History symptoms:

-abdominal pain (usually dull, ill-defined, squeezing)

-nausea

-vomiting

-abdominal distension

-constipation

-vomiting clear liquid (gastric obstruction)

-passing flatus?

-recent medication changes?

-opioids?

-recent surgery? (Gastric and small intestinal motility recover in the first postoperative day, whereas colonic con-tractions return in 3-5 days. Postoperative ileus beyond that time is considered pathological and warrants a search for surgical complications)

-recent MI, fractures, craniotomy, pneumonia, PE, burns

-prior bloody BM? (IBD)

-fevers (infection, IBD

-weight loss (malignancy)

-frequent NSAIDs (PUD)

-foreign body ingestion

-exacerbation with menses? (Endometriosis)

Other causes: post-operative, abdominal trauma, pancreatitis, cholecystitis, appendicitis, diverticulitis, IBD, radiation therapy, mesenteric ischemia, Retroperitoneal disorders (e.g. renal calculi, pyelonephritis, renal transplant, hemorrhage), Metabolic disorders (e.g. electrolyte abnormalities, uremia, sepsis, diabetic ketoacidosis, sickle cell anemia, respiratory insufficiency, porphyria, heavy metal toxicity)

PMHx:

-Diabetes

-Pancreatitis?

-Gallstones?

-Diverticulitis?

-Sickle cell disease?

-Motility disorders/gastroparesis?

-cancer with radiation?

-IBD?

-Scleroderma

-PTH

-porphyria

-heavy metal intoxication

PSHx:

-surgery/adhesions?

-hernias?

Physical exam:

-distress

-distension

-surgical scars

-auscultation: hypoactive/absent in ileus, hyperactive/high pitched BS in obstruction

-hepato/splenomegaly (malignancy)

#Ileus Plan

Recommendations:

-Rule out mechanical obstruction with imaging

***-NPO, fluid and electrolyte repletion as below

***-BID Lytes with high goal repletion--K goal 4, Mg goal 2, Keep Phosphorous wnl

***-Daily KUB

***Decompression of bowel with NG tube

***Rectal tube with enema

-TSH/T4

-send lipase

-send ABG/VBG (evaluate for lactic acidemia, potential infarction)

-KUB

-CT A/P

-If possible--stop all opioids, avoid anticholinergics and CCB

-if no contraindication, ambulation and movement are essential

-if bedbound, recommend turning q4hr--or q2hr if ileus severe

***if constipated--bowel regimen

***if no CV disease/stricture, consider neostigmine

***Prolonged ileus--gastric emptying study

If G tube--low intermittent suction

Chronic intestinal pseudo-obstruction--gastroparesis, long standing poorly controlled DM, rheumatologic disorders

-NPO

-NG/PEG to low intermittent suction

-Daily AXR

-Continue senna BID, Miralax daily

-Please replete and maintain electrolytes for goal K >4, Mg > 2

-Avoid opioids, anticholinergics, calcium channel blockers, and other medications that can slow down gut motility

-Encourage mobility, as tolerated

-consider pyridostigmine 30 mg BID once obstruction is ruled out