Background Acute colonic pseudo-obstruction — that is,massive dilation of the colon without mechanical obstruction— may develop after surgery or severe illness. Althoughit may resolve with conservative therapy, colonoscopic decompressionis sometimes needed to prevent ischemia and perforation of thebowel. Uncontrolled studies have suggested that neostigminemay be an effective treatment.
Methods We studied 21 patients with acute colonic pseudo-obstruction.All had abdominal distention and radiographic evidence of colonicdilation, with a cecal diameter of at least 10 cm, and had hadno response to at least 24 hours of conservative treatment.We randomly assigned 11 to receive 2.0 mg of neostigmine intravenouslyand 10 to receive intravenous saline. A physician who was unawareof the patients' treatment assignments recorded clinical response(defined as prompt evacuation of flatus or stool and a reductionin abdominal distention), abdominal circumference, and measurementsof the colon on radiographs. Patients who had no response tothe initial injection were eligible to receive open-label neostigminethree hours later.
Results Ten of the 11 patients who received neostigmine hadprompt colonic decompression, as compared with none of the 10patients who received placebo (P<0.001). The median timeto response was 4 minutes (range, 3 to 30). Seven patients inthe placebo group and the one patient in the neostigmine groupwithout an initial response received open-label neostigmine;all had colonic decompression. Two patients who had an initialresponse to neostigmine required colonoscopic decompressionfor recurrence of colonic distention; one eventually underwentsubtotal colectomy. Side effects of neostigmine included abdominalpain, excess salivation, and vomiting. Symptomatic bradycardiadeveloped in two patients and was treated with atropine.
Conclusions In patients with acute colonic pseudo-obstructionwho have not had a response to conservative therapy, treatmentwith neostigmine rapidly decompresses the colon.
Source Information
From the Division of Gastroenterology, University of Washington Medical Center, Seattle.
Address reprint requests to Dr. Kimmey at the Division of Gastroenterology, Box 356424, University of Washington, 1959 NE Pacific St., Seattle, WA 98195.
Neostigmine for Acute Colonic Pseudo-Obstruction
Vavilala M. S., Lam A. M., Abbasakoor F., Evans A., Stephenson B. M., Pierach C. A., Nicholson D., Ponec R. J., Saunders M. D., Kimmey M. B.
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N Engl J Med 1999;
341:1622-1623, Nov 18, 1999.
Correspondence
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