ANSWER: B
Critique
This patient has evidence of an acute colonic pseudo-obstruction (known as Ogilvie’s syndrome). This is seen most commonly after non-GI related surgeries such as cardiac or orthopedic surgeries. The exact etiology is uncertain but increased inhibitory sympathetic and/or decreased stimulatory, parasympathetic innervations of the distal colon have been incriminated. The most appropriate first step in management of this patient is a thorough clinical evaluation to ensure there is no evidence of peritonitis to suggest a perforation complication. The next step is to exclude an obstruction and the CT had no clear evidence of obstruction. One could consider a water soluble enema to exclude obstruction but should avoid the use of barium in the event of a perforation. The next steps include restricting all possible culprit medications such as opiates and anticholinergics, encouraging ambulation (although often clinical circumstances limit ambulation), and correcting any potential electrolyte abnormalities.
Placement of a nasogastric tube to low intermittent suction, keeping the patient NPO (nothing by mouth), and placing a rectal tube to gravity are practical measure that can facilitate decompression. If the patient cannot ambulate, some clinicians also advocate rotating the patient into the right lateral decubitus position for several hours, alternating with the supine position, to facilitate gas evacuation. Such conservative measures are appropriate if there is no evidence of clinical toxicity or progression of the condition. Cecal diameters may be monitored on plain abdominal x-rays. If there is no clinical response to the above measures, then further treatments may be considered. Use of an acetylcholinesterase inhibitor has been shown to be beneficial in a placebo-controlled trial. If use of an acetylcholinesterase inhibitor is unsuccessful, colonic decompression can be considered though this typically provides only transient benefit. Finally, an emergent cecostomy can be considered if colonic decompression is unsuccessful.
References
1. De Giorgio R., Cogliandro R.F., Barbara G., Corinaldesi R., Stanghellini V. Chronic intestinal pseudo-obstruction: clinical features, diagnosis, and therapy. Gastroenterol. Clin. North Am. 2011;40:787-807.
2. Ponec R.J., Saunders M.D., KImmey M.B. Neostigmine for the treatment of acute colonic pseudo-obstruction. N. Engl. J. Med. 1999;341:137-41.
