the patient in a prone position or at the knee chest position with hips held high, alternating right and

left lateral decubitus position each hour. A nasogastric tube is helpful if the patient is vomiting and will

prevent swallowed air from passing distally. When bowel ischemia is suspected, surgery is indicated. If

bowel necrosis is found, the affected segment is resected and an ileostomy or colostomy should be

performed. If the bowel is viable, a cecostomy is placed to vent the colon and prevent distention.

If, initially, the distention is painless and the patient shows no signs of toxicity or bowel ischemia,

expectant management is successful in about 50% of cases.223,226 The risk of spontaneous perforation is

approximately 3%, with attendant mortality of 50%. In most patients acute colonic pseudo-obstruction

usually resolves within 3 days.223,227 If worsening and cecal diameter increases beyond 10 to 12 cm or if

it persists for more than 48 hours, intervention is recommended. The duration of distention may be

more important than the absolute size of the cecum with respect to spontaneous perforation.

Colonoscopy should only be performed by experienced endoscopists. Endoscopic decompression is

successful in 60% to 90% of cases, but the condition can recur in up to 40%. This rate of recurrence may

be decreased by placement of a decompressive tube. Recurrence would require repeated colonoscopic

decompression in approximately 40% of cases after initial successful decompression. The placement of a

decompression with the aid of a guidewire at the time of colonoscopy may reduce the need for repeated

colonoscopic decompression. Rectal tubes are ineffective as primary modalities in managing distention

of the proximal colon. Such tubes may be useful in promoting passage of air and feces after colonoscopy

but should not be used as a substitute for colonoscopic decompression. Percutaneous endoscopic leftsided colostomy (PEC), a minimally invasive technique, can be used to treat pseudo-obstruction

provided these cases are carefully selected in the hands of a skilled endoscopist because of a high failure

rate caused by infection.228

Table 49-11 Treatment for Pseudo-Obstruction

In anecdotal reports, prokinetic agents such as cisapride and erythromycin have been used to treat

Ogilvie syndrome with some success. Erythromycin acts by binding to motilin receptors in the small

intestine, causing intestinal smooth muscle contraction and perhaps better coordination with colonic

motor function. Anecdotal reports have suggested the success of erythromycin treatment on either

intravenous route for 3 days or oral route for 10 days.229,230 However, the relative paucity of motilin

receptors in colon smooth muscle may explain why erythromycin is only anecdotally effective in

relieving colonic pseudo-obstruction. Successful resolution of pseudo-obstruction has been reported with

sympatholytic agents or spinal sympathetic block. The efficacies of these modalities have not been

systematically evaluated.223,231

Neostigmine, a parasympathomimmetic, is used in the treatment of acute colonic pseudo-obstruction.

The decompression with this drug has been achieved in 80% to 100% with a recurrence rate of 5%.223

Neostigmine may be a viable alternative to colonoscopy in pregnant women, provided mechanical

obstruction is properly excluded. The administration of a polyerthylene glycol electrolyte balanced

solution after initial resolution of colonic dilation may reduce the recurrence rate with use of

neostigmine.232

Neostigmine has expected cardiovascular side effects such as bradycardia, hypotension, and dizziness;

and is excreted via the kidneys. The few relative contraindications to its use in treatment of acute

colonic pseudo-obstruction are a baseline heart rate of less than 60 beats per minute or systolic blood

pressure of less than 90 mm Hg; active bronchospasm requiring medication; a history of colon cancer or

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partial colonic resection; active gastrointestinal bleeding; pregnancy; or a serum creatinine

concentration of more than 3 mg/dL (265 μmol/L). Other side effects would include mild to moderate

crampy abdominal pain, excessive salivation and vomiting. Side effects such as increasing airway

secretions and bronchospasm, can be reduced by concomitant use of glycopyrrolate without reduction of

colonic response.233,234 Ponec et al.235 recommend use of neostigmine prior to colonoscopy, based on its

easy administration, lower expense, and superior results in comparison to colonoscopy. Reported rates

of response to treatment with neostigmine are 91% (single administration) and 100% (second

administration) in a group of 21 randomized patients.223,235 Colonoscopy is associated with morbidity of

3% and mortality of 1%. Further studies of this combination therapy are warranted. It should be

emphasized however, that patients should undergo immediate exploration if they exhibit signs of

clinical deterioration or bowel perforation (peritoneal signs on physical examination or free air on

radiographs).

Surgery is reserved for patients not responding to medical and endoscopic management and for

patients who develop signs of peritonitis or perforation. Percutaneous endoscopic cecostomy can also be

performed if case conservative measures fail.236 Cecostomy tubes are often poorly tolerated because of

issues related to skin breakdown; in the authors opinion, this approach is advisable only when more

extensive surgical procedures are considered too risky. Procedures such as total colectomy, ileostomy,

and Hartmann procedure are taken into consideration in case of perforation.223

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