileus, use rifaximin, metronidazole, amoxicillin-clavulanic acid, or ciprofloxacin 4, 2, 3

Nutritional Support for Prolonged Ileus

• If oral intake will be inadequate (<50% of caloric requirement) for more than 7 days, initiate early tube feeding 1, 2, 3
• Prefer enteral nutrition over parenteral nutrition when the gut is accessible and functioning 2, 3
• Provide early parenteral nutrition if enteral feeding is contraindicated due to intestinal obstruction, sepsis, intestinal ischemia, high-output fistulae, or severe gastrointestinal hemorrhage 1, 3
• Long-term parenteral nutrition should be reserved for patients with significant malnutrition who cannot tolerate enteral nutrition 4, 3
• Monitor and supplement fat-soluble vitamins (A, D, E, K), vitamin B12, iron, and magnesium 4, 3

Special Considerations

Contraindications for Enemas

• Enemas are contraindicated in patients with neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal or gynecological surgery, recent anal/rectal trauma, severe colitis, inflammation or infection of the abdomen, toxic megacolon, undiagnosed abdominal pain, or recent pelvic radiotherapy 4

When to Investigate Further

• If ileus persists beyond 7 days despite optimal conservative management, perform diagnostic investigation to rule out mechanical obstruction, intra-abdominal sepsis, partial obstruction, enteritis (Clostridium, Salmonella), recurrent disease (Crohn's, radiation), or medication effects 1, 2

Critical Pitfalls to Avoid

• Do not continue high-dose opioids without considering opioid-sparing alternatives or peripheral opioid antagonists 1, 3
• Do not maintain prolonged nasogastric decompression unless there is severe distention, vomiting, or aspiration risk 1, 2
• Do not overload fluids—this is one of the most common and preventable causes of prolonged ileus 1, 2
• Do not allow premature oral intake before return of bowel function in non-postoperative ileus 2, 3
• Do not use antidiarrheal medications (loperamide, diphenoxylate) as they worsen ileus 2, 3
• Do not pursue unnecessary surgery as it can worsen intestinal function and lead to need for reoperation 3