Acute colonic pseudo-obstruction

Management of acute colonic pseudo-obstruction: opportunities to improve care?

BACKGROUND

Acute colonic pseudo-obstruction (ACPO) is a functional bowel obstruction characterised by colonic dilatation in the absence of mechanical obstruction on imaging. Complications include bowel ischaemia, perforation and death. The aim of this study was to explore outcomes for patients treated for ACPO and to assess adherence to current ACPO treatment guidelines.

METHODS

This is a retrospective service evaluation and included patients with a diagnosis of ACPO between 1 March 2018 and 31 March 2023. Process measures were identified following discussion with the clinical team from published guidance. Patients were identified using clinical coding and radiological text reports. Cases were eligible for inclusion if they had radiologically confirmed ACPO. Data were collected following review of patient notes into Microsoft Excel. Descriptive analysis was performed with no formal statistical assessment.

RESULTS

A total of 45 patients were identified, of whom 13 were admitted under general surgery. All patients received admission bloods (n=45). Nearly all patients had computed tomography imaging (43/45, 96%). Only 3/45 (6.7%) of the patients received optimal conservative management (intravenous infusion, nil by mouth, flatus tube, treatment of reversible causes). In all, 11/45 (24%) required further treatment, of whom 7 received this within 72 h. The leading (11/45) complication following diagnosis of ACPO was hospital-acquired pneumonia. Mortality was seen in 9/45.

CONCLUSIONS

ACPO is often managed remotely by general surgeons. This may impact on the quality of conservative management, and timeliness of endoscopic or pharmacological intervention. Further work is needed to optimise management.

Evaluation of 18 CT signs in diagnosing cecal volvulus: a multi-reader retrospective study

PURPOSE

To assess the diagnostic performance and reliability of 18 CT signs to diagnose cecal volvulus, a surgical emergency, versus a group of non-volvulus mimickers.

MATERIALS AND METHODS

Four radiologists retrospectively and independently assessed 18 CT signs in 191 patients with cecal volvulus (n = 63) or a non-volvulus control group ((n = 128), including cecal bascule (n = 19), mobile cecum (n = 95), and colonic pseudo-obstruction (n = 14)) at a single institution from 2013 to 2021. Fleiss' kappa coefficient was used to assess inter-reader agreement. For diagnostic performance metrics, we assessed sensitivity, specificity, and positive and negative predictive values. For predictive performance, all 18 signs were included in bivariate and stepwise lasso multivariate logistic regression models to diagnose cecal volvulus. Performance was assessed by ROC curves.

RESULTS

191 patients (mean age: 63 years +/- 15.5 [SD]; 135 women) were included in the study. Nine of the 18 CT signs of cecal volvulus demonstrated good or better (> 0.6) inter-reader agreement. Individual CT signs with sensitivity, specificity, positive and negative predictive values all above 70% for diagnosing cecal volvulus were transition point, bird beak, and X-marks-the-spot. A lasso regression model determined four CT features: transition point, bird beak, coffee bean, and whirl had excellent prediction (AUC = .979) for cecal volvulus if all present.

CONCLUSION

CT signs for cecal volvulus that have high sensitivity and specificity include: transition point, bird beak, and X-marks-the-spot and were reliable in distinguishing non-volvulus mimickers. If the following four features were present: transition point, bird beak, coffee bean, and whirl, there was excellent prediction (AUC = .979) for cecal volvulus.

From the Heart to the Gut: A Case Report of a Rare Complication After Coronary Artery Bypass Graft Surgery

Coronary artery bypass graft (CABG) surgery has a major role in the management of obstructive coronary artery disease, especially in patients with diabetes or multiple vessel disease. Currently, in the USA, the annual incidence rate of CABG has been reported to be approximately 400,000. Overall, gastrointestinal (GI) complications occur in less than 2% of patients undergoing open-heart surgery. Acute colonic pseudo-obstruction, also known as Ogilvie's syndrome, is a disorder characterized by dilatation of the colon in the absence of an anatomic lesion that obstructs the flow of intestinal contents. This condition occurs in 0.06% of patients following cardiac surgery, and in CABG patients, the reported incidence is approximately 0.046%. In this report, we discuss a case of a patient who developed Ogilvie's syndrome after undergoing CABG.

Percutaneous endoscopic cecostomy for management of Ogilvie's syndrome: a case series and literature review with an update on current guidelines (with video)

INTRODUCTION

Percutaneous endoscopic cecostomy (PEC) is a viable treatment option for patients with persistent or recurrent acute colonic pseudo-obstruction (ACPO; Ogilvie's syndrome). It should be generally considered in patients that are refractory to pharmacologic and endoscopic decompression, especially those not amenable to surgical intervention due to an increased perioperative risk. Physicians are rather unfamiliar with this approach given the limited number of reports in the literature and paucity of guideline resources, although guidelines concerning ACPO and covering the role of endoscopy were recently published by three major expert societies, all within the last 2 years.

PATIENTS AND METHODS

We retrospectively identified three consecutive patients who underwent PEC placement at a Czech tertiary referral center between May 2018 and December 2021: all for recurrent ACPO. In addition, we summarized the current guidelines in order to present the latest knowledge related both to the procedure and management approach in patients with ACPO.

RESULTS

The placement of PEC was successful and resulted in clinical improvement in all cases without any adverse events.

CONCLUSION

The results of our experience are in line with previous reports and suggest that PEC may become a very useful tool in the armamentarium of modalities utilized to treat ACPO. Furthermore, the availability of guideline resources now offers comprehensive guidance for informed decision-making and the procedural aspects.

Acute Colonic Pseudo-Obstruction: Colonoscopy versus Neostigmine First?

INTRODUCTION

Neostigmine (NEO) and decompressive colonoscopy (COL) are two efficacious treatment modalities for acute colonic pseudo-obstruction (ACPO). We hypothesize that a COL first strategy is associated with better outcomes compared to a NEO first strategy.

METHODS

A single-center retrospective analysis was performed from 2013 to 2020. Patients ≥18 y with a diagnosis of ACPO were included. The outcome was a composite measure of acute operative intervention, 30-day readmission with ACPO, and 30-day ACPO-related mortality. A P-value of ≤ 0.05 indicated statistical significance.

RESULTS

Of 910 encounters in 849 patients, 50 (5.5%) episodes of ACPO in 39 patients were identified after exclusion of one patient with colon perforation on presentation. The median (interquartile range) age was 68 (62-84) y. NEO and COL were administered in 21 and 25 episodes, respectively. In 16 (32%) episodes, no NEO or COL was administered. When patients were given NEO first, COL or additional NEO was required in 12/18 (67%) compared with a COL first strategy where a second COL and/or NEO was given in 5/16 (32%) (P = 0.05). Both strategies had similar outcomes (NEO, 4/18 versus COL, 4/16, P = 0.85). Twenty-two (44%) episodes had an early intervention (≤48 h) with NEO and/or COL. There was no difference in outcome between those that received an early intervention and those who did not (5/22 versus 5/28, P = 0.71).

CONCLUSIONS

For patients failing conservative measures, a COL first approach was associated with fewer subsequent interventions, but with similar composite outcomes compared to a NEO first approach. Early (≤48 h) intervention with NEO and/or COL was not associated with improved outcomes.

Pharmacological and nutritional therapy of children and adults with chronic intestinal pseudo-obstruction

INTRODUCTION

Chronic intestinal pseudo-obstruction (CIPO) is a rare, heterogeneous and severe form of gastrointestinal dysmotility.

AREAS COVERED

Pertinent literature on pediatric and adult CIPO management has been assessed via PubMed, Scopus, and EMBASE from inception to June 2022. Prokinetics, aimed at restoring intestinal propulsion (e.g. orthopramides and substituted benzamides, acetyl cholinesterase inhibitors, serotonergic agents and others), have been poorly tested and the available data showed only partial efficacy. Moreover, some prokinetic agents (e.g. orthopramides and substituted benzamides) can cause major side effects. The CIPO-related small intestinal bacterial overgrowth requires treatment preferably via poorly absorbable antibiotics to avoid bacterial resistance. Apart from opioids, which worsen gut motility, analgesics should be considered to manage visceral pain, which might dominate the clinical manifestations. Nutritional support, via modified oral feeding, enteral or parenteral nutrition, is key to halt CIPO-related malnutrition.

EXPERT OPINION

There have been significant roadblocks preventing the development of CIPO treatment. Nonetheless, the considerable advancement in neurogastroenterology and pharmacological agents cast hopes to test the actual efficacy of new prokinetics via well-designed clinical trials. Adequate dietary strategies and supplementation remain of crucial importance. Taken together, novel pharmacological and nutritional options are expected to provide adequate treatments for these patients.

Gastrointestinal Tract Considerations Part I

The upper gastrointestinal (GI) tract is frequently involved in systemic sclerosis (SSc) and may impact quality of life, physical function and survival. Although we are currently very proactive in terms of screening for heart and lung involvement, patients with SSc are not routinely screened for GI involvement. This review details the available investigations for common upper GI symptoms in SSc, including dysphagia, reflux and bloating and provides advice as to how to integrate these investigations into current clinical care.

Delayed Recurrence of Acute Colonic Pseudo-Obstruction in the Setting of Acute Hypoxic Respiratory Failure

Acute colonic pseudo-obstruction (ACPO) is a rare cause of massive colonic dilation without mechanical obstruction. We report on a 58-year-old gentleman who developed two separate episodes of ACPO following different surgical and medical stressors. The initial episode occurred shortly after lumbar laminectomy and was successfully managed with medical therapy. His second episode occurred several months later in the setting of acute hypoxic respiratory failure secondary to bacterial pneumonia and was refractory to conservative, medical, and endoscopic therapy. Recurrence and the refractory nature of symptoms are presumably multifactorial in etiology, likely due to his episode of acute hypoxic respiratory failure in the setting of chronic immobility following recent spine surgery. The patient was discharged in stable condition to a subacute rehabilitation facility with the expectation that physical therapy would improve his abdominal symptoms.

Gastrointestinal Dysmotility in Critically Ill Patients: Bridging the Gap Between Evidence and Common Misconceptions

Disruption of normal gastrointestinal (GI) function in critical illness is linked to increased morbidity and mortality, and GI dysmotility is frequently observed in patients who are critically ill. Despite its high prevalence, the diagnosis and management of GI motility problems in the intensive care unit remain very challenging, given that critically ill patients often cannot verbalize symptoms and the general lack of understanding of underlying pathophysiology. Common clinical presentations of GI dysmotility issues among critically ill patients include: (1) high gastric residual volumes, acid reflux, and vomiting, (2) abdominal distention, and (3) diarrhea. In this review, we discuss the differential diagnosis for intensive care unit patients with symptoms and signs concerning GI motility issues. There are many myths and longstanding misconceptions about the diagnosis and management of GI dysmotility in critical illness. Here, we uncover these myths and discuss relevant evidence in each subject area, with the goal of re-conceptualizing GI motility disorders in critical care and providing evidence-based recommendations for clinical care.

Colonic pseudo-obstruction in a patient with dyssynergic defecation: A case report

Introduction and importance: Colonic pseudo-obstruction (CPO) is characterized by massive colonic dilatation of the large intestine without mechanical obstruction. In this study, we report our surgical experience in treating refractory CPO with increased anal sphincter tone, suggested as type IV dyssynergia.

Case presentation

A 48-year-old man with intellectual disability, depression, heart failure, and end-stage renal disease presented with acute exacerbation of CPO. He had a history of chronic constipation and abdominal distension. Colonic dilatation and defecation difficulty persisted despite medication and repeated colonoscopic decompression. Anal manometry results indicated type IV dyssynergia with increased rectal pressure. Hartmann′s operation was performed to resect the redundant megacolon and to avoid increased anal sphincter pressure during defecation. Hypoganglionosis was observed in the resected colon, which could worsen the chronic process of CPO.

Clinical discussion

Meticulous evaluation and careful management are required to treat CPO patients because the pathophysiology of CPO has not yet been clearly identified. Proper surgical treatment is needed for patients with refractory CPO.

Conclusion

CPO requires meticulous evaluation and careful management owing to the risk of bowel perforation. Precise evaluation to identify other factors affecting defecation problems accompanied by CPO is required to make appropriate treatment decisions.

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Colonic pseudo-obstruction is defined as massive colonic dilatation of the large intestine without mechanical obstruction.

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Dyssynergic defecation results from an abnormality for defecations and discordance for contraction of anal sphincter.

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Surgical resection is considered in patients with refractory colonic pseudo-obstruction and colonic aganglinosis.

Pneumatosis intestinalis with portal, mesenteric and renal gas due to colonic pseudo-obstruction

Objectives

Pneumatosis intestinalis is a rare condition with subserosal or submucosal gas-filled cysts of the gastrointestinal tract. It is often associated with acute mesenteric ischemia, but also non-ischemic causes are described.

Case presentation

A 27-year-old male patient with severe congenital spastic tetraparesis presented to the emergency room with fever and reduced general condition. The patient was hypotonic and tachycardic, had a fever up to 39.7 °C and reduced peripheral oxygen saturation. The laboratory analyses revealed leukocytosis (16.7 G/L) and elevated CRP (162 mg/L).

The patient was admitted to the intensive care unit (ICU) for invasive ventilator treatment because of global respiratory insufficiency and antibiotic therapy due to acute pneumonia and severe acute respiratory distress syndrome (ARDS). In addition, he suffered from colonic pseudo-obstruction but with persistent stool passage. After pulmonary recovery, he was transferred to the normal ward of internal medicine, but signs of colonic pseudo-obstruction were still present.

Under therapy with diatrizoic acid and neostigmine, the abdomen was less distended, and the patient had regular bowel movements. After four days, the patient developed sudden acute abdominal pain and suffered sudden pulseless electrical activity. Immediate cardiopulmonary resuscitation was provided. After the return of spontaneous circulation, the patient underwent computed tomography (CT) and was re-admitted to the ICU. The CT scan showed massive dilatation of the colon, including pneumatosis coli, extensive gas formation within the mesenteric veins and arteries, including massive portal gas in the liver, the splenic vein, the renal veins, and disruption of abdominal aortic perfusion. The patient was then first presented for surgical evaluation, but due to futile prognosis, treatment was ceased on the ICU.

Conclusions

In conclusion, colonic pseudo-obstruction might have led to colonic necrosis and consecutive massive gas formation within the mesenteric vessels. Therefore, intestinal passage should be restored as soon as possible to avoid possible mortality.

Management of acute colonic pseudo-obstruction in a neutropenic patient

Acute colonic pseudo-obstruction, also known as Ogilvie's syndrome, is a rare condition involving acute large bowel dilatation without mechanical obstruction. Management begins with conservative treatment and may include pharmacological therapy, colonoscopic decompression and surgery. Timely resolution is important due to the increased risk of bowel perforation and ischaemia associated with colonic dilatation. However, conditions such as neutropenia that place patients at an elevated risk of infection may limit treatment options. We report a case of acute colonic pseudo-obstruction in a neutropenic elderly man resistant to conservative measures and neostigmine and discuss the additional management considerations in an immunocompromised patient.

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.

Neostigmine for Treating Acute Colonic Pseudo-Obstruction in Neurocritically Ill Patients

Background and Purpose

Acute colonic pseudo-obstruction (ACPO) is a common but understudied complication in neurocritically ill patients. The acetylcholinesterase inhibitor neostigmine can be used to treat ACPO in patients who do not respond to conventional treatment. This study investigated the effectiveness and adverse events when using neostigmine to manage ACPO in neurocritically ill patients.

Methods

This retrospective study investigated patients with ACPO who were treated using neostigmine in the neurological intensive-care units at two centers between March 2017 and August 2020. Neostigmine was administered intravenously or subcutaneously (at doses ranging from 0.25 mg to 2 mg) according to the protocols at the two centers. The outcomes were bowel movements and the changes in colon diameters on abdominal radiographs. Safety events such as bradycardia, vomiting, salivation, and sweating were evaluated.

Results

This study included 31 subjects with a mean age of 46.8 years (65.4% males). All patients had a bowel movement at a median of 120 minutes after administering neostigmine. The colon diameter decreased by a median of 17.5 mm (paired t-test: p<0.001) regardless of the dose and treatment protocols. Multilevel analysis confirmed that the mean colon diameter decreased from 66 mm pretreatment to 47.5 mm posttreatment (p<0.001), with an intraclass correlation coefficient of 13%. Three patients (9.7%) exhibited hypersalivation, sweating, bradycardia, and vomiting. Bradycardia (heart rate, 42 beats/minute) occurred in one patient (3.2%), and was successfully managed by injecting atropine.

Conclusions

Neostigmine injection is a safe and effective treatment option for ACPO in neurocritically ill patients who fail to respond to conservative management.

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.

The rare Ogilvie's Syndrome in pregnancy. How to manage? A case report and literature review

Acute colonic pseudo-obstruction, or Ogilvie's syndrome (OS), is a complication in gynaecology and obstetrics. Its occurrence during pregnancy is rare, redefining the therapeutic decision-making and treatment options. In this review we describe the case of a 37-year-old pregnant patient who developed OS at the 30th week of gestation. A laparotomy with colonic decompression was performed. Foetal condition, regularly monitored throughout the hospital stay, remained normal. The patient experienced an uncomplicated, natural delivery at 40 weeks. A comprehensive literature search, describing the occurrence of OS during pregnancy, was conducted. We identified six cases of OS arising during pregnancy. Demographic, clinical, diagnostic and therapeutic features were analysed. Non-surgical management is generally the first-line option, with intravenous drug administration, rectal and nasogastric tube positioning and colonoscopic decompression the treatments of choice. Surgical decompression in usually performed in cases of failure of the first-line treatments. Including our own experience, in all cases, neither maternal nor foetal mortality was reported. A conservative approach is mandatory as first-line treatment, but when prompt resolution is not achieved, a multidisciplinary team, involving the gynaecologist/obstetrician, the surgeon, the radiologist and the intensivist is mandatory to avoid diagnostic delays, thereby reducing morbidity and mortality rates.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

A woman with adult-onset Still's disease and acute intestinal pseudo-obstruction

Adult-onset Still's disease may cause intestinal pseudo-obstruction via a cytokine storm. Early diagnosis and treatment are the key for patient survival before the development of serious complications such as macrophage activation syndrome.

Ogilvie syndrome: peculiar manifestation of acquired immunodeficiency syndrome in non-institutionalized middle age female in Tanzania

Since it was first documented in 1948 by Sir William Heneage Ogilvie, numerous cases of Ogilvie syndrome have been described in literature due to various medical and surgical causes. Nonetheless, only a handful of cases only have been documented due to underlying Acquired Immunodeficiency Syndrome (AIDS). A 41-year-old female was admitted with an acute abdomen secondary to partial mechanical intestinal obstruction or paralytic ileus based on signs and symptoms and Abdominal X-Ray (AXR). She was known to be HIV/AIDS WHO clinical stage II on treatment. On diagnostic imaging studies she had distended large bowels without features of mechanical intestinal obstruction and the diagnosis of Ogilvie syndrome was suspected after other differentials were excluded. Early recognition and appropriate management are essential, because if left untreated the bowel distension may progress to caecal perforation and fatal peritonitis. Medical imaging with Computer Tomography (CT) scan and colonoscopy has helped in achieving an accurate diagnosis and avoiding unnecessary laparotomies. Although an uncommon disorder, for earlier and accurate diagnosis a high index of suspicion is required by clinicians and radiologists who are treating patients with underlying HIV/AIDS. Ogilvie’s syndrome is a rare condition and if missed can be fatal. In patients with HIV/AIDS, the symptoms may be directly due to HIV infection, secondary to opportunistic infections or possible neurotoxic effects of HIV treatment or lack of vitamin and minerals. It is important to exclude Ogilvie syndrome in patients from surgical causes of the acute abdomen to avoid unnecessary surgical procedures.

Acute colonic pseudo-obstruction with bowel rupture after caesarean section in HELLP syndrome: a case report

Background

Ogilvie syndrome, also known as acute colonic pseudo-obstruction (ACPO), can occur postpartum after caesarean section (C-section), often resulting in caecal dilatation. The incidence rate is approximately 100 cases in 100,000 patients per year (Ross et al., Am Surg 82:102-11, 2016). Without proper diagnosis and treatment, it may progress to intestinal perforation or other fatal complications.

Case presentation

A 39-year-old pregnant woman underwent emergency low-segment C-section due to complications of Haemolysis, Elevated Liver enzymes and Low Platelets syndrome (HELLP) syndrome. ACPO was suspected on the third day after C-section based on inability to pass flatus, evident abdominal distension, slight abdominal pain, and computed tomography (CT) scan revealing severe, diffuse colonic distention with caecal dilatation of approximately 9 cm. Based on these findings, conservative treatment was implemented. However, 6 days after C-section, her symptoms worsened, and CT showed possible intestinal perforation; thus, an emergency laparotomy was performed. Due to a 3-cm (diameter) laceration in the anterolateral wall of the ascending colon and a 5-cm tear in the ileocecal junction, in combination with mucosal eversion in the colon, resection of the ileocecum, distal closure of the ascending colon, and a terminal ileostomy were performed. The patient was discharged 2 weeks post-laparotomy and continued to undergo nursing care for the incision and stoma. Ileostomy was performed 4 months later.

Conclusion

Ogilvie syndrome after C-section is an extremely rare but severe condition, which warrants early recognition and treatment to prevent potentially fatal complications, especially in patients with poor health status.

Pseudoobstrucción colónica aguda (Sindrome de Ogilvie) posterior a una nefrectomía radical: Reporte de caso

El Sindrome de Ogilvie se caracteriza por una dilatación masiva del colon y una clínica sugestiva de obstrucción intestinal mecánica, sin causa orgánica. Presentamos un caso de dilatación aguda idiopática del colon secundaria a una cirugía abdominal.

El objetivo de este reporte fue la descripción de una patología urológica inusual que puede pasarse por alto o tratarse como un íleo adinámico y, la revisión de la literatura relacionada con la definición, factores de riesgos, etiología, fisiopatología y el tratamiento de la misma.

Paciente masculino de 61 años con antecedente de nefrectomía radical izquierda por tumor renal que, a las 48hs del alta hospitalaria, consultó por presentar distensión abdominal aguda. Se solicitó una radiografía abdominal y una tomografía computada que evidenciaba importante dilatación intestinal y un diámetro cecal mayor a 12cm.

Se practicó una laparotomía exploradora de urgencia constatándose dilatación colónica del colon transverso y ascendente con un cambio de diámetro a nivel del ángulo esplénico, sin causa osbtructiva. Finalmente, se realizó colostomía en asa.

A los 6 meses de seguimiento, la videocolonoscopía no mostró lesiones endoluminales concluyendo en un Sindrome de Ogilvie secundario a la nefrectomía. Finalmente, se efectuó reconstrucción del tránsito con buena evolución posterior.

En nuestro caso, el Sindrome de Ogilvie fue una complicación postoperatoria y como fallaron las terapias conservadoras iniciales instauradas, este reporte provee una modalidad de tratamiento alternativo. Si se reconoce temprano y se trata adecuadamente, la pseudoobstrucción se resolverá en la mayoría de los pacientes y la tasa de mortalidad posterior será menor.

Imaging of acute abdomen in cancer patients

The pattern of disease causing acute abdominal pain has changed over last few decades, some of this has been attributed to intraabdominal cancers. The most common acute abdominal complaints in cancer patients are related to the gastrointestinal system. Abdominal emergencies in cancer patients can result from the underlying malignancy itself, cancer therapy and/or result from the standard pathologies causing acute abdomen in otherwise healthy population. Therapy-related or disease-related immunosuppression or high dose analgesics often blunt many of the findings which are usually expected in non-cancer general population. This complicates the clinical picture rendering the clinical exam less reliable in many cancer patients, and resulting in different pathologies which clinicians and the radiologists should remain aware of. This article focuses on imaging illustrations with differential diagnosis for various emergency scenarios related to acute abdomen specifically in oncologic settings.

Ogilvie Syndrome Following an Inflatable Penile Implant

A 59-year-old male patient presented with Ogilvie syndrome which developed after inflatable penile prosthesis placement. The patient presented to the emergency room three days after having an inflatable penile prosthesis with complaints of obstipation. A trial of conservative measures failed, and because of the development of peritonitis, the patient underwent a right hemicolectomy with a loop ileostomy.

Acute Colonic Pseudo-Obstruction After Posterior Spinal Fusion: A Case Report and Literature Review

BACKGROUND

Acute colonic pseudo-obstruction (ACPO) or Ogilvie's syndrome occurs in 0.22%-7% of patients undergoing surgery, with a mortality of up to 46%. ACPO increased median hospital days versus control in spinal surgery (14 vs. 6 days; P < 0.001). If defined as postoperative ileus, the incidence was 7%-13.4%. Postoperative ileus is associated with 2.9 additional hospital days and an $80,000 increase in cost per patient. We present a case of ACPO in an adult patient undergoing spinal fusion for correction of scoliosis and review the available literature to outline clinical characteristics and surgical outcomes.

CASE DESCRIPTION

The patient was a 31-year-old woman with untreated advanced scoliosis with no history of neurologic issues. T2-L3 spinal instrumentation and fusion was completed. Plain abdominal radiography showed of dilated cecum 11 cm and the department of general surgery was consulted. Neostigmine administration was planned after conservative treatment failure after transfer to the intensive care unit. The patient was discharged home with no recurrence >60 days. Thirty cases were found in our literature review using PubMed and Embase databases and summarized.

CONCLUSIONS

Of 30 cases reviewed, only 3 cases of ACPO were specific to patients undergoing spinal fusion for scoliosis. According to the literature, 20% of patients had resolution with conservative treatment, 40% with neostigmine, and 30% with surgical intervention. Other noninvasive treatments may have similar efficacy in preventing complications leading to surgical invention. Sixty clinical trials and 9 systematic reviews were summarized with an updated management algorithm.

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.

Neostigmine treatment protocols applied in acute colonic pseudo-obstruction disease: A retrospective comparative study

BACKGROUND/AIMS

When conservative methods fail, neostigmine is recommended in the pharmacological treatment of acute colonic pseudo-obstruction (ACPO). The objective of this study was to analyze the response of patients to different neostigmine protocols.

MATERIALS AND METHODS

Patients diagnosed with ACPO in the intensive care unit between January 2015 and September 2017 were retrospectively studied. Either of the two neostigmine protocols, the bolus dose (BD) or continuous infusion (CI), was applied to the ACPO patients who were unresponsive to conservative treatments, and the results were analyzed.

RESULTS

In 79 of 122 (64%) patients, the resolution of symptoms was observed with conservative treatments. Of 43 patients who did not respond to conservative treatments, 20 were applied neostigmine as BD, and 23 were applied by CI. A total of 55% of patients in the BD group and 60.9% patients in the CI group responded to neostigmine therapy after the first dose. The group-specific protocols were reapplied in patients unresponsive to the first dose. A total of 25% in the BD group and 8.7% in the CI group responded to the second dose treatment. As a result, 80% of patients from the BD group and 69.6% from the CI group responded to neostigmine therapy. Although an overall response rate was higher in the BD group, there was no significant difference between groups (P=0.322). Colonic complications were observed in 2 patients, 1 from each group. There were no major side effects requiring treatment cessation.

CONCLUSION

The safety and effectiveness of both neostigmine protocols applied to ACPO patients were similar. Clinical and radiological responses were obtained without serious side effects with CI.

Gastrointestinal Failure in Critically Ill Patients With Cirrhosis

Gastrointestinal failure (GIF) is frequent in patients managed in the intensive care units and manifests as gut paralysis or ileus. GIF is often associated with sepsis or multiorgan failure. In critically ill patients, the precipitating causes of GIF include inflammation, sepsis, electrolyte abnormalities, and acidosis. It is possible that GIF is associated with an increase in bacterial translocation, especially in those with cirrhosis and portal hypertension, and this may play a significant pathogenic or prognostic role in acute-on-chronic liver failure (ACLF). The critical care literature suggests that GIF is associated with a higher mortality risk. In this review, we summarize the evidence for a potential association between GIF and ACLF and propose treatment options for the management of GIF. Moreover, we suggest GIF to be considered as another organ failure when the severity of ACLF is assessed.

Ileus in Adults

BACKGROUND

Ileus is one of the more common suspected diagnoses in everyday clinical practice. The term can refer either to mechanical or to functional ileus. Any physician who takes care of patients can be confronted with these entities; thus, all should be familiar with them and competent in their management.

METHODS

Recommendations are summarized for the diagnostic evaluation and treatment of ileus of various causes on the basis of a selective literature review.

RESULTS

The manifestations of ileus and its degree of severity generally depend on the site of blockage. The rule until recently was that a patient with suspected mechanical ileus should be taken to surgery within 12 hours; today, however, ileus-particularly of the small bowel-can often be successfully treated conservatively. Likewise, functional ileus only rarely requires surgery: supportive measures, depending on the etiology, usually suffice.

CONCLUSION

Proper treatment depends on the timely determination of the pathogenesis (mechanical versus functional) and on close interdisciplinary collaboration. A special challenge is posed by patients with peritoneal involvement with cancer who present with symptoms of ileus, in whom a clear distinction between mechanical and functional causation cannot always be drawn.

Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill

Gastrointestinal dysmotility causes delayed gastric emptying, enteral feed intolerance, and functional obstruction of the small and large intestine, the latter functional obstructions being frequently termed ileus and Ogilvie syndrome, respectively. In addition to meticulous supportive care, drug therapy may be appropriate in certain situations. There is, however, considerable variation among individuals regarding what gastric residual volume identifies gastric dysmotility and would encourage use of a promotility drug. While the administration of either metoclopramide or erythromycin is supported by evidence it appears that, dual-drug therapy (erythromycin and metoclopramide) reduces the rate of treatment failure. There is a lack of evidence to guide drug therapy of ileus, but neither erythromycin nor metoclopramide appear to have a role. Several drugs, including ghrelin agonists, highly selective 5-hydroxytryptamine receptor agonists, and opiate antagonists are being studied in clinical trials. Neostigmine, when infused at a relatively slow rate in patients receiving continuous hemodynamic monitoring, may alleviate the need for endoscopic decompression in some patients.

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.

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.

Surgical Critical Care: Gastrointestinal Complications

Critical illness and injury affect the gastrointestinal tract almost uniformly. Complications include the sequelae of direct intestinal injury and repair, impaired motility, intra-abdominal hypertension, and ulceration, among others. Contemporary clinical practice has incorporated many advances in the prevention and treatment of gastrointestinal complications during critical illness. This article discusses the epidemiology, risk factors, means of diagnosis, treatment, and prevention of some of these compilations.

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.

Abdominal radiograph pearls and pitfalls for the emergency department radiologist: a pictorial review

Abdominal plain films are often the first imaging examination performed on a patient with abdominal pain in the emergency department. Radiograph findings can help guide clinical management and the need for advanced imaging. A pictorial review of a range of abdominal radiograph findings is presented, including bowel gas patterns, abdominal organ evaluation, pathologic gas, calcifications, implanted devices, and foreign bodies.

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.

Outcome of emergency surgery for severe neuroleptic-induced colitis: results of a prospective cohort

AIM

The study evaluated the outcome of severe acute antipsychotic (neuroleptic) drug related colitis requiring emergency surgery.

METHOD

From 2009 to 2014, 20 patients underwent emergency surgery for acute and severe neuroleptic-related ischaemic colitis. Neuroleptic-induced colitis was defined as another cause besides inflammatory, infectious or ischaemic colitis with a relationship to treatment by antipsychotic drugs.

RESULTS

The main drugs involved were cyamemazine (n = 9, 45%), loxapine (n = 5, 25%), haloperidol (n = 4, 20%) and alimemazine (n = 4, 20%). Most (n = 14, 70%) patients presented with haemodynamic instability requiring massive resuscitation and vasopressive drugs. CT signs of digestive impairment were found in 13 (65%) patients having emergency surgery. The lesions were pancolonic in 40%; transparietal necrosis was found in 45% and 15% had colonic perforation. Twelve (60%) patients had total or subtotal colectomy and eight (40%) a segmental colectomy with colostomy or ileostomy in all cases. The postoperative mortality was 15% and morbidity was 70%, necessitating surgical reintervention in two (10%) patients. Of the 17 surviving patients, 11 (64.7%) had restoration of intestinal continuity after a median delay of 103 days, with a postoperative morbidity rate of 36.3%. In the intent-to-treat population, the permanent stoma rate was 30%.

CONCLUSION

The morbidity and mortality of surgery for neuroleptic-drug-induced colitis is higher than for colitis due to other causes. A better knowledge of this condition should lead to early diagnosis.

An obstruction not to forget: Pseudo-obstruction (Ogilvie syndrome): Single center experience

Purpose:

Colonic pseudo obstruction disease commonly seen in the elderly, immobile patient group can cause serious mortality and morbidity. Our objective in this retrospective study is to share our clinical experience by evaluating patients with Ogilvie syndrome who were followed and treated in our clinic.

Methods:

Eleven cases with the diagnosis of Ogilvie syndrome followed up and treated between September 2010 and April 2013 were evaluated retrospectively. All the patients that had no symptoms of acute abdominal pain were initiated conservative treatment. Colonoscopic decompression was attempted for patients whose clinical pictures were not recovered. Patients underwent operation if they developed peritoneal irritation symptoms during these procedures and of their number of white blood cells seriously increased during the follow-up period.

Results:

A total of 11 patients were treated for Ogilvie syndrome. 6 of the patients underwent surgical treatment, and 5 were treated medically. Mortality developed in two patients. The main cause of mortality was a delay in diagnosis and additional severe underlying diseases. Seven patients were given Neostigmine. Of these, 2 patients required surgery and 3 patients responded to Neostigmine.

Conclusion:

Ogilvie syndrome is a rare cause of ileus of the colon. It is more common particularly in old patients with additional problems. If the disease is suspected and diagnosed early, unnecessary surgical interventions can be prevented with medical treatment choices.

[Dysmorphic neonatal syndrome and Ogilvie syndrome]

BACKGROUND

Acute colonic pseudo-obstruction, or Ogilvie syndrome, is a motility abnormality characterised by rapid and progressive dilation of the large intestine. To achieve a diagnosis it is fundamental to exclude mechanical obstruction with imaging studies such as computer axial tomography. The combined incidence of Ogilvie and dysmorphic syndrome has not been described.

CLINICAL CASE

Female patient of 28 years old with a history of infant cerebral palsy came to emergency room with 4 days of intestinal obstruction. She had hypokalaemia that was reverted, but persisted with obstruction. Later after 72h with recovery of fluids and electrolytes and administration of prokinetics, the obstruction reversed. She was discharged with no complications.

CONCLUSIONS

Non-invasive medical treatment solves most cases. Promising results have been achieved with neostigmine. In the event of no response to drug therapy, the next step is endoscopic treatment. Even with high recurrence this is preferred due to its lower level of complications in contrast to surgical decompression. Neonatal dysmorphic syndrome is often associated with disorders of the central nervous system. So far, there have been no reports on the incidence of this disease with Ogilvie syndrome, although 9% of cases have been described as associated with neurological events. Conservative management in this disease is the initial approach. Interventions should be reserved for when conservative treatment fails.

Fecal impaction: a systematic review of its medical complications

Background

Fecal impaction (FI) is a common problem in the elderly and other at-risk groups, such as patients with a neuro-psychiatric disease. It has been associated with medical problems and high morbi-mortality. A systematic review of this topic might be useful to improve the knowledge in this area and helpful to make an appropriate and early diagnosis.

Methods

A PubMed systematic search was performed using relevant keywords. Case reports published in English, Spanish or French till June 2014 were included if they had a diagnosis of FI and a medical complication secondary to it. Each case was classified based on its principal complication. The main objective is to create a classification of FI complications based on published clinical cases.

Results

188 articles met inclusion criteria, comprising 280 clinical cases. Out of the total, 43,5 % were over 65 years old, 49 % suffered from chronic constipation, 29 % had an underlying neuropsychiatric disease and 15 % were hospitalised or institutionalised. A total of 346 medical complications secondary to FI were collected. They were divided according to gastrointestinal tract involvement and then classified based on their anatomical and pathophysiological mechanism into three groups: Complications secondary to fecaloma effect on the intestinal wall (73.4 %), on the intestinal lumen (14 %) and on adjacent structures (12.6 %).

Conclusions

FI causes complications that might be fatal. The elderly, underlying neuropsychiatric disease and hospitalised or institutionalised patients integrate the high-risk group in which FI must be suspected. The first FI complications classification is presented to improve the knowledge about this entity.