Acute colonic pseudo-obstruction

Update on the Diagnosis and Management of Acute Colonic Pseudo-obstruction (ACPO)

PURPOSE OF REVIEW

Acute Colonic Pseudo-obstruction (ACPO) is a cause of large intestinal dilation and obstruction without any physical transition point. It remains difficult to diagnose and treat. We review the recent updates on diagnosis and management of ACPO.

RECENT FINDINGS

Recent guidelines have posited that conservative management can be tried in most cases of ACPO, but that early decompression and surgery should be considered. Use of neostigmine is still a viable option but there is also promising data on pyridostigmine as well as prucalopride. Resolution of ACPO should be followed by daily use of polyethylene glycol (PEG) to help prevent recurrence. ACPO warrants early and accurate diagnosis with exclusion of alternate causes of large bowel dilation. Conservative management can be attempted for 48-72 h in those with cecal diameters < 12 cm and without signs of peritonitis and perforation. Early escalation of management should be attempted with neostigmine followed by endoscopy and/or surgery as needed, given that longer periods of dilation are associated with worse outcomes. There is promising new evidence for use of pyridostigmine and prucalopride, but further trials are needed prior to incorporating them into regular use. Finally, studies are lacking regarding prevention of ACPO after initial resolution.

Ogilvie Syndrome in Patients With Traumatic Pelvic and/or Acetabular Fractures: A Retrospective Cohort Study

OBJECTIVES

To assess the incidence, risk factors, and clinical outcomes of Ogilvie syndrome (OS) in patients with pelvic and/or acetabular fractures.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS

One thousand sixty patients with pelvic and/or acetabular fractures treated at Rigshospitalet, Copenhagen, between 2009 and 2020.

INTERVENTION

Interventions comprised the treatment of pelvic and/or acetabular fractures with emergency external and/or internal fixation.

MAIN OUTCOME MEASUREMENTS

Outcomes included diagnosis of OS, perioperative complications, ICU stay and length, length of admission, and mortality.

RESULTS

We identified 1060 patients with pelvic and/or acetabular fractures. Of these, 25 patients were diagnosed with OS perioperatively, corresponding to incidences of 1.6%, 2.7%, and 2.6% for acetabular, pelvic, and combined fractures, respectively. Risk factors included congestive heart failure, diabetes, concomitant traumatic lesions, head trauma, fractures of the cranial vault and/or basal skull, retroperitoneal hematomas and spinal cord injuries, and emergency internal fixation and extraperitoneal packing. Six (24%) patients underwent laparotomy, and all patients had ischemia or perforation of the cecum for which right hemicolectomy was performed. Ogilvie syndrome was associated with a significant increase in nosocomial infections, sepsis, pulmonary embolism, ICU stay, and prolonged hospital admission.

CONCLUSION

Ogilvie syndrome in patients with pelvic and/or acetabular fractures is associated with increased risk of perioperative complications and prolonged hospital and ICU stays, resulting in an increased risk of morbidity and mortality.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction (ACPO) is a functional disorder of the large intestine distinguished by colonic dysmotility resulting in colonic distension in the absence of mechanical obstruction. The underlying pathophysiology of ACPO remains unclear despite technological advances in understanding the physiology of colonic motility, such as spatio-temporal mapping and high-resolution manometry. In many ways, the management of ACPO has remained relatively unchanged for 40 years. Patients with perforation or suspected ischemia undergo operative intervention, while patients without undergo initial conservative management with bowel rest, correction of electrolyte disturbances, and mobilization. Patients who fail conservative management or have prominent cecal dilatation undergo decompression with either neostigmine or colonoscopy. A subset of patients with ACPO will have recurrent symptoms despite endoscopic and medical management. For these patients who are difficult to manage, an underlying colonic functional disorder, such as slow-transit dysmotility or chronic intestinal pseudo-obstruction may be considered. The following review of ACPO aims to provide a concise update of the causes, diagnosis, and management of this emergency surgical condition.

Acute Colonic Pseudo-obstruction and Volvulus: Pathophysiology, Evaluation, and Treatment

Acute colonic pseudo-obstruction (ACPO) and volvulus are two disease processes that affect the colon causing abdominal distension and may necessitate operation intervention. ACPO may be associated with multiple comorbidities, infectious diseases, and cardiac dysfunction. It may be treated with conservative management including endoscopic decompression or neostigmine. If the distension is not addressed, high mortality may result if peritonitis develops. Volvulus most commonly occurs in the sigmoid colon or cecum. If left-sided, endoscopic decompression may resolve the obstruction if detorsion is successful, although sigmoid colectomy should be performed during the admission. If cecal volvulus is identified, right hemicolectomy should be performed.

Incidence and Risk Factors for the Development of Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome) in Total Joint Arthroplasty Patients

BACKGROUND

Acute colonic pseudo-obstruction (Ogilvie syndrome [OS]) is a rare but devastating condition that can develop in orthopaedic patients postoperatively. The objective of this study was to identify the risk factors for developing OS after total hip arthroplasty (THA) or total knee arthroplasty (TKA) and to compare the outcomes between patients who did and did not develop OS postoperatively.

METHODS

This was a retrospective review using the National Inpatient Sample, a national database incorporating inpatient hospitalization information. ICD-9 codes were used to identify patients who underwent primary and revision THA or TKA. Patients were separated based on the diagnosis of OS. Primary outcomes assessed included patient mortality, postoperative complications, length of stay, and cost during index hospitalization.

RESULTS

From 2001 to 2014, a total of 12,541,169 patients underwent primary and revision THA or TKA. Of those, 3,182 patients (0.03%) developed OS postoperatively. There was an increased incidence of OS in revision THA and TKA compared with primary THA and TKA. Fluid and electrolyte disorders were associated with the largest increased adjusted risk of OS. Patients with OS had an increased adjusted risk of overall postoperative complications and being discharged to skilled nursing facility. Patients with OS had an increased average length of stay and hospitalization cost compared with patients without OS.

DISCUSSION

Given our findings, the risk factors for the development of OS, including revision surgery, should be identified and minimized during the perioperative period to prevent the development of this morbid and potentially life-threatening complication.

LEVEL OF EVIDENCE

III (Retrospective cohort study).

Gastrointestinal Complications Warranting Invasive Interventions Following Total Joint Arthroplasty

BACKGROUND

Gastrointestinal (GI) complications following total joint arthroplasty (TJA) are uncommon but can be associated with substantial morbidity and mortality. The current literature on GI complications that warrant invasive procedures after TJA is lacking. This study reviews the incidence and outcomes of GI complications after TJA that went on to require invasive procedures.

METHODS

All TJA patients at our institution between January 2012 and May 2018 who had GI complications requiring an invasive procedure within 30 days of TJA were identified and retrospectively chart reviewed. Descriptive statistics were used to evaluate these patients.

RESULTS

Of 19,090 TJAs in a 6-year period, 34 patients (0.18%) required invasive procedures for GI complications within 30 days of the index surgery. Twenty-two (64%) of the required procedures were endoscopy for suspected GI bleeding. Within this cohort, aspirin was the most common thromboprophylaxis used (63.6% of patients) and smoking was more prevalent (9.1% current smokers) (P = .28). Of the remaining 12 GI procedures required, 75% were exploratory laparotomies, 44.4% of which were performed for obstruction. Three (33.3%) of the exploratory laparotomy patients died during the study period.

CONCLUSION

GI complications necessitating surgical intervention after TJA are rare. Suspected GI bleeding is the most common indication for intervention and is typically managed endoscopically. Other complications, such as GI obstruction, often require more extensive intervention and open procedures. Though rare, GI complications following TJA can lead to detrimental outcomes, significant patient morbidity, and occasionally mortality; therefore, a heightened awareness of these complications is warranted.

Endoscopic Management of Benign Colonic Obstruction and Pseudo-Obstruction

There are a variety of causes of intestinal obstruction, with the most common cause being malignant diseases; however, volvulus, inflammatory bowel disease or diverticulitis, radiation injury, ischemia, and pseudo-obstruction can also cause colonic obstruction. These are benign conditions; however, delayed diagnosis of acute intestinal obstruction owing to these causes can cause critical complications, such as perforation. Therefore, high levels of clinical suspicion and appropriate treatment are crucial. There are variable treatment options for colonic obstruction, and endoscopic treatment is known to be a less invasive and an effective option for such. In this article, the authors review the causes of benign colonic obstruction and pseudo-obstruction and the role of endoscopy in treating them.

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

Acute colonic pseudo-obstruction: A systematic review of aetiology and mechanisms

AIM

To critically review the literature addressing the definition, epidemiology, aetiology and pathophysiology of acute colonic pseudo-obstruction (ACPO).

METHODS

A systematic search was performed to identify articles investigating the aetiology and pathophysiology of ACPO. A narrative synthesis of the evidence was undertaken.

RESULTS

No consistent approach to the definition or reporting of ACPO has been developed, which has led to overlapping investigation with other conditions. A vast array of risk factors has been identified, supporting a multifactorial aetiology. The pathophysiological mechanisms remain unclear, but are likely related to altered autonomic regulation of colonic motility, in the setting of other predisposing factors.

CONCLUSION

Future research should aim to establish a clear and consistent definition of ACPO, and elucidate the pathophysiological mechanisms leading to altered colonic function. An improved understanding of the aetiology of ACPO may facilitate the development of targeted strategies for its prevention and treatment.

Ogilvie's syndrome after rectal prolapse repair and total hemorrhoidectomy: Case report and Discussion

This case highlights the rare diagnosis of Ogilvie's syndrome after minor surgery in a private hospital where facilities and expertise are generally sparse. It shows the importance of knowledge of the subject, proper assessment, accurate diagnosis, and early input from seniors is crucial to prevent ischemia and perforation of colon that carries high mortality.

Acute and chronic pseudo-obstruction: a current update

Acute colonic pseudo-obstruction (ACPO) and chronic intestinal pseudo-obstruction (CIPO) are distinct clinical entities in which patients present similarly with symptoms of a mechanical obstruction without an occlusive lesion. Unfortunately, they also share the issues related to a delay in diagnosis, including inappropriate management and poor outcomes. Advancements have been made in our understanding of the aetiologies of both conditions. Several predisposing factors linked to critical illness have been implicated in ACPO. CIPO is a functional motility disorder, historically misdiagnosed, with unnecessary surgery being performed in many patients with dire consequences. This review discusses the pathophysiology, clinical and diagnostic features, and treatment of each. For ACPO, a safer pharmacological approach to treatment is presented in a modified up-to-date algorithm. The importance of CIPO as a differential diagnosis when seeing patients with recurrent admissions for abdominal pain and distention is also discussed, as well as specific indications for surgery. While surgery is often a last resort, the role of the surgeon in the management of both ACPO and CIPO cannot be undervalued. By characterizing each condition in a common review, the knowledge gleaned aims to optimize outcomes for these frequently complex patients.

[Post cesarean Ogilvie syndrome: a mysterious complication: about a case]

Le syndrome d'ogilvie ou appeler encore Pseudo-occlusion colique aiguë (acute colonic pseudo-obstruction), décrit par Sir William Ogilvie en 1948 et correspond à une dilatation aiguë du colon antérieurement sain, survenant en l'absence d'obstruction mécanique avec un diamètre cæcal > 9 cm, La symptomatologie correspond à celle d'une occlusion intestinale basse, d'installation rapide et l'imagerie fait d'ASP et de TDM abdominale permet de mettre en évidence la distension cæcale dont la mesure de son diamètre permet de prédire le risque de perforation. A travers notre cas et une revue de la littérature nous invitons les obstétriciens à ne pas méconnaitre ce syndrome car seul un diagnostic précoce permet de réduire le risque de perforation cæcale

Ogilvie's syndrome following posterior spinal arthrodesis for scoliosis

We report Ogilvie's syndrome following posterior spinal arthrodesis on a patient with thoracic and lumbar scoliosis associated with intraspinal anomalies. Postoperative paralytic ileus can commonly complicate scoliosis surgery. Ogilvie's syndrome as a cause of abdominal distension and pain has not been reported following spinal deformity correction and can mimic post-surgical ileus. 12 year old female patient with double thoracic and lumbar scoliosis associated with Arnold-Chiari 1 malformation and syringomyelia. The patient underwent posterior spinal fusion from T4 to L3 with segmental pedicle screw instrumentation and autogenous iliac crest grafting. She developed abdominal distension and pain postoperatively and this deteriorated despite conservative management. Repeat ultrasounds and abdominal computer tomography scans ruled out mechanical obstruction. The clinical presentation and blood parameters excluded toxic megacolon and cecal volvulus. As the symptoms persisted, a laparotomy was performed on postoperative day 16, which demonstrated ragged tears of the colon and cecum. A right hemi-colectomy followed by ileocecal anastomosis was required. The pathological examination of surgical specimens excluded inflammatory bowel disease and vascular abnormalities. The patient made a good recovery following bowel surgery and at latest followup 3.2 years later she had no abdominal complaints and an excellent scoliosis correction. Ogilvie's syndrome should be included in the differential diagnosis of postoperative ileus in patients developing prolonged unexplained abdominal distension and pain after scoliosis correction. Early diagnosis and instigation of conservative management can prevent major morbidity and mortality due to bowel ischemia and perforation.

Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome)

Acute colonic pseudo-obstruction is a complication that occurs in hospitalized patients with serious underlying medical or surgical conditions; it is characterized by acute colonic dilatation in the absence of mechanical obstruction. The pathogenesis is incompletely elucidated, but changes in autonomic nervous system function are likely to contribute, as are metabolic and pharmacologic factors. Early diagnosis and appropriate intervention are critical in this disorder, which carries with it considerable morbidity and mortality. Treatment options, consecutively applied, include conservative measures, pharmacologic treatment with neostigmine, and endoscopic decompression. Surgical decompression or resection is necessary in case of refractoriness or perforation, respectively.

Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems

Purpose

Acute gastrointestinal (GI) dysfunction and failure have been increasingly recognized in critically ill patients. The variety of definitions proposed in the past has led to confusion and difficulty in comparing one study to another. An international working group convened to standardize the definitions for acute GI failure and GI symptoms and to review the therapeutic options.

Methods

The Working Group on Abdominal Problems (WGAP) of the European Society of Intensive Care Medicine (ESICM) developed the definitions for GI dysfunction in intensive care patients on the basis of the available evidence and current understanding of the pathophysiology.

Results

Definitions for acute gastrointestinal injury (AGI) with its four grades of severity, as well as for feeding intolerance syndrome and GI symptoms (e.g. vomiting, diarrhoea, paralysis, high gastric residual volumes) are proposed. AGI is a malfunctioning of the GI tract in intensive care patients due to their acute illness. AGI grade I = increased risk of developing GI dysfunction or failure (a self-limiting condition); AGI grade II = GI dysfunction (a condition that requires interventions); AGI grade III = GI failure (GI function cannot be restored with interventions); AGI grade IV = dramatically manifesting GI failure (a condition that is immediately life-threatening). Current evidence and expert opinions regarding treatment of acute GI dysfunction are provided.

Conclusions

State-of-the-art definitions for GI dysfunction with gradation as well as management recommendations are proposed on the basis of current medical evidence and expert opinion. The WGAP recommends using these definitions for clinical and research purposes.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-011-2459-y) contains supplementary material, which is available to authorized users.

Ogilvie's syndrome-related right colon perforation after cesarean section: a case series

The objective of this article is to discuss and report three cases of right colon perforation secondary to postcesarean Ogilvie's syndrome (OS; colonic pseudo-obstruction) requiring right hemicolectomy. We retrospectively reviewed the case notes of three patients who underwent caesarean section and postoperatively developed OS. OS is an uncommon problem in patients undergoing caesarean section. Abdominal X-ray and water-soluble contrast enema are the main diagnostic modalities. Drip-suck therapy along with endoscopic or pharmacological decompression should be performed in early stages. In a significant percentage of patients, diagnosis is delayed resulting in bowel ischemia and perforation requiring surgical resection and adding significant mortality/morbidity. We recommend our obstetric colleagues to involve surgical team in earlier stages to avoid surgery-related mortality and morbidity. We also advocate general surgeons to be aware of OS in patients after caesarean section and recommend a stepwise systematic approach toward the diagnosis and management of OS.

The role of colonoscopy in the management of intestinal obstruction: a 20-year retrospective study

PURPOSE

The aim of the study was to assess the use colonoscopy over time in the assessment of large bowel obstruction in a tertiary university hospital.

METHODS

Retrospective analysis of surgical and colonoscopy records for the years 1990-2009 in a university hospital. All patients diagnosed with non-conservatively managed bowel obstruction were included.

RESULTS

We recorded 644 patients diagnosed with non-conservatively managed bowel obstruction. Four hundred forty-one (67.3%) were managed only by surgery, 157 (23.6%) were managed by colonoscopy, and 46 (6.9%) by combined colonoscopy and surgery. Patients over 77 years were more likely to receive colonoscopy as monotherapy or combined with surgery as compared to younger patients. Management by colonoscopy only and by combined colonoscopy and surgery increased over time.

CONCLUSIONS

Colonoscopy in the management of non-conservatively treated bowel obstruction increased over time. However, therapeutic colonoscopy still has a limited role in bowel obstruction either as monotherapy or combined with surgery.

Acute colonic pseudo-obstruction

Background

Acute colonic pseudo-obstruction is characterized by clinical and radiological evidence of acute large bowel obstruction in the absence of a mechanical cause. The condition usually affects elderly people with underlying co-morbidities, and early recognition and appropriate management are essential to reduce the occurrence of life-threatening complications.

Methods

A part-systematic review was conducted. This was based on key publications focusing on advances in management.

Results and conclusions

Although acute colonic dilatation has been suggested to result from a functional imbalance in autonomic nerve supply, there is little direct evidence for this. Other aetiologies derived from the evolving field of neurogastroenterology remain underexplored. The rationale of treatment is to achieve prompt and effective colonic decompression. Initial management includes supportive interventions that may be followed by pharmacological therapy. Controlled clinical trials have shown that the acetylcholinesterase inhibitor neostigmine is an effective treatment with initial response rates of 60–90 per cent; other drugs for use in this area are in evolution. Colonoscopic decompression is successful in approximately 80 per cent of patients, with other minimally invasive strategies continuing to be developed. Surgery has thus become largely limited to those in whom complications occur. A contemporary management algorithm is provided on this basis.

Amitraz: an unusual aetiology of Ogilvie's syndrome

Amitraz is an insecticide/acaricide of formamidine pesticides used worldwide for ectoparasites in animals. Because of its widespread use, amitraz poisoning is frequently encountered in Turkey.

CASE REPORT

A 36-year-old, comatose female was admitted to the hospital. Although it was stated that she had taken a glass of water containing amitraz, the exact volume of the substance was unknown. On admission, her Glasgow Coma Scale score was 10/15. Clinical findings were vomiting, miosis, bradycardia and hypotension. The patient's vital signs were body temperature 37.2 degrees C, pulse 54 bpm, blood pressure 80/50 mmHg and pulseoximetry 84%. Supportive treatment consisting of oxygen, fluid replacement and gastric lavage, activated charcoal and atropine was administered. On the second day, signs of Ogilvie's syndrome characterized by severe tenderness, distension and pain in the abdomen were seen. On the third day, the patient's condition improved except for abdominal distension and pain, inability to pass faeces or flatus through the anus. Although continuous nasogastric tube decompression was performed, her complaints were not resolved completely. Neostigmine was administered on the fourth day. On the fifth day, abdominal pain and distension were decreased, and stool passage began. She had a complete clinical and laboratory improvement, which warranted her discharge on the seventh day of admission.

Stimulated active potassium secretion in a patient with colonic pseudo-obstruction: a new mechanism of secretory diarrhea

BACKGROUND & AIMS

Secretory diarrhea is caused by inhibition of intestinal active sodium absorption and stimulation of active chloride secretion. The resulting increase in fecal sodium salts causes an isotonic increase in fecal water output. Abnormalities in potassium transport are not known to be a cause of secretory diarrhea. The aim of our report is to describe a patient with secretory diarrhea that was mediated by excess intestinal secretion of potassium.

METHODS

A 78-year-old woman developed colonic pseudo-obstruction, complicated by severe diarrhea and hypokalemia. Her stools were collected quantitatively on 11 occasions and analyzed for electrolyte concentrations. Rectosigmoid potential difference was measured.

RESULTS

The diarrheal fluid had a very high potassium concentration (130-170 mEq/L) and a very low sodium concentration (4-15 mEq/L). Stool potassium losses were as high as 256 mEq/day (normal, 9 mEq/day), and fecal sodium losses were never higher than 13 mEq/day. Potential difference between colonic lumen and a peripheral reference electrode was -14 mV (lumen side negative).

CONCLUSIONS

Fecal potassium salts were the exclusive driving force for severe secretory diarrhea in a patient with colonic pseudo-obstruction. The high fecal output of potassium was due to stimulation of active colonic potassium secretion, possibly because of changes in autonomic nervous system activity and distention of the colon in association with colonic pseudo-obstruction. The extremely low fecal excretion of sodium indicates that active sodium absorption was not inhibited. This case study reveals an ion transport mechanism of secretory diarrhea that has not been previously appreciated.

Acute colonic pseudo-obstruction following major orthopaedic surgery

OBJECTIVE

Acute colonic pseudo-obstruction (ACPO) has been linked with multiple aetiologies including orthopaedic surgery. However, the actual incidence and natural progression are not well described in these patients. We aim to assess the incidence of ACPO in patients undergoing elective orthopaedic procedures, and to examine for potential exacerbating factors.

PATIENTS AND METHODS

All patients from the orthopaedic directorate that had abdominal imaging in the five years from August 1998 to August 2003 were identified from radiology archives. A manual search of the patients' notes was conducted with data recorded on the patients' history, operative details and their postoperative course including their haematological and biochemical results. Details regarding their ACPO were documented with respect to the onset of symptoms, how the diagnosis was achieved, what treatment was instigated and how the condition progressed. A control group of age and sex matched patients was included for comparison.

RESULTS

Thirty-five patients with ACPO were identified. The operations included 21 hip replacements, 10 knee replacements and 4 spinal operations. The incidence of ACPO was 1.3%, 0.65% and 1.19%, respectively. In comparison to control patients, patients with ACPO had a lower postoperative serum sodium (P = 0.001), a higher serum urea (P = 0.021) and remained in hospital longer (P < 0.001).

CONCLUSION

ACPO is uncommon in orthopaedic patients, however, its occurrence results in prolonged hospital stay. Attention to patients' postoperative fluid balance and biochemical status may reduce the incidence.

Acute colonic pseudoobstruction

Acute colonic pseudoobstruction (ACPO) is a clinical condition of acute large bowel obstruction without mechanical blockage. ACPO occurs most often in hospitalized patients with serious underlying medical and surgical conditions. ACPO is an important cause of morbidity and mortality. The pathogenesis of ACPO is not completely understood but likely results from an imbalance in the autonomic regulation of colonic motor function. Metabolic or pharmacologic factors, as well as spinal or retroperitoneal trauma, may alter the autonomic regulation of colonic function, leading to excessive parasympathetic suppression or sympathetic stimulation. This imbalance results in colonic atony and pseudoobstruction. Early recognition and appropriate management are critical to minimizing morbidity and mortality. The mortality rate is estimated at 40% when ischemia or perforation occurs. The best documented treatment of ACPO is intravenous neostigmine, which leads to prompt decompression in the majority of patients after a single infusion. In patients failing or having contraindications to neostigmine, colonoscopic decompression is the active intervention of choice. Surgery is reserved for those with overt peritonitis or perforation.

Ogilvie's syndrome: a rare complication of inguinal hernia repair

A 49-year-old man had an open, tension-free, mesh (Lichtenstein) repair performed under general anaesthetic for a left-sided direct inguinal hernia. His immediate postoperative recovery was uneventful and he was discharged the following day. He was readmitted as an emergency 2 days later with intermittent abdominal pain, nausea and complete constipation. On examination his abdomen was slightly distended, but was not tender. X-ray (Figure 1) showed dilated loops of small bowel with gas in the colon and rectum.

He was managed conservatively. However, over the next 24 hours his symptoms became worse with increasing abdominal pain and vomiting. He was still passing no flatus. His abdomen became more distended and generally tender to light palpation. Repeat X-ray (Figure 2) revealed markedly distended small bowel and a grossly distended caecum. He proceeded to theatre as the caecal distension was increasing and he had developed signs of peritoneal irritation.

At laparotomy his bowel was free from the left hernia repair and no mechanical cause for the obstruction was found. The colon was distended to the rectum and the caecum was 10 cm in diameter with tearing almost imminent. It was therefore decompressed with an aspiration needle and on-table sigmoidoscopy. Appendicectomy was performed and the stump used to place a caecostomy. Recovery was slow but he was discharged home 2 weeks after readmission.

Assessment of predictors of response to neostigmine for acute colonic pseudo-obstruction

OBJECTIVE

Acute colonic pseudoobstruction (ACPO) most commonly develops after surgery, with narcotic administration, or in association with severe illness. Most cases resolve with conservative management. Colonoscopic decompression may be required in patients failing to respond to conservative treatment. Neostigmine has been proposed as an effective treatment for ACPO as an alternative to colonoscopic decompression. We sought to identify factors associated with spontaneous resolution of ACPO and to identify variables associated with a response to i.v. administration of neostigmine for the treatment of ACPO.

METHODS

Retrospective analysis of Mayo Clinic's diagnostic index revealed all patients who developed ACPO between July, 1999 and September, 2001 at the Mayo Clinic Medical Center. We separately analyzed those patients who did not resolve ACPO with conservative management and to whom i.v. neostigmine was administered. Patient records were abstracted for demographic data, etiology of ACPO, management, and response to treatment.

RESULTS

A total of 151 patients were identified with ACPO between July, 1999 and September, 2001; 117 patients (77%) had spontaneous resolution of symptoms. Of the 34 "nonresolvers," 18 patients received neostigmine, whereas 16 did not receive neostigmine. Of those 16 patients, 11 required colonoscopic decompression, two underwent surgery, and three died of underlying illness. "Spontaneous resolvers" were less likely to be taking narcotics (59% vs 74%, p = 0.08). Of the 16 nonresolvers who did not receive neostigmine, only one had a contraindication to neostigmine use. Of the 18 patients that who received neostigmine, 16 patients (89%) had prompt evacuation (<30 min) of flatus or stool. Sustained clinical response to neostigmine was noted in 11 of 18 (61%); the remaining seven patients (39%) required colonoscopic decompression or surgery for recurrent or persistent colonic dilation. Neostigmine-responders were more likely to be older (mean age, 76 yr vs 54 yr, p = 0.03), than nonresponders. Preneostigmine cecal diameter did not differ significantly between responders (median, 12 cm) and nonresponders (median, 13 cm), p = 0.9. Median time to resolution of ACPO in spontaneous resolvers was 4 days compared to 2 days in patients responding to neostigmine; p = 0.038.

CONCLUSIONS

Most patients with ACPO respond to conservative treatment. Female gender and older age are associated with a response to neostigmine in those patients who do not respond to conservative management. Neostigmine appears to be under-used in patients with ACPO who do not have a true contraindication to its use.

Acute colonic pseudo-obstruction after elective total joint arthroplasty

A retrospective review of 31 patients who developed acute colonic pseudo-obstruction (ACPO) after total joint arthroplasty was undertaken to determine predisposing factors related to, and outcomes following, therapeutic intervention. Comparison with all patients who underwent total joint arthroplasty revealed an overall 1.2% incidence of ACPO. There was a higher incidence of ACPO in patients undergoing sequential bilateral total knee arthroplasty (3.4%) compared with unilateral total knee arthroplasty (0.3%) and a higher incidence in patients undergoing revision total hip arthroplasty (5.6%) compared with primary total hip arthroplasty (1.4%). Additional risk factors for developing ACPO included slow postoperative mobilization and male gender. No association was found with respect to body mass index, age, comorbidity, anesthetic type, international normalized ratio level, or postoperative analgesia. There were no deaths, and 2 patients required operative intervention. The remaining cases of ACPO resolved with nonsurgical treatment. In all cases, there was a prolonged length of hospitalization (mean, 13.2 days) compared with all other arthroplasties performed at our institution (mean, 7.5 days).

The use of neostigmine to treat postoperative ileus in orthopedic spinal patients

Ileus is a common complication of spinal surgery, affecting 5% to 12% of all patients. Often this ileus is secondary to acute colonic pseudo-obstruction. This study is a prospective clinical trial of neostigmine in seven spinal patients with ileus after surgery to demonstrate its efficacy. All patients had evidence of the Ogilvie syndrome that was unresponsive to 24 hours of conservative therapy. Patients received 2 mg neostigmine, and abdominal circumference, clinical response, and radiographic colonic measurements were recorded. Patients were followed for recurrence of ileus for their remaining time in the hospital. Six patients had prompt colonic decompression, and no patient had recurrence of colonic distension. Side effects were minimal. These results suggest that postoperative spinal patients with ileus secondary to acute colonic pseudo-obstruction that is unresponsive to conservative therapy benefit from treatment with neostigmine, resulting in safe, rapid decompression of the colon.

Review article: the pharmacological treatment of acute colonic pseudo-obstruction

Acute colonic pseudo-obstruction (Ogilvie's syndrome) can be defined as a clinical condition with symptoms, signs and radiological appearance of acute large bowel obstruction unrelated to any mechanical cause. Recent reports of the efficacy of cholinesterase inhibitors in relieving acute colonic pseudo-obstruction have fuelled interest in the pharmacological treatment of this condition. The aim of the present review is to outline current perspectives in the pharmacological treatment of patients with acute colonic pseudo-obstruction. The best documented pharmacological treatment of Ogilvie's syndrome is intravenous neostigmine (2-2.5 mg), which leads to quick decompression in a significant proportion of patients after a single infusion. However, the search for new colokinetic agents for the treatment of lower gut motor disorders has made available a number of drugs that may also be therapeutic options for Ogilvie's syndrome. Among these agents, the potential of 5-hydroxytryptamine-4 receptor agonists and motilin receptor agonists is discussed.

Update on acute colonic pseudo-obstruction

Acute colonic pseudo-obstruction is characterized by distention of the colon in the absence of mechanical obstruction. This presentation is typically related to recent surgery, severe illness, or medication. Nasogastric and rectal tube decompression and correction of electrolyte abnormalities are the standard of care. Colonoscopic decompression, performed in a number of these cases, was felt to be unwarranted in many situations and is associated with a high recurrence rate. Medical management beyond conservative measures has been limited. Medical therapy with pharmacologic agents such as erythromycin, metoclopromide, and cisapride was of limited use. Recent findings confirm that an older agent, neostigmine, provides excellent results, including colonic decompression and clinical improvement after administration. This suggests a new standard of care.

Retrospective Study of Neostigmine for the Treatment of Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction (ACPO) typically develops postoperatively or after severe illness. Studies suggest that pharmacologic manipulation with intravenous (IV) neostigmine (NSM) may be an effective and less invasive treatment modality for ACPO with minimal side effects. The purpose of this study was to retrospectively assess the efficacy and incidence of complications of an IV NSM bolus in patients with ACPO. Eight patients with ten episodes of ACPO were treated with a bolus dose of NSM. Rapid and effective decompression of the colon was achieved in six episodes after a single dose of NSM at a mean of 22.8 ± 13.5 minutes. In three episodes decompression occurred after a second dose of NSM at a mean of 44.7 ± 37.7 minutes. One patient failed NSM treatment but responded to a Cystografin enema. One patient experienced significant bradycardia. NSM is a simple, safe, and effective treatment for ACPO and based on result comparison of this study and previous studies both bolus and slow infusion dosing practices of NSM are effective. The NSM bolus dosing side effect profile has been shown to include significant bradycardia, whereas when NSM was infused over one hour significant bradycardic episodes requiring treatment have not been encountered. We propose that a prospective study evaluating NSM dosing as an IV bolus versus an IV infusion would be useful in determining whether NSM infusion can be proven safer than bolus dosing for the treatment of ACPO.

Postoperative colonic motility and tone in patients after colorectal surgery

PURPOSE

Colonic motility is crucial for the resolution of postoperative ileus. However, few data are available on postoperative colonic motility and no data on postoperative colonic tone. We aimed to characterize postoperative colonic tone and motility in patients.

METHODS

Nineteen patients were investigated with combined barostat and manometry recordings after left colonic surgery. During surgery a combined recording catheter was placed in the colon with two barostat bags and four manometry channels cephalad to the anastomosis. Recordings were performed twice daily from Day 1 to Day 3 after surgery.

RESULTS

Manometry showed an increasing colonic motility index, which was a mean (+/- standard error of the mean) of 37 +/- 5 mmHg/minute on Day 1, 87 +/- 19 mmHg/minute on Day 2, and 102 +/- 13 mmHg/minute on Day 3 (P < 0.05 for Day 1 vs. Day 2 and Day 2 vs. Day 3). Low barostat bag volumes indicating a high colonic tone were observed on Day 1 after surgery and increased subsequently (barostat bag I was 19 +/- 4, 32 +/- 6, and 32 +/- 6 ml; barostat bag II was 13 +/- 1, 19 +/- 3, and 22 +/- 5 ml on Days 1, 2, and 3, respectively; for both barostat bags P < 0.05 for Day 1 vs. Day 2 but not Day 2 vs. Day 3).

CONCLUSIONS

Colonic motility increased during the postoperative course. The low barostat bag volumes indicated a high colonic tone postoperatively which would correspond to a contracted rather than to a distended colon. High colonic tone postoperatively may be relevant for pharmacologic treatment of postoperative ileus.

Treatment of acute colonic pseudo-obstruction with neostigmine

BACKGROUND

Colonic pseudo-obstruction is a poorly understood syndrome, described by Ogilvie, and characterized by signs of large-bowel obstruction, without a mechanical cause. An imbalance in the autonomic nerve supply to the colon has been suggested as the pathophysiology. Recently, promising results with pharmacologic manipulation with neostigmine have been described.

STUDY DESIGN

A prospective study was undertaken with 11 consecutive patients with clinical and radiologic signs of colonic pseudo-obstruction, in one general hospital, over a 1-year period. Patients were treated primarily with 2.5 mg of neostigmine in 100 mL of saline for 1 hour, under cardiac monitoring. Results were assessed by the clinical and radiologic responses.

RESULTS

Rapid and effective spontaneous decompression of the colon was achieved in 8 patients after a single dose of neostigmine, within a mean of 90 minutes from the beginning of treatment. In another two patients decompression occurred only after a second dose was administered 3 hours after the first dose. In one patient, no changes were observed and colonoscopic decompression was performed. No significant bradycardia was observed in any of the patients.

CONCLUSIONS

Neostigmine is a simple, safe, and effective therapy for treatment of colonic pseudo-obstruction.

Neostigmine for the treatment of acute colonic pseudo-obstruction

BACKGROUND

Acute colonic pseudo-obstruction -- that is, massive dilation of the colon without mechanical obstruction -- may develop after surgery or severe illness. Although it may resolve with conservative therapy, colonoscopic decompression is sometimes needed to prevent ischemia and perforation of the bowel. Uncontrolled studies have suggested that neostigmine, may be an effective treatment.

METHODS

We studied 21 patients with acute colonic pseudo-obstruction. All had abdominal distention and radiographic evidence of colonic dilation, with a cecal diameter of at least 10 cm, and had had no response to at least 24 hours of conservative treatment. We randomly assigned 11 to receive 2.0 mg of neostigmine intravenously and 10 to receive intravenous saline. A physician who was unaware of the patients' treatment assignments recorded clinical response (defined as prompt evacuation of flatus or stool and a reduction in abdominal distention), abdominal circumference, and measurements of the colon on radiographs. Patients who had no response to the initial injection were eligible to receive open-label neostigmine three hours later.

RESULTS

Ten of the 11 patients who received neostigmine had prompt colonic decompression, as compared with none of the 10 patients who received placebo (P<0.001). The median time to response was 4 minutes (range, 3 to 30). Seven patients in the placebo group and the one patient in the neostigmine group without an initial response received open-label neostigmine; all had colonic decompression. Two patients who had an initial response to neostigmine required colonoscopic decompression for recurrence of colonic distention; one eventually underwent subtotal colectomy. Side effects of neostigmine included abdominal pain, excess salivation, and vomiting. Symptomatic bradycardia developed in two patients and was treated with atropine.

CONCLUSIONS

In patients with acute colonic pseudo-obstruction who have not had a response to conservative therapy, treatment with neostigmine rapidly decompresses the colon.

Acute colonic pseudo-obstruction (Ogilvie's syndrome) after renal transplantation

BACKGROUND

Acute colonic pseudo-obstruction (Ogilvie's syndrome) in the immunosuppressed patient is associated with increased morbidity and mortality. Renal transplant recipients possess several comorbidities that increase the risk of acute pseudo-obstruction of the colon. The aims of this study were to present our experience with this syndrome and to evaluate the potentiating factors in these patients. A review of the literature for pseudo-obstruction following renal transplantation is presented.

METHODS

Seven patients who developed Ogilvie's syndrome were identified in a retrospective review of 550 kidney-only transplants. Pretransplant data, potential risk factors, presentation, management, and outcome details were retrieved. The medical literature was reviewed using Medline.

RESULTS

Seventy-eight patients with Ogilvie's syndrome in the early posttransplant period have been reported. The associated morbidity and mortality was heightened in this immunocompromised population. Obese transplant recipients (body mass index >30 kg/m2) were at significantly increased risk for developing this syndrome.

CONCLUSION

A broad armamentarium of treatment options is available, but the key to successful resolution lies in early recognition.

Intestinal pseudo-obstruction

Pseudo-obstruction syndromes are increasingly recognized in clinical practice. They result from impairment of intrinsic neuromuscular or extrinsic control of gut motility. Typically, pseudo-obstruction syndromes result in features suggestive of mechanical obstruction and bowel dilatation in the absence of any demonstrable obstruction or mucosal disease. The syndrome may affect any region of the gut. Less severe variants without bowel dilatation are diagnosed by measurement of gastrointestinal transit and pressure profiles. The aims of treatment are restoration of nutrition and hydration, symptom relief, normalization of intestinal propulsion with prokinetics, and suppression of bacterial overgrowth. Surgery plays a limited role, adjunctive to medical treatment, facilitating enteral nutrition and decompression by means of jejunostomy. Infrequently, resection of localized disease or intestinal transplantation are indicated. The roles of intestinal pacemakers (interstitial cells of Cajal) and genetic mutations in the etiology of pseudo-obstruction, as well as the cost-benefit ratio of transplantation for pseudo-obstruction, will be clarified in the future.

Acute colonic pseudo-obstruction

BACKGROUND

Acute colonic pseudo-obstruction is an acute non-mechanical colonic obstruction. Twenty patients with this condition presenting between 1988 and 1996 were retrospectively reviewed to identify the incidence and potential aetiologic factors, and to establish a uniform therapeutic approach.

METHODS

Patients who fulfilled the criteria of acute pseudo-obstruction of the colon were reviewed retrospectively from a computerized database, and from a study of the hospital notes.

RESULTS

There were 12 men and eight women with a median age of 71 years. Seventeen patients (85%) had various coexisting medical conditions, and none of the cases had a recent surgical operation or trauma. Four patients had previous similar attacks. Patients had a median duration of symptoms and a hospital stay of 3 and 7 days, respectively. Diagnosis was based on the clinical features coupled with the findings on plain abdominal X-rays and contrast enema. Sixteen patients were successfully treated conservatively over a median time of 5 days. Three patients had a laparotomy: two patients had tube caecostomy (followed by complications), and one patient had no further treatment. One patient had colonoscopy with an unsatisfactory result. Two patients (10%) died and three (15%) developed complications.

CONCLUSIONS

Acute colonic pseudo-obstruction is an uncommon but serious condition. The majority of our patients (17/20) had associated significant medical problems. Most of the patients were successfully managed conservatively. This was the preferred initial line of treatment in this department during the study period.

Early resolution of Ogilvie's syndrome with intravenous neostigmine: a simple, effective treatment

PURPOSE

Our aim was to assess the value of a parasympathomimetic drug (neostigmine) in the early resolution of acute colonic pseudo-obstruction (Ogilvie's syndrome).

METHODS

A prospective study was undertaken in 18 consecutive patients (mean age, 76 (range, 31-87) years) with acute colonic pseudo-obstruction. After a varying period of conservative treatment in all cases, 16 patients with persistent, massive abdominal distention were given intravenous neostigmine.

RESULTS

A rapid and satisfactory clinical and radiologic decompression of the large bowel was obtained in 12 patients (75 percent) after a single dose of the drug; another patient had complete resolution after a second dose, and the other 3 patients had only partial resolution, in one of them after a second dose of the drug. No patient required surgical decompression of the bowel.

CONCLUSION

These results give support to the theory of excessive parasympathetic suppression in most cases of Ogilvie's syndrome. The treatment with intravenous neostigmine has proved very effective, preventing in many cases prolonged periods of uncomfortable and potentially hazardous conventional conservative management and avoiding surgical treatment in a consecutive series of patients.

Recurrence of acute colonic pseudo-obstruction in selective adrenergic dysautonomia associated with infectious toxoplasmosis

BACKGROUND

Acute colonic pseudo-obstruction is a life-threatening condition associated with several pathologic conditions, whose pathophysiology is still uncertain.

CASE

Autonomic function in a young patient operated on for acute colonic pseudo-obstruction was carefully evaluated; none of the common clinical conditions described in the literature was found to have caused the syndrome. Selective adrenergic failure was suggested by the presence of severe orthostatic hypotension, low basal plasma catecholamine level, and absence of the expected increase on standing and by the findings of provocation tests, cardiovascular tests, and acetylcholine sweat spot test. Biopsy specimens from the colon and small-bowel wall did not show any morphologic or immunohistochemical alteration either in muscle layers or in the autonomic plexus, testifying to the possible occurrence of extrinsic denervation in the presence of an intact plexus. Infectious toxoplasmosis was proved through indirect and direct hemagglutination assays, enzyme-linked immunosorbent assay IgG, IgM, and IgA, immunosorbent agglutination IgM assay, and the protozoa were demonstrated in a biopsy specimen from the rectus abdominis muscle.

CONCLUSIONS

Selective adrenergic denervation of the gut resulted in recurrent episodes of colonic pseudo-obstruction, probably by direct toxicity or a cross-reaction between the immune process and a toxoplasmic antigen, stressing the importance of sympathetic inhibitory modulation on colon motor activity.

Colonic pseudo-obstruction: a complication of herpes zoster

Herpes zoster has been associated rarely with somatic and visceral motor complications, including segmental motor paralysis, neurogenic bladder dysfunction and, unusually, colonic pseudo-obstruction. We report a patient who developed acute pseudo-obstruction of the colon which followed the appearance of dermatomal herpes zoster.

Colonic pseudo-obstruction: a complication of herpes zoster

Herpes zoster has been associated rarely with somatic and visceral motor complications, including segmental motor paralysis, neurogenic bladder dysfunction and, unusually, colonic pseudo-obstruction. We report a patient who developed acute pseudo-obstruction of the colon which followed the appearance of dermatomal herpes zoster.

Septicaemia and abdominal distension

Images

Endoscopic decompression for acute colonic pseudo-obstruction

BACKGROUND

Acute colonic pseudo-obstruction is often treated by colonoscopic decompression. Efficacy, safety, and outcome of endoscopic decompression was assessed.

METHODS

Colonoscopic decompressions from 1988 to 1994 were reviewed. Resolution without further endoscopic intervention was defined as clinical success.

RESULTS

Acute colonic pseudo-obstruction was diagnosed in 50 patients. Thirty-three cases followed surgery or trauma and 17 developed during severe medical illness. Orthopedic joint surgery was most common. Nineteen of 50 patients (38%) had severe underlying medical disease. Forty-one patients (82%) had one colonoscopic decompression with clinical success in 39 (95%). Nine patients (18%) required multiple (2 to 4) colonoscopic decompressions with clinical success in 5 (56%). A decompression tube positioned in the right colon (57%) and in the transverse colon (33%) had similar clinical success. In 8 procedures a decompression tube was not placed, with poor clinical success (25%). The overall clinical success of colonoscopic decompression was 88% (44 of 50). An endoscopic perforation occurred in 1 patient (2%). Overall hospital mortality was 30%.

CONCLUSIONS

Colonoscopic decompression is effective and safe for acute colonic pseudo-obstruction that does not respond to conservative therapy. Most patients will respond to one colonoscopic decompression with decompression tube placement. Complete colonoscopy and cecal tube placement is unnecessary.

Cytomegalovirus causing acute colonic pseudo-obstruction in a renal transplant recipient

A female patient presented with pyrexia and features of large intestinal obstruction, 10 weeks posttransplantation, with biopsy-proven colitis caused by cytomegalovirus (CMV) and positive CMV antigenaemia and IgM tests. The symptoms resolved after treatment with ganciclovir, nasogastric aspiration and intravenous fluid replacement.