What is the treatment plan for ileus (intestinal obstruction)?

From the Guidelines

The treatment plan for ileus should prioritize supportive care with intravenous crystalloids, anti-emetics, and bowel rest, as recommended by the most recent evidence 1. The initial management of ileus involves addressing the underlying cause and providing supportive care to prevent complications and promote recovery. Key components of the treatment plan include:

• Intravenous fluids, such as isotonic dextrose-saline crystalloid and balanced isotonic crystalloid replacement fluids containing supplemental potassium, to maintain hydration and electrolyte balance 1
• Bowel rest, with the patient in NPO status, to reduce the workload on the bowel and allow it to recover
• Placement of a nasogastric tube for decompression to relieve abdominal distension and prevent vomiting, as well as to analyze gastric contents and diagnose potential underlying conditions 1
• Monitoring of urine output through a Foley catheter to assess renal function and overall fluid status
• Pain management using opioid-sparing approaches whenever possible to minimize the risk of worsening ileus
• Early mobilization to stimulate bowel motility and promote recovery, as soon as the patient's condition allows
• Consideration of prokinetic medications, such as metoclopramide or erythromycin, in cases of paralytic ileus, and alvimopan for postoperative ileus prevention
• Targeted treatment of any underlying conditions, such as infection or obstruction, to address the root cause of the ileus
• Surgery reserved for cases with mechanical obstruction, perforation, or ischemia, as these conditions require prompt intervention to prevent severe complications. The treatment duration varies based on the cause and response, typically lasting 3-7 days, and the goal is to restore normal peristalsis while preventing complications and promoting overall recovery 1.

From the FDA Drug Label

The efficacy of alvimopan in the management of postoperative ileus was evaluated in 6 multicenter, randomized, double-blind, parallel-group, placebo-controlled studies: 5 U.S. studies (Studies 1 to 4 and 6) and 1 non-U. S. study (Study 5) In each of the 6 studies, alvimopan accelerated the time to recovery of gastrointestinal function, as measured by the composite endpoint GI2, and time to discharge order written as compared with placebo.

The treatment plan for ileus includes the use of alvimopan (PO) to accelerate the time to recovery of gastrointestinal function. Key points of the treatment plan include:

• Administration of alvimopan 12 mg orally at least 30 minutes and up to 5 hours prior to the scheduled start of surgery
• Subsequent doses of alvimopan 12 mg administered twice daily beginning on the first postoperative day and continued until hospital discharge or a maximum of 7 days
• Implementation of a standardized accelerated postoperative care pathway, including early nasogastric tube removal, early ambulation, and early diet advancement 2

From the Research

Treatment Plan for Ileus

The treatment plan for ileus typically involves addressing the underlying cause and providing supportive care. Some key points to consider include:

• The use of methylnaltrexone, a peripheral opioid antagonist, has been studied as a potential treatment for postoperative ileus, but its effectiveness is uncertain 3.
• Promotility agents such as metoclopramide and erythromycin have been evaluated for the treatment of ileus in adult surgical patients, but neither has been shown to be effective in expediting the resolution of ileus 4.
• Early enteral nutrition (EEN) has been strongly recommended to expedite the resolution of ileus in patients who have undergone abdominal surgery 4.
• A comprehensive review of evidence-based strategies to prevent and treat postoperative ileus has identified several perioperative strategies that may be beneficial, including avoidance of preoperative fasting and mechanical bowel preparation, use of epidural-local anesthetics, and modification of pain management strategies to limit opioid administration 5.
• In critically ill patients, bowel dysfunction such as ileus is common and can be associated with worse outcomes, and treatment options such as cholinesterase inhibitors and enteral opioid antagonists may be considered 6.

Key Considerations

Some key considerations in the treatment of ileus include:

• Determining the underlying cause of the ileus, whether mechanical or functional, and developing a treatment plan accordingly 7.
• Providing supportive care, such as bowel rest and gastric decompression, as needed 3.
• Considering the use of promotility agents or other medications to help manage symptoms and expedite the resolution of ileus 4, 6.
• Implementing a fast-track multimodal treatment plan that includes a combination of strategies to prevent and treat postoperative ileus 5.

Treatment Options

Some potential treatment options for ileus include:

• Methylnaltrexone 3
• Metoclopramide and erythromycin 4
• Early enteral nutrition (EEN) 4
• Cholinesterase inhibitors 6
• Enteral opioid antagonists 6
• Bowel rest and gastric decompression 3
• Avoidance of preoperative fasting and mechanical bowel preparation 5
• Use of epidural-local anesthetics 5
• Modification of pain management strategies to limit opioid administration 5