eMedicine Specialties > Gastroenterology > Intestine

Ileus: Treatment & Medication

Author: Sandeep Mukherjee, MB, BCh, MPH, FRCPC, Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center
Coauthor(s): Eseroghene Otah, MD, Locum Tenens General Surgeon, Department of Surgery, Our Lady of Mercy Hospital; Kenneth E Otah, MD, MSc, Postdoctorate Fellow, Department of Internal Medicine, Division of Cardiology, Johns Hopkins Hospital; Oluwagbenga Serrano, MD, Consulting Staff, Lake Havasu Gastroenterology, PC; John Walker, MD, Consulting Staff, Department of Gastroenterology, Rogue Valley Medical Center; Avram M Cooperman, MD, Professor of Surgery and Radiation Oncology, Cabrini Medical Center
Contributor Information and Disclosures

Updated: Jun 3, 2008

Treatment

Medical Care

Most cases of postoperative ileus resolve with watchful waiting and supportive treatment. Patients should receive intravenous hydration. For patients with vomiting and distension, 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 of bowel sound occurrence and the passage of flatus and stool.13

The use of postoperative narcotics can be diminished by supplementation with nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDS may improve ileus by improving local inflammation and by decreasing the amount of narcotics used. Myoelectric activities recorded from electrodes placed on the colon have revealed faster resolution from ileus in patients given ketorolac versus those given morphine14 ; however, the drawbacks of NSAID use include platelet dysfunction and gastric mucosal ulceration. Consider the use of cyclooxygenase-2 agents, which negate these adverse effects.

No single objective variable accurately predicts the resolution of ileus. A 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.

Diet

Generally, delay oral feeding until ileus resolves clinically. However, the presence of ileus does not preclude enteral feeding. Postpyloric feeding into the small bowel can be cautiously performed. Start feeds at one-quarter or one-half strength at a slow rate and gradually advance.

One report showed that gum chewing as a form of sham feeding enhanced early recovery from postoperative ileus after laparoscopic colectomy.15 Nineteen patients who underwent elective laparoscopic colectomy were randomized. Ten patients were assigned to a gum-chewing group and 9 to a control group. The gum-chewing group used gum 3 times a day from the first postoperative morning until oral intake. Passage of flatus occurred earlier in the gum-chewing group than in the control group (2.1 d vs 3.2 d). The first bowel movement was noted in 3.1 days in the gum-chewing group versus 5.8 days in the control group. These values were statistically significant. Laparoscopic colon resection has been associated with shorter periods of ileus than open colon resection.16

Activity

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.17 Hence, postoperative ambulation remains beneficial in preventing the formation of atelectasis, deep vein thrombosis, and pneumonia but has no role in treating ileus.

Medication

No randomized trials have assessed the benefits of suppositories and enemas for the treatment of ileus. In one nonrandomized study, 20 gynecological patients were given milk of magnesia and biscolic suppositories. For these patients, the length of hospital stay was 4 days, and their ileus resolved in 4 days.18

Use of prokinetic agents has had moderate success. Rectal cisapride (Propulsid), a serotonin agonist, has reportedly been successful in treating ileus, but the US Food and Drug Administration (FDA) has withdrawn this agent because of the possibility it causes cardiac dysrhythmias.

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. Data have shown that the drug may actually worsen ileus.

Thoracic epidural administration has been shown to be beneficial. 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.19,20

Methylnaltrexone and ADL 8-2698 (alvimopan [Entereg]) are now approved by the FDA in the United States. These agents inhibit peripheral mu-opioid receptors. Receptor blockade abolishes the adverse gastrointestinal effects of opioids without impairing the analgesic effects of such drugs.21 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.22

Alvimopan is indicated to help prevent postoperative ileus following bowel resection. Taguchi et al examined 78 postoperative patients randomized to receive either placebo or alvimopan.23 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 placebo24 and a study that found alvimopan to accelerate GI tract recovery after bowel resection, regardless of age, gender, race, or concomitant medication.25

Both methylnaltrexone and alvimopan do not traverse the blood-brain barrier, and the latter agent has the advantage of being long acting.

Opioid antagonist, selective

Indicated to prevent postoperative ileus.


Alvimopan (Entereg)

Peripherally acting mu-opioid receptor antagonist. Binds mu-opioid receptors in gut, thereby selectively inhibiting negative opioid effects on GI function and motility. Indicated for postoperative ileus following bowel resection with primary anastomosis. Five clinical studies with enrollment >2500 patients demonstrated accelerated recovery time of upper and lower tract GI function with alvimopan compared with placebo. Decrease of hospital days also observed in alvimopan group compared with placebo.
Only available to hospitals after they complete a registration process designed to maintain the benefits associated with short-term use and prevent long-term, outpatient use (Entereg Access Support and Education [EASE] program).

Adult

12 mg PO as single dose 0.5-5 h preoperatively, followed by 12 mg PO bid starting the day after surgery; not to exceed treatment duration of 7 days (or 15 doses)

Pediatric

Not established

Data limited; substrate for p-glycoprotein; does not inhibit or induce CYP 1A2, 2C9, 2C19, 3A4, 2D6, and 2E1; does not inhibit p-glycoprotein

Documented hypersensitivity; >7 consecutive days of opioids immediately prior to alvimopan

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Patients recently exposed to opioids may be more sensitive to alvimopan effects and experience abdominal pain, nausea, vomiting, and diarrhea; not recommended with severe hepatic impairment or end-stage renal disease; common adverse effects include anemia, dyspepsia, hypokalemia, back pain, and urinary retention; higher number of MIs reported in alvimopan group compared with placebo over a 12-mo period, but causality has not been established

More on Ileus

Overview: Ileus
Differential Diagnoses & Workup: Ileus
Treatment & Medication: Ileus
Follow-up: Ileus
Multimedia: Ileus
References
[ CLOSE WINDOW ]

References

  1. Livingston EH, Passaro EP Jr. Postoperative ileus. Dig Dis Sci. Jan 1990;35(1):121-32. [Medline].

  2. Shibata Y, Toyoda S, Nimura Y, Miyati M. Patterns of intestinal motility recovery during the early stage following abdominal surgery: clinical and manometric study. World J Surg. Oct 1997;21(8):806-9; discussion 809-10. [Medline].

  3. Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surg. Nov 2000;87(11):1480-93. [Medline].

  4. Resnick J, Greenwald DA, Brandt LJ. Delayed gastric emptying and postoperative ileus after nongastric abdominal surgery: part I. Am J Gastroenterol. May 1997;92(5):751-62. [Medline].

  5. Resnick J, Greenwald DA, Brandt LJ. Delayed gastric emptying and postoperative ileus after nongastric abdominal surgery: part II. Am J Gastroenterol. Jun 1997;92(6):934-40. [Medline].

  6. Kalff JC, Schraut WH, Simmons RL, Bauer AJ. Surgical manipulation of the gut elicits an intestinal muscularis inflammatory response resulting in postsurgical ileus. Ann Surg. Nov 1998;228(5):652-63. [Medline].

  7. Espat NJ, Cheng G, Kelley MC, Vogel SB, Sninsky CA, Hocking MP. Vasoactive intestinal peptide and substance P receptor antagonists improve postoperative ileus. J Surg Res. Jun 1995;58(6):719-23. [Medline].

  8. Kalff JC, Schraut WH, Billiar TR, Simmons RL, Bauer AJ. Role of inducible nitric oxide synthase in postoperative intestinal smooth muscle dysfunction in rodents. Gastroenterology. Feb 2000;118(2):316-27. [Medline].

  9. Cameron JL, ed. Current Surgical Therapy. 7th ed. Chicago: Mosby; 2001.

  10. Tollesson PO, Cassuto J, Rimbäck G. Patterns of propulsive motility in the human colon after abdominal operations. Eur J Surg. Apr 1992;158(4):233-6. [Medline].

  11. Loftus CG, Harewood GC, Baron TH. Assessment of predictors of response to neostigmine for acute colonic pseudo-obstruction. Am J Gastroenterol. Dec 2002;97(12):3118-22. [Medline].

  12. Schwartz SI, ed. Principles of Surgery. 7th ed. New York, NY: McGraw-Hill; 1999.

  13. Cali RL, Meade PG, Swanson MS, Freeman C. Effect of Morphine and incision length on bowel function after colectomy. Dis Colon Rectum. Feb 2000;43(2):163-8. [Medline].

  14. Ferraz AA, Cowles VE, Condon RE, Carilli S, Ezberci F, Frantzides CT, et al. Nonopioid analgesics shorten the duration of postoperative ileus. Am Surg. Dec 1995;61(12):1079-83. [Medline].

  15. Asao T, Kuwano H, Nakamura J, Morinaga N, Hirayama I, Ide M. Gum chewing enhances early recovery from postoperative ileus after laparoscopic colectomy. J Am Coll Surg. Jul 2002;195(1):30-2. [Medline].

  16. Milsom JW, Böhm B, Hammerhofer KA, Fazio V, Steiger E, Elson P. A prospective, randomized trial comparing laparoscopic versus conventional techniques in colorectal cancer surgery: a preliminary report. J Am Coll Surg. Jul 1998;187(1):46-54; discussion 54-5. [Medline].

  17. Waldhausen JH, Schirmer BD. The effect of ambulation on recovery from postoperative ileus. Ann Surg. Dec 1990;212(6):671-7. [Medline].

  18. Fanning J, Yu-Brekke S. Prospective trial of aggressive postoperative bowel stimulation following radical hysterectomy. Gynecol Oncol. Jun 1999;73(3):412-4. [Medline].

  19. Liu SS, Carpenter RL, Mackey DC, Thirlby RC, Rupp SM, Shine TS, et al. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology. Oct 1995;83(4):757-65. [Medline].

  20. Mann C, Pouzeratte Y, Boccara G, Peccoux C, Vergne C, Brunat G, et al. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology. Feb 2000;92(2):433-41. [Medline].

  21. Maron DJ, Fry RD. New therapies in the treatment of postoperative ileus after gastrointestinal surgery. Am J Ther. Jan-Feb 2008;15(1):59-65. [Medline].

  22. Yuan CS, Foss JF, Osinski J, Toledano A, Roizen MF, Moss J. The safety and efficacy of oral methylnaltrexone in preventing morphine-induced delay in oral-cecal transit time. Clin Pharmacol Ther. Apr 1997;61(4):467-75. [Medline].

  23. Taguchi A, Sharma N, Saleem RM, Sessler DI, Carpenter RL, Seyedsadr M, et al. Selective postoperative inhibition of gastrointestinal opioid receptors. N Engl J Med. Sep 27 2001;345(13):935-40. [Medline].

  24. [Best Evidence] Tan EK, Cornish J, Darzi AW, Tekkis PP. Meta-analysis: Alvimopan vs. placebo in the treatment of post-operative ileus. Aliment Pharmacol Ther. Jan 1 2007;25(1):47-57. [Medline].

  25. Senagore AJ, Bauer JJ, Du W, Techner L. Alvimopan accelerates gastrointestinal recovery after bowel resection regardless of age, gender, race, or concomitant medication use. Surgery. Oct 2007;142(4):478-86. [Medline].

  26. Bauer AJ, Boeckxstaens GE. Mechanisms of postoperative ileus. Neurogastroenterol Motil. Oct 2004;16 Suppl 2:54-60. [Medline].

  27. Behm B, Stollman N. Postoperative ileus: etiologies and interventions. Clin Gastroenterol Hepatol. Mar 2003;1(2):71-80. [Medline].

  28. Carter S. The surgical team and outcomes management: focus on postoperative ileus. J Perianesth Nurs. Apr 2006;21(2A Suppl):S2-6. [Medline].

  29. Correia MI, da Silva RG. The impact of early nutrition on metabolic response and postoperative ileus. Curr Opin Clin Nutr Metab Care. Sep 2004;7(5):577-83. [Medline].

  30. Delaney CP. Clinical perspective on postoperative ileus and the effect of opiates. Neurogastroenterol Motil. Oct 2004;16 Suppl 2:61-6. [Medline].

  31. Delaney CP, Senagore AJ, Viscusi ER, Wolff BG, Fort J, Du W, et al. Postoperative upper and lower gastrointestinal recovery and gastrointestinal morbidity in patients undergoing bowel resection: pooled analysis of placebo data from 3 randomized controlled trials. Am J Surg. Mar 2006;191(3):315-9. [Medline].

  32. Jones MP, Wessinger S. Small intestinal motility. Curr Opin Gastroenterol. Mar 2006;22(2):111-6. [Medline].

  33. Mattei P, Rombeau JL. Review of the pathophysiology and management of postoperative ileus. World J Surg. Aug 2006;30(8):1382-91. [Medline].

  34. Miedema BW, Johnson JO. Methods for decreasing postoperative gut dysmotility. Lancet Oncol. Jun 2003;4(6):365-72. [Medline].

  35. Moore BA, Albers KM, Davis BM, Grandis JR, Togel S, Bauer AJ. Altered inflammatory gene expression underlies increased susceptibility to murine postoperative ileus with advancing age. Am J Physiol Gastrointest Liver Physiol. Jun 2007;292(6):G1650-9. [Medline].

  36. [Best Evidence] Ng WQ, Neill J. Evidence for early oral feeding of patients after elective open colorectal surgery: a literature review. J Clin Nurs. Jun 2006;15(6):696-709. [Medline].

  37. Nunley JC, FitzHarris GP. Postoperative ileus. Curr Surg. Jul-Aug 2004;61(4):341-5. [Medline].

  38. Person B, Wexner SD. The management of postoperative ileus. Curr Probl Surg. Jan 2006;43(1):6-65. [Medline].

  39. Saclarides TJ. Current choices--good or bad--for the proactive management of postoperative ileus: A surgeon's view. J Perianesth Nurs. Apr 2006;21(2A Suppl):S7-15. [Medline].

  40. Saunders MD. Acute colonic pseudo-obstruction. Gastrointest Endosc Clin N Am. Apr 2007;17(2):341-60, vi-vii. [Medline].

  41. [Best Evidence] Schuster R, Grewal N, Greaney GC, Waxman K. Gum chewing reduces ileus after elective open sigmoid colectomy. Arch Surg. Feb 2006;141(2):174-6. [Medline].

  42. Sutton DH, Harrell SP, Wo JM. Diagnosis and management of adult patients with chronic intestinal pseudoobstruction. Nutr Clin Pract. Feb 2006;21(1):16-22. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

postoperative adynamic ileus, paralytic ileus, pseudo-obstruction, Ogilvie syndrome, mechanical bowel obstruction, postoperative adynamic ileus, paralytic ileus, pseudo-obstruction, Ogilvie syndrome, mechanical bowel obstruction, Ogilvie's syndrome, pseudoobstruction, surgical bowel complications, bowel dysfunction, dysmotility, postoperative bowel dysfunction

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Sandeep Mukherjee, MB, BCh, MPH, FRCPC, Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center
Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Coauthor(s)

Eseroghene Otah, MD, Locum Tenens General Surgeon, Department of Surgery, Our Lady of Mercy Hospital
Eseroghene Otah, MD is a member of the following medical societies: Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Kenneth E Otah, MD, MSc, Postdoctorate Fellow, Department of Internal Medicine, Division of Cardiology, Johns Hopkins Hospital
Disclosure: Nothing to disclose.

Oluwagbenga Serrano, MD, Consulting Staff, Lake Havasu Gastroenterology, PC
Disclosure: Nothing to disclose.

John Walker, MD, Consulting Staff, Department of Gastroenterology, Rogue Valley Medical Center
John Walker, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Avram M Cooperman, MD, Professor of Surgery and Radiation Oncology, Cabrini Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Ann Ouyang, MBBS, Professor, Department of Internal Medicine, Pennsylvania State University College of Medicine; Attending Physician, Division of Gastroenterology and Hepatology, Milton S Hershey Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Oscar S Brann, MD, FACP, Associate Clinical Professor, Department of Medicine, University of California at San Diego; Consulting Staff, Mecklenburg Medical Group
Oscar S Brann, MD, FACP is a member of the following medical societies: American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.