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Acute and chronic pseudo-obstruction: A current update
Abstract
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.
© 2015 Royal Australasian College of Surgeons.
... Pseudo-intestinal obstruction is a relatively rare morbid condition [4,5]. Although the exact mechanism of acute onset has not been elucidated, there is strong support for increased sympathetic tone and decreased parasympathetic tone via several pathways due to multifactorial etiology [4]. ...
... Although the exact mechanism of acute onset has not been elucidated, there is strong support for increased sympathetic tone and decreased parasympathetic tone via several pathways due to multifactorial etiology [4]. The prognosis is poor in cases of ischemia or perforation, but most cases improve within several days with conservative treatment [5]. In the present case, oral rehydration for CDI decreased during the fasting period due to periodic vomiting, while vasopressin requirements decreased with normalization of sodium levels. ...
... In the present case, oral rehydration for CDI decreased during the fasting period due to periodic vomiting, while vasopressin requirements decreased with normalization of sodium levels. Since the patient developed permanent CDI and hypopituitarism after surgery, we believe that this is not due to a transient improvement in CDI, but rather to an enhanced masking effect of cortisol deficiency on CDI [2][3][4][5][6]. There have been several reports of relative adrenal insufficiency in critically ill patients presenting with pseudo-intestinal obstruction [7,8]. ...
Craniopharyngioma surgery is frequently associated with the occurrence of central diabetes insipidus, and oral rehydration therapy is reliable for postoperative management if the patient’s thirst is normal. A 61-year-old Japanese male patient underwent extended endoscopic transsphenoidal surgery for craniopharyngioma. He was undergoing acute treatment for postoperative central diabetes insipidus and hypopituitarism in the intensive care unit. Two days after the surgery, he started to vomit occasionally, despite receiving oral rehydration therapy for central diabetes insipidus. Despite increasing the dose of parenteral hydrocortisone, the periodic vomiting persisted during fasting periods and progressed to aspiration pneumonia and severe sepsis. Abdominal computed tomography was performed to identify the cause of persistent vomiting and revealed the presence of a pseudo-intestinal obstruction extending from the small to large intestine. When oral rehydration therapy for central diabetes insipidus is accompanied by vomiting symptoms suggestive of hypopituitarism, a holistic evaluation of the gastrointestinal system is advisable.
... Idiopathic causes include non-familial visceral neuropathy (sporadic hollow visceral neuropathy or chronic idiopathic intestinal pseudo-obstruction). Congenital cases present in younger patients and are caused by various enteric and visceral neuropathies, of which Hirschsprung's disease is the most well-known [5] . The incidence and outcomes for acute pseudo-obstruction are difficult to measure. ...
... A time to decompression in excess of seven days is associated with a mortality rate of up to 73%, compared with 27% in those delayed four to seven days [6] . Therefore, duration of symptoms must be considered during clinical assessment and intervention after 48 hours without resolution would be reasonable if the caecal diameter is below 12cm and the patient is without signs of ischaemia or perforation [5] . Daily plain abdominal radiographs should be obtained to assess for worsening caecal distension. ...
... There is a perception that decompressive colonoscopy carries more risk to the patient than neostigmine [30] . Other reviews have suggested neostigmine treatment to be equivalent to decompressive colonoscopy depending on local resources [5] . One study found decompressive colonoscopy to be superior to neostigmine [22] . ...
p class="BodyText1">Acute colonic pseudo-obstruction is characterised by massive colonic distension without distal mechanical obstruction. It affects a wide variety of patients who often have multiple comorbidities, which makes studies on pseudo- obstruction difficult to perform and interpret. Few advances have been made in recent years in our understanding and management, which remain challenging. This article explores and provides interpretation of the key studies and concepts that have shaped our management of this condition. </p
... According to presentation, this syndrome can be divided in acute (ACPO) and chronic (CCPO) form; the former, also known as Ogilvie's syndrome, is defined by acute and rapid colonic dilatation, while the latter is characterized by recurrent episodes of bowel obstruction, without severe colonic distention, and associated with recurrent abdominal pain/bloating in the absence of anatomical abnormality which may explain the symptoms. Differently from the chronic presentation, the ACPO may represent a life-threatening condition, due to the high risk of perforation and ischemia [86,87]. The pathophysiological mechanisms underlying acute clinical presentation are still poorly identified. ...
... Rarely, autoimmune syndromes, such as systemic lupus erythematosus (SLE) and systemic sclerosis (SS), or hematologic diseases, like multiple myeloma, may induce an acute colonic adynamic ileus. Only in 5-10% of patients with ACPO, there is no evidence of other underlying diseases, defining the field of idiopathic pseudo-obstructions, usually related to a specific form of intestinal neuropathies [87][88][89]. ...
... To reduce the risk of recurrence after medical or endoscopic treatment, some authors evaluated the use of polyethylene glycol (PEG) electrolyte-balanced solution after the resolution of acute distension, showing a significant decrease of relapse; however further evidence is needed [97]. In the absence of complications, the conservative approach should be continued for 3-6 days, in case of medical failure or worsening of colon dilatation, a surgical approach should be considered [87]. Colonic perforation, especially at caecum level, is associated with a high risk of mortality (up to 40%). ...
In this chapter, we aim to highlight some of the new developments and trends in the emergency treatment of the gastrointestinal emergencies. There are only four pathologic processes that occur as an emergency of the inflammatory conditions and obstruction of the gastrointestinal tract: hemorrhage, ischemia, obstruction, and infection. Most abdominal pathology involves one or a combination of these processes and may give rise to severe clinical conditions of sufficient gravity to constitute an emergency. Gastrointestinal emergencies due to an acute inflammatory diseases and acute obstruction of the abdominal viscera and their complications may be roughly classified as follows: peritonitis, intussusception, torsion, perforation with abscess formation, complications involving chronic lesions of the upper part of the digestive tract such as acute perforation of peptic ulcer, duodenal obstruction, and bleeding. Despite the new and ever-expanding array of medications for the treatment of inflammatory diseases, there are still clear indications for operative management for the majority of complications of acute inflammatory conditions. We present here an overview of indications, procedures, considerations, and controversies in the diagnostic strategies and therapies for the most important gastrointestinal emergencies.
... 1 It most commonly presents acutely with pseudo-obstruction involving the large bowel (Ogilvie syndrome), typically in the setting of the elderly with abdominopelvic pathology. 2 It may be clinically indistinguishable from large bowel obstruction; however, no mechanical cause is found. ...
... However, a small proportion have identifiable congenital deficiencies in a number of genes regulating bowel motility, including defects involving the interstitial cells of Cajal (intestinal pacemaker cells) or visceral smooth muscle. 2 In secondary CIPO, systemic conditions secondarily impair gut neuromuscular function. This includes a wide range of disease processes, 2, 4 including endocrine causes such as hypothyroidism; electrolyte abnormalities (particularly hypokalemia and hypercalcemia); metabolic causes such as diabetes mellitus; paraneoplastic syndromes; and FIG. 1. Coronal section on CT demonstrating grossly distended small bowel without evidence of obstruction. ...
... Other procedures may be performed for symptom palliation, but careful patient selection is essential. 2 In summary, chronic intestinal pseudo-obstruction is a rare and challenging condition in regard to both diagnosis and treatment. Clinicians should be aware of the disease and resist the temptation to resect bowel in the absence of complications. ...
... Su incidencia no está bien establecida, aunque es un motivo frecuente de interconsulta hospitalaria a los servicios de gastroenterología desde otras especialidades tanto médicas como quirúrgicas. Aunque se trata de una entidad bien descrita y documentada, su diagnóstico en ocasiones es difícil y puede demorarse, lo que a su vez implica un retraso en el tratamiento con importantes implicaciones pronósticas 1,6,9 . ...
... Como ya se ha dicho, la PCA es una urgencia médica que requiere de una intervención apropiada lo antes posible, dadas las implicaciones pronósticas que puede tener una demora en la actuación. Existen algunas guías de práctica clínica 27,28 y numerosas revisiones de la literatura 1,5,8,[13][14][15][16]18,24,26 , algunas muy recientes, con recomendaciones y algoritmos terapéuticos, todos ellos muy similares, que iremos desglosando a continuación. El manejo terapéutico de la PCA implica un abordaje en forma de cuatro líneas sucesivas de tratamiento (Tabla 2): 1) vigilancia-soporte; 2) tratamiento farmacológico; 3) descompresión endoscópica; 4) cirugía. ...
... Las medidas de soporte incluyen reposo intestinal, hidratación, corrección electrolítica y descompresión mediante sonda nasogástrica y/o rectal cuando es necesario, teniendo especial cuidado con la administración de enemas, que pueden empeorar la situación. Siempre que sea posible hay que movilizar al paciente, de acuerdo con su estado clínico (deambulación, sedestación o cambios posturales alternando posiciones de decúbito lateral con decúbito prono y posición genupectoral, para facilitar la expulsión de gas) 1,8,27,28 . Por otra parte, la eliminación o corrección de factores predisponentes-precipitantes tales como infecciones, descompensación de una enfermedad de base, fármacos con efecto sobre la motilidad intestinal, etc. (Tabla 1) tiene una importancia clave. ...
La pseudoobstrucción colónica aguda es una entidad caracterizada por una propulsión intestinal alterada sin causa obstructiva mecánica, que cursa con distensión abdominal aguda y dilatación de asas colónicas. Se da habitualmente en pacientes con enfermedades médicas o quirúrgicas graves subyacentes. Su patogenia es desconocida, aunque parece existir un desequilibrio en la regulación motora simpática-parasimpática, existiendo en más del 90% de los casos factores precipitantes metabólicos, infecciosos, farmacológicos, etc. Su pronóstico está determinado por la gravedad de la enfermedad subyacente y comorbilidades del paciente, así como por la aparición de complicaciones (isquemia o perforación) en cuyo caso la mortalidad alcanza el 40%. El tratamiento inicial es conservador e incluye la instauración precoz de medidas de vigilancia-soporte y la corrección de factores precipitantes. Debe excluirse la existencia de obstrucción mecánica y la infección por Clostridium difficile, y es preciso evaluar periódicamente la presencia de signos de isquemia o perforación. Si el diámetro cecal supera los 10-12 cm o no hay respuesta tras 48 horas, la administración de neostigmina intravenosa, bajo monitorización cardiorrespiratoria, es el tratamiento de elección. Aquellos pacientes que fracasan deben someterse a colonoscopia descompresiva, reservándose la cirugía para casos refractarios o con isquemia o perforación. El íleo postoperatorio es una alteración transitoria de la motilidad del intestino delgado que suele producirse tras una cirugía intra o extraabdominal y que cursa con signos-síntomas de obstrucción intestinal. Su aparición implica, además de un retraso en la recuperación del paciente, un aumento en la estancia hospitalaria y un mayor riesgo de complicaciones postoperatorias. Son factores de riesgo la cirugía muy invasiva, el uso rutinario de sonda nasogástrica, el retraso en la realimentación vía oral y la utilización de analgésicos opiáceos. Dado que no existe tratamiento específico, es esencial la prevención, basada en un abordaje integral sobre los factores de riesgo. Abstract Acute colonic pseudoobstruction is a condition characterized by impaired intestinal propulsion in the absence of a mechanical obstructive cause that leads to acute abdominal distension and dilation of colonic loops. It usually occurs in elderly patients with underlying medical or surgical conditions. Pathogenesis is unknown although it has been suggested to result from an imbalance in the sympathetic-parasympathetic regulation of the colonic motor function, with precipitating factors (metabolic, infectious and pharmacological) in more than 90% of cases. Prognosis is determined by the severity of the underlying disease and comorbidities as well as by the occurrence of complications (ischemia or perforation) in which case the mortality rate reaches 40%. Initial management is conservative and includes early establishment of surveillance-support measures and correction REVISIONES TEMÁTICAS ACUTE INTESTINAL PSEUDOOBSTRUCTION
... 95 % der Patienten nachgewiesen werden, die idiopathische Form ist selten (▶ Tab. 7)[44,46]. Abzugrenzen sind andere Ursachen ▶ Tab. 6 Symptome bei chronischer intestinaler Pseudoobstruktion (in % der Patienten)[43]. ...
... Kolonparese fehlt die normale ▶ Tab. 7 Prädisponierende Faktoren und mit ACPO assoziierte Erkrankungen[46].Inflammatorisch/infektiös: akute Appendizitis, akute Cholezystitis, akute Pankreatitis, Gastritis, Abszess, Sepsis, Herpes-Zoster-Infektion, Pneumonie Gynäkologisch: normale Schwangerschaft, vaginale Geburt, Kaiserschnitt, Placenta praevia, Hysterektomie Organtransplantation: Leber, Niere, Herz, Lungen Urologisch: Nephrolithiasis Trauma (nicht operativ): Beckentrauma, mechanische Ventilation, Spinalkanaltrauma Kardiovaskulär/zerebrovaskulär: Myokardinfarkt, kongestive Herzinsuffizienz, Schlaganfall Metabolisch: Hypokaliämie, Hyponatriämie, Hypo-/Hyperkalzämie, Hypothyreoidismus, Diabetes mellitus, Leberversagen, Niereninsuffizienz, Alkoholabusus Medikamentös: Antidepressiva, Opiate, Anticholinergika, Benzodiazepine, Phenothiazide, Laxanzienabusus, Kalzium-Kanalblocker, Anti-Parkinson-Medikamente, Amphetamine (Überdosis), zytotoxische Medikamente, Clonidin Neurologisch: M. Parkinson, M. Alzheimer, Multiple Sklerose Pulmologisch: COPD Onkologisch: Kleinzelliges Lungenkarzinom, Multiples Myelom, Leukämie, retroperitoneale Tumoren, disseminierte Beckentumoren Andere: Verbrennung, gastrointestinale Blutung, retroperitoneales Hämatom, mesenteriale Thrombose, Kraniotomie, Aortenaneurysma, Thorakotomie Idiopathisch tonische Kontraktion des Kolons in Antwort auf eine hochkalorische Mahlzeit völlig. Betroffene, häufig junge Frauen, sprechen auf konservative Maßnahmen einschließlich einer hochdosierten Laxanzientherapie meist nicht an ...
... The exact etiology is unknown, however there are several theories. The main theory involves autonomic imbalance, probably augmented sympathetic over parasympathetic tone [5]. The increased sympathetic activity, dynamically dilates the proximal colon, whereas the reduced parasympathetic tone collapses the distal colon (functional obstruction) [6] .This theory is supported by the presence of a "cut-off sign" between the area of dilated &collapsed bowel around the splenic flexure resembling the transition zone between the vagal and sacral parasympathetic nerve supply [7]. ...
... Literature suggested that postpartum patients with abdominal distension & pain should have imaging to identify colonic perforation. The postpartum mortality appears to be low compared to other patients with ACPO [5,16]. ...
... the absence of mechanical obstruction [1]. The incidence of ACPO is not known, and its pathophysiology in not clear; it is associated with imbalanced extrinsic autonomic innervation of gastrointestinal tract [1,2]. Many conditions are associated with ACPO: medical or surgical causes and some medications. ...
... Supportive therapy must always be provided as soon as the diagnosis is made, it includes: fluid resuscitation, correction of serum electrolyte abnormalities (hypokalemia and hypomagnesemia), avoidance or minimization of all drugs delaying gut motility (such as opiates, anticholinergics and calcium-channel blockers), identification and treatment of concomitant infection, bowel rest, ambulation, knee-chest or prone positioning to promote flatus, and the insertion of nasogastric and rectal tubes to facilitate intestinal decompression [1,4,9]. These measures may be continued for up to 48 to 72 hours [1,2,9,10] as long as the patient remains stable and has no peritoneal signs or increase in cecal diameter to 12 cm [10]. Success rates between 35% and 96% have been reported with these measures, and a risk of colonic perforation of less than 2.5% and a mortality ranging from 0-14% [4]. ...
... Altered extrinsic regulation of colonic function by the sympathetic and parasympathetic nervous systems is the most commonly suggested mechanism for ACPO [10,[24][25][26][27][28][29] . This mechanism was first postulated by Ogilvie, who proposed a "sympathetic deprivation" of the colon [1] . ...
... Permanent impairment of the ENS, ICC, and/or myopathy characterises many forms of CIPO [24,[57][58][59] . However, the acute onset, reversibility, and different epidemiology of ACPO implies a distinct pathophysiological process from CIPO, hence these findings should not be extrapolated to the acute form of pseudo-obstruction. ...
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.
... Acute colonic pseudo-obstruction (ACPO, also known as Ogilvie syndrome) is a rare cause of massive colonic dilation without mechanical obstruction and is most frequently seen in severely ill medical or surgical patients [1][2][3][4]. While most cases of ACPO resolve with conservative management, complicated cases can result in bowel ischemia, perforation, and peritonitis, with mortality rates as high as 44% [4][5][6]. ...
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.
... Medication therapies and colonoscopic decompression techniques to relieve such symptoms, such as enemas, laxatives, and cisapride, are used to treat CPO. Surgery may be considered when the disease is refractory to medication [10]. Cecostomy or subtotal resection of the colon with primary anastomosis can be considered, but Hartmann ′ s operation is also often performed [6]. ...
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.
... Endoscopy was not only more effective compared to the medical therapy [7,8] but also the chance of avoiding a second treatment modality was higher [7]. A review examining this matter found the endoscopic and medical treatment to be comparable [9]. No matter, if conservative or endoscopic treatment is chosen for upfront therapy, a close and interdisciplinary patient observation is necessary for our opinion not to miss the right time point for a more aggressive treatment strategy. ...
... Endoscopy was not only more effective compared to the medical therapy [7,8] but also the chance of avoiding a second treatment modality was higher [7]. A review examining this matter found the endoscopic and medical treatment to be comparable [9]. No matter, if conservative or endoscopic treatment is chosen for upfront therapy, a close and interdisciplinary patient observation is necessary for our opinion not to miss the right time point for a more aggressive treatment strategy. ...
Purpose
Although Ogilvie’s syndrome was first described about 70 years ago, its etiology and pathogenesis are still not fully understood. But more importantly, it is also not clear when to approach which therapeutic strategy.
Methods
Patients who were diagnosed with Ogilvie’s syndrome at our institution in a 17-year time period (2002–2019) were included and retrospectively evaluated regarding different therapeutical strategies: conservative, endoscopic, or surgical.
Results
The study included 71 patients with 21 patients undergoing conservative therapy, 25 patients undergoing endoscopic therapy, and 25 patients undergoing surgery. However, 38% of patients ( n = 8) who were primarily addressed for conservative management failed and had to undergo endoscopy or even surgery. Similarly, 8 patients (32%) with primarily endoscopic treatment had to proceed for surgery. In logistic regression analysis, only a colon diameter ≥ 11 cm ( p = 0.01) could predict a lack of therapeutic success by endoscopic treatment. Ninety-day mortality and overall survival were comparable between the groups.
Conclusion
As conservative and endoscopic management fail in about one-third of patients, a cutoff diameter ≥ 11 cm may be an adequate parameter to evaluate surgical therapy.
... It is more common in males, individuals over the age of 60, and typically manifests as abdominal pain, distention, and alterations in bowel habits [1]. The pathophysiology of ACPO is incompletely understood but is thought to be related to disruptions in the enteric nervous system, specifically, imbalances between stimulatory neurotransmitters mediating contraction such as acetylcholine (Ach), and inhibitory neurotransmitters mediating relaxation including nitric oxide (NO) and vasoactive intestinal peptide (VIP) [1,2]. Patients with uncomplicated ACPO (cecal diameter < 12 cm, absence of significant abdominal pain, ischemia, or peritonitis) should initially receive conservative treatment including mobilization, electrolyte repletion, and nasogastric or rectal tube decompression. ...
Background:
Acute colonic pseudo-obstruction (ACPO) is characterized by acute colonic dilation in the absence of anatomical obstruction. Neostigmine is an acetylcholinesterase inhibitor recommended as first-line salvage therapy for uncomplicated ACPO. Decompressive colonoscopy is recommended if neostigmine is contraindicated or unsuccessful. There is a need to better characterize relative efficacy and factors impacting treatment choice. The aim of the study was to examine the use, efficacy, and safety of neostigmine and decompressive colonoscopy in the management of ACPO at a single academic center.
Methods:
Patients ≥ 18 years of age meeting established criteria for uncomplicated ACPO and with cecal diameter ≥ 10 cm on imaging between 1999 and 2019 were identified. Individuals were categorized as having received supportive care alone or subsequent trials of neostigmine or decompressive colonoscopy. Demographics and pre- and post-intervention data were collected, including indication and contraindication to intervention used, time to intervention, initial response, and adverse events.
Results:
In 46 cases of ACPO (N = 42 patients), all but one individual received initial supportive care. Seven responded to conservative measures alone. Of the patients failing supportive care, 15 cases were initially treated with neostigmine (response rate 86.7%) and 24 initially underwent decompressive colonoscopy (response rate 95.8%) (P = 0.390). One episode of transient bradycardia, resolved with atropine, occurred in the neostigmine group. One patient experienced respiratory instability during colonoscopy.
Conclusions:
Both neostigmine and decompressive colonoscopy appear effective for treating uncomplicated ACPO in individuals failing conservative therapy. Adverse events were infrequent in both cohorts. Future prospective studies examining treatment for ACPO should focus on whether either intervention is superior to the other.
... В настоящее время наибольшую популярность получил термин «острая толстокишечная псевдообструкция» [2, 3, 5, 7-9, 11, 18, 19, 22-37]. По клиническому течению различают острую и хроническую формы СО [6,28,38]. Острая псевдообструкция манифестирует признаками толстокишечной непроходимости и массивным расширением ободочной кишки (ОК) без видимого механического препятствия. Хроническая форма заболевания характеризуется рецидивирующим течением и возвратом эпизодов толстокишечной непроходимости в течение последних 6 месяцев у пациентов при отсутствии анатомических и структурных изменений ОК, доказанных с помощью лучевой диагностики в предыдущие 3 месяца. ...
The aim of the review was to describe the evolution of scientific ideas about the syndrome of pseudo-obstruction of the large intestine (Ogilvie syndrome), taking into account the etiopathogenesis, clinical manifestations, the incidence of the disease, the state-of-art in diagnosis and treatment. The paper presents an analysis of the literature on the pseudoobstruction of the colon (Ogilvie syndrome) – the acute dilatation of the colon in the absence of any mechanical obstruction. The essence of the concept, the correctness of the notation, definitive criteria, terminology, pathophysiological and pathogenetic aspects of the disease according to the literature are described. The diagnostic and treatment algorithms are correctly described with an assessment of their effectiveness in accordance with the principles of evidence-based medicine. Despite the large number of publications devoted to Ogilvie syndrome and the increased awareness of doctors of various specialties on this pathology, its diagnostics is still difficult and often untimely.
... It is often seen postoperatively after cesarean section, pelvic, spinal, or other orthopedic surgery, such as knee arthroplasty. 1 One study demonstrated an incidence of acute colonic pseudo-obstruction of 1.3% following hip replacement surgery. 2 The most common symptoms are abdominal distension, pain, nausea, vomiting, constipation, or diarrhea. Bowel sounds are present in the majority of cases. ...
Acute colonic pseudo-obstruction is a postsurgical dilatation of the colon that presents with abdominal distension, pain, nausea, vomiting, constipation, or diarrhea and may lead to colonic ischemia and bowel perforation.
... Additionally, there are cases of intestinal pseudo-obstruction in which no stricture can be localized [3] . Intestinal pseudo-obstruction is a heterogeneous disorder caused by neuromuscular damage [4] , which may result from inherited gene mutations, connective tissue disease, paraneoplastic syndrome, metabolic and endocrine disorders, neuromuscular syndromes, surgery, medication, and infection, including systemic sepsis and pneumonia, and chronic obstructive pulmonary diseases [5,6] . ...
Background:
Duodenal obstruction is a common clinical scenario that can either be mechanical or a pseudo-obstruction. Clinical management of intestinal obstruction starts from localization and proceeds to histological examination of the stenotic intestine. Systemic factors and dysfunction of distant organs might contribute to the development of intestinal obstruction. Here, we report a unique case of idiopathic mechanical duodenal obstruction, which resolved spontaneously after 3 mo of conservative treatment, but was followed by intestinal pseudo-obstruction.
Case summary:
An 84-year-old woman presented with worsened postprandial vomiting accompanied by prolonged pneumonia. Thorough noninvasive investigations revealed complete circumferential stenosis in the descending duodenum without known cause. Exploratory surgery was postponed due to septic shock and possible pulmonary fungal infection. Conservative treatment for 3 mo for ileus and control of pulmonary infection resolved the intestinal obstruction completely. Unfortunately, 2 wk later, she had regurgitation and postprandial vomiting again, complicated by deteriorating wheezing and dyspnea. Computed tomography revealed a dilated stomach and proximal duodenum without new intestinal stricture or pulmonary infiltration. The patient fully recovered after combined treatment with antireflux agents, enema, prokinetics, and bronchodilators.
Conclusion:
This complicated case highlights the inter-relationship of local and systemic contributions to ileus and gut dysfunction, which requires multidisciplinary treatment.
... Confusion regarding the definition of AGID and diagnostic/therapeutic protocols renders the evaluation and management of AGID difficult. The chronic IPO is historically misdiagnosed, resulting in unnecessary surgeries, often with dire consequences [92]. Univocal diagnostic criteria, treatment protocols, and outcome definitions are required for prompt diagnosis and treatment and for appropriate management of immunotherapy, which will assist in circumventing the need for unnecessary surgeries and improving patient outcome. ...
Autoimmune gastrointestinal dysmotility (AGID), an idiopathic or paraneoplastic phenomenon, is a clinical form of limited autoimmune dysautonomia. The symptoms of AGID and gastrointestinal manifestations in patients with autoimmune rheumatic diseases are overlapping. Antineuronal autoantibodies are often detected in patients with AGID. Autoantibodies play a key role in GI dysmotility; however, whether they cause neuronal destruction is unknown. Hence, the connection between the presence of these autoantibodies and the specific interference in synaptic transmission in the plexus ganglia of the enteric nervous system has to be determined. The treatment options for AGID are not well-defined. However, theoretically, immunomodulatory therapies have been shown to be effective and are therefore used as the first line of treatment. Nonetheless, diverse combined immunomodulatory therapies should be considered for intractable cases of AGID. We recommend comprehensive autoimmune evaluation and cancer screening for clinical diagnosis of AGID. Univocal diagnostic criteria, treatment protocols, and outcome definitions for AGID are required for prompt diagnosis and treatment and appropriate management of immunotherapy, which will circumvent the need for surgeries and improve patient outcome. In conclusion, AGID, a disease at the interface of clinical immunology and neurogastroenterology, requires further investigations and warrants cooperation among specialists, especially clinical immunologists, gastroenterologists, and neurologists.
... In patients with ACPO, surgical intervention is the last resort after conservative management if colonic decompression fails or if clinical signs of perforation, ischemia, or abdominal sepsis are present. [10,30] Tube cecostomy is the procedure of choice if ischemic perforation is not present; the tube may be removed later without another surgical intervention. [16,31] However, a cecal or right colon resection is needed if the cecal wall is thin due to severe dilatation. ...
... Evaluation of electrolytes, acid base status, thyroid function test, and basic metabolic panel is required as they lead or worsen any colonic dysmotility. Lastly, other diagnostic tool would be water contrast enema which in some cases could have therapeutic effect by inducing osmotic bowel movements potentially decompressing colon, however, the small risk of perforation needs to be considered [11][12][13][14]. The severity of ACPO ranges from mild distention to obstruction, followed by ischemia of the bowel and perforation [11]. ...
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
Objective
Rare co-existance of disease or pathology
Background
Acute colonic pseudo-obstruction (ACPO) is an infrequent entity characterized by non-toxic, non-mechanical, abrupt, functional dilation of the colon. Clinically patients present with abdominal distention, anxiety, severe abdominal pain, nausea, and vomiting. This rare entity can lead to a fatal outcome if not recognized early. A high level of suspicions is paramount for early diagnosis and prompt intervention.
Case Report
A 50-year-old male was admitted to the intensive unit care due to acute hypoxic respiratory failure, pneumonia, and septic shock requiring mechanical ventilation and intravenous vasopressors. Two weeks after admission, his clinical course deteriorated and was complicated with acute abdominal distension, pain, and ileus. Imaging confirmed acute onset of ileus and after ruling out metabolic and infectious causes, the diagnosis of ACPO was made. Aggressive medical and surgical management resulted in a favorable outcome.
Conclusions
Critically ill patients on ventilator are commonly sedated; therefore, usual symptoms of ACPO can be missed or misinterpreted leading to late diagnosis with increased morbidity and mortality. Clinicians must be aware of potential harm and side effects from common sedatives used in the intensive care unit and should be current on medical literature. Alpha-2 agonists, i.e., dexmedetomidine, is increasingly been used in critical care setting and there are few reports of a possible association with ACPO. We present here a case of a patient with dexmedetomidine-induced ACPO, and we provide a review of the existing literature and pathophysiology of the condition.
... However, among the diseases with reported delays of ≥20 years, some are well-known for being often diagnosed late. This is the case, for instance, for Ehlers-Danlos syndrome, 2,15,16 Marfan disease 2,17 or chronic intestinal pseudo-obstruction, 18 which were also associated with very long delays in our survey. These diseases are highly representative of the long delay issue. ...
Purpose
A barometer has been set up to provide better knowledge about the daily situation of French rare disease (RD) patients, their families and relatives, in order to contribute to the elaboration of improvement measures. This report focuses on the care and life path of RD patients.
Patients and methods
A preliminary survey was carried out with three patients, five parents and three RD experts to identify the main hurdles and disruptions in the life path of RD patients. It was used to design a larger survey comprising 60 questions as well as open fields allowing free expression. Respondents (448) comprised patients, parents of RD children and close relatives of patients. The Percentage of Maximum Deviation, Yates’ correction for continuity and Fisher’s test were employed to compare the responses between groups.
Results
Large disparities in the delays to obtain a diagnosis were identified (<1 year to >20 years), and longer delays were associated with negative perception of care conditions. While good interactions with education teams were reported (59% of respondents), the professional situation of both patients and parents was strongly and negatively impacted by the disease (51% did not work or stopped working). Three hundred respondents expressed various needs and psychological and personal issues were reported by 62% and 75% of respondents, respectively. Interestingly, the medical care path and daily life of RD patients were positively impacted by the follow-up in a specialized consultation, as reflected by changes in scores measured by our barometer (Fisher’s test, p<0.05).
Conclusion
Some of the main hurdles and sources of disruption in the life path of RD patients were identified, as well as some positive outcomes. These data could serve not only as a background for further studies, but also to better adapt the support to real needs and to improve the synergies between the many people involved in the life path of RD patients.
... Moreover, what triggered the potential alteration of microRNAs-SCF is still unclear. Based on the literatures, we noticed that GI distention is a common pathological feature in GMD patients [13,14]. Previous studies reported that stretch could arouse intracellular signalling cascade by activating membrane sensors, e.g. ...
Gastrointestinal motility disorders (GMDs) are attributed to loss of interstitial cells of Cajal (ICC), whose survival and function are deeply dependent on the activation of KIT/SCF signalling. Based on the facts that gastrointestinal distention is common in GMD patients and SCF produced by smooth muscle cells (SMCs) is usually decreased before ICC loss, we considered a possible contribution of persistent gastrointestinal distention/stretch to SCF deficiency. In this study, chronic colonic distention mouse model, diabetic gastrointestinal paresis mouse model, cultured mouse colonic SMCs and colon specimens from Hirschsprung's disease patients were used. The results showed that SCF was clearly decreased in distent colon of mice and patients, and microRNA array and real-time PCR indicated a concomitant increase of miR-34c in distent colon. A negative regulation of miR-34c on SCF expression was confirmed by luciferase reporter assays together with knock-down and overexpression of miR-34c in cultured colonic SMCs. Using EMSA and ChIP assays, we further consolidated that in response to persistent stretch, the transcription factor AP-1/c-Jun was highly activated in colonic SMCs and significantly promoted miR-34c transcription by binding to miR-34c promoter. Knock-down or overexpression of AP-1/c-Jun in cultured colonic SMCs leads to down- or up-regulation of miR-34c, respectively. In addition, the activation of AP-1/c-Jun was through ERK1/2 signalling provoked by Ca(2+) overload in colonic SMCs that were subject to persistent stretch. In conclusion, our data demonstrated that persistent distention/stretch on colonic SMCs could suppress SCF production probably through Ca(2+) -ERK-AP-1-miR-34c deregulation, resulting in ICC loss or impairment and GMD progress.
... 6,7 Acute colonic pseudo-obstruction has been observed in approximately 25% of cases of pheochromocytoma. 8 Though the mechanism is somewhat controversial, high levels of circulating catecholamines are thought to cause intestinal smooth muscle relaxation, thereby causing non-mechanical obstruction. ...
Lesson
Patients presenting with diabetic ketoacidosis and acute colonic pseudo-obstruction should undergo a focused evaluation to identify underlying precipitants.
... There are a variety of risk factors linked to paralytic ileus, some of which were present in our patients (table 1). 6 We propose that bortezomib be added to this list, particularly in the setting of renal impairment. We believe that the hypercalcaemia in case 1 and the opiate use/hypokalaemia/hypomagnesemia in case 2 had a cumulative effect on the patients' paralytic ileus. ...
While bortezomib is known to cause adverse effects involving the autonomic nervous system, gastrointestinal side effects are typically mild. We describe herein a series of patients with myeloma and impaired renal function who developed severe paralytic ileus secondary to bortezomib use. Our patients had other risk factors for paralytic ileus including electrolyte abnormalities and opiate use. The striking commonality in our patients is the development of paralytic ileus with intravenous bortezomib in the setting of reduced renal function, followed by ileus resolution with bortezomib dose reduction. We discuss the existing literature on this subject and propose a strategy in order to reduce the risk of paralytic ileus in these patients. Upfront bortezomib dose reduction to 1 mg/m² intravenously in patients with myeloma with a glomerular filtration rate (GFR) of <30 mL/min may prevent paralytic ileus, while not compromising the clinical outcomes. Our conclusions will have to be validated in larger studies.
Acute colonic pseudo-obstruction (ACPO), known as Ogilvie syndrome is defined by the dilation of the colon and rectum in the absence of a mechanical obstruction and was first described by Heneage Ogilvie in 1948. After analyzing the current literature, we highlighted the lack of a defined diagnostic algorithm for ACPO. The present study aims to identify the diagnostic criteria necessary to guide the clinician in choosing the right therapeutic management and avoiding unnecessary laparotomies. The lack of high-quality studies makes it impossible to perform systematic meta-analyzes or reviews to address the problem of Ogilvie syndrome diagnosis. Various attempts to standardize the therapeutic protocol in the case of these patients can be identified in the literature, however no consensus has been reached regarding a diagnostic algorithm. After analyzing the literature, we identified and grouped criteria of ACPO that can be used in the rapid assessment of patients with suspected Ogilvie syndrome. We organized those features in 5 categories: the patient background, the symptoms, clinical exam, laboratory tests and imaging studies. We consider that the diagnosis of ACPO can be made in a patient who has at least one criterion from each of the 5 categories. Oglivie syndrome / ACPO is an underdiagnosed entity whose management often includes an unnecessary laparotomy that can have negative repercussions on the patient's life. On the other hand, the delay of the surgical management in case of complications is associated with an increased mortality.
Background:
Chronic intestinal pseudo-obstruction (CIPO) may be a primary or secondary phenomenon and is often multifactorial. Treatment is largely directed at improving colonic motility. The use of cholinesterase inhibitors such as pyridostigmine has been hypothesized to increase acetylcholine in the bowel, improving symptoms and transit times.
Methods:
A systematic review of the use of pyridostigmine in CIPO was conducted using scientific and commercial search engines identifying scientific studies enrolling adult human subjects, published from 2000 to 2022 in the English language.
Results:
Four studies were identified including two randomized controlled trials (RCT) and two observational studies. The studies had heterogenous inclusion criteria, dosing regimens and reported outcomes. Two studies were identified as being at high risk of bias. All studies reported improved patient outcomes with use of pyridostigmine, and low rates (4.3%) of mild cholinergic side effects. No major side effects were reported.
Conclusion:
The use of pyridostigmine in management of CIPO is biologically plausible due to its ability to increase colonic motility, and early studies on its role are uniformly suggestive of benefit with low side-effect profile. Four clinical studies have been conducted to date, with small sample sizes, heterogeneity and high risk of bias. Further high-quality studies are required to enable assessment of pyridostigmine's utility as an effective management strategy in CIPO.
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:
1060 Patients with pelvic and/or acetabular fractures treated at Rigshospitalet, Copenhagen, between 2009–2020.
Intervention:
Interventions comprised the treatment of pelvic and/or acetabular fractures with either 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. OS was associated with a significant increase in nosocomial infections, sepsis, pulmonary embolism, ICU stay, and prolonged hospital admission.
Conclusion:
OS 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 III. See Instructions for Authors for a complete description of levels of evidence.
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.
Background:
Intestinal pseudo obstruction both acute and chronic is an uncommon severe motility disorder that affect both children and adults, can lead to significant morbidity burden and have no standard management strategy. Prucalopride a highly selective serotonin receptor agonist is an effective laxative with reported extra colon action. We aim to report our experience in children with acute and chronic intestinal pseudo obstruction who responded to prucalopride and systemically review the use of prucalopride in intestinal pseudo obstruction.
Methods:
A report of clinical experience and systemic review of the relevant medical databases to identify the outcome of usage of prucalopride in patients with acute and chronic intestinal pseudo obstruction. Studies meeting the selection criteria were reviewed including abstract only and case reports.
Results:
All reported cases showed clinical response to prucalopride. There were three full text, two abstracts only and three case reports all reporting clinical improvement with prucalopride.
Conclusion:
Prucalopride appears to show promising results in children and adults with acute and chronic intestinal pseudo obstruction.
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.
Introduction: The article presents information about the peculiarities of the course of pregnancy and childbirth in women with a syphilitic infection in the anamnesis. The peculiarities of the state of newborn babies born from mothers who have suffered syphilis are described. To date, the incidence of syphilis in Ukraine has a clear tendency to decline, but still remains quite high. The maximum incidence of syphilis is observed in women aged 15-20 years. The combination of pregnancy and syphilitic infection in an anamnesis is an unfavorable factor in regard to high risk of perinatal complications, the frequency of which does not tend to decrease. The aim - study the features of the course of pregnancy and childbirth in women with a syphilitic infection in the anamnesis, the evaluation of the state of newborns. Materials and methods: A prospective examination of 57 healthy women and their newborns (control group) and 60 pregnant women with a history of syphilitic infection (the main group) had been conducted. All pregnant women had undergone ultrasound examination, including feto- and placentometry, an estimate of the amount of amniotic fluid. The effect of the transferred syphilis on the state of the newborn had been assessed in accordance with the results of the clinical examination of an anthropometric data, including an Apgar score. Results: It is stated that the incidence of latent (41,66%) and forms with a prolonged course (20,00%) of syphilitic infection. The threat of premature childbirth was almost 3,5 times higher than in women with syphilis, cases of an anemia in pregnant women – 2 times, hypertensive disorders of pregnant women were 2,4 times more common in women of the main group, fetal development retardation syndrome 6,4 times, while a greater percentage of this disorder was recorded among women in the main group who were ill with latent forms and suffered secondary recurrent syphilis (35%). In 20% of the cases, pregnancy in women with syphilis has been completed by the cesarean section, an abnormality of the contractile capacity of the uterus was significantly higher – 23,33%. The adaptive capacity of the newborns in the main group has been significantly lower, compared to the control group. Conclusions: Syphilitic infection in the anamnesis complicates the course of pregnancy with numerous pathological conditions. Syphilitic infection, borne before pregnancy, affects not only the course of pregnancy, but also the course of childbirth and the postpartum period. The pathological conditions in infants are due to a decrease in resistance to birth stress, early depletion of adaptive resources of newborns under the influence of a syphilitic infection of the mother. In children who have experienced chronic intrauterine hypoxia, the risk of hemorrhagic syndrome is significantly higher due to increased permeability of the vascular wall. Such children have a tendency to develop neurological disorders and respiratory system lesions.
Ogilvie syndrome is a clinical condition in which there is a colorectal distention in the absence of mechanical obstacles. Early diagnosis and appropriate therapy significantly reduce mortality. The incidence of this is not known. This paper presents the course of diagnosis and treatment, both conservative and operational, of an 82 year old patient with pulmonary embolism, burdened with coronary artery disease, hypertension, heart failure and chronic kidney failure, in which the hospital diagnosed Ogilvie syndrome.
Introduction: Human health depends on various factors that have a different physical origin, degree of influence on the human body, methods of manifestation and other characteristics. Within public health, their research is carried out implementing an integrated approach and understanding the causation of the factors that influence each other as well as their effects on the human body. The natural environment, namely its state in general and individual natural objects, in particular, is one of the elements having both direct and indirect effects on human health. The aim: To analyze the legal basis for the regulation of the impact of the natural environment as a component of public health. Materials and methods: The study examines provisions of international documents and scientists’ attitudes. The article analyzes generalized information from scientific journals by means of scientific methods from a medical and legal point of view. This article is based on dialectical, comparative, analytic, synthetic and comprehensive research methods. Within the framework of the system approach, as well as analysis and synthesis, the concepts of public health, health and influence of the natural environment on them are researched. Review: As a result of the study of a particular range of problems, it may be noted that human health depends on a number of factors that allow it to be adequately addressed. The environmental component, namely, the state of the natural environment affecting the human body both directly and indirectly, is not the least of them. Proper legal settlement of the above-mentioned range of problems will allow a comprehensive approach to understanding the causation of human health and the natural environment. Conclusions: when researching the impact of the natural environment within public health, it can be noted that the legal basis for the multidimensional regulation of the notion of health in general, as well as its individual components, in particular, has been formed and reflected in a number of regulatory legal acts. In turn, inadequate implementation of the systematic approach with an in-depth understanding of the real and potential factors that affect human condition in one way or another does not allow the fullest possible determination of their causation both on the positive and negative sides.
Introduction: A significant part of patients with HIV / AIDS develops damage to the nervous system. There are also cases where opportunistic infections of the nervous system, especially herpes viral origin, can hide the underlying disease, making it difficult diagnosis. The aim: To show the possibility of HIV infection mimicry a neurological pathology. Clinical case: A 41-years-old female presented to The Cеntег of Infectious disorders of the Nervous System (Kyiv, Ukraine) in August, 2018 after developing acute fever following by a left side hemiparesis, violation of coordination. Tuberculosis and HIV denied. Her physical examination showed tremor in her hands during a Barre-probe. She performed the coordination tests with intent, staggering in the Romberg pose. A small brain lesion was revealed at MRI. Antibodies to HSV1/2, CMV, Tox. gondii were found in the CSF and blood. Blood PCR was reported to be positive for EBV DNA, and HCV RNA. A rapid HIV test was negative. A repeated blood test performed 10 days after admission showed low level of CD4+ T cells (36 cells /1 μl), and HIV RNA (850,104 cp / ml). HIV antibodies were also revealed. As a result, patient was transferred to a specialized department for further treatment. Conclusion: Considering high clinical polymorphism of HIV/AIDS, physicians of all specialties should be alert for the possible neurologic manifestations of this disease to timely examine patients.
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.
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.
Autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder of widespread autonomic failure. Approximately half of the patients with AAG have the autoantibodies against the neuronal nicotinic acetylcholine receptor (AChR) in autonomic ganglia. These ganglionic AChR antibodies have the potential to mediate the synaptic transmission in sympathetic, parasympathetic, and enteric ganglia. Therefore, seropositive AAG patients exhibit various autonomic symptoms. Extra-autonomic manifestations (coexistence with brain involvement, sensory disturbance, endocrine disorders, autoimmune diseases and tumors) are present in many patients with AAG. The nicotinic AChRs comprise a family of abundantly expressed ligand-gated cation channels found throughout the central and peripheral nervous systems. Moreover, limited manifestations of autoimmune dysautonomia including autoimmune gastrointestinal dysmotility are newly recognized clinical entity. Although combined immunomodulatory therapy is beneficial for almost all patients with AAG, several case reports of some AAG patients with small benefit exist. This review focuses on the recent progress in the clinical approaches of AAG and its related disorders involving the role of autoantibodies and clinical practice.
Background
Intravenous neostigmine is a well‐established treatment for acute colonic pseudo‐obstruction (ACPO). Its use is hampered by the perceived requirement for continuous cardiac monitoring, and patients are often transferred to high‐dependency units for close observation during treatment. Subcutaneous neostigmine has the potential to minimize adverse cardiovascular effects while maintaining efficacy. This study aims to assess the safety of subcutaneous neostigmine on ward inpatients with ACPO monitored with standard nursing care.
Methods
This is a retrospective case series of 30 patients with ACPO who were treated with subcutaneous neostigmine between August 2008 and October 2012. Data were collected prospectively. All patients were diagnosed using clinical examination and radiology and were assessed for contraindications to neostigmine. Patients were treated on regular wards and monitored with standard nursing observations. The main outcomes were time to flatus and bowels working and complications.
Results
No serious complications such as clinically evident bradycardia were encountered. Ninety‐three percent of patients had clinically successful resolution of ACPO. Two patients (7%) developed caecal tenderness and proceeded to colonoscopic decompression, which was successful in both instances.
Conclusions
Subcutaneous neostigmine appears to be safe for the treatment of ACPO. No clinically evident serious adverse events occurred, meaning continuous cardiac monitoring as a routine may not be necessary. In our cohort, we achieved similar success rates compared with reported rates using intravenous neostigmine.
Intestinal pseudo‐obstruction is a clinical condition in which patients present with symptoms and signs of bowel obstruction in the absence of any occlusive gut lesion. There are two main types: acute colonic pseudo‐obstruction (ACPO) and chronic intestinal pseudo‐obstruction (CIPO). The true incidence of ACPO is unknown but majority of these patients are middle aged or elderly. CIPO is largely idiopathic in origin. Most are sporadic in nature but familial forms have been reported including autosomal dominant, autosomal recessive, and X‐linked recessive. Postoperative ileus and CIPO, entities that used to be part of Ogilvie's syndrome, are recognized to have very different underlying pathophysiology and clinical course. A common first‐line investigation performed would be an abdominal radiograph demonstrating dilated large bowel loops. Conservative management is the mainstay of treatment due to its high success rate of between 77% and 96% and time to response has been reported to be between three to five days.
Adult patients who present to the emergency department (ED) with chronic or recurrent abdominal pain pose many challenges in management and disposition for the emergency care provider. It is important to be aware of potentially life-threatening causes of chronic abdominal pain and consider commonly missed diagnoses which may be amenable to specific therapies. Chronically recurring abdominal pain is a symptom of many clinical entities. Functional or nonorganic disorders are diagnoses of exclusion. As with many chronic pain patients, frequent visits to the ED are often characteristic of opiate dependence and may complicate the search for undiagnosed but treatable conditions.
A 47‐year‐old male patient without a documented past medical history was referred to Sanno Hospital because of constipation and abdominal pain, which he had had for more than 5 years. Abdominal X‐ray and CT scan showed an enlarged ascending colon from the cecum to the transverse colon, without apparent mechanical obstruction. The patient was diagnosed with chronic idiopathic colonic pseudo‐obstruction, and because his symptoms were resistant to medication, surgical treatment was required. Laparoscopic subtotal colectomy was performed without any complications. Constipation was relieved, and the patient began defecating 2–3 times a day without medication. Pathological specimens showed that Meissner's plexus and Auerbach's plexus had decreased and that there were fewer ganglion cells—findings consistent with chronic idiopathic intestinal pseudo‐obstruction.
Background:
The existence of several autoantibodies suggests an autoimmune basis for gastrointestinal (GI) dysmotility. Whether GI motility disorders are features of autoimmune autonomic ganglionopathy (AAG) or are related to circulating anti-ganglionic acetylcholine receptor (gAChR) antibodies (Abs) is not known. The aim of this study was to determine the associations between autonomic dysfunction, anti-gAChR Abs, and clinical features in patients with GI motility disorders including achalasia and chronic intestinal pseudo-obstruction (CIPO).
Methods:
First study: retrospective cohort study and laboratory investigation. Samples from 123 patients with seropositive AAG were obtained between 2012 and 2017. Second study: prospective study. Samples from 28 patients with achalasia and 14 patients with CIPO were obtained between 2014 and 2016, and 2013 and 2017, respectively. In the first study, we analyzed clinical profiles of seropositive AAG patients. In the second study, we compared clinical profiles, autonomic symptoms, and results of antibody screening between seropositive, seronegative achalasia, and CIPO groups.
Results:
In the first study, we identified 10 patients (8.1%) who presented with achalasia, or gastroparesis, or paralytic ileus. In the second study, we detected anti-gAChR Abs in 21.4% of the achalasia patients, and in 50.0% of the CIPO patients. Although patients with achalasia and CIPO demonstrated widespread autonomic dysfunction, bladder dysfunction was observed in the seropositive patients with CIPO as a prominent clinical characteristic of dysautonomia.
Conclusions:
These results demonstrate a significant prevalence of anti-gAChR antibodies in patients with achalasia and CIPO. Anti-gAChR Abs might mediate autonomic dysfunction, contributing to autoimmune mechanisms underlying these GI motility disorders.
The Acute Colonic Pseudo-Obstruction (ACPO), also known as Ogilvie's syndrome, is defined by a poor peristaltic activity of the colon that mimics mechanical obstruction in the absence of any mechanical occlusive gut lesion. This case report is the first to be published on ACPO following a robotic- assisted radical hysterectomy. Since robotic-assisted laparoscopic surgery has become the next major stage of advancement for a range of operations especially in gynecologic oncology surgery, this report emphasizes the importance of recognizing precipitating factors associated with this syndrome, including minimally invasive surgery.
Objective:
The prognosis from acute ischemic stroke (AIS) is worsened by poststroke medical complications. The incidence, risk factors, and outcomes of gastrointestinal bowel obstruction (GIBO) in AIS are not known.
Methods:
We queried the Nationwide Inpatient Sample (2002-2011) to identify all patients with a primary diagnosis of AIS and subsets with and without a secondary diagnosis of GIBO without hernia. Multivariable analysis was utilized to identify risk factors for GIBO in AIS patients and the association between GIBO, in-hospital complications, and outcomes.
Results:
We identified 16,987 patients with GIBO (.43%) among 3,988,667 AIS hospitalizations and 4.2% of these patients underwent surgery. In multivariable analysis, patients with 75+ years of age were two times as likely to suffer GIBO compared to younger patients (P < .0001). African Americans were 42% more likely to have GIBO compared to Whites (P < .0001). Stroke patients with pre-existing comorbidities (coagulopathy, cancer, blood loss anemia, and fluid/electrolyte disorder) were more likely to experience GIBO (all P < .0001). AIS patients with GIBO were 184% and 39% times more likely to face moderate-to-severe disability and in-hospital death, respectively (P < .0001). GIBO occurrence increased length of stay and total costs by an average of 9.7 days and $22,342 (P < .0001).
Conclusion:
GIBO is a rare but burdensome complication of AIS, associated with complications, disability, and mortality. The risk factors identified in this study aim to encourage the monitoring of patients at highest risk for GIBO. The predominant form of stroke-related GIBO is nonmechanical obstruction, although the causative relationship remains unknown.
Gastrointestinal (GI) distention is a common pathological characteristic in most GI motility disorders (GMDs), however, their detail mechanism remains unknown. In this study, we focused on Ca(2+) overload of smooth muscle, which is an early intracellular reaction to stretch, and its downstream MAPK signaling and also reduction of SCF in vivo and in vitro. We successfully established colonic dilation mouse model by keeping incomplete colon obstruction for 8 days. The results showed that persistent colonic dilation clearly induced Ca(2+) overload and activated all the three MAPK family members including JNK, ERK and p38 in smooth muscle tissues. Similar results were obtained from dilated colon of patients with Hirschsprung's disease and stretched primary mouse colonic smooth muscle cells (SMCs). Furthermore, we demonstrated that persistent stretch-induced Ca(2+) overload was originated from extracellular Ca(2+) influx and endoplasmic reticulum (ER) Ca(2+) release identified by treating with different Ca(2+) channel blockers, and was responsible for the persistent activation of MAPK signaling and SCF reduction in colonic SMCs. Our results suggested that Ca(2+) overload caused by smooth muscle stretch led to persistent activation of MAPK signaling which might contribute to the decrease of SCF and development of the GMDs.
Our aim was to collect a large number of casesto characterize clinical presentation, outcome, andprognosis of chronic intestinal pseusoobstruction inchildren. We conducted a retrospective multicenter study that included children treated forchronic intestinal pseusoobstruction defined asrecurrent episodes of intestinal obstruction with nomechanical obstruction, excluding Hirschsprung'sdisease. In all, 105 children, 57 boys and 48 girls, werestudied, including five familial forms. Prenataldiagnosis was made in 18 patients. Eighty patients wereless than 12 months old at onset; the disease began at birth for 37 patients. The most frequentsigns were abdominal distension, vomiting, andconstipation. Megacystis was noted in myopathies (7cases), neuropathies (10 cases) and unclassified forms(13 cases). For all but three cases (two patientswith CMV infection, one with Munchhausen-by-proxysyndrome), the associated diseases and disorders couldnot account for chronic intestinal pseusoobstruction as a secondary disorder. At least onefull-thickness biopsy from the digestive tract wasstudied for 99 patients. The diagnosis recorded wasvisceral neuropathy in 58 cases, visceral myopathy in 17cases, and uncertain or normal biopsy results in 24cases. Seventy-eight children were fed intravenously,and only 18 were able to be fed orally throughout theirillness. Seventy-one patients underwent surgery during their illness, and 217 surgicalprocedures, a mean of 3 per patient, were performed.Ostomy was the most performed procedure. Follow-upcontinued in 89 patients for 3 months to 16 years (mean85 months). Forty-two patients were still fed byparenteral (39 patients) or enteral nutrition (3patients) at the time of the study. Eleven patients diedbetween the age of 1 month and 14 years 7months.
Acute colonic pseudo-obstruction (ACPO) or Ogilvie syndrome is an idiopathic syndrome of dilation of the colon without mechanical obstruction that develops in hospitalized patients usually in the setting of significant medical and surgical conditions. Standard care therapy includes colonoscopic decompression or neostigmine. The latter is not Food and Drug Administration-approved for this indication but has been the recent intervention of choice. A patient with ACPO failed 2 injections of neostigmine. A clinical trial of subcutaneous methylnaltrexone was administered because she was on opioid therapy. There was a brisk response to methylnaltrexone, a μ-opioid-receptor antagonist which does not cross the blood-brain barrier. This is the first case report in the literature and in the pharmaceutical company's data bank that illustrates a potential role for methylnaltrexone in ACPO. Prospective, larger studies to determine the role of methylnaltrexone in ACPO are warranted.
We report the clinical and intestinal manometric findings in a group of 42 patients with chronic idiopathic intestinal pseudo-obstruction evaluated at the Mayo Clinic. The main clinical manifestations in these patients were nausea and vomiting (83%), abdominal pain (74%), distension (57%), constipation (36%), diarrhoea (29%), and urinary symptoms (17%). These symptoms preceded surgery in all patients. Air fluid levels or distended bowel loops occurred in 57% and a dilated bladder or urinary excretory pathway in 17%. All patients showed intestinal manometric abnormalities none of which are seen in healthy individuals: aberrant configuration or propagation of interdigestive motor complexes in 25 patients; bursts (greater than 2 min duration) of non-propagated phasic pressure activity in fasting and/or fed state in 30 patients; sustained incoordinated fasting pressure activity in 15 patients; and inability of an ingested meal to convert fasting into fed pattern in 28 patients. We conclude that qualitative analysis of intestinal manometry provides evidence of gut dysmotility in patients with the clinical syndrome of chronic intestinal pseudo-obstruction. These abnormalities of motility can help to establish the correct diagnosis.
Chronic idiopathic intestinal pseudo-obstruction, a syndrome of ineffectual motility due to a primary disorder of enteric nerve or muscle, is rare.
To determine the clinical spectrum, underlying pathologies, response to treatments, and prognosis in a consecutive unselected group of patients.
Cross sectional study of all patients with clinical and radiological features of intestinal obstruction in the absence of organic obstruction, associated with dilated small intestine (with or without dilated large intestine), being actively managed in one tertiary referral centre at one time.
Twenty patients (11 men and nine women, median age 43 years, range 22-67) fulfilled the diagnostic criteria. Median age at onset of symptoms was 17 years (range two weeks to 59 years). Two patients had an autosomally dominant inherited visceral myopathy. Major presenting symptoms were pain (80%), vomiting (75%), constipation (40%), and diarrhoea (20%). Eighteen patients required abdominal surgery, and a further patient had a full thickness rectal biopsy. The mean time interval from symptom onset to first operation was 5.8 years. Histology showed visceral myopathy in 13, visceral neuropathy in three, and was indeterminate in three. In the one other patient small bowel motility studies were suggestive of neuropathy. Two patients died within two years of symptom onset, one from generalised thrombosis and the other from an inflammatory myopathy. Of the remaining 18 patients, eight were nutritionally independent of supplements, two had gastrostomy or jejunostomy feeds, and eight were receiving home parenteral nutrition. Five patients were opiate dependent, only one patient had benefited from prokinetic drug therapy, and five patients required formal psychological intervention and support.
In a referral setting visceral myopathy is the most common diagnosis in this heterogeneous syndrome, the course of the illness is usually prolonged, and prokinetic drug therapies are not usually helpful. Ongoing management problems include pain relief and nutritional support.
Critical illness-related colonic ileus (CIRCI) is characterized by the non-passage of stools in critically ill patients as a result of the absence of prokinetic movements of the colon, while the upper gastrointestinal tract functions properly and mechanical ileus is absent: We investigated whether neostigmine resulted in defecation in patients with CIRCI.
Double-blinded, placebo-controlled prospective study.
Eighteen-bed intensive care unit.
Thirty ventilated patients with multiple organ failure with CIRCI for > 3 days.
Continuous intravenous administration of neostigmine 0.4-0.8 mg/h over 24 h, or placebo.
Time to first defecation and adverse reactions were recorded. Thirty patients were randomized, 24 could be evaluated. The mean prestudy time was 5 days, mean APACHE II score on admission was 23.2, and mean MOF score on the day of the study was 6.4. Of the 13 patients receiving neostigmine, 11 passed stools, whereas none of the placebo-treated patients passed stools (P < 0.001). After 24 h, the non-responders received in a cross-over fashion neostigmine or placebo respectively. Eight out of the 11 neostigmine patients now passed stools (mean 11.4 h), and none of the placebo patients. Overall, in none of the patients did passage of stools occur during placebo infusion, whereas 19 of the 24 neostigmine-treated patients had defecation (79%). No acute serious adverse effects occurred, but three patients had ischemic colonic complications 7-10 days after treatment.
Continuous infusion of 0.4-0.8 mg/h of neostigmine promotes defecation in ICU patients with a colonic ileus without important adverse reactions.
Chronic intestinal pseudo-obstruction (CIP) represents a particularly difficult clinical challenge. It is a rare and highly morbid syndrome characterised by impaired gastrointestinal propulsion together with symptoms and signs of bowel obstruction in the absence of any lesions occluding the gut lumen. CIP can be classified as either "secondary" to a wide array of recognised pathological conditions or "idiopathic" (CIIP). This review will focus on CIIP, and specifically on the underlying pathological abnormalities. Combined clinical and histopathological studies are needed to highlight new perspectives in the understanding and management of chronic intestinal pseudo-obstruction.
This pathologically accelerated transit is often well accepted by patients since it is associated with partial relief of other digestive symptoms, but it contributes to determine intestinal malabsorption and deteriorate nutritional conditions. Indeed, many patients are afflicted by inability to maintain a normal body weight, despite dietary manipulations, both because of the deranged digestive functions and because food ingestion often exacerbates digestive symptoms and consequently patients tend to avoid a normal oral nutrition.
The histopathological approach of chronic intestinal pseudo-obstruction (CIP) is critical, and the findings are often missed by the histopathologists for lack of awareness and nonavailability of standard criteria. We aimed to describe a detailed histopathological approach for working-up cases of CIP by citing our experience. Eight suspected cases of CIP were included in the study to determine and describe an approach for reaching the histopathological diagnosis collected over a period of the last 1.5 years. The Hirschsprung's disease was put apart from the scope of this study. A detailed light microscopic analysis was performed along with special and immunohistochemical stains. Transmission electron microscopy was carried out on tissue retrieved from paraffin embedded tissue blocks. Among the eight cases, three were neonates, one in the pediatric age group, two adolescent, and two adults. After following the described critical approach, we achieved the histological diagnoses in all the cases. The causes of CIP noted were primary intestinal neuronal dysplasia (IND) type B (in 4), mesenchymopathy (in 2), lymphocytic myenteric ganglionitis (in 1), and duplication of myenteric plexus with leiomyopathy (in 1). Desmosis was noted in all of them along with other primary pathologies. One of the IND patients also had visceral myopathy, type IV. Histopathologists need to follow a systematic approach comprising of diligent histological examination and use of immunohistochemistry, immunocytochemistry, and electron microscopy in CIP workup. Therapy and prognosis vary depending on lesions identified by pathologists. These lesions can be seen in isolation or in combinations.
Chronic intestinal pseudo-obstruction (CIPO) has been treated in adults by total parenteral nutrition (TPN) or, if complications arise, by multivisceral transplantation because the stomach is often involved. Eleven adults with CIPO were transplanted by intestinal graft in our center from 2000 to 2011.
Nine patients underwent isolated intestinal transplant and 2 patients had multivisceral transplant. Immunosuppression was represented by FK and steroids plus induction with alemtuzumab, daclizumab, or thymoglobulin. Average age at transplant was 33.5 years. We reported 1 graftectomy, followed by retransplantation.
Seven patients are currently alive with working small bowel; cause of death was infection in the 4 remaining cases. In 9 isolated intestinal transplants, we performed different digestive reconstructions to allow gastric emptying. In 2 cases we were forced, after transplant, to perform ileostomy to improve intestinal motility. Graft and patient survival after 5 years are 60% and 70%, respectively, while after 10 years, 45% and 56%, respectively.
Adults with CIPO and irreversible TPN complications benefit from isolated intestinal transplant with different surgical techniques to empty the native stomach: this strategy achieves good gastric emptying, with effective establishment of oral feeding and graft and patient survivals comparable to isolated intestinal transplant for short bowel syndrome.
Chronic intestinal pseudo-obstruction (CIPO) is a recurrent disorder caused by intestinal dysmotility. Although, CIPO is not a surgically remediable condition, surgery is a common issue in CIPO patients. The aim of this study was to assess postoperative morbidity and mortality of patients operated on for CIPO and risk of re-operation.
Adult patients that have undergone surgery for CIPO since 1980 were included in this retrospective study using a prospective database. Postoperative morbidity, according to Clavien-Dindo classification and CIPO-related re-operation rates were evaluated with univariate and multivariate analysis.
Sixty-three patients (33 women, median age 37 [range: 15-79] years) were included. Median follow-up was 6 (0.2-28) years. Overall postoperative mortality rate was 7.9%. Overall morbidity rate was 58.2% (Clavien-Dindo ≥3 in 20.7%) leading to re-operation in 17% of cases. In multivariate analysis, major postoperative morbidity (Clavien-Dindo ≥3) was significantly increased when there was an intraoperative bowel injury (HR = 15.7 [2.4-102], P = 0.004), idiopathic CIPO (HR = 4.2 [1.5-12], P = 0.007) and emergency procedure (HR = 3 [1.3-6.8]. After the first surgery, probabilities of CIPO-related re-operation were 44%, 60%, and 66% at 1, 3, and 5 years respectively. In multivariate analysis, CIPO-related reoperation for CIPO was significantly increased when there was a major postoperative morbidity (HR = 2.1 [1.1-4.4], P = 0.040) and intraoperative bowel injury (HR = 33.1 [2-553], P = 0.015) after the first procedure.
The surgical management of CIPO patients was associated with high postoperative morbidity and mortality rates and frequent re-operation. Attempts should be made to avoid surgery when possible and optimize nutritional status.
This study was designed to assess the efficacy of i.v. infusion of neostigmine in patients with acute colonic pseudo-obstruction, which was defined as colonic distention with a cecal diameter of at least 10 cm on plain radiographs and no radiographic evidence of mechanical obstruction. Patients who failed to respond to conventional management (nothing by mouth, nasogastric suction, postural changes, i.v. fluids, electrolyte replacement, and discontinuation of any drugs that affect colonic motility) for 24 h were included in the study. Those with bradycardia (heart rate 3 mg/dL were excluded. Twenty patients were included in this prospective, randomized, double-blind, placebo-controlled study. Eleven patients received neostigmine 2.0 mg i.v. over 3–5 min with electrocardiographic monitoring, and 10 received placebo. Patients were evaluated for immediate clinical response (passage of flatus or stools associated with decreased abdominal distention within 30 min) and sustained response with decreased abdominal girth and reduced colonic dilation on radiographs 3 h after infusion. Ten patients in the neostigmine group had an immediate clinical response (median time, 4 min) compared to none in the placebo group (p < 0.001). Three patients in the neostigmine group (27%) and eight in the placebo group (80%) failed to show sustained improvement 3 h after infusion (p = 0.04). Eight patients (one—neostigmine; seven—placebo) who failed to respond received open-label treatment with neostigmine. Seven patients responded; one patient from the placebo group failed and eventually required colonic resection. In conclusion, from a total of 18 patients treated with neostigmine, 17 (94%) had immediate clinical response, and 16 (89%) did not have recurrent colonic dilation. The most common side effect was crampy abdominal pain reported in 13 patients, although usually mild (nine). Symptomatic bradycardia requiring atropine occurred in two patients. Two patients in the neostigmine group died, but death was felt not to be related to acute colonic pseudo-obstruction or its treatment.
We evaluated 85 children with congenital chronic intestinal pseudoobstruction (CIP) over the past 10 years. Twelve (14%) were born prematurely. One had a family history of CIP. Six had systemic diseases. Thirty-five (41%) had urinary bladder involvement. Manometric features were consistent with myopathy in 32, neuropathy in 48, and mixed disease in 5. Of 48 patients with neuropathy, 6 had urinary bladder involvement (12.5%) (P vs myopathy), and 10 had malrotation (21%) (P = NS vs myopathy). Upon referral, 53 (62%) were dependent on partial or total parenteral nutrition (PN). At the time of chart review (median 25 months after evaluation), 22 patients had died, 14 of whom were on total PN, 13 of them died because of PN-related complications and 1 died of sepsis. Three others died of sepsis while on partial PN (P = 0.007 vs mortality in patients fed enterally) and five died after small bowel transplantation. In conclusion, in children with congenital CIP, the risk for prematurity is increased twofold, the majority of cases are sporadic, abnormal bladder function is more common in myopathic CIP, and complications related to parenteral nutrition are the main cause of death in children with CIP.
Although acute colonic pseudo-obstruction (ACPO), also known as Ogilvie syndrome, is a well-known clinical entity, in many respects it remains poorly understood and continues to challenge physicians and surgeons alike. Our understanding of ACPO continues to evolve and its epidemiology has changed as new conditions have been identified predisposing to ACPO with critical illness providing the common thread among them. A physician must keep ACPO high in the list of differential diagnoses when dealing with the patient experiencing abdominal distention, and one must be prepared to employ and interpret imaging studies to exclude mechanical obstruction. Rapid diagnosis is the key, and institution of conservative measures often will lead to resolution. Fortunately, when this fails pharmacologic intervention with neostigmine often proves effective. However, it is not a panacea: consensus on dosing does not exist, administration techniques vary and may impact efficacy, contraindications limit its use, and persistence and or recurrence of ACPO mandate continued search for additional medical therapies. When medical therapy fails or is contraindicated, endoscopy offers effective intervention with advanced techniques such as decompression tubes or percutaneous endoscopic cecostomy providing effective results. Operative intervention remains the treatment of last resort; surgical outcomes are associated with significant morbidity and mortality. Therefore, a surgeon should be aware of all options for decompression-conservative, pharmacologic, and endoscopic-and use them in best combination to the advantage of patients who often suffer from significant concurrent illnesses making them poor operative candidates.
Background:
Colonic pseudo-obstruction in critically ill patients may lead to devastating colonic perforation. Neostigmine is often the first-line intervention, because colonoscopy is more invasive and labor intensive.
Methods:
A retrospective 10-year review at a tertiary medical center identified 100 patients with Ogilvie's syndrome, in whom treatment course and clinical and radiographic response were evaluated.
Results:
Colonoscopy was significantly more successful than neostigmine (defined as no further therapy) after 1 or 2 interventions (75.0% vs 35.5%, P = .0002, and 84.6% vs 55.6%, P = .0031, respectively). One colonoscopy was more effective than 2 neostigmine administrations (75.0% vs 55.6%, P = .044). Clinical response (poor, fair, or good) was significantly better after colonoscopy than neostigmine after 1 or 2 interventions (P = .0028 and P = .00079). Cecal diameters decreased significantly more after colonoscopy than neostigmine (from 10.2 ± .5 cm to 7.1 ± .4 cm vs from 10.5 ± .5 cm to 8.8 ± .5 cm, P = .026). Neostigmine administration before colonoscopy did not affect outcomes. There were 3 perforations (3.7%): 1 each after colonoscopy, neostigmine, and no intervention. Neostigmine dose or repetition did not affect radiographic (P = .41) or clinical (P = .31) response.
Conclusions:
Colonoscopy is superior to neostigmine for Ogilvie's syndrome and should be considered first-line therapy, although neostigmine is useful in select patients and repeat interventions.
We reviewed the clinical presentation, management, and outcome of 25 patients with Ogilvie's syndrome (acute colonic pseudoobstruction) at Memorial Sloan-Kettering Cancer Center from 1982 through 1985. All patients had cancer and severe associated medical problems. Abdominal x-rays uniformly showed cecal distension ranging between 9 and 18 cm. Twenty-four of the 25 patients were treated with conservative nonendoscopic management. One patient had an exploratory laparotomy for prophylactic cecostomy after only one day of conservative therapy. Of the 24 patients treated conservatively, 23 (96%) improved by both clinical and radiologic criteria in a mean of 3.0 days. The remaining patient died of multisystem failure not related to the acute colonic pseudoobstruction. Colonoscopic decompression was not attempted in any of the 25 patients. There were no colonic perforations, and there were no pseudoobstruction-related deaths. This study questions the need for early endoscopic or surgical treatment in cancer patients with acute colonic pseudoobstruction.
A patient with chronic idiopathic pseudo-obstruction is reported and the results of a double blind therapeutic trial of metoclopramide are described. Within the limits of this trial metoclopramide was ineffective by all clinical criteria.
Four additional cases of Ogilvie's syndrome (acute colonic pseudo-obstruction), representing the first cases described in
Italy, are reported. The medical literature concerning the subject is also thoroughly reviewed.
Ogilvie's syndrome is an acute massive dilatation of the large bowel without organic obstruction of the distal colon. Three
hundred and fifty-one cases have been described in the literature to date. Eighty-eight per cent of cases were associated
with various extracolonic affections (metabolic and organ dysfunctions, postoperative and posttraumatic states, etc.). Twelve
per cent of cases were not associated with known disorders and were defined as idiopathic. The pathophysiology of the syndrome
is still unknown. Ogilvie, who first described the syndrome in 1948, suggested an imbalance between the sympathetic and parasym-pathetic
innervation of the colon: this neurogenic hypothesis has been shared by other authors, although explanations may differ slightly.
The clinical and radiologic picture closely resembles mechanical obstruction of the large bowel. The most marked dilatation
usually takes place in the right colon and cecum: if the distended cecum reaches a diameter larger than 9 to 12 cm, perforation
is likely to occur; if perforation occurs, the mortality rate incrases from 25 to 31 per cent to about 43 to 46 per cent.
If conservative management fails to control the dilatation and cecal rupture is impending or suspected emergency surgery is
indicated, the surgical procedure of choice is dictated by the general conditions of the patient as well as by the intestinal
findings: operation may consist of cecostomy, colostomy, or right hemicolectomy or simply emptying the bowel.
Background & aims:
No controlled trial has examined the clinical efficacy of antibiotics in small bowel bacterial overgrowth.
Methods:
Ten patients with bacterial overgrowth-related diarrhea underwent the following five 7-day treatment periods: untreated (control period), then placebo, and subsequently, in random order and blinded fashion, norfloxacin (800 mg/day), amoxicillin-clavulanic acid (1500 mg/day), and Saccharomyces boulardii (1500 mg/day). A hydrogen breath test was performed on the first and last day of each period.
Results:
Daily stool frequency was similar during the control and placebo periods (4.2 +/- 0.6 vs. 3.9 +/- 0.6 [mean +/- SEM], respectively). Norfloxacin and amoxicillin-clavulanic acid led to a significant reduction in daily stool frequency (2.3 +/- 0.4 and 3.0 +/- 0.5, respectively; P < 0.01 vs. placebo period) after 2.0 +/- 1.4 and 1.2 +/- 0.4 days, which was maintained for 6.1 +/- 3.7 and 6.0 +/- 9.6 days, respectively. Breath-expired H(2) volume decreased with norfloxacin (37 +/- 8 to 12 +/- 5 mL per 2 hours; P < 0.01) and amoxicillin-clavulanic acid (24 +/- 6 to 8 +/- 4 mL per 2 hours, respectively; P = 0.01), but H(2) breath test result was negative in only 3 and 5 patients.
Conclusions:
Norfloxacin and amoxicillin-clavulanic acid are effective in the treatment of bacterial overgrowth-related diarrhea.
CIPO is the very “tip of the iceberg” of functional gastrointestinal disorders, being a rare and frequently misdiagnosed condition characterized by an overall poor outcome. Diagnosis should be based on clinical features, natural history and radiologic findings. There is no cure for CIPO and management strategies include a wide array of nutritional, pharmacologic, and surgical options which are directed to minimize malnutrition, promote gut motility and reduce complications of stasis (ie, bacterial overgrowth). Pain may become so severe to necessitate major analgesic drugs. Underlying causes of secondary CIPO should be thoroughly investigated and, if detected, treated accordingly. Surgery should be indicated only in a highly selected, well characterized subset of patients, while isolated intestinal or multivisceral transplantation is a rescue therapy only in those patients with intestinal failure unsuitable for or unable to continue with TPN/HPN. Future perspectives in CIPO will be directed toward an accurate genomic/proteomic phenotying of these rare, challenging patients. Unveiling causative mechanisms of neuro-ICC-muscular abnormalities will pave the way for targeted therapeutic options for patients with CIPO.
The therapeutic action of opioid analgesics is compromised by peripheral adverse effects, among which constipation is the most disabling as laxatives often fail to provide satisfactory relief. This review highlights recent advances in the specific control of opioid-induced constipation by opioid receptor antagonists with limited systemic bioavailability or a peripherally restricted site of action.
The specific management of opioid-induced bowel dysfunction is currently based on three drug entities: oral alvimopan for the shortening of postoperative ileus associated with opioid-induced pain control after bowel resection, subcutaneous methylnaltrexone for the reduction of opioid-induced constipation in patients with advanced illness, and a fixed combination of oral prolonged-release naloxone with prolonged-release oxycodone for the treatment of noncancer and cancer pain. All three drug entities have been shown to attenuate opioid-induced motor stasis in the gut with a favorable adverse effect profile, while the analgesic effect of opioids remains unabated.
The availability of opioid receptor antagonists with restricted access to the central nervous system provides a novel opportunity to specifically control opioid-induced constipation and other peripheral adverse effects of opioid analgesics. Further studies are needed to evaluate the long-term efficacy, safety and cost-effectiveness of this approach.
Acute colonic pseudo-obstruction (ACPO), also known as Ogilvie's syndrome, is a condition characterized by massive colonic distension in the absence of mechanical obstruction. Patients presenting with Ogilvie's syndrome have underlying medical and surgical conditions predisposing them to the syndrome. Ogilvie's syndrome can often be managed by conservative therapy. However, unrecognized and untreated, the continued distension associated with Ogilvie's syndrome can lead to perforation that is associated with a high mortality rate. In this article, the pathophysiology, epidemiology, and treatment options are reviewed.
Disorders of colonic motility, such as severe constipation and pseudo-obstruction, remain difficult to treat. The pathophysiology of these conditions is not completely understood, but previous studies suggest a deficiency of cholinergic innervation and an imbalance in autonomic regulation of colonic motor function as contributing factors. Therefore, increasing the availability of acetylcholine in the bowel wall with a cholinesterase inhibitor, such as pyridostigmine, may improve symptoms.
We studied thirteen patients with severe constipation (slow transit type) or recurrent pseudo-obstruction. The six patients with slow transit constipation had mechanical obstruction and pelvic floor dysfunction excluded, and normal calibre colon and slow transit confirmed. These patients were offered pyridostigmine in an attempt to avoid surgery. The seven patients with pseudo-obstruction had dilated bowel on imaging, and mechanical obstruction was excluded. These patients received pyridostigmine when symptoms recurred, despite previous treatments. Pyridostigmine was initiated at 10 mg b.i.d. and increased if required.
One of the six patients with slow transit constipation reported improvement of symptoms and had concurrently weaned anti-psychotic medications. Pyridostigmine was ceased in the remaining five patients due to lack of efficacy and/or side effects. Four patients proceeded to surgery for refractory symptoms. All seven patients with pseudo-obstruction had some improvement of symptoms with few side effects. Of these, two later had surgery for recurrent symptoms.
In patients with slow transit constipation, treatment with pyridostigmine does not improve symptoms. However, it does improve symptoms in patients with recurrent pseudo-obstruction with few side effects, offering an extra treatment option for these patients.
Chronic intestinal pseudo-obstruction (CIPO) is a rare, disabling disorder responsible for motility-related intestinal failure. Because it induces malnutrition, CIPO is a significant indication for home parenteral nutrition (HPN). The objective of the study was to evaluate long-term outcome of CIPO patients requiring HPN during adulthood.
In total, 51 adult CIPO patients (18 men/33 women, median age at symptom occurrence 20 (0-74) years, 34/17 primary/secondary CIPO) followed up at our institution for HPN management between 1980 and 2006 were retrospectively studied for survival and HPN dependence rates using univariate and multivariate analysis.
Follow-up after diagnosis was 8.3 (0-29) years. Surgery was required in 84% of patients. The number of interventions was 3 +/- 3 per patient (mean +/- s.d.), leading to short bowel syndrome in 19 (37%) patients. Actuarial survival probability was 94, 78, 75, and 68% at 1, 5, 10, and 15 years, respectively. Multivariate analysis showed that lower mortality was associated with the ability to restore oral feeding at baseline (hazard ratio (HR) = 0.2 (0.06-0.65), P = 0.008) and symptom occurrence before the age of 20 years (HR=0.18 (0.04-0.88), P = 0.03). Higher mortality was associated with systemic sclerosis (HR=10.4 (1.6-67.9), P = 0.01). Actuarial HPN dependence was 94, 75, and 72% at 1, 2, and 5 years, respectively.
In this large cohort of CIPO adult patients with severe intestinal failure, i.e., those requiring HPN, we found a higher survival probability than previously reported. These results should be taken into account when considering intestinal transplantation.
Colonic pseudo-obstruction is often confused with mechanical intestinal obstruction. It occurs when there is an autonomic imbalance resulting in sympathetic over-activity affecting some part of the colon. The patient is often elderly with numerous comorbidities. Once mechanical obstruction is excluded by contrast enema, the patient should be treated conservatively with nasogastric and flatus tubes for at least 48 hours, and precipitating factors should be treated. When pseudo-obstruction does not settle with waitful watching, prokinetic agents and/or colonoscopic decompression can be tried. When there is a risk of impending perforation of the caecum from massive colonic dilatation and colonic ischaemia, it should be dealt with by caecostomy or hemicolectomy. In spite of available medical and surgical interventions, the outcome remains poor.
Rifaximin is a broad-range, gastrointestinal-specific antibiotic that demonstrates no clinically relevant bacterial resistance. Therefore, rifaximin may be useful in the treatment of gastrointestinal disorders associated with altered bacterial flora, including irritable bowel syndrome (IBS) and small intestinal bacterial overgrowth (SIBO).
To review rifaximin for treatment of IBS and SIBO.
Review of rifaximin clinical trials.
Rifaximin improved global symptoms in 33 - 92% of patients and eradicated SIBO in up to 84% of patients with IBS, with results sustained up to 10 weeks post-treatment. Rifaximin caused a lower number of adverse events compared with metronidazole or levofloxacin and may have a more favorable adverse event profile than systemic antibiotics, without clinically relevant antibiotic resistance.
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.
A part-systematic review was conducted. This was based on key publications focusing on advances in management.
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.
A patient with chronic idiopathic pseudo-obstruction is reported and the results of a double blind therapeutic trial of metoclopramide are described. Within the limits of this trial metoclopramide was ineffective by all clinical criteria.
The syndrome of acute colonic pseudo-obstruction is well delineated but its aetiology remains poorly understood and patients are still treated inappropriately. This article reviews the pathogenesis and surgical management of this condition. Early diagnosis is stressed as a pivotal factor in reducing morbidity and mortality.
We reviewed the clinical presentation, management, and outcome of 25 patients with Ogilvie's syndrome (acute colonic pseudoobstruction) at Memorial Sloan-Kettering Cancer Center from 1982 through 1985. All patients had cancer and severe associated medical problems. Abdominal x-rays uniformly showed cecal distension ranging between 9 and 18 cm. Twenty-four of the 25 patients were treated with conservative nonendoscopic management. One patient had an exploratory laparotomy for prophylactic cecostomy after only one day of conservative therapy. Of the 24 patients treated conservatively, 23 (96%) improved by both clinical and radiologic criteria in a mean of 3.0 days. The remaining patient died of multisystem failure not related to the acute colonic pseudoobstruction. Colonoscopic decompression was not attempted in any of the 25 patients. There were no colonic perforations, and there were no pseudoobstruction-related deaths. This study questions the need for early endoscopic or surgical treatment in cancer patients with acute colonic pseudoobstruction.
Chronic intestinal pseudo-obstruction (CIP) is a clinical syndrome characterized by symptoms and signs of intestinal occlusion, in absence of any mechanical obstruction of the gut lumen. It causes impaired transit of intestinal contents and is determined by abnormalities of motor activity. The term CIP is used to indicate a heterogeneous group of disorders with many different pathogenic mechanisms. The defect in the regulation of intestinal transit can be at any level of motility control. Two main types of CIP are recognized, termed respectively myogenic (when smooth muscle cells are affected) and neurogenic (caused by abnormalities of extrinsic and/or intrinsic nervous supplies). Both types may be secondary to a variety of recognizable diseases or idiopathic. In myogenic CIP, intestinal transit is impaired because of lack of propulsive strength; in the neurogenic form, contractions are powerful but not sufficiently co-ordinated to propel intestinal contents aborally in an organized fashion. CIP belongs to the large and loosely defined group of digestive functional disorders. These disorders probably share common pathogenic mechanisms but with different expressiveness. The reasons why only some patients present recurrent symptomatological bouts resembling mechanical occlusion has not been clarified. This aspect is of great clinical relevance and deserves attention, as CIP patients, unlike other patients with severe functional disorders, may undergo repeated, useless and potentially dangerous operations. The diagnosis of CIP may be suggested by clinical features and is based on radiological, endoscopic, manometric, and histological findings. Recent technological improvements facilitate the recognition of this intriguing syndrome. In particular, manometric recording of the small bowel motility, which has long been considered an important research technique, can now also be regarded as a useful diagnostic tool.
In addition to the presentation of 14 of our own patients, this study analyzes 1027 cases with acute colonic pseudo-obstruction reported in the literature from 1948 to 1987. Principal associated diseases are cardiopulmonary insufficiencies, postoperative conditions, and systemic disorders. The syndrome is related to a disturbance of colonic autonomic innervation resulting in gross dilatation of the cecum and the right hemicolon. Therapeutic measures include conservative management, colonoscopic decompression, and surgical procedures. The latter have been associated with high morbidity and mortality. Our data support a nonoperative approach to this condition, including conservative measures and colonoscopic decompression as the initial therapy of choice with few complications and high efficacy.
This study analyzes 400 cases of acute pseudo-obstruction of the colon (Ogilvie's syndrome). Seven cases were reported at St. Elizabeth Hospital Medical Center between October 1982 and February 1985; 393 cases were reported in the literature from 1970-1985. Ogilvie's syndrome is most commonly reported in patients in the sixth decade, and is more predominant in men. It is caused by an unknown disturbance to the autonomic innervation of the distal colon, and is associated with different conditions. Plain abdominal roentgenogram is the most useful diagnostic test. If the cecal diameter is 12 cm or greater, or conservative management is unsuccessful, colonoscopic or operative decompression is needed. The mode of treatment, age, cecal diameter, delay in decompression, and status of the bowel significantly influence the mortality rate, which is approximately 15 percent with early appropriate management, compared with 36 to 44 percent in perforated or ischemic bowel.
The syndrome of chronic idiopathic intestinal pseudo-obstruction is defined and differentiated from other clinically similar states. Five carefully documented cases are reported and compared with five previously recorded cases in which the material presented permitted adequate analysis. Our patients had repeated bouts of intestinal pseudo-obstruction for which no organic cause or disease could be found. The obstruction was accompanied by diarrhea (at times steatorrheal), weight loss and in some instances progressive deterioration and death from malnutrition. Some patients had family members who apparently suffered or had died from a similar type of illness. Roentgenographic and motility studies showed delayed transit, hypomotility and gross distention of the small and occasionally the large intestine. Sweating disturbances and hypothermia were also features in some patients. Essentially normal gastrointestinal histologic appearance was found in all instances and permitted the differentiation of idiopathic intestinal pseudo-obstruction as an entity distinct from scleroderma. The motility disturbance of the bowel and the questionable response to cholinergic drugs suggest a functional failure of the myenteric plexus. No form of treatment was found consistently effective in controlling the manifestations of this disease, although broad-spectrum antibiotics were transiently helpful in two patients. Avoidance of unnecessary surgical procedures, once the diagnosis has been established, is important.
Four additional cases of Ogilvie's syndrome (acute colonic pseudo-obstruction), representing the first cases described in Italy, are reported. The medical literature concerning the subject is also thoroughly reviewed. Ogilvie's syndrome is an acute massive dilatation of the large bowel without organic obstruction of the distal colon. Three hundred and fifty-one cases have been described in the literature to date. Eighty-eight per cent of the cases were associated with various extracolonic affections (metabolic and organ dysfunctions, postoperative and posttraumatic states, etc.). Twelve per cent of cases were not associated with known disorders and were defined as idiopathic. The pathophysiology of the syndrome is still unknown. Ogilvie, who first described the syndrome in 1948, suggested an imbalance between the sympathetic and parasympathetic innervation of the colon: this neurogenic hypothesis has been shared by other authors, although explanations may differ slightly. The clinical and radiologic picture closely resembles mechanical obstruction of the large bowel. The most marked dilatation usually takes place in the right colon and cecum: if the distended cecum reaches a diameter larger than 9 to 12 cm, perforation is likely to occur; if perforation occurs, the mortality rate increases from 25 to 31 per cent to about 43 to 46 per cent. If conservative management fails to control the dilatation and cecal rupture is impending or suspected emergency surgery is indicated, the surgical procedure of choice is dictated by the general conditions of the patient as well as by the intestinal findings: operation may consist of cecostomy, colostomy, or right hemicolectomy or simply emptying the bowel.
The surgeon's role in the treatment of patients with chronic intestinal pseudoobstruction (CIP) is under-appreciated. Our aim was to determine the effects of operative treatment on symptomatic relief of CIP.
Records of all 21 patients who underwent surgery for CIP from 1980 to 1990 were reviewed. CIP was diagnosed by a combination of manometric, radiological, and/or histological examinations.
Six of the nine patients who underwent resection or bypass of presumably localized disease are currently maintained on oral intake; one patient with multiple sclerosis who cannot eat is fed via a gastrostomy tube. Enterostomy tube(s) were placed in the other 12 patients; four no longer use the enterostomy tube(s), and eight rely on these decompressive tube enterostomies for symptomatic relief. After operative treatment, hospital readmissions decreased from a mean of 0.5 to 0.1 admission/year. All 19 patients currently alive report improved quality of life.
Selective and directed operative treatment of patients with CIP can result in therapeutic and palliative benefits. The surgeon should have an active role in the evaluation and possible treatment of patients with CIP.
Acute colonic pseudo-obstruction is often treated by colonoscopic decompression. Efficacy, safety, and outcome of endoscopic decompression was assessed.
Colonoscopic decompressions from 1988 to 1994 were reviewed. Resolution without further endoscopic intervention was defined as clinical success.
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%.
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.
To determine whether computed tomography (CT) can satisfactorily diagnose and evaluate patients with suspected colonic obstruction.
Seventy-five patients with suspected colonic obstruction were evaluated prospectively by CT and compared with the gold standards of surgery and/or endoscopy in 65 patients, clinical course in nine, and contrast enema (CE) in one. A limited comparison between CT and CE (26) patients was also made in those patients who had both studies.
CT successfully diagnosed colonic obstruction in 45 of 47 patients (96% sensitivity). Pseudo-obstruction was correctly diagnosed in 26 of 28 patients (93% specificity). CT correctly localized the point of obstruction in 44 of 47 patients (94%). CE successfully diagnosed obstruction in only 20 of 25 patients (80% sensitivity).
In this study, CT proved to be a satisfactory modality in evaluating patients with suspected colonic obstruction. CT may in certain circumstances be preferable to the traditional CE in evaluating these patients.
Our aim was to collect a large number of cases to characterize clinical presentation, outcome, and prognosis of chronic intestinal pseusoobstruction in children. We conducted a retrospective multicenter study that included children treated for chronic intestinal pseusoobstruction defined as recurrent episodes of intestinal obstruction with no mechanical obstruction, excluding Hirschsprung's disease. In all, 105 children, 57 boys and 48 girls, were studied, including five familial forms. Prenatal diagnosis was made in 18 patients. Eighty patients were less than 12 months old at onset; the disease began at birth for 37 patients. The most frequent signs were abdominal distension, vomiting, and constipation. Megacystis was noted in myopathies (7 cases), neuropathies (10 cases) and unclassified forms (13 cases). For all but three cases (two patients with CMV infection, one with Munchhausen-by-proxy syndrome), the associated diseases and disorders could not account for chronic intestinal pseusoobstruction as a secondary disorder. At least one full-thickness biopsy from the digestive tract was studied for 99 patients. The diagnosis recorded was visceral neuropathy in 58 cases, visceral myopathy in 17 cases, and uncertain or normal biopsy results in 24 cases. Seventy-eight children were fed intravenously, and only 18 were able to be fed orally throughout their illness. Seventy-one patients underwent surgery during their illness, and 217 surgical procedures, a mean of 3 per patient, were performed. Ostomy was the most performed procedure. Follow-up continued in 89 patients for 3 months to 16 years (mean 85 months). Forty-two patients were still fed by parenteral (39 patients) or enteral nutrition (3 patients) at the time of the study. Eleven patients died between the age of 1 month and 14 years 7 months.
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.
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.
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.
In patients with acute colonic pseudo-obstruction who have not had a response to conservative therapy, treatment with neostigmine rapidly decompresses the colon.
This study was designed to assess the efficacy of i.v. infusion of neostigmine in patients with acute colonic pseudo-obstruction, which was defined as colonic distention with a cecal diameter of at least 10 cm on plain radiographs and no radiographic evidence of mechanical obstruction. Patients who failed to respond to conventional management (nothing by mouth, nasogastric suction, postural changes, i.v. fluids, electrolyte replacement, and discontinuation of any drugs that affect colonic motility) for 24 h were included in the study. Those with bradycardia (heart rate <60/min), hypotension (systolic blood pressure <90 mm Hg), active bronchospasm, clinical or radiographic evidence of perforation, history of partial colonic resection, active gastrointestinal bleeding, pregnancy, or serum creatinine >3 mg/dL were excluded. Twenty patients were included in this prospective, randomized, double-blind, placebo-controlled study. Eleven patients received neostigmine 2.0 mg i.v. over 3-5 min with electrocardiographic monitoring, and 10 received placebo. Patients were evaluated for immediate clinical response (passage of flatus or stools associated with decreased abdominal distention within 30 min) and sustained response with decreased abdominal girth and reduced colonic dilation on radiographs 3 h after infusion. Ten patients in the neostigmine group had an immediate clinical response (median time, 4 min) compared to none in the placebo group (p<0.001). Three patients in the neostigmine group (27%) and eight in the placebo group (80%) failed to show sustained improvement 3 h after infusion (p = 0.04). Eight patients (one-neostigmine; seven-placebo) who failed to respond received open-label treatment with neostigmine. Seven patients responded; one patient from the placebo group failed and eventually required colonic resection. In conclusion, from a total of 18 patients treated with neostigmine, 17 (94%) had immediate clinical response, and 16 (89%) did not have recurrent colonic dilation. The most common side effect was crampy abdominal pain reported in 13 patients, although usually mild (nine). Symptomatic bradycardia requiring atropine occurred in two patients. Two patients in the neostigmine group died, but death was felt not to be related to acute colonic pseudo-obstruction or its treatment.
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.
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.
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.
Neostigmine is a simple, safe, and effective therapy for treatment of colonic pseudo-obstruction.
We evaluated 85 children with congenital chronic intestinal pseudoobstruction (CIP) over the past 10 years. Twelve (14%) were born prematurely. One had a family history of CIP. Six had systemic diseases. Thirty-five (41%) had urinary bladder involvement. Manometric features were consistent with myopathy in 32, neuropathy in 48, and mixed disease in 5. Of 48 patients with neuropathy, 6 had urinary bladder involvement (12.5%) (P < 0.0001 vs myopathy), and 10 had malrotation (21%) (P = NS vs myopathy). Upon referral, 53 (62%) were dependent on partial or total parenteral nutrition (PN). At the time of chart review (median 25 months after evaluation), 22 patients had died, 14 of whom were on total PN, 13 of them died because of PN-related complications and 1 died of sepsis. Three others died of sepsis while on partial PN (P = 0.007 vs mortality in patients fed enterally) and five died after small bowel transplantation. In conclusion, in children with congenital CIP, the risk for prematurity is increased twofold, the majority of cases are sporadic, abnormal bladder function is more common in myopathic CIP, and