Recommendations

Key Recommendations

The treatment of ileus focuses on supportive care and correction of any underlying or predisposing conditions.

General management in all patients

All patients with ileus are made nothing by mouth (NPO) and require intravenous hydration. The initial choice of intravenous solution will depend on the baseline hydration state of the patient and the presence of comorbidities. A significantly hypovolemic patient may benefit from a bolus of several liters of normal saline. Following this initial hydration, the maintenance intravenous solution should be physiologic and provide some glucose. Fluids should be administered at a maintenance rate according to body weight. This rate should be tailored to the patient's urine output and hemodynamics.

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.

Postoperative ileus

Attempts to prevent postoperative ileus should begin in the perioperative setting, including appropriate intra-operative fluid management and avoidance of opioid analgesia. Enhanced recovery after surgery (ERAS) pathways are increasingly utilized in an attempt to expedite recovery of intestinal function and shorten hospital length of stay.[3][28][32] The mainstays of ERAS pathways include minimally invasive surgery, avoiding opioids, multimodal pain control, early ambulation, and early intake of oral fluids and solids.[3][28][31][32]

In patients undergoing surgery and requiring opioid analgesia, decreasing the use of systemically administered opioid analgesics helps to prevent postoperative ileus.[28] Patient-controlled analgesia pumps are beneficial as they reduce the overall amount of opioid given compared with round-the-clock analgesic dosing administered by a nurse.[33] Useful adjuncts for pain management include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ketorolac, other nonopioid analgesics such as acetaminophen, and local anesthetics administered via epidural.[3][34][35][36][37][38][39][40][41][42][53][85][86]

Several randomized controlled trials and meta-analyses have shown decreased duration of postoperative ileus in patients given chewing gum after surgery.[60][68][69][70][71][72][73][74][75] It is a safe and easy modality that can be utilized in most patients; however, it is not routinely recommended because the quality of evidence is very low.[28][76]

Patients with significant abdominal distention and repeated vomiting should have a nasogastric (NG) tube placed.[3][32] Gastric output should be measured and lost volume should be replaced with an intravenous physiologic saline solution. The decision to remove the NG tube is based on measured gastric output over time and clinical resolution of ileus. The patient is assessed for absence of abdominal distention and cramping, decreasing NG tube output, and passage of flatus and stool with a view to removal of the NG tube. The NG tube may require reinsertion if the patient again displays evidence of ongoing ileus with abdominal distention and vomiting. Studies have shown that routine NG decompression is unnecessary and may be detrimental.[87] Therefore, routine NG decompression is reserved for selective use.[87] Often, orogastric decompression is performed intra-operatively, but the tube is removed at the completion of surgery.[28]

Patients with prolonged postoperative ileus (ileus on or after day 4 postsurgery without prior resolution of postoperative ileus) may not have any oral intake for several weeks. Parenteral nutrition is recommended for patients who do not have any oral intake for more than 7 days.[3][78] It is beneficial in patients who are on bowel rest for more than 14 days or who have underlying malnutrition.[88] Electrolytes should be checked daily to identify electrolyte abnormalities associated with postoperative intravenous feeding and the NPO state. The benefits of starting parenteral nutrition earlier than 7 days are fewer than the risks associated with parenteral nutrition and central venous access. In most patients, the postoperative "starvation" state is not associated with increased morbidity or mortality. Insertion of a central venous line is associated with increased risk of iatrogenic injury to nearby vessels, pneumothorax, deep vein thrombosis, and central line-associated bacteremia. [Figure caption and citation for the preceding image starts]: CT scan showing significantly dilated stomachFrom the personal collection of Dr Paula I. Denoya [Citation ends].CT scan showing significantly dilated stomach[Figure caption and citation for the preceding image starts]: Nasogastric tubeFrom the personal collection of Dr Paula I. Denoya [Citation ends].Nasogastric tube

Management of underlying causes

Underlying conditions, such as sepsis, intra-abdominal infections, or other acute/systemic illnesses should be treated.

Some pharmacologic agents (e.g., opioids, anticholinergics) reduce gastrointestinal motility and can cause ileus, so these should be discontinued or reduced. Chronic opioid use contributes to ileus, but cessation or reduction of opioids should be managed carefully in these patients due to the risk of withdrawal symptoms.[89][90]​

Electrolyte imbalance, particularly hypermagnesemia, has been associated with ileus.[82] Electrolytes should be monitored and corrected as necessary.

Other evaluated therapies

In patients with acute small bowel obstruction as a result of adhesions, there is some evidence that water-soluble contrast agents (e.g., diatrizoate meglumine/diatrizoate sodium solution [Gastrografin®]) are an effective treatment, avoiding surgery, as well as correlating with a reduction in hospital stay.[3][91] However, two small double-blind placebo-controlled trials of patients with prolonged postoperative ileus after elective colorectal surgery suggest that Gastrografin® is of limited clinical utility in these patients, and the therapeutic value of these treatments remains controversial and uncertain.[77][92][93]

Promotility agents have been used to treat ileus with limited success.[64] While metoclopramide is helpful in treating delayed gastric emptying, it has not proved useful in postoperative ileus when evaluated in randomized controlled trials.[94][95] Intravenous erythromycin has been found not to be beneficial for the treatment of postoperative ileus, and the evidence is insufficient to recommend the use of cholecystokinin-like drugs, cisapride, dopamine agonists, propranolol, or vasopressin.[64][95][96]

Nasogastric tube insertion animated demonstration
Nasogastric tube insertion animated demonstration

How to insert a fine bore nasogastric tube for feeding.

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