S2046 Pseudo Pseudo? Chronic Intestinal Pseudo-Obstruction Presenting as Mechanical Obstruction and Recurring Despite Surgery

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INTRODUCTION: Chronic intestinal pseudo-obstruction (CIPO) is a rare, characterized by chronic abdominal pain with intermittent exacerbations of bowel obstruction. An attempt to surgically remove an apparent involved segment is often not recommended and is associated with potentially worse long term outcomes. CASE DESCRIPTION/METHODS: A 72 year old man, with a history of pre-diabetes and chronic constipation had first presented 5 years ago with abdominal pain. CT showed evidence of marked redundancy and gaseous distention of the sigmoid colon without evidence of mechanical obstruction. He was diagnosed with sigmoid volvulus and laparoscopic sigmoid colectomy was performed. Thereafter, he was presumably thought to have an acute exacerbation of colonic pseudo-obstruction, for which he had an elective subtotal colectomy performed. 4 months after surgery, the patient presented to our ER with abdominal pain and distention. CT showed marked gaseous distention of small bowel loops and the stomach with no evidence of structural obstruction. The patient was kept NPO and was decompressed with a nasogastric and rectal tube. Prokinetic erythromycin was started. Interval CT documented decompressed stomach, improvement in gaseous distention of small bowel loops although measuring up to 6.1 cm. DISCUSSION: CIPO is rare, with prevalence and incidence estimated to be 0.9 and 0.23 cases per 100,000, respectively. Either secondary or idiopathic, 3 underlying pathologic entities suggested for CIPO: neuropathic, myopathies or mesenchymopathy. Imaging revealing dilated small or large bowels in the abscess of anatomical obstruction is required for the diagnosis. Impaired motility supports the diagnosis. Rarely, CIPO might present with an actual anatomical obstruction, especially in the setting of previous abdominal surgeries, masking or delaying the diagnosis. Proper diagnosis of CIPO is crucial, as the mainstay of management remains treating the underlying primary condition. Despite segmental appearing disease, an attempt to selectively remove the affected area is ill-advised, as it might promote post-operative mechanical obstruction, proven inefficacious in preventing pseudo-obstruction of other segments with a probabilities of CIPO-related re-operation of 66% after 5 years. This case demonstrates the complexity of CIPO diagnosis when newly presenting with mechanical obstruction and the ineffectiveness of colectomy in preventing further exacerbations.Figure 1.: CT showing gastric pneumatosis and marked distention of the stomach containing fluid, debris, and gas with no evidence of structural obstruction from the stomach.Figure 2.: CT showing gaseous distention of small bowel loops without sharp transition point.