Ileus

Treat hemodynamic instability, peritonitis, suspected perforation, or concern for strangulation/ischemia as an urgent surgical problem. Begin isotonic IV fluid resuscitation and correct electrolyte abnormalities; use nasogastric decompression for clinically important vomiting, gastric distention, or aspiration risk. Mechanical small-bowel obstruction with strangulation, ischemia, or failure to resolve requires operative management. PubMedPubMedSmall Bowel Obstruction - StatPearls - NCBI Bookshelf - NIH

In an adult with postoperative or acute inpatient distention, obtain abdominal imaging to define the distribution of bowel dilation and assess for a mechanical transition point or other obstructing lesion. Multiple dilated, fluid-filled bowel loops can represent either paralytic ileus or mechanical small-bowel obstruction, so radiographic dilation alone does not establish functional disease. WHOWHO[PDF] Good clinical diagnostic practice

Do not use passage of stool or flatus as reassurance when abdominal distention is progressing. A reported pseudo-obstruction case developed marked enlargement despite regular bowel movements and flatus after conservative treatment; serial examination and repeat assessment of abdominal girth or colonic diameter should drive escalation. PubMedPubMedNeostigmine to Relieve a Suspected Colonic Pseudo-Obstruction in a Burn Patient: A Case-Based Review of the Literature - PMC

Postoperative ileus is commonly driven by recent surgical inflammation and opioid analgesia; it occurs in up to 50% of patients after abdominal surgery. Initial management is directed at removing the precipitant, particularly replacing opioid analgesia with nonopioid options where feasible, while encouraging ambulation and using nasogastric decompression if worsening emesis or distention develops. PubMedPubMedQuestion Sets and Answers - PMC - NIH

Acute colonic pseudo-obstruction (Ogilvie syndrome) is colonic dysmotility with colonic distention in the absence of mechanical obstruction. It occurs after surgery or trauma in approximately 50% to 60% of reported cases and is associated with older age, immobility or neurologic impairment, opioid exposure, infection, metabolic disorders, extensive surgery, and medications that inhibit intestinal motility. JAMA+2JAMAOgilvie Syndrome as a Postoperative ComplicationScienceDirectAdynamic Ileus and Acute Colonic Pseudo-Obstruction - ScienceDirectPubMedQuestion Sets and Answers - PMC - NIH

Measure and trend the maximal colonic diameter when acute colonic pseudo-obstruction is suspected. A colon greater than 10 cm is described as at risk for perforation, with the cecum particularly vulnerable because it has the largest radius; this threshold should trigger active decompression planning after exclusion of mechanical obstruction. PubMedPubMedQuestion Sets and Answers - PMC - NIH

Place patients with clinically significant ileus or pseudo-obstruction on bowel rest while treating the precipitating condition. Replace fluid, electrolyte, and metabolic deficits, and discontinue or reduce medications that impair motility, especially opioids and anticholinergic agents. For postoperative ileus, changing pain treatment from opioid to nonopioid analgesia is an early intervention; for pseudo-obstruction, wean narcotics to the lowest dose that provides acceptable analgesia. PubMed+2PubMedSmall Bowel Obstruction - StatPearls - NCBI Bookshelf - NIHPubMedNeostigmine to Relieve a Suspected Colonic Pseudo-Obstruction in a Burn Patient: A Case-Based Review of the Literature - PMCPubMedQuestion Sets and Answers - PMC - NIH

Use nasogastric decompression selectively for gastric distention, persistent vomiting, or aspiration risk; it relieves distention and vomiting but does not correct the underlying dysmotility. In pseudo-obstruction conservative care, nasogastric suction, NPO status, IV fluids, electrolyte replacement, avoidance of offending medications, frequent repositioning, and ambulation are used while serially reassessing distention. PubMed+2PubMedSmall Bowel Obstruction - StatPearls - NCBI Bookshelf - NIHPubMedNeostigmine and glycopyrronium: a potential safe alternative for patients with pseudo-obstruction without access to conventional methods of decompression - PMCPubMedNeostigmine to Relieve a Suspected Colonic Pseudo-Obstruction in a Burn Patient: A Case-Based Review of the Literature - PMC

For postoperative prevention and recovery, implement the relevant components of an enhanced-recovery pathway: minimally invasive surgery when feasible, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake when not contraindicated, laxatives, and omission or early removal of postoperative nasogastric intubation. The ERAS emergency-laparotomy guideline rates this multifaceted approach as a strong recommendation with moderate-quality evidence. PubMedPubMedConsensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2—Emergency Laparotomy: Intra- and Postoperative Care - PMC

For acute colonic pseudo-obstruction refractory to conservative management, administer neostigmine 2 mg intravenously in a monitored setting. In a randomized placebo-controlled trial of 21 patients, IV neostigmine produced effective colonic decompression in refractory disease. GastroenterologyGastroenterologyNeostigmine for acute colonic pseudo–obstruction: New use for an old drug? - Gastroenterology

Continuous cardiac monitoring is required during neostigmine administration because the drug can cause bradycardia, heart block, and life-threatening arrhythmias. These adverse effects are the principal operational limitation of pharmacologic decompression. PubMedPubMedNeostigmine and glycopyrronium: a potential safe alternative for patients with pseudo-obstruction without access to conventional methods of decompression - PMC

Use colonoscopic decompression when decompression is needed and neostigmine is unsuitable, unavailable, or unsuccessful. Endoscopic decompression is an established specific therapy for acute colonic pseudo-obstruction; other described nonsurgical approaches include fluoroscopically guided decompression tubes and percutaneous cecostomy through endoscopic, laparoscopic, or surgical approaches. ScienceDirect+1ScienceDirectAdynamic Ileus and Acute Colonic Pseudo-Obstruction - ScienceDirectPubMedNeostigmine to Relieve a Suspected Colonic Pseudo-Obstruction in a Burn Patient: A Case-Based Review of the Literature - PMC

Escalate beyond medical or endoscopic management if perforation, peritonitis, or a mechanical process is identified. Do not redirect a patient with suspected ischemia, strangulation, or unresolved mechanical obstruction into an ileus pathway. PubMedPubMedSmall Bowel Obstruction - StatPearls - NCBI Bookshelf - NIH

For patients undergoing emergency laparotomy, use a bundled ileus-prevention strategy rather than a single intervention: minimally invasive approaches when feasible, optimized fluid administration, opioid-sparing analgesia, early mobilization, early postoperative feeding when clinically permissible, laxatives, and avoidance or early removal of a nasogastric tube. PubMedPubMedConsensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2—Emergency Laparotomy: Intra- and Postoperative Care - PMC

If a presumed postoperative ileus worsens after initial opioid reduction, ambulation, electrolyte correction, and selective gastric decompression, reopen the structural differential rather than repeatedly adding promotility agents. Worsening emesis, increasing distention, or failure to improve should trigger reassessment for mechanical obstruction and surgical complications. PubMed+1PubMedSmall Bowel Obstruction - StatPearls - NCBI Bookshelf - NIHPubMedQuestion Sets and Answers - PMC - NIH

After bowel surgery or emergency laparotomy, advance oral or enteral nutrition when gastrointestinal function recovers and contraindications have ended. When enteral feeding cannot be used, early parenteral nutrition is recommended to mitigate inadequate intake, with transition back to oral or enteral feeding once caloric needs can be met safely. PubMedPubMedConsensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2—Emergency Laparotomy: Intra- and Postoperative Care - PMC