Ileus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction. Although the exact pathogenesis of ileus remains multifactorial and complex, the clinical picture appears to be transiently impaired propulsion of intestinal contents. The complex interaction between autonomic and central nervous system function, as well as local and regional substances, may alter the intestinal equilibrium, resulting in disorganized electrical activity and paralysis of intestinal segments. This lack of coordinated propulsive action leads to the accumulation of gas and fluids within the bowel.

Note the images below.

View Image

Postoperative ileus after an open cholecystectomy.

View Image

Ogilvie pseudo-obstruction in a septic elderly patient. Note the massive dilatation of the colon, especially the right colon and cecum.

Although ileus has numerous causes, the postoperative state is the most common setting for the development of ileus. Indeed, ileus is an expected consequence of abdominal surgery. Physiologic ileus spontaneously resolves within 2-3 days, after sigmoid motility returns to normal. Ileus that persists for more than 3 days following surgery is termed postoperative adynamic ileus or paralytic ileus.[1] Frequently, ileus occurs after major abdominal operations, but it may also occur after retroperitoneal and extra-abdominal surgery, as well as general anesthesia alone. The longest duration of ileus is noted to occur after colon and rectal surgery.[2, 3] Laparoscopic colon resection has been associated with shorter periods of ileus than open colon and rectal resection.[4]

The clinical consequences of postoperative ileus can be profound. Patients with ileus are immobilized, have discomfort and pain, and are at increased risk for pulmonary complications. Ileus also enhances catabolism because of poor nutrition. Overall, ileus increases the cost of medical care because it prolongs hospital stays. In 1990, Livingston and Passaro estimated that ileus costs $750 million annually ($1500 per patient) in the United States.[1]

Iyer et al assessed healthcare utilization and costs in colectomy surgery patients who developed postoperative ileus versus those who did not.[5] A retrospective cohort study design was used in which 17,876 patients with primary procedure code for colectomy were identified. Mean hospital stay was significantly longer in patients with postoperative ileus (13.8 [13.3] days) compared with patients without postoperative ileus (8.9 [9.5] days; P < .001), and the presence of postoperative ileus was a significant predictor of hospital stay (P < .001).[5] Additional significant predictors of hospital length of stay included female sex (P = 0.002), greater severity level (P < .001), and hospital bed size >500 (P = .013).

The investigators found the presence of postoperative ileus was found to be a significant predictor of hospitalization costs (P < .001), controlling for covariates.[5] The authors concluded that postoperative ileus in colectomy patients is a significant predictor of hospital resource utilization.

The main focus of this article is postoperative ileus.


The exact pathogenesis of ileus remains unclear. Postoperative ileus may be mediated via activation of inhibitory spinal reflex arcs. Anatomically, 3 distinct reflexes are involved: ultrashort reflexes confined to the bowel wall, short reflexes involving prevertebral ganglia, and long reflexes involving the spinal cord.[3] The long reflexes are the most significant. Spinal anesthesia, abdominal sympathectomy, and nerve-cutting techniques have been demonstrated to either prevent or attenuate the development of ileus.[6, 7]

The surgical stress response leads to systemic generation of endocrine and inflammatory mediators that also promote the development of ileus. Rat models have shown that laparotomy, eventration, and bowel compression lead to increased numbers of macrophages, monocytes, dendritic cells, T cells, natural killer cells, and mast cells, as demonstrated by immunohistochemistry.[8] Macrophages residing in the muscularisexterna and mast cells are probably the key players in this inflammatory cascade.[9] Calcitonin gene–related peptide, nitric oxide, vasoactive intestinal peptide, and substance P function as inhibitory neurotransmitters in the bowel nervous system. Nitric oxide and vasoactive intestinal peptide inhibitors and substance P receptor antagonists have been demonstrated to improve gastrointestinal function.[10, 11]



United States

Postoperative ileus occurs in approximately 50% of patients who undergo major abdominal surgery.[12] Kuruba et al studied the incidence and risk factors for prolonged ileus in patients undergoing elective colon surgery retrospectively. The incidence of prolonged ileus was similar in patients with epidural versus nonepidural versus laparoscopic surgery. The incidence of prolonged ileus was similar in all 3 groups studied.[13]

A pooled, post-hoc, phase III study analyzed placebo groups and partial bowel resection and total abdominal hysterectomy multicenter trials.[14] Postoperative ileus was still observed in 15% of patients in the partial bowel resection group and in 3% of the total abdominal hysterectomy patients, regardless of the standardized accelerated postoperative care pathway used. This study also provides significant differences in gastrointestinal recovery patterns between bowel resection and total abdominal hysterectomy.


Patients with ileus typically have vague, mild abdominal pain and bloating. They may report nausea, vomiting, and poor appetite. Abdominal cramping is usually not present. Patients may or may not continue to pass flatus and stool.


The abdomen may be distended and tympanic, depending on the degree of abdominal and bowel distention, and may be tender. A distinguishing feature is absent or hypoactive bowel sounds, in contrast to the high-pitched sound of obstruction. The silent abdomen of ileus reveals no discernible peristalsis or succussion splash.


Most cases of ileus occur after intra-abdominal operations. Normal resumption of bowel activity after abdominal surgery follows a predictable pattern: the small bowel typically regains function within hours; the stomach regains activity in 1-2 days; and the colon regains activity in 3-5 days.[15]

Serial abdominal radiographs mapping the distribution of radiopaque markers have shown that the colonic gradient for resolution of postoperative ileus is proximal to distal. The return of propulsive activity to the right colon occurs earlier than to the transverse or left colon.[16]

Other causes of adynamic ileus are as follows:

Laboratory Studies

Laboratory studies and blood work should focus on evaluations for infectious, electrolytic, and metabolic derangements.

Preoperative albumin, postoperative deep venous thrombosis, and electrolyte levels are associated with postoperative ileus. Age, previous abdominal surgery, and chronic preoperative use of narcotics were independently correlated with postoperative ileus.[18]

Imaging Studies

On plain abdominal radiographs, ileus appears as copious gas dilatation of the small intestine and colon. With enteroclysis, the contrast medium in patients with paralytic ileus should reach the cecum within 4 hours; if the contrast medium remains stationary for longer than 4 hours, mechanical obstruction is suggested.[19]

Medical Care

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 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.[20]

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[21] ; 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.


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, 22, 23]


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.[24] Hence, postoperative ambulation remains beneficial in preventing the formation of atelectasis, deep vein thrombosis, and pneumonia but has no role in treating ileus.

Medication Summary

Thoracic epidural administration has been shown to be beneficial, both with open and with endoscopic colorectal surgery.[25] Epidural blockade with local anesthetics improves postoperative ileus by blockage of inhibitory reflexes and efferent sympathetics. Studies have shown that combinations of thoracic epidurals containing bupivacaine alone or in combination with opioids improve postoperative ileus.[26, 27] Continuous intravenous administration of lidocaine during and after abdominal surgery may decrease the duration of postoperative ileus.[28]

In a randomized study, systemic infusion of lidocaine is compared with placebo infusions in postoperative patients. Patients in the lidocaine group appear to have earlier return of flatus, bowel function, and discharge to home. Although only 11 patients were used in the each arm, systemic lidocaine lessened the postoperative pain sensation. Therefore, it is recommended that further studies are warranted to evaluate systemic lidocaine infusion in postoperative patients.[29]

Peripherally selective opioid antagonists are an option for the treatment of postoperative ileus.[30] Methylnaltrexone (Relistor) and alvimopan (Entereg) are approved by the Food and Drug Administration. These agents inhibit peripheral mu-opioid receptors, which abolishes the adverse gastrointestinal effects of opioids; however, because these agents do not cross the blood-brain barrier, they do not impair the analgesic effects of opioids.[31] Methylnaltrexone is indicated for opioid-induced constipation in patients with advanced illness receiving palliative care, when response to laxatives has not been sufficient. In a study of 14 healthy volunteers evaluating the use of morphine plus oral methylnaltrexone in increasing doses, methylnaltrexone significantly reduced morphine-induced delay in oral-cecal transit.[32] Another study reported subcutaneous methylnaltrexone is effective in inducing laxation in patients receiving palliative care who have opioid-induced constipation and inwhomconventionallaxatives have failed.[33] However, because methylnaltrexone has only recently been approved by the US Food and Drug Administration (FDA), more rigorous trials are needed.

Another phase III multicenter, double-blind, placebo-controlled study revealed that methylnaltrexone at 12-mg and 24-mg doses did not reduce the duration of postoperative ileus.[34] Although the utility of intravenous methylnaltrexone was not demonstrated, it was well tolerated by postcolectomy patients.[34]

Alvimopan is indicated to help prevent postoperative ileus following bowel resection. It has a longer duration of action than methylnaltrexone. Taguchi et al examined 78 postoperative patients randomized to receive either placebo or alvimopan.[35] Fifteen patients underwent partial colectomy, 36 were status post simple hysterectomy, and the remaining 27 underwent radical hysterectomy. All of the patients were on patient-controlled analgesia pumps using either meperidine or morphine. Compared with patients on placebo, patients on alvimopan had their first bowel movement 2 days earlier, resumed a solid diet 1.3 days earlier, and returned home 1.4 days earlier. Other recent trials have been completed, including a meta-analysis comparing alvimopan with placebo[36] and a study that found alvimopan to accelerate gastrointestinal tract recovery after bowel resection, regardless of age, gender, race, or concomitant medication.[37]

Use of prokinetic agents has shown mixed results. Randomized trials have shown some benefit of the colon-stimulating laxative bisacodyl for the treatment of ileus.[38, 39] Erythromycin, a motilin receptor agonist, has been used for postoperative gastric paresis but has not been shown to be beneficial for ileus.[40] Metoclopramide (Reglan), a dopaminergic antagonist, has antiemetic and prokinetic activities, but data have shown that the drug may actually worsen ileus. In a randomized controlled study on 210 patients undergoing major abdominal surgery, Wattchow et al reported that perioperative low dose celecoxib markedly reduced the development of paralytic ileus compared to diclofenac.[41] The effect was independent of narcotic use and was not associated with any increase in postoperative complications.

A review of meta-analyses and randomized controlled trials on drugs used for post-operative ileus was reported by Yeh et al.[42] The investigators identified three meta-analyses (2 on gum-chewing and 1 on alvimopan) and 18 clinical trials. Only gum chewing and alvimopan were effective in preventing ileus but due to safety concerns and costs with alvimopan, gum chewing may be preferred as first-line therapy. Gum chewing has also been used in women recovering from cesearian section with good effect when compared to standard of care in a randomized study conducted.[43]

In summary, ileus remains a significant health problem in North America. Successful therapy involves multimodality treatment such as minimally invasive/less traumatic surgery, opiate-sparing pain management, and fast tract recovery protocols.

Alvimopan (Entereg)

Clinical Context:  Peripherally acting mu-opioid receptor antagonist. Binds mu-opioid receptors in gut, thereby selectively inhibiting negative opioid effects on GI function and motility. Indicated for postoperative ileus following bowel resection with primary anastomosis. Five clinical studies with enrollment >2500 patients demonstrated accelerated recovery time of upper and lower tract GI function with alvimopan compared with placebo. Decrease of hospital days also observed in alvimopan group compared with placebo.

Only available to hospitals after they complete a registration process designed to maintain the benefits associated with short-term use and prevent long-term, outpatient use (Entereg Access Support and Education [EASE] program).

Class Summary

Selective opioid antagonists are indicated to prevent postoperative ileus.


Burt Cagir, MD, FACS, Assistant Professor of Surgery, State University of New York Upstate Medical University; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Alex J Mechaber, MD, FACP, Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Avram M Cooperman, MD Professor of Surgery and Radiation Oncology, Cabrini Medical Center

Disclosure: Nothing to disclose.

Sandeep Mukherjee, MB, BCh, MPH, FRCPC Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Ese Otah, MD, FACS Consulting Surgeon, Center For General and Laparoscopic Surgery, PA; Consulting Staff, St Luke's Sugar Land Hospital, Memorial Hermann Southwest Hospital, Memorial Hermann Sugar Land Hospital

Ese Otah, MD, FACS is a member of the following medical societies: American College of Surgeons and Association of Women Surgeons

Disclosure: Nothing to disclose.

Kenneth E Otah, MD, MSc, FACC Consulting Staff, Methodist and Memorial Hermann Hospital Systems, Total Heart Cardiovascular Consultants, LLC

Kenneth E Otah, MD, MSc, FACC is a member of the following medical societies: American College of Cardiology, American College of Physicians, and Association of Black Cardiologists

Disclosure: Nothing to disclose.

Oluwagbenga Serrano, MD Consulting Staff, Lake Havasu Gastroenterology, PC

Disclosure: Nothing to disclose.

John A Walker, MD Consulting Staff, Gastroenterology Consultants PC; Consulting Staff, Department of Gastroenterology, Rogue Valley Medical Center, Providence-Medford Medical Center, Surgery Center of Southern Oregon and Ashland Community Hospital

John A Walker, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.


  1. Livingston EH, Passaro EP Jr. Postoperative ileus. Dig Dis Sci. Jan 1990;35(1):121-32. [View Abstract]
  2. 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. Oct 1997;21(8):806-9; discussion 809-10. [View Abstract]
  3. Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surg. Nov 2000;87(11):1480-93. [View Abstract]
  4. Vasquez W, Hernandez 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. Apr 2009;13(4):649-56. [View Abstract]
  5. Iyer S, Saunders WB, Stemkowski S. Economic burden of postoperative ileus associated with colectomy in the United States. J Manag Care Pharm. Jul-Aug 2009;15(6):485-94. [View Abstract]
  6. Resnick J, Greenwald DA, Brandt LJ. Delayed gastric emptying and postoperative ileus after nongastric abdominal surgery: part I. Am J Gastroenterol. May 1997;92(5):751-62. [View Abstract]
  7. Resnick J, Greenwald DA, Brandt LJ. Delayed gastric emptying and postoperative ileus after nongastric abdominal surgery: part II. Am J Gastroenterol. Jun 1997;92(6):934-40. [View Abstract]
  8. 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. Nov 1998;228(5):652-63. [View Abstract]
  9. Boeckxstaens GE, de Jonge WJ. Neuroimmune mechanisms in post-operative ileus. Gut. 2009/09;58(9):1300-11.
  10. 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. Jun 1995;58(6):719-23. [View Abstract]
  11. 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. Feb 2000;118(2):316-27. [View Abstract]
  12. Senagore AJ. Pathogenesis and clinical and economic consequences of postoperative ileus. Am J Health Syst Pharm. Oct 15 2007;64(20 Suppl 13):S3-7. [View Abstract]
  13. 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. Nov 2012;204(5):613-8. [View Abstract]
  14. 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. Jul 2007;205(1):43-51. [View Abstract]
  15. Cameron JL, ed. Current Surgical Therapy. 7th ed. Chicago: Mosby; 2001.
  16. Tollesson PO, Cassuto J, Rimback G. Patterns of propulsive motility in the human colon after abdominal operations. Eur J Surg. Apr 1992;158(4):233-6. [View Abstract]
  17. Loftus CG, Harewood GC, Baron TH. Assessment of predictors of response to neostigmine for acute colonic pseudo-obstruction. Am J Gastroenterol. Dec 2002;97(12):3118-22. [View Abstract]
  18. Kronberg U, Kiran RP, Soliman MS, Hammel JP, Galway U, Coffey JC. A characterization of factors determining postoperative ileus after laparoscopic colectomy enables the generation of a novel predictive score. Ann Surg. Jan 2011;253(1):78-81. [View Abstract]
  19. Schwartz SI, ed. Principles of Surgery. 7th ed. New York, NY: McGraw-Hill; 1999.
  20. Cali RL, Meade PG, Swanson MS, Freeman C. Effect of Morphine and incision length on bowel function after colectomy. Dis Colon Rectum. Feb 2000;43(2):163-8. [View Abstract]
  21. Ferraz AA, Cowles VE, Condon RE, et al. Nonopioid analgesics shorten the duration of postoperative ileus. Am Surg. Dec 1995;61(12):1079-83. [View Abstract]
  22. Purkayastha S, Tilney HS, Darzi AW, Tekkis PP. Meta-analysis of randomized studies evaluating chewing gum to enhance postoperative recovery following colectomy. Arch Surg. Aug 2008;143(8):788-93. [View Abstract]
  23. 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. May 2010;27(5):387-91. [View Abstract]
  24. Waldhausen JH, Schirmer BD. The effect of ambulation on recovery from postoperative ileus. Ann Surg. Dec 1990;212(6):671-7. [View Abstract]
  25. 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. Feb 2009;23(2):276-82. [View Abstract]
  26. Liu SS, Carpenter RL, Mackey DC, et al. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology. Oct 1995;83(4):757-65. [View Abstract]
  27. Mann C, Pouzeratte Y, Boccara G, et al. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology. Feb 2000;92(2):433-41. [View Abstract]
  28. Marret E, Rolin M, Beaussier M, Bonnet F. Meta-analysis of intravenous lidocaine and postoperative recovery after abdominal surgery. Br J Surg. Nov 2008;95(11):1331-8. [View Abstract]
  29. 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. Aug 2009;198(2):231-6. [View Abstract]
  30. Becker G, Blum HE. Novel opioid antagonists for opioid-induced bowel dysfunction and postoperative ileus. Lancet. Apr 4 2009;373(9670):1198-206. [View Abstract]
  31. Maron DJ, Fry RD. New therapies in the treatment of postoperative ileus after gastrointestinal surgery. Am J Ther. Jan-Feb 2008;15(1):59-65. [View Abstract]
  32. 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. Apr 1997;61(4):467-75. [View Abstract]
  33. 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. Jan 19 2011;CD003448. [View Abstract]
  34. Yu CS, Chun HK, Stambler N, Carpenito J, Schulman S, Tzanis E. 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. May 2011;54(5):570-8. [View Abstract]
  35. Taguchi A, Sharma N, Saleem RM, et al. Selective postoperative inhibition of gastrointestinal opioid receptors. N Engl J Med. Sep 27 2001;345(13):935-40. [View Abstract]
  36. [Best Evidence] Tan EK, Cornish J, Darzi AW, Tekkis PP. Meta-analysis: Alvimopan vs. placebo in the treatment of post-operative ileus. Aliment Pharmacol Ther. Jan 1 2007;25(1):47-57. [View Abstract]
  37. Senagore AJ, Bauer JJ, Du W, Techner L. Alvimopan accelerates gastrointestinal recovery after bowel resection regardless of age, gender, race, or concomitant medication use. Surgery. Oct 2007;142(4):478-86. [View Abstract]
  38. 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. Dec 2008;23(12):1175-83. [View Abstract]
  39. 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. Jul 2007;30(3):167-72. [View Abstract]
  40. Traut U, Brugger L, Kunz R, et al. Systemic prokinetic pharmacologic treatment for postoperative adynamic ileus following abdominal surgery in adults. Cochrane Database Syst Rev. Jan 23 2008;CD004930. [View Abstract]
  41. 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. Nov 15 2009;30(10):987-98. [View Abstract]
  42. Yeh YC, Klinger EV, Reddy P. Pharmacologic options to prevent postoperative ileus. Ann Pharmacother. Sep 2009;43(9):1474-85. [View Abstract]
  43. Abd-El-Maeboud KH, Ibrahim MI, Shalaby DA, Fikry MF. Gum chewing stimulates early return of bowel motility after caesarean section. BJOG. Sep 2009;116(10):1334-9. [View Abstract]
  44. Behm B, Stollman N. Postoperative ileus: etiologies and interventions. Clin Gastroenterol Hepatol. Mar 2003;1(2):71-80. [View Abstract]
  45. Carter S. The surgical team and outcomes management: focus on postoperative ileus. J Perianesth Nurs. Apr 2006;21(2A Suppl):S2-6. [View Abstract]
  46. Delaney CP, Senagore AJ, Viscusi ER, 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. Mar 2006;191(3):315-9. [View Abstract]
  47. Houwen RH, van der Doef HP, Sermet I, 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. Jan 2010;50(1):38-42. [View Abstract]
  48. Jones MP, Wessinger S. Small intestinal motility. Curr Opin Gastroenterol. Mar 2006;22(2):111-6. [View Abstract]
  49. Mattei P, Rombeau JL. Review of the pathophysiology and management of postoperative ileus. World J Surg. Aug 2006;30(8):1382-91. [View Abstract]
  50. Moore BA, Albers KM, Davis BM, Grandis JR, Togel S, Bauer AJ. Altered inflammatory gene expression underlies increased susceptibility to murine postoperative ileus with advancing age. Am J Physiol Gastrointest Liver Physiol. Jun 2007;292(6):G1650-9. [View Abstract]
  51. Ng WQ, Neill J. Evidence for early oral feeding of patients after elective open colorectal surgery: a literature review. J Clin Nurs. Jun 2006;15(6):696-709. [View Abstract]
  52. Person B, Wexner SD. The management of postoperative ileus. Curr Probl Surg. Jan 2006;43(1):6-65. [View Abstract]
  53. Saclarides TJ. Current choices--good or bad--for the proactive management of postoperative ileus: A surgeon's view. J Perianesth Nurs. Apr 2006;21(2A Suppl):S7-15. [View Abstract]
  54. Saunders MD. Acute colonic pseudo-obstruction. Gastrointest Endosc Clin N Am. Apr 2007;17(2):341-60, vi-vii. [View Abstract]
  55. [Best Evidence] Schuster R, Grewal N, Greaney GC, Waxman K. Gum chewing reduces ileus after elective open sigmoid colectomy. Arch Surg. Feb 2006;141(2):174-6. [View Abstract]
  56. 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. Jan 2010;395(1):27-31. [View Abstract]
  57. Sutton DH, Harrell SP, Wo JM. Diagnosis and management of adult patients with chronic intestinal pseudoobstruction. Nutr Clin Pract. Feb 2006;21(1):16-22. [View Abstract]

Postoperative ileus after an open cholecystectomy.

Ogilvie pseudo-obstruction in a septic elderly patient. Note the massive dilatation of the colon, especially the right colon and cecum.

Ogilvie pseudo-obstruction in a septic elderly patient. Note the massive dilatation of the colon, especially the right colon and cecum.

Mechanical bowel obstruction due to a left colon carcinoma. Note the paucity of bowel gas throughout the colon.

Contrast study, in the same patient as in Media File 3, showing the classic "apple-core" lesion of colon carcinoma.

Postoperative ileus after an open cholecystectomy.

Ogilvie pseudo-obstruction in a septic elderly patient. Note the massive dilatation of the colon, especially the right colon and cecum.

Mechanical bowel obstruction due to a left colon carcinoma. Note the paucity of bowel gas throughout the colon.

Contrast study, in the same patient as in Media File 3, showing the classic "apple-core" lesion of colon carcinoma.

IleusPseudo-obstructionMechanical Obstruction (Simple)
SymptomsMild abdominal pain, bloating, nausea, vomiting, obstipation, constipationCrampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexiaCrampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia
Physical Examination FindingsSilent abdomen, distention, tympanicBorborygmi, tympanic, peristaltic waves, hypoactive or hyperactive bowel sounds, distention, localized tendernessBorborygmi, peristaltic waves, high-pitched bowel sounds, rushes, distention, localized tenderness
Plain RadiographsLarge and small bowel dilatation, diaphragm elevatedIsolated large bowel dilatation, diaphragm elevatedBow-shaped loops in ladder pattern, paucity of colonic gas distal to lesion, diaphragm mildly elevated, air-fluid levels