Ileus

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

postoperative ileus

1st line – nil by mouth and intravenous fluids

Plus – reduction in opioid analgesia ± replacement with non-opioid analgesia

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Plus –

reduction in opioid analgesia ± replacement with non-opioid analgesia

Treatment recommended for ALL patients in selected patient group

Opioid analgesics have been shown to slow down bowel motility.

In patients undergoing surgery and requiring opioid analgesia, decreasing the use of systemically administered opioid analgesics is recommended through the use of multimodal anaesthesia and analgesia techniques. For example, using adjuncts such as paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) such as ketorolac, and analgesics and local anaesthetics administered via epidural.[27][28][31][36][37][38][39][40][41][42][43][44][45][46][47] The use of epidural analgesia helps to prevent postoperative ileus, although in practice can be challenging due to its impact on the patients' mobility.[28][33][34][35] For more information on perioperative measures to prevent postoperative ileus, see Prevention.

Primary options

paracetamol: <51 kg body weight: 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; ≥51 kg body weight: 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

ketorolac: 10 mg intravenously/intramuscularly initially, followed by 10-30 mg every 4-6 hours when required for up to 2 days, maximum 60 mg (body weight <50 kg or elderly) or 90 mg (body weight ≥50 kg)

Consider – nasogastric decompression

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Consider –

nasogastric decompression

Additional treatment recommended for SOME patients in selected patient group

Place a nasogastric (NG) tube for decompression of the gut in patients with significant abdominal distention and repeated vomiting or who are at high risk of aspiration.[6]

Measure gastric output and replace lost volume using Hartmann’s solution (Ringer’s lactate/acetate solution) according to body weight. An intravenous physiological saline with appropriate additions of potassium can be used as an alternative.[70]

Assess the patient for absence of abdominal distention, decreasing NG tube output, and passage of flatus and stool, with a view to removing the NG tube.

The decision to remove the NG tube is based on measured gastric output over time and clinical resolution of ileus. A trial of spigotting (i.e., blocking) the NG tube to test whether the gastrointestinal tract is patent and working is sometimes used to avoid taking it out too soon.

If the patient displays evidence of ongoing ileus with abdominal distention and vomiting, reinsert the NG tube.

Once ileus begins to resolve, as seen by passage of flatus and resolution of abdominal distention and nausea, the patient can be started on a liquid diet and advanced as tolerated.

The passage of flatus or stool and tolerance of an oral diet is the best clinical endpoint of postoperative ileus.[3][4]

non-surgical cause

1st line – nil by mouth and intravenous fluids

Plus – management of the underlying condition(s)

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Plus –

management of the underlying condition(s)

Treatment recommended for ALL patients in selected patient group

Treat any underlying condition, such as sepsis, intra-abdominal infections, or other acute/systemic illnesses associated with intestinal hypomotility such as diabetes mellitus, Chagas disease, scleroderma, and neurological diseases.

Reduce or discontinue pharmacological agents (e.g., opioids, anticholinergics) that slow gastrointestinal motility and can cause ileus.

Correct any electrolyte imbalance, particularly hyper-magnesaemia, which has been associated with ileus.[59]

Practical tip

Think ' Could this be sepsis?' based on acute deterioration in an adult patient in whom there is clinical evidence or strong suspicion of infection.[65][66][67] See Sepsis in adults.

The patient may present with non-specific or non-localised symptoms (e.g., acutely unwell with a normal temperature) or there may be severe signs with evidence of multi-organ dysfunction and shock.[65][66][67]
Remember that sepsis represents the severe, life-threatening end of infection.[71]
It is important to distinguish between small bowel obstruction and ileus; small bowel obstruction may progress to a more serious condition with bowel ischaemia if there is a twist of the intestines or vascular compromise. Ischaemic bowel disease and bowel perforation can cause rapid deterioration into septic shock.[69] In practice, if computed tomography shows extensive ischaemia in a patient who is very frail or has significant comorbidities, palliative care may be the treatment of choice (rather than antibiotics and source control); this decision should always be made in discussion with a consultant.

Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[65][66][68][72] Consult local guidelines for the recommended approach at your institution.

Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis:[69]

Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6).

Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[69][72]

In the community: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[67]

Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
At risk of neutropenic sepsis.

Consider – nasogastric decompression

ONGOING

ileus lasting 4 days or longer post-surgery (prolonged ileus)

1st line – parenteral nutrition

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Ileus

postoperative ileus

nil by mouth and intravenous fluids

reduction in opioid analgesia ± replacement with non-opioid analgesia

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

nasogastric decompression

non-surgical cause

nil by mouth and intravenous fluids

management of the underlying condition(s)

Practical tip

nasogastric decompression

ileus lasting 4 days or longer post-surgery (prolonged ileus)

parenteral nutrition

Ileus

Treatment algorithm

postoperative ileus

nil by mouth and intravenous fluids

reduction in opioid analgesia ± replacement with non-opioid analgesia

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

nasogastric decompression

non-surgical cause

nil by mouth and intravenous fluids

management of the underlying condition(s)

Practical tip

nasogastric decompression

ileus lasting 4 days or longer post-surgery (prolonged ileus)

parenteral nutrition