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Acute Colonic Pseudo-Obstruction

Acute Colonic Pseudo-Obstruction. By Matt Johnson. American Society for GI Endoscopy. The Standards and Practice Committee Class A = Randomised control trial Class B = Observational studies Class C = Anecdotal / Valued opinion. Acute Colonic Pseudo-Obstruction. Definition

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Acute Colonic Pseudo-Obstruction

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  1. Acute Colonic Pseudo-Obstruction By Matt Johnson

  2. American Society for GI Endoscopy • The Standards and Practice Committee • Class A = Randomised control trial • Class B = Observational studies • Class C = Anecdotal / Valued opinion

  3. Acute Colonic Pseudo-Obstruction • Definition • Colonic dilatation in the absence of a mechanical obstruction • Other synonyms include;- • Ogilvie’s Syndrome and Acute colonic ileus • 3-15% Complications (eg Perforation, Ischaemia) • 50% Mortality • Increase with caecal diameters > 10cm • Increase when duration extends > 6/7 • LaPlace’s Law (^diameter ~ ^colonic wall tension) • predicts critical threshold of 9cm in transverse + 12cm in caecum

  4. Acute Colonic Pseudo-Obstruction

  5. Acute Colonic Pseudo-Obstruction

  6. Causes • Post Surgical • Intra-peritoneal • Extra-peritoneal (Spinal,Ortho,Gynae,Uro) • Trauma • Spinal or Retroperitoneal • Medical • Age • Sepsis • Neurological disorders • Hypothyroid • Viral (HSV, HVZ) • Cardiac / Respiratory / Renal • Electrolyte disturbance • Medications (narcotics,anaesthesia,TCA,anti-psychotics,anti-Parkinsons)

  7. Conservative Management (upto 48º) • Adequately resuscitate the patient • NBM, IV Fluids, NG aspiration • Water soluble contrast (exclude mechanical obstruction) • Correction of electrolyte/metabolite (K,Mg,Ca,PO4,TFT) • Investigate and treat concurrent infection • Stop ppt drugs (eg anticholinergic and anti-motility drugs • Monitor Roentgenographic progress (daily AXR) • Mobilise • Body Positioning (hourly) • Success in 20-92%, Meantime 3/7 Sloyer et al, DigDisSci 1988;33:1391-6 • Type 2 DM • Hypertension • Gout • AF • DHx • Losartan • Glucophage • Sotolol • Warfarin

  8. Pharmacological • Neostigmine • Anticholinesterase parasympathomimetic agent • 2 - 2.5 mg IV • SEx = bradycardia, asystole, hypotension, restlesness, seizures, tremor, miosis, bronchoconstriction, hyperperistalsis, nausea, vomiting, salivation, diarrhoea, sweating • Therefore administration must be accompanied by • Atropine (for reversal) • Crash trolley (for cardio/respiratory monitoring) • CIx • Direct • Hypersensitivity • Mechanical urinary obstruction • Mechanical intestinal obstruction • Relative • Recent MI, asthma, acidosis, bradycardia, B-blockers, PU, acidosis

  9. Pharmacological • Neostigmine (Class A Data) • Several small randomised double blind crossover trials • Hutchinson et al. Ann R Coll Surg Eng 1992;74:364-7 • 8 of 11 improved • guanethidine (SNS blocker) then neostigmine • Stephenson et al. Dis Col Rect 1995;38:424-7 • 11 of 12 improved (using 2.5mg) • Ponec et al. NEJM 1999;35:1135-42 • 10 of 11 (using 2mg) • 2 patients required atropine for bradycardia • Anecdotal reports for cisapride, erythromycin, metoclopramide • New Agents (Motilin®+5-Hydroxytryptamine 4® agents)

  10. Endoscopic Management • Colonoscopic Decompression • Class B data from several trials (total patient No>200) • Jetmore et al. Dis Col Rec 1992;35:1135-42 • Bender et al. Radiology 1992;188:395-8 • Geller et al 1996;44:144-50 • Success +/- tube placement = 60-80% • Recurrence = 20-35% (almost all without tube inserted) • Complications = <4% (3% from perforation) • No randomised trial / No direct comparison with Neostigmine

  11. Surgical Management • Caecostomy or Colectomy • Reserved for:- • patients who fail endoscopic / pharmacological therapy • patients in whom exploration of the peritoneal cavity mat otherwise be indicated

  12. Management Summary • 1) Gastrografin/Barium Enema (Mechanical Vs Pseudo) • 2) Conservative Management (48 hours) • 3) Treat reversible causes • 4) Neostigmine (2-2.5mg IV) • 5) Colonic Decompression (+/- flatus tube inserted) • 6) Surgical/Percutaneous Caecostomy

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