Recurrent Colonic Pseudo-obstruction

Abstract

Recurrent colonic pseudo-obstruction can be particularly difficult to manage. These patients have often failed medical management, are not surgical candidates, and further treatment options are limited. A 69-year-old woman with hypothyroidism and bilateral lower extremity chronic venous stasis ulcers presented from her nursing home for abdominal distension. Her abdominal distension was associated with discomfort, constipation, and emesis. She had four similar admissions over the prior 12 months and had been treated for acute colonic pseudo-obstruction including multiple rounds of neostigmine and colonic decompression. She was discharged last admit with a decompression tube which soon fell out. Over her previous admissions she had been titrated off narcotic therapy for her venous stasis ulcers and her thyroid function was optimized. She had previously been deemed a poor surgical candidate. On examination she was bedbound due to pain from her venous stasis ulcers and was obese. Her abdomen was distended, mildly tender, tympanic, and with bowel sounds. She was diagnosed with recurrent colonic pseudo-obstruction and treated conservatively without improvement. The patient had recurrence despite neostigmine and endoscopic decompression. The patient was started on oral pyridostigmine 10 mg twice daily with resolution of symptoms. She was discharged with pyridostigmine and has not been readmitted. Colonic pseudo-obstruction is believed to be due to dysregulation of colonic motor function. Most gastroenterologist are well equipped for the management of acute colonic-pseudo obstruction but patients presenting with recurrent colonic pseudo-obstruction are difficult to manage. Despite its high prevalence rate there are limited studies evaluating its management. Pyridostigmine is a long acting oral anti-cholinergic. O'Dea et al (2010), performed an observational study of 10 patients with recurrent or chronic pseudo-obstruction treated with pyridostimine who had previously failed conservative management. All patients treated with oral pyridostigime had improvement of symptoms with no side effects. Only two of the ten patients eventually required surgery. O'Dea et al, concluded that in patients with chronic or acute/recurrent pseudo-obstruction, pyridostigmine was effective in treating and potentially preventing further episodes. We present this case to add to the literature the role of pyridostigmine in this common yet difficult to manage clinical scenario.FigureFigure