ACPO Without Ischemia or Perforation — When Neostigmine via Alternative Routes Has Not Worked
Acute colonic pseudo-obstruction (ACPO), also known as Ogilvie's syndrome, is characterised by acute massive dilation of the large intestine without a mechanical cause. This protocol applies to patients without ischemia, without perforation, and without signs of peritonitis — specifically when an earlier pharmacological step has not produced the expected response.
Clinical Scenario
Uncomplicated ACPO — absence of ischemia, peritonitis, and perforation — in a patient who has progressed beyond initial pharmacological management without achieving adequate resolution.
Previous Step — Failure Condition
The prior regimen used neostigmine via alternative routes of administration — subcutaneous neostigmine or continuous intravenous infusion of neostigmine. The target of that step was passage of stool and flatus. When that endpoint is not achieved, escalation to the next intervention is indicated.
Next-Line Approach (Partial Overview)
The next step is endoscopic colonic decompression with decompression tube placement, carried out by an experienced endoscopist. The full protocol specifies the procedural technique, choice of insufflation medium, and sedation requirements for this intervention.
Complete procedural details, sedation guidance, and technical requirements are available in the full structured protocol below.
Treatment Goal
Resolution of colonic distention.
References
DOI: 10.1016/j.gie.2019.09.007
- 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 or have failed conservative therapy (up to 72 hours) and have no contraindication to endoscopy, we suggest colonic decompression with decompression tube placement as an alternative.
- The procedure should be performed by an experienced endoscopist using water infusion and minimal to no insufflation of carbon dioxide rather than air.
- Sedation with benzodiazepines or other non-narcotic medication is preferred, because narcotics potentiate colonic atony.
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