Postoperative Ileus Treatment & Management
- Author: Burt Cagir, MD, FACS; Chief Editor: Julian Katz, MD more...
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 postoperative patients receiving vasopressor support, limited data suggest that these patients can be safely initiated and advanced on enteral nutrition; clinicians must take into account the specific vasopressor agent, its dose and changes in regimen, as well as the patient's clinical condition and characteristics.
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 ; 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. Indeed, findings from a systematic review indicate that the best clinical endpoint of postoperative ileus is postoperative defecation in conjunction with solid food tolerance, whereas other clinical signs such as the presence of bowel sounds and the passage of flatus don't appear to correlate with complete recovery of bowel motility.
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.
Encapsulating peritoneal sclerosis is a rare cause of ileus in renal transplant patients during or following peritoneal dialysis. In a case report of 3 patients with this unusual complication, 1 patient improved with conservative therapy and the remaining 2 patients eventually underwent surgical intervention after a long trial of medical management. The authors of the report advised that, before renal transplantation, obtain a detailed history to evaluate for the presence of intermittent bowel obstruction (ie, symptoms) from patients who have previously received peritoneal dialysis.
It is generally advisable to 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.
Having patients chew gum has been advocated as a means of promoting recovery from postoperative ileus. Chewing gum may constitute a form of sham feeding that stimulates gastrointestinal motility. Meta-analyses have shown that gum chewing can reduce the time to first flatus and passage of feces, and marginally decrease the length of hospital stay after intestinal surgery.[4, 29, 30]
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. Hence, postoperative ambulation remains beneficial in preventing the formation of atelectasis, deep vein thrombosis, and pneumonia but has no role in treating ileus.
Livingston EH, Passaro EP Jr. Postoperative ileus. Dig Dis Sci. 1990 Jan. 35(1):121-32. [Medline].
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. 1997 Oct. 21(8):806-9; discussion 809-10. [Medline].
Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surg. 2000 Nov. 87(11):1480-93. [Medline].
Vásquez W, Hernández AV, Garcia-Sabrido JL. Is gum chewing useful for ileus after elective colorectal surgery? A systematic review and meta-analysis of randomized clinical trials. J Gastrointest Surg. 2009 Apr. 13(4):649-56. [Medline].
Barletta JF, Senagore AJ. Reducing the burden of postoperative ileus: evaluating and implementing an evidence-based strategy. World J Surg. 2014 Aug. 38 (8):1966-77. [Medline].
Iyer S, Saunders WB, Stemkowski S. Economic burden of postoperative ileus associated with colectomy in the United States. J Manag Care Pharm. 2009 Jul-Aug. 15(6):485-94. [Medline].
Resnick J, Greenwald DA, Brandt LJ. Delayed gastric emptying and postoperative ileus after nongastric abdominal surgery: part I. Am J Gastroenterol. 1997 May. 92(5):751-62. [Medline].
Resnick J, Greenwald DA, Brandt LJ. Delayed gastric emptying and postoperative ileus after nongastric abdominal surgery: part II. Am J Gastroenterol. 1997 Jun. 92(6):934-40. [Medline].
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. 1998 Nov. 228(5):652-63. [Medline]. [Full Text].
Boeckxstaens GE, de Jonge WJ. Neuroimmune mechanisms in post-operative ileus. Gut. 2009/09;58(9):1300-11.
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. 1995 Jun. 58(6):719-23. [Medline].
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. 2000 Feb. 118(2):316-27. [Medline].
Cameron JL, ed. Current Surgical Therapy. 7th ed. Chicago: Mosby; 2001.
Tollesson PO, Cassuto J, Rimbäck G. Patterns of propulsive motility in the human colon after abdominal operations. Eur J Surg. 1992 Apr. 158(4):233-6. [Medline].
Senagore AJ. Pathogenesis and clinical and economic consequences of postoperative ileus. Am J Health Syst Pharm. 2007 Oct 15. 64(20 Suppl 13):S3-7. [Medline].
Kuruba R, Fayard N, Snyder D. Epidural analgesia and laparoscopic technique do not reduce incidence of prolonged ileus in elective colon resections. Am J Surg. 2012 Nov. 204(5):613-8. [Medline].
Wolff BG, Viscusi ER, Delaney CP, Du W, Techner L. Patterns of gastrointestinal recovery after bowel resection and total abdominal hysterectomy: pooled results from the placebo arms of alvimopan phase III North American clinical trials. J Am Coll Surg. 2007 Jul. 205(1):43-51. [Medline].
Kitahata R, Nakajima S, Suzuki T, Plitman E, Mimura M, Uchida H. Relapse of ileus in patients with psychiatric disorders: A 2-year chart review. Gen Hosp Psychiatry. 2015 Sep 21. [Medline].
Gokce AM, Ozel L, Ibisoglu S, et al. A rare reason of ileus in renal transplant patients with peritoneal dialysis history: encapsulated peritoneal sclerosis. Exp Clin Transplant. 2015 Dec. 13 (6):588-92. [Medline].
Loftus CG, Harewood GC, Baron TH. Assessment of predictors of response to neostigmine for acute colonic pseudo-obstruction. Am J Gastroenterol. 2002 Dec. 97(12):3118-22. [Medline].
Wu Z, Boersema GS, Dereci A, Menon AG, Jeekel J, Lange JF. Clinical endpoint, early detection, and differential diagnosis of postoperative ileus: a systematic review of the literature. Eur Surg Res. 2015. 54 (3-4):127-38. [Medline].
Kronberg U, Kiran RP, Soliman MS, Hammel JP, Galway U, Coffey JC, et al. A characterization of factors determining postoperative ileus after laparoscopic colectomy enables the generation of a novel predictive score. Ann Surg. 2011 Jan. 253(1):78-81. [Medline].
Liang X, Li W, Zhao B, Zhang L, Cheng Y. Comparative analysis of MDCT and MRI in diagnosing chronic gallstone perforation and ileus. Eur J Radiol. 2015 Oct. 84 (10):1835-42. [Medline].
Schwartz SI, ed. Principles of Surgery. 7th ed. New York, NY: McGraw-Hill; 1999.
Bruns BR, Kozar RA. Feeding the postoperative patient on vasopressor support: feeding and pressor support. Nutr Clin Pract. 2015 Dec 24. [Medline].
Cali RL, Meade PG, Swanson MS, Freeman C. Effect of Morphine and incision length on bowel function after colectomy. Dis Colon Rectum. 2000 Feb. 43(2):163-8. [Medline].
Ferraz AA, Cowles VE, Condon RE, Carilli S, Ezberci F, Frantzides CT, et al. Nonopioid analgesics shorten the duration of postoperative ileus. Am Surg. 1995 Dec. 61(12):1079-83. [Medline].
Yang PF, Morgan MJ. Laparoscopic versus open reversal of Hartmann's procedure: a retrospective review. ANZ J Surg. 2014 Dec. 84(12):965-9. [Medline].
Purkayastha S, Tilney HS, Darzi AW, Tekkis PP. Meta-analysis of randomized studies evaluating chewing gum to enhance postoperative recovery following colectomy. Arch Surg. 2008 Aug. 143(8):788-93. [Medline].
Shang H, Yang Y, Tong X, Zhang L, Fang A, Hong L. Gum chewing slightly enhances early recovery from postoperative ileus after cesarean section: results of a prospective, randomized, controlled trial. Am J Perinatol. 2010 May. 27(5):387-91. [Medline].
Zingg U, Miskovic D, Hamel CT, Erni L, Oertli D, Metzger U. Influence of thoracic epidural analgesia on postoperative pain relief and ileus after laparoscopic colorectal resection : Benefit with epidural analgesia. Surg Endosc. 2009 Feb. 23(2):276-82. [Medline].
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. 1995 Oct. 83(4):757-65. [Medline].
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. 2000 Feb. 92(2):433-41. [Medline].
Marret E, Rolin M, Beaussier M, Bonnet F. Meta-analysis of intravenous lidocaine and postoperative recovery after abdominal surgery. Br J Surg. 2008 Nov. 95(11):1331-8. [Medline].
Harvey KP, Adair JD, Isho M, Robinson R. Can intravenous lidocaine decrease postsurgical ileus and shorten hospital stay in elective bowel surgery? A pilot study and literature review. Am J Surg. 2009 Aug. 198(2):231-6. [Medline].
Becker G, Blum HE. Novel opioid antagonists for opioid-induced bowel dysfunction and postoperative ileus. Lancet. 2009 Apr 4. 373(9670):1198-206. [Medline].
Maron DJ, Fry RD. New therapies in the treatment of postoperative ileus after gastrointestinal surgery. Am J Ther. 2008 Jan-Feb. 15(1):59-65. [Medline].
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. 1997 Apr. 61(4):467-75. [Medline].
Candy B, Jones L, Goodman ML, Drake R, Tookman A. Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2011 Jan 19. CD003448. [Medline].
Yu CS, Chun HK, Stambler N, Carpenito J, Schulman S, Tzanis E, et al. Safety and efficacy of methylnaltrexone in shortening the duration of postoperative ileus following segmental colectomy: results of two randomized, placebo-controlled phase 3 trials. Dis Colon Rectum. 2011 May. 54(5):570-8. [Medline].
Earnshaw SR, Kauf TL, McDade C, et al. Economic impact of alvimopan considering varying definitions of postoperative ileus. J Am Coll Surg. 2015 Nov. 221 (5):941-50. [Medline].
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. 2001 Sep 27. 345(13):935-40. [Medline].
Tan EK, Cornish J, Darzi AW, Tekkis PP. Meta-analysis: Alvimopan vs. placebo in the treatment of post-operative ileus. Aliment Pharmacol Ther. 2007 Jan 1. 25(1):47-57. [Medline].
Tan EK, Cornish J, Darzi AW, Tekkis PP. Meta-analysis: Alvimopan vs. placebo in the treatment of post-operative ileus. Aliment Pharmacol Ther. 2007 Jan 1. 25(1):47-57. [Medline].
Zingg U, Miskovic D, Pasternak I, Meyer P, Hamel CT, Metzger U. Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery: a prospective, randomized trial. Int J Colorectal Dis. 2008 Dec. 23(12):1175-83. [Medline].
Wiriyakosol S, Kongdan Y, Euanorasetr C, Wacharachaisurapol N, Lertsithichai P. Randomized controlled trial of bisacodyl suppository versus placebo for postoperative ileus after elective colectomy for colon cancer. Asian J Surg. 2007 Jul. 30(3):167-72. [Medline].
Traut U, Brügger L, Kunz R, Pauli-Magnus C, Haug K, Bucher HC, et al. Systemic prokinetic pharmacologic treatment for postoperative adynamic ileus following abdominal surgery in adults. Cochrane Database Syst Rev. 2008 Jan 23. CD004930. [Medline].
Wattchow DA, De Fontgalland D, Bampton PA, Leach PL, McLaughlin K, Costa M. Clinical trial: the impact of cyclooxygenase inhibitors on gastrointestinal recovery after major surgery - a randomized double blind controlled trial of celecoxib or diclofenac vs. placebo. Aliment Pharmacol Ther. 2009 Nov 15. 30(10):987-98. [Medline].
Yeh YC, Klinger EV, Reddy P. Pharmacologic options to prevent postoperative ileus. Ann Pharmacother. 2009 Sep. 43(9):1474-85. [Medline].
Abd-El-Maeboud KH, Ibrahim MI, Shalaby DA, Fikry MF. Gum chewing stimulates early return of bowel motility after caesarean section. BJOG. 2009 Sep. 116(10):1334-9. [Medline].
Behm B, Stollman N. Postoperative ileus: etiologies and interventions. Clin Gastroenterol Hepatol. 2003 Mar. 1(2):71-80. [Medline].
Carter S. The surgical team and outcomes management: focus on postoperative ileus. J Perianesth Nurs. 2006 Apr. 21(2A Suppl):S2-6. [Medline].
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. 2006 Mar. 191(3):315-9. [Medline].
Houwen RH, van der Doef HP, Sermet I, Munck A, Hauser B, Walkowiak J, et al. Defining DIOS and constipation in cystic fibrosis with a multicentre study on the incidence, characteristics, and treatment of DIOS. J Pediatr Gastroenterol Nutr. 2010 Jan. 50(1):38-42. [Medline].
Jones MP, Wessinger S. Small intestinal motility. Curr Opin Gastroenterol. 2006 Mar. 22(2):111-6. [Medline].
Mattei P, Rombeau JL. Review of the pathophysiology and management of postoperative ileus. World J Surg. 2006 Aug. 30(8):1382-91. [Medline].
Moore BA, Albers KM, Davis BM, Grandis JR, Tögel S, Bauer AJ. Altered inflammatory gene expression underlies increased susceptibility to murine postoperative ileus with advancing age. Am J Physiol Gastrointest Liver Physiol. 2007 Jun. 292(6):G1650-9. [Medline].
Ng WQ, Neill J. Evidence for early oral feeding of patients after elective open colorectal surgery: a literature review. J Clin Nurs. 2006 Jun. 15(6):696-709. [Medline].
Person B, Wexner SD. The management of postoperative ileus. Curr Probl Surg. 2006 Jan. 43(1):6-65. [Medline].
Saclarides TJ. Current choices--good or bad--for the proactive management of postoperative ileus: A surgeon's view. J Perianesth Nurs. 2006 Apr. 21(2A Suppl):S7-15. [Medline].
Saunders MD. Acute colonic pseudo-obstruction. Gastrointest Endosc Clin N Am. 2007 Apr. 17(2):341-60, vi-vii. [Medline].
Schuster R, Grewal N, Greaney GC, Waxman K. Gum chewing reduces ileus after elective open sigmoid colectomy. Arch Surg. 2006 Feb. 141(2):174-6. [Medline].
Sumi T, Katsumata K, Tsuchida A, Sonoda I, Shimazu M, Aoki T. Evaluation of sequential organ failure assessment score for patients with strangulation ileus. Langenbecks Arch Surg. 2010 Jan. 395(1):27-31. [Medline].
Sutton DH, Harrell SP, Wo JM. Diagnosis and management of adult patients with chronic intestinal pseudoobstruction. Nutr Clin Pract. 2006 Feb. 21(1):16-22. [Medline].
Sanger GJ, Furness JB. Ghrelin and motilin receptors as drug targets for gastrointestinal disorders. Nat Rev Gastroenterol Hepatol. 2016 Jan. 13 (1):38-48. [Medline].
Mosinska P, Zielinska M, Fichna J. Expression and physiology of opioid receptors in the gastrointestinal tract. Curr Opin Endocrinol Diabetes Obes. 2016 Feb. 23 (1):3-10. [Medline].
|Ileus||Pseudo-obstruction||Mechanical Obstruction (Simple)|
|Symptoms||Mild abdominal pain, bloating, nausea, vomiting, obstipation, constipation||Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia||Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia|
|Physical Examination Findings||Silent abdomen, distention, tympanic||Borborygmi, tympanic, peristaltic waves, hypoactive or hyperactive bowel sounds, distention, localized tenderness||Borborygmi, peristaltic waves, high-pitched bowel sounds, rushes, distention, localized tenderness|
|Plain Radiographs||Large and small bowel dilatation, diaphragm elevated||Isolated large bowel dilatation, diaphragm elevated||Bow-shaped loops in ladder pattern, paucity of colonic gas distal to lesion, diaphragm mildly elevated, air-fluid levels|