Clinical Practice Guidelines for Colon Volvulus and Acute Colonic Pseudo-Obstruction

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus

Colonic volvulus and acute colonic pseudo-obstruction (ACPO) are 2 causes of benign large-bowel obstruction. Colonic volvulus occurs most commonly in the sigmoid colon as a result of bowel twisting along its mesenteric axis. In contrast, the exact pathophysiology of ACPO is poorly understood, with the prevailing hypothesis being altered regulation of colonic function by the autonomic nervous system resulting in colonic distention in the absence of mechanical blockage. Prompt diagnosis and intervention leads to improved outcomes for both diagnoses. Endoscopy may play a role in the evaluation and management of both entities. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on the evaluation and endoscopic management of sigmoid volvulus and ACPO.

Colonic Decompression Reduces Proximal Acute Colonic Pseudo-obstruction and Related Symptoms

BACKGROUND

Colonoscopic decompression is performed in inpatients for management of acute colonic pseudo-obstruction. Evidence for its efficacy is limited to small descriptive studies published before the use of neostigmine for acute colonic pseudo-obstruction. Furthermore, therapeutic end points were not defined.

OBJECTIVE

The aim was to compare the effectiveness of colonic decompression with standard medical therapy (supportive and pharmacologic therapy) to standard medical therapy alone.

DESIGN

This is a retrospective, propensity-matched study.

SETTING

The study was conducted at a tertiary care center.

PATIENTS

Inpatients with first diagnosis of acute colonic pseudo-obstruction between 2000 and 2016 were selected.

INTERVENTIONS

The intervention group received colonic decompression as well as supportive and/or pharmacologic therapy. The control group did not receive colonic decompression.

MAIN OUTCOME MEASURES

The primary outcome was the resolution of overall colonic dilation on imaging 48 hours following colonic decompression or the initiation of standard medical therapy alone. Secondary outcomes included symptom improvement, colonic segment diameter percentage change, perforation, 30-day readmission, and all-cause mortality.

RESULTS

The standard medical therapy and colonic decompression groups included 61 and 83 patients. Of the patients who underwent colonic decompression, 47.7% had complete resolution of acute colonic pseudo-obstruction versus 19.9% of patients who underwent standard medical therapy (p < 0.001). There were no significant differences in mid or distal colon diameter reduction between groups. The 30-day readmission rate was 15.7% in the colonic decompression group versus 26.2% in the standard medical therapy group. No immediate adverse events were noted in either group. Thirty-day all-cause mortality was 8.4% for the colonic decompression group and 14.8% in the standard medical therapy group.

LIMITATIONS

The study was a retrospective review on a highly comorbid population.

CONCLUSIONS

Colonic decompression is effective compared to standard medical therapy alone for proximal colonic dilation or symptoms associated with acute colonic pseudo-obstruction. On segmental analysis, colonic decompression does not provide any additional benefit over standard medical therapy in improving transverse or distal colonic dilation. See Video Abstract at http://links.lww.com/DCR/B32. LA DESCOMPRESIÓN COLÓNICA REDUCE LA PSEUDOOBSTRUCCIÓN COLÓNICA AGUDA PROXIMAL Y LOS SÍNTOMAS RELACIONADOS.: La descompresión colonica se realiza en pacientes hospitalizados para el tratamiento de la pseudoobstrucción colónica aguda. La evidencia de su eficacia se limita a pequeños estudios descriptivos antes del uso de neostigmina para la pseudoobstrucción colónica aguda. Además, los puntos finales terapéuticos no se definieron.El objetivo fue comparar la efectividad de la descompresión colónica mas el tratamiento médico estándar (tratamiento de apoyo y farmacológico) contra el tratamiento médico estándar solamente.Este es un estudio retrospectivo de propensión coincidente.El estudio se realizó en un centro de atención de tercer nivel.Pacientes hospitalizados con diagnóstico de pseudoobstrucción colónica aguda entre 2000 y 2016.El grupo de intervención recibió descompresión colónica, así como tratamiento de apoyo o farmacológica. El grupo control no recibió descompresión colónica.La medida de resultado primaria fue la resolución de la dilatación colónica general en la imagen 48 horas después de la descompresión colónica o el inicio del tratamiento médico estándar solo. Los resultados secundarios incluyeron mejoría de los síntomas, cambio porcentual en el diámetro del segmento colónico, perforación, reingreso a los 30 días y mortalidad por cualquier causa.La terapia médica estándar y los grupos de descompresión colónica incluyeron 61 y 83 pacientes, respectivamente. El 47,7% de los pacientes con descompresión colónica tuvieron una resolución completa de la pseudoobstrucción colónica aguda frente al 19,9% de los pacientes con terapia médica estándar (p < 0,001). No hubo diferencias significativas en la reducción del diámetro del colon medio o distal entre los grupos. La tasa de reingreso a los 30 días fue del 15,7% en el grupo de descompresión colónica frente al 26,2% en el grupo de tratamiento médico estándar. No se observaron eventos adversos inmediatos en ninguno de los dos grupos. La mortalidad por cualquier causa a los 30 días fue del 8.4% para la descompresión del colon y del 14.8% en los grupos de terapia médica estándar.El estudio fue una revisión retrospectiva en una población altamente comórbida.La descompresión colónica es efectiva en comparación con el tratamiento médico estándar solo para la dilatación del colon proximal o los síntomas asociados con la pseudoobstrucción colónica aguda. En el análisis segmentario, la descompresión colónica no proporciona ningún beneficio adicional sobre el tratamiento médica estándar para mejorar la dilatación colónica transversal o distal. Vea el resumen del video en http://links.lww.com/DCR/B32.

Abdominal Compartment Syndrome: Improving Outcomes With A Multidisciplinary Approach - A Narrative Review

Abdominal compartment syndrome (ACS) refers to a severe increase in intra-abdominal pressure associated with single or multiorgan failure. ACS with specific pathophysiological processes and detrimental outcomes may occur in a variety of clinical conditions. Patients with ACS are predominantly managed in critical care settings, however, a wide range of multidisciplinary interventions are frequently required from medical, surgical, radiological and nursing specialties. The medical management, aiming to prevent the progression of intra-abdominal hypertension to ACS, is extensively reviewed. Timing and techniques of surgical decompression techniques, as well as management of open abdomen, are outlined. In summary, the current narrative review provides data on history, definitions, epidemiology and pathophysiology of the syndrome and highlights the importance of multidisciplinary approach in the management of ACS in adults.

The recurrence of colonic volvulus due to nonrotation after intestinal resection in adulthood: a case report

Background

Intestinal nonrotation is a rare congenital condition that causes fatal colonic volvulus at any age. Once volvulus attack occurs, radical surgical therapy is required for treatment and the prevention of recurrence. This report describes the case of an adult female patient with a recurrence of cecum volvulus due to intestinal nonrotation after transverse colon resection for colonic volvulus.

Case presentation

A 27-year-old female visited our emergency room (ER) with intermittent abdominal pain and nausea. Enhanced computed tomography (CT) showed enlargement of the level of the ascending and transverse colon and an obstruction with a whirlpool sign at the transverse colon. The small intestine was distributed on the right side of the abdominal cavity, and the large intestine occupied the left side. She was diagnosed with volvulus with intestinal nonrotation, and emergency surgery was performed. Surgical examination indicated that the ascending colon to the transverse colon was not fixed to the retroperitoneum, and the transverse colon was rotated 180° clockwise. The axis of the volvulus was a mesenteric adhesion of the transverse colon. The involved transverse colon was resected, and the intestine was reconstructed by functional end-to-end anastomosis (FEEA). Six years after the initial surgery, the patient presented to the ER with abdominal fullness and lower abdominal pain. Enhanced CT revealed that the cecum, ascending colon, and remaining transverse colon were dilated with an obstruction. The appendix was located in the left upper abdominal cavity. The clinical diagnosis was cecal volvulus with intestinal nonrotation. An emergency laparotomy revealed that the cecum was rotated 180° clockwise. The terminal ileum to the remaining transverse colon was resected, and FEEA was performed. Seven months later, she suffered obstruction of the intestine caused by an operative adhesion, and conservative treatment was successful. The patient has had no abdominal symptoms for one and a half years so far.

Conclusions

Surgeons should realize that nonrotation of the intestines induces volvulus in adulthood and should familiarize themselves with its clinical findings, appropriate treatment, and prognosis. Even after surgical treatment, awareness of the recurrence of volvulus should be maintained to avoid a late diagnosis.

Subcutaneous neostigmine appears safe and effective for acute colonic pseudo-obstruction (Ogilvie's syndrome)

BACKGROUND

Intravenous neostigmine is a well-established treatment for acute colonic pseudo-obstruction (ACPO). Its use is hampered by the perceived requirement for continuous cardiac monitoring, and patients are often transferred to high-dependency units for close observation during treatment. Subcutaneous neostigmine has the potential to minimize adverse cardiovascular effects while maintaining efficacy. This study aims to assess the safety of subcutaneous neostigmine on ward inpatients with ACPO monitored with standard nursing care.

METHODS

This is a retrospective case series of 30 patients with ACPO who were treated with subcutaneous neostigmine between August 2008 and October 2012. Data were collected prospectively. All patients were diagnosed using clinical examination and radiology and were assessed for contraindications to neostigmine. Patients were treated on regular wards and monitored with standard nursing observations. The main outcomes were time to flatus and bowels working and complications.

RESULTS

No serious complications such as clinically evident bradycardia were encountered. Ninety-three percent of patients had clinically successful resolution of ACPO. Two patients (7%) developed caecal tenderness and proceeded to colonoscopic decompression, which was successful in both instances.

CONCLUSIONS

Subcutaneous neostigmine appears to be safe for the treatment of ACPO. No clinically evident serious adverse events occurred, meaning continuous cardiac monitoring as a routine may not be necessary. In our cohort, we achieved similar success rates compared with reported rates using intravenous neostigmine.

Acute Colonic Pseudo-Obstruction Caused by Dexmedetomidine: A Case Report and Literature Review

Patient: Male, 50

Final Diagnosis: Acute colonic pseudo-obstruction

Symptoms: Abdominal pain • cough • fever

Medication: —

Clinical Procedure: Colonoscopy decompression and colectomy

Specialty: Critical Care Medicine

Sigmoid volvulus: Comorbidity with sigmoid gangrene

Sigmoid volvulus (SV) is the wrapping of the sigmoid colon around its mesentery, and sigmoid gangrene is a catastrophic complication of SV. Although the diagnosis of SV is generally not difficult, unfortunately, most of the clinical, laboratory and radiological signs are not pathognomonic in demonstrating sigmoid gangrene. The treatment of gangrenous SV requires emergency surgery. Sigmoid gangrene worsens the prognosis of SV by doubling the mortality rate.

Fluoroscopy-guided trans-anal decompression tube placement in the treatment of acute colonic pseudo-obstruction: a single center experience

PURPOSE

Acute colonic pseudo-obstruction (ACPO or Ogilvie's syndrome) is a rare but often fatal disease; timely colonic decompression may be essential for successful treatment. This study describes a technique of placing a trans-anal tube via fluoroscopy-guiding and investigates the effect of colon decompression on ACPO.

METHODS

Patients undergoing colonic decompression via fluoroscopy-guided trans-anal tube placement from April 2015 to May 2017 were included. The technical and clinical successes of this procedure were evaluated. Clinical features and long-term outcomes are described.

RESULTS

Decompression was successful in 72.73% (16/22) of the patients; the procedure was considered a clinical success in 50% (11/22) of the patients. 31.82% (7/22) of the patients underwent elective surgery, and only 18.19% (4/22) of the patients need emergency surgery.

CONCLUSIONS

Fluoroscopy-guided trans-anal decompression tube placement was an easy and efficient method for treating ACPO. Additionally, ACPO once required emergency surgery, but now may only require elective surgery in certain instances.

From Endoscopic Detorsion to Sigmoid Colectomy—The Art of Managing Patients with Sigmoid Volvulus: A Survey of the Members of the American Society of Colon and Rectal Surgeons

This study queried American Society of Colon and Rectal Surgeons members for management of sigmoid volvulus and aimed to determine whether surgeon experience impacts decision-making. American Society of Colon and Rectal Surgeons members received a 16-item survey in March, 2017. Items included endoscopic detorsion technique and colonic decompression, preoperative dietary considerations, surgical approach, and respondents’ demographics. Respondents were separated into low experience (LE; ≤10 years in practice) and high experience (HE; >10 years in practice). Of 1996 survey recipients, 10 per cent (197) responded; 124 were HE and 73 were LE. Most were fellowship-trained (93.8%) and primarily in colorectal surgery practice (74.6%), however only 27.4 per cent managed >20 sigmoid volvulus cases as attendings. Fifty-two per cent use rectal tubes for continued colonic decompression after successful endoscopic detorsion; 81.2 per cent would perform sigmoid colectomy on the index admission after successful detorsion, but within a variable timeframe (one to seven days postdetorsion) and with variable dietary restrictions in the interval period; 49.7 per cent would perform a laparoscopic colectomy and 68.3 per cent would perform a stapled colorectal anastomosis. LE surgeons reported a higher proportion of gastrointestinal-performed endoscopic detorsions (P = 0.015), were more likely allow regular diet in the interval period (P = 0.031), and were more inclined to use laparoscopy (P = 0.008), versus HE surgeons. There remains controversy among many of the components in the management of sigmoid volvulus after successful endoscopic detorsion.

Risk of recurrence of sigmoid volvulus: a single-centre cohort study

AIM

Sigmoid volvulus is a condition with a tendency to recur if treated conservatively. Little is known about the best type of treatment or when to perform definitive surgery. The aim of this study was to review treatment, and assess the outcome, of sigmoid volvulus in adult patients treated at a Swedish university hospital.

METHOD

The medical records of patients treated for sigmoid volvulus at Sahlgrenska University Hospital, Sweden from January 2000 to September 2016 were reviewed retrospectively. Median follow-up time was 8.3 years.

RESULTS

One hundred and sixty-eight patients were included with a total of 453 admissions for sigmoid volvulus. Nonoperative decompression was attempted as the initial treatment in 438/453 (97%), with a success rate of 92% (403/438), which was not influenced by whether it was the first episode or a recurrence. Without planned surgery, recurrence occurred after 84% of successful nonoperative decompressions with a median of two recurrences (1-16). Recurrence was less common after the first episode compared with subsequent episodes. Median time until recurrence was 58 days. Mortality after planned surgery following successful decompression was 3.3% (2/61) compared with 13% (6/46) following emergency surgery.

CONCLUSION

In our cohort, the recurrence rate of sigmoid volvulus following successful nonoperative decompression was high. Still, more than 20% of patients did not experience a recurrence after their first episode. Nonoperative decompression could thus be suggested as the sole treatment for the first episode of volvulus. However, after the second episode it is probable that early planned surgery would improve outcome and reduce health-care consumption.

Recurrent Volvulus during Pregnancy: Case Report and Review of the Literature

Introduction

Sigmoid colon volvulus (SV) represents the most common etiology of antepartum gastrointestinal obstruction, with repetitive antepartum episodes rarely reported.

Case Presentation

A 25-year-old multiparous patient with history of SV at 26 weeks in her previous pregnancy presented with recurrent episodes of SV at 32 0/7, 32 4/7, 37 0/7, and 38 1/7 weeks successfully managed with colonoscopic decompression. Labor was successfully induced at 38 4/7 weeks, and she experienced two further episodes on postpartum days #1 and #32 also treated with colonoscopic decompression, followed by laparoscopic resection.

Conclusion

Successful treatment of antepartum SV with colonoscopic decompression does not preclude recurrence later in gestation and in future pregnancies.

Efficacy and Safety of Subcutaneous Neostigmine for Ileus, Acute Colonic Pseudo-obstruction, or Refractory Constipation

Background: Neostigmine is traditionally administered intravenously for treatment of acute colonic pseudo-obstruction (ACPO), though use is associated with administration constraints and adverse effects. Objective: To evaluate whether an alternative route of administration for neostigmine via subcutaneous (SQ) delivery is safe and effective in a broad cohort of medical and surgical patients. Methods: This multicenter, retrospective observational study included adult patients administered SQ neostigmine for ileus, ACPO, or refractory constipation. Efficacy indicators were time to first bowel movement (BM) following initiation of the medication, total SQ neostigmine dose administered to produce a BM, and administration of a rescue intervention to produce a BM. Safety events evaluated were cardiac arrest, bradycardia, bronchospasm requiring intervention, nausea requiring intervention, or severe salivation, lacrimation, or diarrhea. Results: A total of 182 patients were eligible for inclusion. The most commonly utilized dosing strategy of neostigmine was 0.25 mg SQ 4 times daily. The median time to first BM following initiation of SQ neostigmine was 29.19 hours (interquartile range = 12.18-56.84) with a median dose administered before first BM of 1.25 mg. Three patients (1.65%) experienced an adverse drug event leading to drug discontinuation, with 2 developing bradycardia that resolved with drug discontinuation alone. Conclusions: SQ neostigmine may be reasonable for management of ileus, ACPO, or refractory constipation, though use should be avoided in patients with new-onset heart block, a history of second-degree heart block, or following bowel resection with primary anastomosis. Despite the low incidence of adverse drug events observed, monitoring for bradycardia with telemetry may be considered.

Determination of patients requiring elective surgery following successful endoscopic detorsion in sigmoid volvulus

Sigmoid volvulus (SV) is an unusual type of colonic obstruction, in which the sigmoid colon wraps around itself. As a rule, SV is decompressed via endoscopy in uncomplicated cases, while surgery is required in complicated cases. However, the recurrence rate following endoscopic detorsion is relatively high, with a relatively high mortality rate. Consequently, as a prophylactic procedure to prevent recurrence, elective surgery is suggested in some patients. Nevertheless, the selection criteria are open to questioning. In this report, we evaluate those criteria based on the broad experience of our clinic, and suggest elective surgery in patients in ASA classes I-III.

Secretory diarrhea and hypokalemia associated with colonic pseudo-obstruction: A case study and systematic analysis of the literature

BACKGROUND

Colonic pseudo-obstruction (CPO) is characterized by colonic distention in the absence of mechanical obstruction or toxic megacolon. Concomitant secretory diarrhea (SD) with hypokalemia (SD-CPO) due to gastrointestinal (GI) loss requires further characterization.

AIM

To perform a systematic review of SD-CPO, report a case study, and compare SD-CPO with classical CPO (C-CPO).

METHODS

We performed a search of MEDLINE, EMBASE, Cochrane, and Scopus for reports based on a priori criteria for CPO, SD and GI loss of potassium. An additional case at Mayo Clinic was included.

RESULTS

Nine publications met inclusion criteria, with a total of 14 cases. Six studies had high, three moderate, and our case high methodological quality. Median age was 74 years (66-97), with 2:1 male/female ratio. Kidney disease was present in 6/14 patients. Diarrhea was described as profuse, watery, or viscous in 10 patients. Median serum, stool, and urine potassium concentrations (mmol/L) were 2.4 (range: 1.9-3.1), 137 (100-180), and 17 (8-40), respectively. Maximal diameter of colon and cecum (median) were 10.2 cm and 10.5 cm, respectively. Conservative therapy alone was effective in five out of 14 patients. Median potassium supplementation was 124 mEq/d (40-300). Colonic decompression was effective in three out of six patients; one had a total colectomy; three out of 14 had died. The main differences between SD-CPO and C-CPO were lower responses to treatments: conservative measures (35.7% vs 73.6%, P=.01), neostigmine (17% vs 89.2%, P<.001), and colonic decompression (50% vs 82.4%, P=.02).

CONCLUSION

SD-CPO is a rare phenotype associated with increased fecal potassium and is more difficult to treat than C-CPO.

What is done when endoscopic examination reveals borderline bowel ischemia in patients with sigmoid volvulus?

Sigmoid volvulus (SV) is a rare colonic obstruction in which the sigmoid colonwraps around itself. The principal strategy for the treatment of uncomplicated SV is emergency endoscopic detorsion, while emergency surgery is needed in complicated SV with bowel gangrene, bowel perforation, peritonitis, or unsuccessful endoscopic treatment. In the endoscopic examination of SV, endoscopic detorsion is performed if the bowels are viable, while emergency surgery is needed if the bowels are gangrenous. However, the treatment approach is not clear when endoscopic examination reveals borderline bowel ischemia, and in this short report, the possible treatment strategies are discussed.

Large Bowel Obstruction in the Emergency Department: Imaging Spectrum of Common and Uncommon Causes

Although large bowel obstruction (LBO) is less common than small bowel obstruction, it is associated with high morbidity and mortality due to delayed diagnosis and/or treatment. Plain radiographs are sufficient to diagnose LBO in a majority of patients. However, further evaluation with multidetector computed tomography (MDCT) has become the standard of care to identify the site, severity, and etiology of obstruction. In this comprehensive review, we illustrate the various causes of LBO emphasizing the role of MDCT in the initial diagnosis and detection of complications along with the tips to differentiate from disease which can mimic LBO.

Acute Colonic Pseudo-Obstruction with Feeding Intolerance in Critically Ill Patients: A Study according to Gut Wall Analysis

Objective. To compare the differences between acute colonic pseudo-obstruction (ACPO) with and without acute gut wall thickening. Methods. ACPO patients with feeding tolerance were divided into ACPO with no obvious gut wall thickening (ACPO-NT) group and ACPO with obvious acute gut wall thickening (ACPO-T) group according to computed tomography and abdominal radiographs. Patients' condition, responses to supportive measures, pharmacologic therapy, endoscopic decompression, and surgeries and outcomes were compared. Results. Patients in ACPO-T group had a significantly higher APACHE II (11.82 versus 8.25, p = 0.008) and SOFA scores (6.47 versus 3.54, p < 0.001) and a significantly higher 28-day mortality (17.78% versus 4.16%, p = 0.032) and longer intensive care unit stage (4 versus 16 d, p < 0.001). Patients in ACPO-NT group were more likely to be responsive to supportive treatment (62.50% versus 24.44%, p < 0.001), neostigmine (77.78% versus 17.64%, p < 0.001), and colonoscopic decompression (75% versus 42.86%, p = 0.318) than those in ACPO-T group. Of the patients who underwent ileostomy, 81.25% gained benefits. Conclusions. ACPO patients with gut wall thickening are more severe and are less likely to be responsive to nonsurgical treatment. Ileostomy may be a good option for ACPO patients with gut wall thickening who are irresponsive to nonsurgical treatment.