Acute Colonic Pseudo-Obstruction When Conservative Management Has Not Worked
Clinical Scenario
Acute colonic pseudo-obstruction (ACPO), also known as Ogilvie’s syndrome, presents as acute massive dilation of the large intestine with no mechanical cause. In uncomplicated cases — without ischemia, perforation, or peritonitis — conservative measures are tried first. When those measures do not achieve adequate decompression, a structured pharmacologic protocol becomes the appropriate next step.
First-Line Therapy That Did Not Succeed
Conservative management was attempted for 48 to 72 hours and included: keeping the patient with nothing by mouth, nasogastric decompression, identification and discontinuation of predisposing medications (such as narcotics), correction of fluid and electrolyte disorders, ambulation, and treatment of infections.
That line is considered to have failed when either of the following goals was not reached:
- Resolution of colonic distention within 48 to 72 hours
- Cecal diameter reduced to less than 12 cm
This protocol addresses the step taken after that failure.
Next-Line Approach (Partial Overview)
After conservative management has not met the required endpoints, pharmacologic therapy — administered intravenously under appropriate cardiovascular monitoring — is indicated in eligible patients who have no contraindication. An adjunct agent may also be employed to reduce the side-effect profile of the primary drug.
Full eligibility criteria, contraindication screening, the complete regimen, and the required monitoring protocol are available in the structured reference below.
References
- ACPO, synonymous with Ogilvie’s syndrome, is characterized by an acute presentation of massive dilation of the large intestine in the absence of a mechanical etiology.
- In patients with uncomplicated ACPO (absence of ischemia, peritonitis, cecal diameter >12 cm, and/or significant abdominal pain), conservative management remains first-line therapy.
- For patients with ACPO who are not candidates for conservative therapy, have failed conservative therapy (up to 72 hours), or are at risk for perforation and have no contraindication to its use, we recommend pharmacologic therapy with neostigmine (2 mg over 3-5 minutes) with appropriate cardiovascular monitoring.
- Neostigmine, a short-acting anticholinesterase parasympathomimetic agent, remains the pharmacologic agent of choice in the management of ACPO.
- Coadministration of glycopyrrolate may be useful in preventing side effects of the medication, including hypersalivation and bronchospasm.
DOI: 10.1016/j.gie.2019.09.007
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