Introduction Loss of peristalsis without structural obstruction Common in elderly on opiates recent surgery severe medical illness hypothyroidism diabetes medications that slow GI motility opiates anticholinergics Presentation Symptoms diffuse, constant, moderate, abdominal discomfort nausea and vomiting Physical exam abdominal distention absence of flatulence or bowel movements decreased to no bowel sounds mechanical obstruction has high pitched tinkling sounds No peritoneal signs Evaluation Supine and upright films to rule out perforation Diagnosis based on AXR showing distended small and large bowel air-fluid levels Rule out thyroid disease with TSH Differential Partial obstruction, appendicitis, gastroenteritis, pancreatitis, neoplasm Treatment NPO or dietary restriction NG suction and parenteral feeds Replete fluids and electrolytes Discontinue contributing medications