A Clinical Vignette Demonstrating the Efficacy of Treating CIPO in a Patient With ALS

Abstract

Introduction: Amyotrophic lateral sclerosis (ALS) is a progressive incurable neurodegenerative disorder leading to worsening dysphagia, respiratory failure, and ultimately death. Chronic intestinal pseudoobstruction (CIPO) is a pan-enteric functional bowel disorder characterized by chronic obstructive symptoms and multiple air fluid levels on radiographic imaging without any evidence of mechanical obstruction. To date, there is only one case published demonstrating efficacy of neostigmine in treating constipation in an ALS patient (Fu A. Dynamics. 2005:16(1):13). Here we report a case of an ALS patient suffering from CIPO who showed response to treatment with neostigmine infusion.Figure 1Case Report: Our patient is a 48-year-old African American male who was diagnosed with ALS 2 years prior to presentation after initially presenting with bilateral lower and upper extremity weakness. One and a half months prior to presentation he developed chronic dysphagia and PEG tube was placed. He presented to ER in respiratory distress and progressive weakness. His ICU stay was protracted secondary to unresolving respiratory failure. Despite treatment for pneumonia, he required intubation and ultimately tracheostomy tube placement. One month later he developed nausea, vomiting, and obstipation. He was found to have ileus on KUB (Fig A). Despite aggressive interventions his symptoms persisted for 1 month. The patient was then given a trial of 1.5 mg neostigmine IV push with atropine and glycopyrrolate, which he tolerated well without any significant change in his vital signs. His symptoms resolved immediately, passing 5 bowel movements in the first 24 hours. Discussion: The etiology of the patient’s CIPO is likely multifactorial and due to a combination of electrolyte abnormalities, immobility, medication side effects, and being in the post operative period. His symptoms did not respond to correction of these issues. Neostigmine has long been shown to be a useful adjunct in the treatment of acute colonic pseudo-obstruction but its efficacy in an ALS patient with CIPO has not previously been demonstrated. Conclusion: Neostigmine was effective at treating this ALS patient with CIPO.