GASTROENTEROLOGY LITERATURE ALERT

GASTROENTEROLOGY LITERATURE ALERT!

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LANDMARK ARTICLE - Required reading

Ponec RJ, Saunders MD, Kimmey MB. Neostigmine For The Treatment Of Acute Colonic Pseudo-Obstruction. N Engl J Med 1999 - (early on-line release, final article to be published July 15)

Major Findings

Neostigmine, 2.0 mg given intravenously over a period of 3 to 5 minutes as a single dose resulted in prompt decompression of the colon in 10 of 11 patients, compared to 0 of 10 patients who received placebo.

The median time to response was 4 minutes, with a range of 3 to 30 minutes.

Clinical response consisted of prompt evacuation of flatus or stool with a reduction in abdominal distention

In most, the response was sustained. Only 2/10 who responded required subsequent colonic decompression.

Most frequent side effect was abdominal pain, crampy in nature, mild in 9 patients, moderate to severe in 4 patients. Symptomatic bradycardia occurred in two patients, required atropine. Excessive salivation occurred in 8 patients, and emesis in 2.

FACTS TO REMEMBER FOR BOARDS

Acute colonic pseudo-obstruction, also known as Ogilvie’s syndrome is felt to be caused by excessive parasympathetic suppression, or sympathetic stimulus; leading to colonic atony. [parasympathetic stimuli causes contraction, in contrast, sympathetic stimuli causes atony of the colon].

Most patients with colonic pseudo-obstruction will respond to conservative measures within 3 days. Conservative measures include: NPO, nasogastric suction, IV fluid and electrolyte correction, withdrawal of narcotics and anticholinergics.

The risk of colonic perforation increases when the cecal diameter exceeds 12cm, or when distention has lasted over 6 days.

Colonoscopic decompression is successful in 70% of patients. Recurrence of colonic dilation occurs in 40% if no decompression tube is placed during colonoscopy.

Patients receiving beta-blockers, those with bronchospasm, and those with a history of brady-arrhythmias should not be treated with neostigmine.

Clinical Application

In patients with colonic pseudo-obstruction, who do not respond to conservative measures or who have a cecal diameter of >12 cm, neostigmine administration may be successful in reversing the pseudo-obstruction.

Neostigmine should not be used in patient with bradycardia or bronchospasm. Atropine should be readily available to counteract any side effects.

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