A report of Three Cases of Acute Colonic Pseudo-Obstruction (Ogilvieʼs Syndrome) with Differing Presentation and Response to Neostigmine

Abstract

Purpose: Acute Colonic Pseudo-Obstruction (ACPO) is characterized by the signs of large-bowel obstruction (usually cecum and right hemicolon, although occasionally extending to the rectum) without any mechanical cause. ACPO is a common but unrecognized life threatening digestive complication occurring in ICUs and floors. It may cause ischemic necrosis and colonic perforation with a mortality rate as high as 50%. The most common associations are trauma (11%), burns, cardiac disorders (10%), neurologic disorders (9%), infections (10%), abdominal/pelvic surgery (9%), obstetric or gynecologic disease (10%), electrolyte abnormalities, opoids and miscellaneous medical conditions (metabolic, cancer, respiratory failure, renal failure etc). The radiological and clinical diagnosis is important because this condition can be treated medically by Neostigmine or surgically. Methods: In this report, we present three cases of ACPO differing significantly in presentation and response to treatment. Two patients had dilatation of caecum and right hemi-colon while one patient had dilatation of the sigmoid colon. None of them responded initially to conservative treatment (nothing per oral, nasogastric suction, proctosigmoidoscopic decompression). As there was no initial response, all three patients underwent medical treatment with a one time dose of Intra-venous neostigmine. Two patients responded while one patient didn't respond. The two patients, who initially responded to neostigmine, had a recurrence of ACPO and were given a repeat dose of neostigmine with a favorable response. They had no further episodes of ACPO until discharge. The patient who didn't respond, got an additional dose of neostigmine without any improvement in his clinical condition. He underwent exploratomy laparotomy with sigmoid colon resection. Conclusion: It is important to understand the role of neostigmine in the treatment of ACPO when patients fail conservative treatment.