Ileus Treatment & Management

Medical Care

The management of ileus may vary greatly depending on the nature of the disease and the surgical procedure. Management of ileus starts with correction of underlying medical conditions, electrolyte abnormalities, and acid base abnormalities.

Most cases of postoperative ileus resolve with watchful waiting and supportive treatment. Patients should receive intravenous hydration. For patients with vomiting and distention, use of a nasogastric tube provides symptomatic relief; however, no studies in the literature support the use of nasogastric tubes to facilitate resolution of ileus. Long intestinal tubes have no benefit over nasogastric tubes.

For patients with protracted ileus, mechanical obstruction must be excluded with contrast studies. Underlying sepsis and electrolyte abnormalities, particularly hypokalemia, hyponatremia, and hypomagnesemia, may worsen ileus. These contributing conditions are easily diagnosed and corrected.

Discontinue medications that produce ileus (eg, opiates). In one study, the amount of morphine administered directly correlated with the time elapsed before the return of bowel sounds and the passage of flatus and stool.

The use of postoperative narcotics can be diminished by supplementation with nonsteroidal anti-inflammatory drugs (NSAIDs). In addition to permitting lower narcotic doses by providing pain relief, NSAIDS may improve ileus by reducing local inflammation. Myoelectric activities recorded from electrodes placed on the colon have revealed faster resolution from ileus in patients given ketorolac versus those given morphine^[21] ; however, the drawbacks of NSAID use include platelet dysfunction and gastric mucosal ulceration. Consider the use of a cyclooxygenase-2 selective agent (ie, celecoxib), which negates these adverse effects.

No single objective variable accurately predicts the resolution of ileus. The clinician must assess the overall status of the patient and evaluate for adequate oral intake and good bowel function. A patient's report of flatus, bowel sounds, or stool passage may prove misleading; therefore, clinicians must not rely solely on self-reporting.

Serial abdominal radiographs mapping the distribution of radiopaque markers have shown that the colonic gradient for resolution of postoperative ileus is proximal to distal. The return of propulsive activity to the right colon occurs earlier than to the transverse or left colon.

Other causes of adynamic ileus are as follows:

• Sepsis
• Drugs (eg, anesthesia, opioids, psychotropics, anticholinergics, antacids, warfarin, amitriptyline, chlorpromazine)
• Endocrine disorders (eg, diabetes, adrenal insufficiency, hypothyroidism)
• Metabolic (eg, low potassium, magnesium, or sodium levels; anemia; hyposmolality)
• Cardiopulmonary failure (eg, myocardial infarction)
• Pneumonia
• Trauma (eg, fractured ribs, fractured spine)
• Biliary and renal colic
• Neurosurgical procedures, spinal cord and head injuries
• Intra-abdominal inflammation and peritonitis
• Retroperitoneal and mediastinal pathology (eg, hematomas, infections)

Surgical Care

Yang and Morgan suggest that postoperative restoration of bowel function following a Hartmann procedure using a laparoscopic approach is not only safe and effective but also may result in significantly faster recovery time and fewer postprocedure complications compared to the open approach; therefore, it may be a viable alternative to open Hartmann reversal. Their retrospective study of reversal of Hartmann procedure (2001-2012) comprised 43 patients who underwent laparoscopic reversal and 64 patients who underwent the open reversal procedure.

Although the operative time was longer for the laparascopic group compared to the open procedure group (276.4 mins vs 242.0 mins; P = 0.02), the time to passage of flatus (2.8 vs 4.0 days; P < 0.001) and feces (4.2 vs 5.6 days; P = 0.02) and the hospital stay (6.7 vs 10.8 days; P < 0.001) were shorter and there were fewer postprocedure complications (14% vs 31%; P = 0.04) in the laparoscopic group. Postoperative ileus occurred in 2% of patients in this group compared to 17% in the group who underwent the open reversal procedure (P = 0.02). However 3 of 43 patients (7%) required conversion to laparotomy

Conventional wisdom and wide practice foster the notion that ambulation stimulates bowel function and improves postoperative ileus, although this has not been shown in the literature.

In a nonrandomized study evaluating 34 patients, seromuscular bipolar electrodes were placed in segments of the gastrointestinal tract after laparotomy. Ten patients were assigned to ambulate on postoperative day 1, and the other 24 were assigned to ambulate on postoperative day 4. No significant difference between the 2 groups was displayed in myoelectric recovery in the stomach, jejunum, or colon.^[25] Hence, postoperative ambulation remains beneficial in preventing the formation of atelectasis, deep vein thrombosis, and pneumonia but has no role in treating ileus.

Medication Summary

Thoracic epidural administration has been shown to be beneficial, both with open and with endoscopic colorectal surgery. Epidural blockade with local anesthetics improves postoperative ileus by blockage of inhibitory reflexes and efferent sympathetics. Studies have shown that combinations of thoracic epidurals containing bupivacaine alone or in combination with opioids improve postoperative ileus. Continuous intravenous administration of lidocaine during and after abdominal surgery may decrease the duration of postoperative ileus.

In a randomized study, systemic infusion of lidocaine is compared with placebo infusions in postoperative patients. Patients in the lidocaine group appear to have earlier return of flatus, bowel function, and discharge to home. Although only 11 patients were used in the each arm, systemic lidocaine lessened the postoperative pain sensation. Therefore, it is recommended that further studies are warranted to evaluate systemic lidocaine infusion in postoperative patients.

Peripherally selective opioid antagonists are an option for the treatment of postoperative ileus. Methylnaltrexone (Relistor) and alvimopan (Entereg) are approved by the Food and Drug Administration. These agents inhibit peripheral mu-opioid receptors, which abolishes the adverse gastrointestinal effects of opioids; however, because these agents do not cross the blood-brain barrier, they do not impair the analgesic effects of opioids.

Methylnaltrexone is indicated for opioid-induced constipation in patients with advanced illness receiving palliative care, when response to laxatives has not been sufficient. In a study of 14 healthy volunteers evaluating the use of morphine plus oral methylnaltrexone in increasing doses, methylnaltrexone significantly reduced morphine-induced delay in oral-cecal transit. Another study reported subcutaneous methylnaltrexone is effective in inducing laxation in patients receiving palliative care who have opioid-induced constipation and in whom conventional laxatives have failed. However, because methylnaltrexone has only recently been approved by the US Food and Drug Administration (FDA), more rigorous trials are needed.

Another phase III multicenter, double-blind, placebo-controlled study revealed that methylnaltrexone at 12-mg and 24-mg doses did not reduce the duration of postoperative ileus. Although the utility of intravenous methylnaltrexone was not demonstrated, it was well tolerated by postcolectomy patients.

Alvimopan is indicated to help prevent postoperative ileus following bowel resection. It has a longer duration of action than methylnaltrexone. Taguchi et al examined 78 postoperative patients randomized to receive either placebo or alvimopan. Fifteen patients underwent partial colectomy, 36 were status post simple hysterectomy, and the remaining 27 underwent radical hysterectomy. All of the patients were on patient-controlled analgesia pumps using either meperidine or morphine. Compared with patients on placebo, patients on alvimopan had their first bowel movement 2 days earlier, resumed a solid diet 1.3 days earlier, and returned home 1.4 days earlier. Other recent trials have been completed, including a meta-analysis comparing alvimopan with placebo and a study that found alvimopan to accelerate gastrointestinal tract recovery after bowel resection, regardless of age, gender, race, or concomitant medication.

Use of prokinetic agents has shown mixed results. Randomized trials have shown some benefit of the colon-stimulating laxative bisacodyl for the treatment of ileus. Erythromycin, a motilin receptor agonist, has been used for postoperative gastric paresis but has not been shown to be beneficial for ileus.Metoclopramide (Reglan), a dopaminergic antagonist, has antiemetic and prokinetic activities, but data have shown that the drug may actually worsen ileus. In a randomized controlled study on 210 patients undergoing major abdominal surgery, Wattchow et al reported that perioperative low dose celecoxib markedly reduced the development of paralytic ileus compared to diclofenac. The effect was independent of narcotic use and was not associated with any increase in postoperative complications.

A review of meta-analyses and randomized controlled trials on drugs used for post-operative ileus was reported by Yeh et al. The investigators identified three meta-analyses (2 on gum-chewing and 1 on alvimopan) and 18 clinical trials. Only gum chewing and alvimopan were effective in preventing ileus but due to safety concerns and costs with alvimopan, gum chewing may be preferred as first-line therapy. Gum chewing has also been used in women recovering from cesearian section with good effect when compared to standard of care in a randomized study conducted.

In summary, ileus remains a significant health problem in North America. Successful therapy involves multimodality treatment such as minimally invasive/less traumatic surgery, opiate-sparing pain management, and fast tract recovery protocols.