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2025 PACUPrep BCCCP Preparatory Course Ileus and Acute Intestinal Pseudo-obstruction Ileus and Acute Intestinal Pseudo-obstruction

Lesson 30, Topic 4

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Ileus and Acute Intestinal Pseudo-obstruction

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Supportive Care and Monitoring in Ileus and Acute Intestinal Pseudo-obstruction

Objective

Recommend appropriate supportive care and monitoring to manage complications associated with ileus and acute intestinal pseudo-obstruction and its treatment.

Learning Points:

Identify indications for and key considerations of supportive care measures such as nasogastric decompression and IV fluid management.
Propose strategies to prevent common ICU-related complications such as electrolyte imbalances and stress-related mucosal bleeding.
Describe management of iatrogenic complications arising from therapy, such as cholinergic adverse effects or aspiration pneumonitis.
Discuss the role of multidisciplinary goals-of-care conversations when considering highly invasive or burdensome therapies.

1. Supportive Care Modalities

Early decompression and tailored fluid resuscitation relieve symptoms, prevent aspiration, and support gut mucosal perfusion.

A. Nasogastric Decompression

Indications: high gastric residuals (>500 mL/day), refractory vomiting, severe abdominal distension
Tube selection: large-bore (14–18 Fr) for particulate drainage; small-bore (10–12 Fr) if prolonged use
Insertion & securement: gentle advancement, confirm placement by aspiration or imaging, use nasal bridle or adhesive device
Monitoring: drainage volume and character, symptom relief, serial abdominal exams
Complications: mucosal erosion, epistaxis, sinusitis, aspiration if tube occludes or is displaced

Clinical Pearl: Early NG Decompression

Initiate NG decompression early to reduce aspiration risk and facilitate safe administration of diagnostic contrast.

B. Intravenous Fluid Management

Goals: restore intravascular volume, maintain organ and splanchnic perfusion, correct electrolyte losses
Fluid choice: isotonic crystalloids (normal saline or balanced solutions); consider balanced fluids to minimize hyperchloremic acidosis
Hemodynamic monitoring: dynamic indices (pulse pressure variation, stroke volume variation, bedside ultrasound); urine output > 0.5 mL/kg/h
Avoid fluid overload: titrate infusion rates, monitor for signs of third-spacing and abdominal compartment syndrome; use diuretics judiciously once euvolemic

Clinical Pearl: Fluid Choice and Resuscitation

Balanced crystalloids may preserve acid–base balance better than normal saline; avoid overresuscitation that worsens gut edema.

2. Prevention of ICU-Related Complications

Protocolized electrolyte repletion and stress ulcer prophylaxis minimize treatment-related morbidity.

A. Electrolyte Imbalance Prevention

Monitoring frequency: at least daily K+, Mg2+, Ca2+; more frequent in unstable or high-dose suction patients
Replacement targets: K+ > 4.0 mmol/L; Mg2+ > 2.0 mg/dL; ionized Ca2+ within normal range
Infusion protocols:
- KCl: peripheral ≤ 10 mEq/h; central ≤ 20 mEq/h with continuous ECG monitoring
- MgSO4: 1–2 g/h IV infusion, adjust for renal function
- Ca gluconate: IV peripheral 1–2 g over 10–20 min, monitor for tissue irritation
Watch for overcorrection: ECG changes (peaked T waves, QT shortening), loss of deep tendon reflexes, altered mental status

Clinical Pearl: Electrolyte Repletion Sequence

Correct hypomagnesemia before potassium repletion—magnesium deficiency impairs renal K+ retention.

B. Stress-Related Mucosal Bleeding Prophylaxis

Risk stratification: mechanical ventilation > 48 h; coagulopathy (INR > 1.5 or platelets < 50 x 10^3/µL); high APACHE II
Nonpharmacologic: early enteral feeding when feasible to maintain mucosal integrity
Pharmacologic options:
- Proton pump inhibitors (PPIs) for highest-risk patients
- H2-receptor antagonists (H2RAs) for moderate risk or PPI contraindications
Duration: limit to period of highest risk; discontinue upon extubation or resolution of coagulopathy

Clinical Pearl: Balancing SUP Risks

Balance bleeding risk reduction against increased pneumonia and C. difficile risk with acid suppressive therapy.

3. Pharmacotherapy for Stress Ulcer Prophylaxis

PPIs provide potent acid suppression but carry infection risks; H2RAs are less potent but may be safer in select patients.

Pharmacotherapy Options for Stress Ulcer Prophylaxis
Agent Type	Mechanism	Indication	Dosing	Monitoring	Pitfalls
PPI	Irreversible H+/K+ ATPase inhibition	MV > 48 h; coagulopathy; prior GI bleed	Pantoprazole 40 mg IV daily	Serum Mg2+; watch for C. difficile	Increased pneumonia risk; long-term bone loss
H2RA	Competitive H2 receptor blockade	Moderate risk; PPI contraindication	Famotidine 20 mg IV q12 h	Renal function; neurologic status	Less potent acid suppression; delirium

Clinical Pearl: SUP Administration

Administer PPIs 30 min before enteral feeds; adjust H2RA dosing in renal impairment.

4. Management of Iatrogenic Complications

Rapid recognition and treatment of cholinergic toxicity and aspiration pneumonitis preserve patient safety and therapy efficacy.

A. Cholinergic Effects from Neostigmine

Presentation: bradycardia, bronchospasm, sialorrhea, abdominal cramping
Prevention & rescue:
- Have atropine (0.4–1 mg IV q3–5 min; max 3 mg) at bedside
- Consider glycopyrrolate for fewer CNS effects
Contraindications: acute bronchospasm, high-degree AV block, angle-closure glaucoma
Monitoring: continuous ECG, heart rate, blood pressure, respiratory status

Clinical Pearl: Managing Neostigmine Side Effects

Glycopyrrolate blunts central cholinergic side effects without inhibiting colonic response.

B. Aspiration Pneumonitis

Risk factors: depressed consciousness, inadequate NG decompression, supine positioning
Preventive measures: head-of-bed ≥ 30°; ensure NG tube patency and drainage
Recognition: sudden respiratory distress, hypoxemia, new diffuse infiltrates on chest imaging
Management: supplemental oxygen; airway protection; bronchoscopy if large particulate matter; antibiotics only if secondary infection suspected

Clinical Pearl: Aspiration Prevention with Contrast

Confirm effective NG decompression before administering oral contrast to minimize aspiration risk.

5. Multidisciplinary Goals of Care Conversations

Structured discussions align invasive interventions with patient values and prognosis.

A. Criteria for Invasive or Burdensome Therapies

Indications:
- Persistent distension despite 48 h of optimal medical therapy
- Cecal diameter ≥ 12 cm or rising intra-abdominal pressure
- Signs of ischemia (lactic acidosis, peritonism) or perforation

B. Team Roles & Communication Frameworks

Pharmacist: optimize drug regimens, monitor for interactions and adverse effects
Surgeon: assess need for colonoscopic or surgical decompression
Nutritionist: advance enteral feeding protocols
Palliative care: facilitate goals-of-care and symptom management discussions
Communication tool: SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, Summary)

Clinical Pearl: Value of Multidisciplinary Discussion

Early multidisciplinary discussion reduces non-beneficial interventions and aligns care with patient goals.

References

Catena F, De Simone B, Coccolini F, et al. Bowel obstruction: a narrative review for all physicians. World J Emerg Surg. 2019;14:20.
Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med. 1999;341:137–141.
Kamm MA. Intestinal pseudo-obstruction. Gut. 2000;47(Suppl IV):iv84.
Johnson CD, Rice RP, Kelvin FM, et al. The radiographic evaluation of gross cecal distention. AJR Am J Roentgenol. 1985;145:1211–1217.
Vanek VW, Al-Salti M. Acute pseudo-obstruction of the colon (Ogilvie’s syndrome): an analysis of 400 cases. Dis Colon Rectum. 1986;29:203–210.
Rex DK. Colonoscopy and acute colonic pseudo-obstruction. Gastrointest Endosc Clin N Am. 1997;7:499–508.

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