12/1/2015
Management of Postoperative Ileus
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Postoperative ileus is condition of absent or abnormal gastrointestinal peristalsis after surgery causing a functional bowel obstruction in the absence of a mechanical blockage. The main symptoms include abdominal pain and distension, nausea, vomiting, delayed or absent flatus, and intolerance of oral intake. These symptoms commonly lead to prolonged hospital stays and increased risk of developing additional postoperative and hospital-acquired complications. The differential diagnosis for these symptoms includes mechanical small bowel obstruction, visceral injury, intra-abdominal or retroperitoneal bleeding, and intra-abdominal abscess.
Risk factors for postoperative ileus include prolonged abdominal or pelvic surgery, laparotomy surgical approach requiring bowel manipulation, lower gastrointestinal surgery, intra-abdominal infection, intraoperative bleeding, and narcotic use. Enhanced Recovery After Surgery (ERAS) protocols incorporate efforts to prevent postoperative ileus through preoperative, perioperative, and postoperative interventions.
Laboratory evaluation includes a complete blood count to evaluate for potential infection and/or bleeding, electrolytes to exclude conditions such as hypokalemia (e.g. Ogilvie’s syndrome), creatinine to evaluate kidney function, and liver function tests. Plain abdominal films (e.g. kidney, ureter, bladder X-ray) can assist in differentiating ileus from mechanical small bowel obstruction: patients with postoperative ileus will have dilated loops of bowel and air in the colon and rectum, whereas those with a small bowel obstruction will have air fluid levels and may demonstrate a transition point. A transition point is represented on imaging as the area between dilated loops of small bowel followed abruptly by decompressed small bowel distally.
Once the diagnosis of postoperative ileus has been established, initial treatment includes maintaining an NPO diet, volume should be maintained with intravenous fluids, narcotic and constipating medication should be discontinued, and pro-motility agents administered. Mu opioid-receptor antagonists such as alvimopan or methylnaltrexone may offer additional benefit to offset side effects of opioid medications and accelerate gastrointestinal recovery.
Electrolytes, including magnesium, should be monitored and replaced as appropriate. Pain management options not expected to worsen a postoperative ileus includes nonsteroidal anti-inflammatory medications (e.g. ibuprofen, indomethatin, etc.), acetaminophen, gabapentin, and tramadol as needed.
Patients with persistent vomiting or significant abdominal distention may benefit from decompression of the bowel with a nasogastric tube. The nasogastric tube should be removed when the output of the nasogastric tube is minimal, and the bowel demonstrates return of function. If a patient experiences further decompensation or does not improve after 24-48 hours of supportive therapy, additional evaluation, including consideration of computed tomography of the abdomen and pelvis, is warranted to assess/evaluate other postoperative complications.
Further Reading:
Mannava S, Vogler A, Markel T. Pathophysiology and Management of Postoperative Ileus in Adults and Neonates: A Review. J Surg Res. 2024 May;297:9-17. doi: 10.1016/j.jss.2024.02.001. Epub 2024 Feb 29. PMID: 38428262.
Liu GXH, Milne T, Xu W, Varghese C, Keane C, O'Grady G, Bissett IP, Wells CI. Risk prediction algorithms for prolonged postoperative ileus: A systematic review. Colorectal Dis. 2024 Jun;26(6):1101-1113. doi: 10.1111/codi.17010. Epub 2024 May 2. PMID: 38698504.
Committee on Gynecologic Practice. ACOG Committee Opinion, #750 - Perioperative pathways: enhanced recovery after surgery. Obstet Gynecol. 2018 Sep;132(3):e120-e130. doi: 10.1097/AOG.0000000000002818. Erratum in: Obstet Gynecol. 2019 Jun;133(6):1288. Obstet Gynecol. 2019 Nov;134(5):1121.
Initial Approval: March 2010; Reaffirmed September 2018. Revised March 2020; Revised November 2021; Reaffirmed September 2023; Revised July 2025.
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