Case Of Acute Colonic Pseudo-obstruction Research Articles

A119 ACUTE COLONOC PSEUDO-OBSTRUCTION AFTER ENDOSCOPIC RESECTION OF A FULLY CIRCUMFERENTIAL LARGE NON-PEDUNCULATED COLORECTAL POLYP

Abstract Background Complex large non-pedunculated colorectal polyps (LNPCPs), including those involving the full circumference of the bowel, are now readily managed by minimally invasive endoscopic resection techniques. Established procedure-related adverse events include sedation related adverse events, deep mural injury, clinically significant post-resection bleeding, delayed perforation and serositis. An appreciation for potential procedure-related adverse events is critical to the effective implementation of these techniques. Aims To describe a case of acute colonic pseudo-obstruction after endoscopic resection of a fully circumferential LNPCP. Methods Case report and review of the literature Results A 91-year-old male with a history of atrial fibrillation, chronic kidney disease and suspected McKittrick-Wheelock syndrome underwent successful endoscopic mucosal resection (EMR) of a 100mm fully circumferential LNPCP in the sigmoid colon. Histopathology diagnosed a tubulovillous adenoma with high-grade dysplasia. After elective admission, he suffered from clinically significant post-EMR bleeding requiring 2 units of packed red blood cells. On post-operative day 1 he began to suffer from nausea, abdominal pain and obstipation. On examination, he was visibly distended. Abdominal X-ray revealed extensive gas-filled loops of small and large bowel with the absence of gas in the rectum. He was managed conservatively with nasogastric tube decompression. Total duration of hospital stay was 9 days. Conclusions Critical to the continued expansion of minimally invasive endoscopic resection techniques is an awareness for potential procedure-related adverse events. To our knowledge this is the first description of acute colonic pseudo-obstruction after endoscopic resection Funding Agencies None

Update on the Diagnosis and Management of Acute Colonic Pseudo-obstruction (ACPO).

Acute Colonic Pseudo-obstruction (ACPO) is a cause of large intestinal dilation and obstruction without any physical transition point. It remains difficult to diagnose and treat. We review the recent updates on diagnosis and management of ACPO. Recent guidelines have posited that conservative management can be tried in most cases of ACPO, but that early decompression and surgery should be considered. Use of neostigmine is still a viable option but there is also promising data on pyridostigmine as well as prucalopride. Resolution of ACPO should be followed by daily use of polyethylene glycol (PEG) to help prevent recurrence. ACPO warrants early and accurate diagnosis with exclusion of alternate causes of large bowel dilation. Conservative management can be attempted for 48-72h in those with cecal diameters < 12cm and without signs of peritonitis and perforation. Early escalation of management should be attempted with neostigmine followed by endoscopy and/or surgery as needed, given that longer periods of dilation are associated with worse outcomes. There is promising new evidence for use of pyridostigmine and prucalopride, but further trials are needed prior to incorporating them into regular use. Finally, studies are lacking regarding prevention of ACPO after initial resolution.

S2232 An Unusual Case of Acute Colonic Pseudo-Obstruction in an Immunocompetent Adult With Refractory Cryptosporidium Infection

Introduction: Acute colonic pseudo-obstruction (ACPO) is characterized by acute colonic dilatation in the absence of mechanical obstruction and carries a 15% risk of perforation. Infectious agents such as VZV, Herpes virus, and CMV have been documented to cause ACPO. Cryptosporidium is a protozoan parasite that causes self-limited diarrhea in the immunocompetent and prolonged severe diarrhea in the immunocompromised. Case Description/Methods: A 58-year-old male with bipolar disorder and BMI 34 presented with sepsis, rhabdomyolysis and AKI. His wife reported that he had ongoing watery diarrhea for 6 weeks. CT showed colonic distention. Stool culture was positive for cryptosporidium antigen. HIV, C. difficile, stool ova and parasites, Campylobacter and Shiga toxin tests were negative. Common variable immunodeficiency was ruled out. Diarrhea persisted despite 2 courses of Nitazoxanide. Repeat stool culture was positive for cryptosporidium. Infectious Diseases (ID) suggested a prolonged course of Nitazoxanide. The patient was transferred to inpatient rehab, where diarrhea continued, and he had persistent hypokalemia despite scheduled potassium replacement. On rehab day 9, XR showed a transverse colon diameter of 13 cm, and patient was transferred to the ICU. CRP and calprotectin were within normal ranges. Other causes of ACPO were ruled out. Sigmoidoscopic decompression was done, with biopsies showing focal hyperplastic changes. NGT was placed and aggressive bowel regimen was started. A trial of neostigmine for the colonic pseudo-obstruction resulted in bradycardia. Repeat colonic decompression was performed which showed diffuse colonic dilation with large amount of stool. Patient initially declined any surgical procedures, and remained in PCU for TPN, scheduled IV potassium replacement and close monitoring of distended abdomen. After 1 month of attempted restimulation, patient agreed for total abdominal colectomy with end ileostomy for the chronic dilated colon, refractory to medical management. He continued to have high output from his ostomy. He succumbed to cardiopulmonary arrest on day 54 (Figure). Discussion: This is an unusual case of Cryptosporidium causing chronic refractory diarrhea and ACPO in an immunocompetent adult. Though other infectious agents have shown to cause enteric autonomic dysfunction leading to ACPO, Cryptosporidium-induced dysmotility has not yet been documented. Management of such cases remains challenging with inter-disciplinary efforts between GI, Surgery, ID and Critical Care.Figure 1.: A: CT Abdomen and Pelvis on admission, that showed diffuse dilation of colon and rectum with gas and liquified stool, measuring up to 11 cm in diameter; B: XR abdomen showing Sitz markers in the right abdomen, that did not change position in 5 days (yellow arrow); C: Colonoscopy showing diffuse colonic dilation. This was noted up to the level of the transverse colon; D: Colectomy specimen showing colonic mucosa with congestion and focal hemorrhage.

Ogilvie’s syndrome following cesarean delivery: a case report

Ogilvie’s syndrome (OS) or acute pseudo-obstruction of the large bowel, is a rare condition and the true incidence is unknown. We present a case of acute colonic pseudo-obstruction (OS) post cesarean section in a 35-year-old patient with fetal distress, following cesarean delivery at term under general anesthesia. On the second postoperative day, she complained of abdominal distension, pain, nausea, vomiting, bloating and no passage of stool. As the patient's condition did not improve, she continued to have persistent abdominal distention. A plain abdominal film was taken and abdominal ultrasound was done, which showed massive gaseous distention of the bowels without fluid level. At laparotomy, a huge distended gut, pussy flakes on intestine, and massive dilatation of the whole colon were found. Postoperatively, the patient was managed with fluids, antibiotics, nutritional support, etc., along with the standard guidelines for management of peritonitis. The patient recovered and was discharged after 1 day of intensive care unit management to the ward. The need for awareness about the syndrome and early diagnosis is emphasized.

A Case of Acute Colonic Pseudo-obstruction (Ogilvie Syndrome) after Laparoscopic Surgery

A Case of Acute Colonic Pseudo-obstruction (Ogilvie Syndrome) after Laparoscopic Surgery

A Case of Acute Colonic Pseudo-obstruction Caused by Spinal Bleeding

A Case of Acute Colonic Pseudo-obstruction Caused by Spinal Bleeding

An Unfortunate Case of Acute Colonic Pseudo-Obstruction

An Unfortunate Case of Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction after hysterectomy in a patient with Friedreich ataxia

Acute colonic pseudo-obstruction is a rare complication of gynecological surgery. Despite the complete description of this condition, diagnosis remains difficult and is often delayed. Due to delay in diagnosis and existence of serious comorbid illnesses, morbidity and mortality approaches higher levels. Early recognition of signs and symptoms of this condition and prompt accurate management are vital to prevent serious mortality. Here, we report a case of acute colonic pseudo-obstruction after total abdominal hysterectomy in a patient with known Friedreich ataxia.

A Case of Acute Colonic Pseudo-Obstruction Combined with Rhabdomyolysis induced by Severe Hypokalemia

Correspondence to In Hee Lee, M.D. Department of Internal Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 705-718, Korea Tel: +82-53-650-4216, Fax: +82-53-650-4570, E-mail: ihlee@cu.ac.kr Copyrightc 2013 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 중증 저칼륨혈증에 의해 발생한 횡문근 융해증이 합병된 급성 대장 가성 폐쇄증 1예

緊急経虫垂減圧術で対処し人工肛門造設を回避した急性結腸偽性閉塞症の1例

緊急経虫垂減圧術で対処し人工肛門造設を回避した急性結腸偽性閉塞症の1例

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

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.

Letters to the Editor

Letters to the Editor

Successful Treatment of Acute Colonic Pseudo-Obstruction in an Elderly Patient

Acute colonic pseudo-obstruction is a syndrome characterized by massive dilation of the colon without mechanical obstruction. It develops in hospitalized patients with serious underlying medical and surgical conditions. We report on such a case that was successfully treated conservatively in our hospital. A 67-year-old man presented to the emergency room with gradual onset of abdominal distension and pain. According to his history, chronic diarrhea related to severe hypokalemia developed after he had received radical proctectomy because of rectal adenocarcinoma 1 year previously. During admission, extreme large-bowel dilatation (to 11cm, without obstruction) was shown on plain abdominal X-ray and computed tomography. Conservative treatment was given, including nothing by mouth, nasogastric and anal tube decompression, intravenous fluid hydration, nutrition supplementation, and antibiotics. Electrolytes, particularly for hypokalemia, were aggressively corrected. We did not perform neostigmine infusion, decompressive colonoscopy or surgery. The patient recovered smoothly and was discharged. We, therefore, report a case of acute colonic pseudo-obstruction that, through early detection by emergency department clinicians, had an excellent outcome following conservative management only.

Síndrome de Ogilvie y lesión medular. A propósito de un caso

Introduction To report a case of acute colonic pseudo-obstruction (Ogilvie's syndrome) in a patient with spinal cord injury (SCI). Case report A 50-year-old man suffered a high-energy fall, resulting in: luxation-fracture of the thoracolumbar spine between T12 and L1 with spinal cord injury. After 8 months of evolution, he developed abdominal distension, nausea, vomiting and pain. Simple × rays revealed colonic dilation and a diagnosis of acute colonic pseudo-obstruction was made. Computerized tomography scan confirmed the diagnosis and excluded mechanical obstruction. Despite supportive measures, his symptoms progressed over the following hours, and emergency surgery was performed. He died during surgery 24 hours after the initiation of the problem. Discussion SCI may interfere with the accurate assessment of the abdomen. This syndrome should be borne in mind in patients with SCI who develop ileus after the acute damage phase, because early diagnosis and appropriate treatment would reduce morbidity and mortality.

Acute colonic pseudo-obstruction (Ogilvie′s syndrome) in critical care unit

Acute Colonic pseudo-obstruction (Ogilvie’s syndrome) is common occurrence in both the ICU and longterm acute care units. If not treated in time, it may lead to Colonic perforation or ischemia. Recent report showed that intravenous neostigmine, an acetylcholienastrase inhibitor, produces rapid colonic decompression in patients with acute colonic pseudo-obstruction (ACPO). We report four cases of acute colonic pseudo-obstruction in critical care unit and the response of neostigmine therapy.

OGILVIE'S SYNDROME POST RENAL TRANSPLANT AND ITS ASSOCIATION WITH DELAYED GRAFT FUNCTION OR PRIMARY NON-FUNCTIONING GRAFT

316 Ogilvie's syndrome (acute colonic pseudo-obstruction), a known complication of retroperitoneal surgery, is a potentially serious condition that may lead to severe life threatening complications (e.g. colonic perforation or necrosis) if unrecognized. Here we report the first retrospective study showing an association between delayed graft function (DGF) or primary graft non-function (PGNF) post renal transplant and Ogilvie's syndrome (OS). Methods: All renal transplant patients with intra-abdominal complications were reviewed. Cases of acute colonic pseudo-obstruction were identified. Presence or absence of immediate renal function, cause of renal dysfunction, age, amount of narcotic analgesics and presence of retroperitoneal collections were noted. DGF was defined as lack of >15% spontaneous drop in serum creatinine by day 3 ± need for dialysis in the first week post transplant. PGNF was due to hyperacute rejection or vascular complications. Results: Between July 1993- December 1998, 511(350 cadaveric, 161 live donor) renal transplants were performed in adult patients at our institution. 15 patients had OS diagnosed by clinical picture+abdominal series±colonoscopy±contrast colon studies. Only 2 patients with OS had peri-renal fluid collection. Sixty-nine patients had DGF (67 cadaveric, 2 live donor transplant) and 11 patients had PGNF. Of 80 patients with DGF or PGNF, 11 developed OS (13.7%), compared to 4 patients with OS and immediate graft function (4/432, 0.9%) (p=0.0000, χ2 test, odds ratio=17). There was no statistically significant difference in age between patients with or without OS (mean±SD 43±14 vs 41±13 year). Patients with and without OS received equivalent narcotic analgesic in first week post transplant (424±141 mg meperidine HCl and 348±128 mg codeine phosphate vs 484±110 mg meperidine HCl and 467±122 mg codeine phosphate, respectively; differences were not statistically significant). OS was treated conservatively ± rectal tube decompression in 10 cases. Four patients had one or more colonoscopic decompression. Two patients with OS developed colonic perforation and subsequently underwent open surgery; one of them developed septic shock post-operatively and died despite aggressive treatment. Conclusion: OS is associated with DGF and PGNF post-renal transplant. To our knowledge this is the first retrospective study showing this association. Knowledge of this association can lead to early recognition of this potentially serious condition, which in turn might prevent occurrence of further complications.