Acute Intestinal Pseudo-obstruction Research Articles

Case report: acute intestinal pseudo-obstruction as a rare complication of pheochromocytoma

Case report: acute intestinal pseudo-obstruction as a rare complication of pheochromocytoma

Acute intestinal pseudo-obstruction secondary to Sjogren’s syndrome in pregnancy: a case report and literature review

BackgroundIntestinal pseudo-obstruction (IPO) is a rare disease, and its clinical manifestations can resemble mechanical intestinal obstruction leading to unnecessary and potentially harmful surgery. Certain autoimmune diseases have been associated with IPO, however, cases secondary to Sjögren’s syndrome (SjS) are especially rare.Case presentationWe described the first case of SjS-associated acute IPO in pregnancy, which was successfully treated with combined immunosuppressive therapy and resulted in an uneventful caesarean delivery.ConclusionsWomen with SjS is likely to experience more complications during pregnancy, and IPO rather than the classic symptoms could be the first sign of SjS flares. IPO should be suspected in patients with unrelenting symptoms of small bowel obstruction, and a multidisciplinary approach can provide optimal management of such high-risk pregnancies.

Intestinal Pseudo-Obstruction with Life-Threatening Hypokalaemia in a Patient with Adult-Onset Still's Disease.

Acute intestinal pseudo-obstruction is one of the systemic complications that can occur in autoinflammatory diseases such as AOSD, although it has rarely been described.If AOSD presents with abdominal presentation, such as acute intestinal pseudo-obstruction, then amyloidosis should always be carefully considered.

Acute intestinal pseudo-obstruction by pheochromocytoma: A case report with review of literature.

IntroductionPheochromocytomas are rare tumors of the adrenal gland. Intestinal pseudo-obstruction is a very rare presentation of a functioning catecholamine-secreting tumor. We present a case of intestinal pseudo-obstruction due to a large functioning pheochromocytoma.Case reportA 29-year-old female presented with abdominal distension, pain, nausea, and vomiting with constipation for 3 weeks. She was hypertensive and diabetic and was on multiple medications. She reported frequent spells of severe headaches, palpitations, night sweats, and a 17 kg weight loss over 6 months. She had pallor, dyspnea, marked abdominal distension, and diminished bowel sounds. Her blood pressure was high at 200/120 mmHg. She had tachycardia (pulse 120 bpm) and tachypnea (35 pm). Serum metanephrine levels were significantly elevated, measuring 1203 pg/ml. Abdominal CT showed a heterogeneous, hyper-vascular mass near the upper pole of the left kidney, measuring 10.75 cm × 8.72 cm. Open left adrenalectomy was performed through an anterior subcostal approach to remove the tumor with the left adrenal gland. Histopathological examinations were consistent with pheochromocytoma.DiscussionSome authors documented the correlation between tumor size and metabolic activity of catecholamine-secreting tumors with intestinal pseudo-obstruction by paralytic ileus. This case corresponds with these findings, with a tumor mass of 350 g and a serum metanephrine level of 1203 pg/ml.ConclusionAlthough it is extremely rare, functioning pheochomocytoma could be a cause of instestinal obstruction or pseudo-obstruction.

ENDOSCOPIC VS COMBINED MEDICAL AND SURGICAL MODALITIES OF TREATMENT OF RADIATION INDUCED PROCTOCOLITIS – OUR INSTITUTE EXPERIENCE

Background: GIGastrointestinal injury may occur following irradiation of thoracic,abdominal,and pelvic malignancies limiting radiation doses that can be delivered as well as causing significant morbidity requiring intervention. Radiation proctocolitis, both acute and chronic, is one such complication requiring multidisciplinary management for good outcomes.We analyzed the injury with respect to spectrum of injury, severity, morbidity and compared endoscopic vs combined medical and surgical modalities of treatment. Methods: Patients with acute and chronic radiation proctocolitis defined as illness presenting before and after 3 months respectively,of radiation treatment were included in the study.The study period was five years. Results: Total number of patients studied were 75.Acute disease was seen in 5 patients,presenting predominantly with diarrhea, abdominal pain and acute intestinal pseudo-obstruction. Chronic radiation proctocolitis was seen in 70 patients. Bleeding per rectum was the most common symptom. Anemia was the commonest sign. Grade 2 injury was most commonly seen. Pharmacotherapy was equally effective in grade 1 injury whereas Endoscopic treatment was superior to pharmacotherapy in Grade 2,3. Surgery offered lesser rates of rehospitalization in grade 3 but was associated with higher complications. There were no deaths in endoscopic arm while there were 2 deaths in pts who required surgery. Surgical combined with medical was superior to endoscopic treatment in grade 4 while local agents were ineffective.Preventive strategies prior to radiation were associated with lower grade of injury. Conclusion: Radiation proctocolitis causes significant morbidity requiring prolonged treatment and hospitalization. Dose and duration of radiation had direct relation to the severity of injury. Concurrent chemotherapy had no effect on severity of injury.Our study showed acute proctocolitis required predominantly supportive medical treatment.Chronic form from grade 1 to 3 required predominantly endoscopic treatment with prolonged duration of treatment but less morbidity.Grade 4 required surgical and intensive care and local therapy was ineffective.

Prucalopride in intestinal pseudo obstruction, paediatric experience and systematic review.

Intestinal pseudo obstruction both acute and chronic is an uncommon severe motility disorder that affect both children and adults, can lead to significant morbidity burden and have no standard management strategy. Prucalopride a highly selective serotonin receptor agonist is an effective laxative with reported extra colon action. We aim to report our experience in children with acute and chronic intestinal pseudo obstruction who responded to prucalopride and systemically review the use of prucalopride in intestinal pseudo obstruction. A report of clinical experience and systemic review of the relevant medical databases to identify the outcome of usage of prucalopride in patients with acute and chronic intestinal pseudo obstruction. Studies meeting the selection criteria were reviewed including abstract only and case reports. All reported cases showed clinical response to prucalopride. There were three full text, two abstracts only and three case reports all reporting clinical improvement with prucalopride. Prucalopride appears to show promising results in children and adults with acute and chronic intestinal pseudo obstruction.

3220 Systemic Sclerosis Leading to Recurrent Small Bowel Pseudo-Obstruction

INTRODUCTION: Systemic sclerosis (SSc) is a chronic systemic disease defined by early microvascular obliterative changes, early activation of T and B-lymphocytes, and extensive fibrosis of the skin and internal organs. Although gastrointestinal involvment of SSc is common, severe intestinal disease manifested by malabsorption, recurrent pseudo-obstruction, or need for parenteral nutrition carries a poor prognosis and is seldom seen. We present the uncommon case of a patient with severe scleroderma bowel causing debilitating disease. CASE DESCRIPTION/METHODS: A 76-year-old female with history of atrial fibrillation, systemic sclerosis, achalasia s/p Botox injections, and duodenal bulb ulcer presented to our institution with vomiting of blood-streaked emesis, epigastric abdominal pain, and distension for two days. She had multiple hospitalizations for presumed obstructions in the past treated medically. Endoscopy 3 months prior revealed a large cratered duodenal ulcer located at the duodenal sweep with recent stigmata of bleeding (Forrest Class IIa) treated with epinephrine. Upon evaluation the patient was afebrile and normotensive. Physical exam was significant for mild diffuse abdominal tenderness and no gross blood on rectal exam. Labs were remarkable for Hgb 11.9, MCV 92.8, lactic acid 1.0, and lipase within normal limits. CT A/P showed multiple dilated small bowel loops with air-fluid levels and a fluid-filled patulous esophagus that was unchanged. Trauma surgery was consulted and we managed the patient conservatively with bowel rest, IV fluids, and continuation of her PPI. Her clinical course improved and she was able to pass flatus and stool. We attributed her recurrent symptoms to intestinal pseudo-obstruction precipitated by scleroderma. DISCUSSION: SSc is a chronic autoimmune condition commonly affecting the gastrointestinal tract. Major manifestations of small intestinal involvement are due to reduced peristalsis, causing abdominal distension and pain from dilated bowel loops. Acute intestinal pseudo-obstruction is a medical emergency that warrants hospital admission. Most patients have spontaneous resolution with conservative measures like bowel rest, nasogastric decompression, and intravenous hydration but may require frequent readmissions. Surgery is discouraged due to risk of prolonged ileus or anastomotic failure although “venting” jejunostomy allows for air aspiration in chronic pseudo-obstruction. Recurrent intestinal pseudo-obstruction in these patients thus poses a therapeutic challenge.

Acute Intermittent Porphyria Presented with Acute Intestinal Pseudo-obstruction.

Acute Intermittent Porphyria Presented with Acute Intestinal Pseudo-obstruction.

Acute Intestinal Pseudo-Obstruction in a Patient with MELAS Syndrome

Acute Intestinal Pseudo-Obstruction in a Patient with MELAS Syndrome

Imaging Evidence Demonstrating Effectiveness of Osteopathic Visceral Manipulation Techniques in Treating Pseudo-Obstruction

Abstract This report describes the case of a 66-year-old afebrile woman seen on the hospital inpatient service with nausea, vomiting, bloating, and constipation for 5 days prior to admission. The patient was diagnosed with idiopathic acute small bowel pseudo-obstruction by gastroenterology. The epidemiology of acute small-bowel pseudo-obstruction is briefly reviewed. Osteopathic manipulative treatment (OMT) was performed on the patient using mostly abdominal and visceral manipulation techniques. This case represents the first report of imaging evidence that demonstrates the effectiveness of osteopathic visceral manipulation techniques in successfully treating patients who have acute intestinal pseudo-obstruction.

Initial Experience With Naloxone Hydrochloride for the Treatment of Acute Intestinal Pseudo-obstruction in Intensive Care Unit Patients

BACKGROUND: In acute intestinal pseudo-obstruction there is dilation of the intestinal loops without mechanical obstruction; it may develop after surgery or severe illness. This condition is due to an acute imbalance of the normal extrinsic autonomic innervation of the bowel. Although it may resolve with conservative therapy, colonoscopic decompression is sometimes needed to prevent ischemia and perforation of the bowel. Studies suggest that neostigmine is an effective treatment. However there is no reported experience from India with Naloxone hydrochloride. Naloxone hydrochloride, an opiod antagonist, is a synthetic congener of oxymorphone. METHODS:We studied patients admitted in intensive care unit (ICU) fulfilling criteria of acute intestinal pseudoobstruction in the form of clinical abdominal distention and radiographic evidence of significant small bowel and colonic dilation. Reversible and mechanical causes of abdominal distenstion were ruled out. When there was no response to at least 24 hours of conservative treatment, we prospectively recruited patients to receive 3.0 mg of Naloxone (one ampule contains 0.4 mg, so seven and half ampule inj Naloxone) given through ryles tube, ryles tube clamped for one hour, medicine administered every 6 hours. A physician, who was unaware of the patients’ treatment assignments, recorded clinical responses defined as evacuation of flatus or stool and a reduction in abdominal distention, abdominal circumference, and measurements of the small bowel and colon on radiographs. Patients who had no response to the initial dose were eligible to receive open-label Naloxone 6 hours later and subsequent doses 6 hourly for 24 hours. RESULTS: Prospectively 19 patients were included in study since April 2014, 7 patients were having pneumonia, septicaemia, three patients with pylenephritis, septicaemia, one patient with cerebrovascular accident, intracranial bleed, one post complicated spinal surgery, 3 with polytrauma due to road traffic accident, one with CRF and septicaemia, one patient with subacute bacterial endocarditis, septicaemia, and 2 with cirhosis liver. Eleven patients who received Naloxone had early intestinal decompression in the form of passage of flatus, passage of motion, decrease in abdominal girth, significant decrease in bowel diameter on x-ray flat plate abdomen, improvement in clinical parameters especially respiratory rate, oxygen saturation. In one patient colonoscopic decompression and also an injection of Neostigmine 2 mg was required. The median time to response was 4 hours (range, 212). Side effects of Naloxone included tachycardia in two patients, rise in blood pressure, irritability in one patient each. CONCLUSION: This initial observation suggests that Ryles tube administration of Naloxone hydrochloride is beneficial and safe in the treatment of ICU-admitted patients with acute intestinal pseudoobstruction.

Acute and chronic pseudo‐obstruction: a current update

Acute colonic pseudo-obstruction (ACPO) and chronic intestinal pseudo-obstruction (CIPO) are distinct clinical entities in which patients present similarly with symptoms of a mechanical obstruction without an occlusive lesion. Unfortunately, they also share the issues related to a delay in diagnosis, including inappropriate management and poor outcomes. Advancements have been made in our understanding of the aetiologies of both conditions. Several predisposing factors linked to critical illness have been implicated in ACPO. CIPO is a functional motility disorder, historically misdiagnosed, with unnecessary surgery being performed in many patients with dire consequences. This review discusses the pathophysiology, clinical and diagnostic features, and treatment of each. For ACPO, a safer pharmacological approach to treatment is presented in a modified up-to-date algorithm. The importance of CIPO as a differential diagnosis when seeing patients with recurrent admissions for abdominal pain and distention is also discussed, as well as specific indications for surgery. While surgery is often a last resort, the role of the surgeon in the management of both ACPO and CIPO cannot be undervalued. By characterizing each condition in a common review, the knowledge gleaned aims to optimize outcomes for these frequently complex patients.

Ogilvie's syndrome following posterior spinal instrumentation in thoraco lumbar trauma.

Objectives:To report unique cases of Ogilvie's syndrome (acute intestinal pseudo-obstruction) following posterior spinal instrumentation in thoraco lumbar trauma.Materials and Methods:A single centre retrospective study. We reviewed the surgical data of 420 patients who underwent thoracolumbar spinal surgery over a period of four years. Two patients who developed post operative Ogilvie's syndromes were identified.Results:The clinical presentation and blood investigations ruled out any infectious pathology. Computed tomography scans ruled out the mechanical obstruction. All patients improved with conservative management.Conclusion:Ogilvie's syndrome should be considered as a differential diagnosis in patients with postoperative significant abdominal distension who had undergone posterior instrumentation for spinal trauma. Early recognition and appropriate conservative treatment would be necessary to prevent complications such as bowel ischemia and perforation.

Mortality, recurrence, and hospital course of patients with systemic sclerosis-related acute intestinal pseudo-obstruction.

Acute intestinal pseudo-obstruction is a rare gastrointestinal manifestation of systemic sclerosis (SSc) with few data existing as to its demographics, clinical course, outcomes, and mortality. We undertook a case-control study to describe 64 cases in 37 unique patients, of whom 70% had spontaneous resolution with conservative measures of intravenous hydration and bowel rest, 9% underwent surgical resection, and 25% required prolonged total parenteral nutrition (TPN). Hospital course was for a mean of 12 ± 12.5 days and there was a 16% patient mortality in our population. In a subgroup analysis, patients who had recurrent episodes of pseudo-obstruction were less likely to have esophageal involvement from SSc, and more likely to need prolonged TPN. Mortality tended to be higher in male patients and patients who did not have SSc-related esophageal involvement, and also in patients who had low hemoglobin and serum albumin at presentation. The need for a nasogastric tube for decompression and a surgical intervention correlated with a more prolonged hospital stay. To the best of our knowledge, ours is the largest study looking at this rare manifestation of SSc.

Acute intestinal pseudo-obstruction (Ogilvie's syndrome): A case report

Acute colonic pseudo-obstruction, also known as Ogilvie's syndrome, is an acute clinical condition with clinical and radiological features of an acute large bowel obstruction in the absence of any mechanical cause. Patients presenting with Ogilvie's syndrome usually have underlying medical and surgical conditions predisposing them to the syndrome. In this article, we describe an elderly patient who presented with acute colonic pseudo-obstruction without any apparent cause.

Visceral myopathy causing acute colonic pseudoobstruction

Visceral myopathy is a rare disorder characterized by atrophy,losing and fibrosis of visceral smooth muscle.Digestive tract is often invaded by the lesions,and the symptoms are various according to different lesions and degrees.Small intestinal involvement is characterized by abdominal distension,diarrhea and vomiting.Colon involvement is characterized by chronic intestinal pseudoobstruction.Malnutrition and hypoproteinemia may be secondary to this disease.The diagnosis of visceral myopathy is difficult,paralytic ileus,chronic constipation and systemic sclerosis must be considered in the differential diagnosis.The progression of the disease is slow,and the longterm prognosis is poor.In this article,the diagnosis and treatment of visceral myopathy causing acute intestinal pseudoobstruction were introduced based on the clinical data of 1 patient. Key words: Visceral myopathy; Acute colonic pseudoobstruction; Diagnosis; Treatment

Visceral Myopathy Presenting as Acute Appendicitis and Ogilvie Syndrome

Background. Visceral myopathy is rare pathological condition of gastrointestinal tract with uncertain clinical presentation and unknown etiology. It often presents with symptoms of chronic intestinal pseudoobstruction of colon. We report a case of visceral myopathy which presented to us as acute appendicitis and Ogilvie syndrome, and we managed it surgically. Method and Result. A case report of 20-year female clinically presented as acute appendicitis and we performed laparoscopic exploration which revealed inflamed appendix with grossly dilated ascending colon. We performed laparoscopic appendectomy and postoperatively managed the patients with IV fluids, antibiotics, neostigmine, and extended length rectal tube for enema and decompression. During postoperative period, she developed abdomen distension and peritonitis, and we ordered abdomen CT which revealed colon pseudo- obstruction. We performed right hemicolectomy with permanent ileostomy, and the histopathology reports of resected colon were visceral myopathy. Conclusion. Visceral myopathy is very rare group of disease and poorly understood condition that may present with chronic or acute intestinal pseudo-obstruction and often mimic other more common gastrointestinal disease. VM should be considered as differential diagnosis whenever the patient presents with acute appendicitis, uncharacteristic abdominal symptoms, recurrent attacks of abdominal distention, and pain with no radiological evidence of intestinal obstruction.

Clozapine Induced Ogilvie’s Syndrome

We report a case of clozapine induced acute intestinal pseudo obstruction (also known as Ogilvie’s syndrome) in a 54-year female with a history significant for multiple psychiatric disorders. The diagnosis was made after a challenging clinical presentation where collaboration between multiple medical services resulted in reaching a unified diagnosis. The diagnosis was established based on multiple radiological imaging modalities and confirmed by a documented response to colonic decompression through colonoscopy and discontinuation of the offending medication. DOI: http://dx.doi.org/10.3329/jom.v13i2.12769 J Medicine 2012; 13 : 237-239

S.P.61 Recurrent pseudo-obstruction and sigmoid volvulus in Duchenne Muscular Dystrophy: A case report

Abstract Dystrophin is expressed in the smooth muscle of the gastrointestinal tract (GIT). In Duchenne Muscular Dystrophy (DMD) a disruption of protein expression can lead to functional disturbances of the GIT including acute gastric dilatation, gastroparesis and intestinal pseudo-obstruction. We report a case of a 24 year old young man with DMD confirmed by a nonsense mutation of intron 44, who developed sigmoid volvulus requiring multiple surgical interventions. Our patient presented with a long-standing history of abdominal bloating and constipation. These episodes, which were initially attributed to the use of night-time BiPAP, progressed into acute abdominal distension with visible large loop of bowels and peristalsis. He had no preceding history of vomiting or abdominal pain. Abdominal radiography showed a dilated sigmoid colon with features suggestive of volvulus. He had recurrent episodes of pseudo-obstruction over the course of two months, requiring several emergency sigmoidoscopy procedures to decompress obstructed bowel. An abdominal CT scan with contrast confirmed significant pancolonic dilatation with volvulus. A definitive procedure was deemed necessary and he underwent subtotal colectomy with ileostomy and gastrostomy insertion. One week later he developed acute gastric necrosis, requiring total gastrectomy and oesophago-jejunostomy. His post-operative course was aggravated by a peritonitis necessitating a third emergency laparotomy with drainage of the peritoneum. Post-operatively he remained in ICU fully ventilated with a tracheostomy in situ and total parenteral nutrition. Echocardiography showed a moderately impaired systolic function. Our case illustrates that GIT functional disturbances may be serious sequelae in DMD. Non-invasive ventilation and use of steroids can be confounders for underlying GIT dysmotility. Young adults with DMD, who present with a history of abdominal bloating, should be routinely investigated with abdominal radiography.

Case Report: Clozapine Induced Ogilvie′s Syndrome

We report a case of clozapine induced acute intestinal pseudo obstruction (also known as Ogilvie’s syndrome) in a 54-year female with a history significant for multiple psychiatric disorders. The diagnosis was made after a challenging clinical presentation where collaboration between multiple medical services resulted in reaching a unified diagnosis. The diagnosis was established based on multiple radiological imaging modalities and confirmed by a documented response to colonic decompression through colonoscopy and discontinuation of the offending medication.