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Practice Guideline Highlights in Gastroenterology
q Acute colonic distention in the setting of severe medical or surgical illness
q There are multiple causes including severe surgical or medical stress (MI, Sepsis), post-operative complication in elderly individuals, metabolic and electrolyte disturbances, paraneoplastic syndromes, neurologic diseases, narcotic and sedative use, particularly phenothiazines
q Perforation occurs in 2%-5% of cases and the risk is determined more by chronicity than cecal diameter. Risk increases with diameter >12cm and higher risk if persistent dilation for > 6 days
q Diagnosis:
ü Analyze electrolytes, calcium, magnesium
ü Exclude a mechanical obstruction (air in the rectosigmoid)
ü Water-soluble contrast enema (diagnostic and maybe therapeutic)
q Treatment
ü Nasogastric decompression
ü Correction of fluid and electrolyte imbalance
ü Treatment of any underlying illness
ü Rectal flatus tube rarely may help
ü Stop medications that might affect intestinal transit including anticholinergics, opiates, and phenothiazines
ü Conservative treatment should be continued for about 2-5 days
q Treat the patient, not the X-ray!
Conservative measures first
Eliminate inciting factors
In most patients, 5 to 6 days of observation is safe
Neostigmine, colonoscopy and surgery are options for non-responders. 2 mg neostigmine IV over 3-5 minutes, monitor for arrhythmia, cardiovascular complications. Relatively contraindicated in patients with renal insufficiency.
Ponec R J, Saunders MD, Kimmey MB. Neostigmine for the Treatment of Acute Colonic Pseudo-Obstruction N Engl J Med 1999; 341:137- 41
