IN HIS NAME

Surgery or colonoscopy???

That is the problem!!!!

Acute colonic pseudo-obstruction (ACPO) is characterised by massive colonic dilation with symptoms and signs of colonic obstruction without mechanical blockage

Ischemia and perforation are the feared complications of ACPO

INTRODUCTION

Ischemia and perforation are the feared

complications of ACPO Spontaneous perforation has been reported in

3%–15% of cases with a mortality rate estimated at 50% or higher when this occurs .

The main issues for the clinician to consider are: (1) what is the correct diagnosis? (2) Is ischemia or perforation present? (3) What is the appropriate evaluation and management?

INTRODUCTION

Colonic pseudoobstruction was first described

in 1948 by Sir Heneage Ogilvie, who reported two patients with chronic colonic dilation associated with malignant infiltration of the celiac plexus.

An imbalance in autonomic innervation, produced by a variety of factors, leads to excessive parasympathetic suppression or sympathetic stimulation

PATHOGENESIS

In comparison to control patients, patients

who developed ACPO had significantly lower postoperative serum sodium, a higher serum urea and remained in hospital longer

Predisposing factors

ACPO most often affects those in late middle age

(mean of 60 years of age), with a slight male predominance (60%)

ACPO occurs almost exclusively in hospitalised or institutionalised patients with serious underlying medical and surgical conditions. Abdominal distention usually develops over 3–7 days but can occur as rapidly as 24–48 h.7 In surgical patients, symptoms and signs develop at a mean of 5 days postoperatively.

CLINICAL PRESENTATION

abdominal distention (80 %) abdominal pain (80%) nausea and/or vomiting (60%) Passage of flatus or stool is reported in up to

40% of patients high incidence of fever inpatients with

ischemic or perforated bowel

clinical features

suggested by the clinical presentation and

confirmed by plain abdominal radiographs, which show varying degrees of colonic dilation

The right colon and cecum show the most marked distention, and ‘cutoffs’ at the splenic flexure and descending colon are common

DIAGNOSIS

MANAGEMENT

outcome

spontaneous perforation to be approximately

3%. The risk of colonic perforation has been

reported to increase with cecal diameter greater than 12 cm and when distention has been present for more than 6 days

A two-fold increase in mortality occurs when cecal diameter is greater than 14 cm and a fivefold increase when delay in decompression is greater than seven days.

outcome

Treatment options for ACPO include

appropriate supportive measures, pharmacologic therapy, colonoscopic decompression, and surgery

Treatment

Supportive therapy

patients with marked cecal distention (>10

cm) of significant duration (>3–4 days) and those not improving after 24–48 h of supportive therapy are candidates for further intervention

Treatment

Neostigmine: a reversible acetylcholinesterase inhibitor administered intravenously, has a rapid onset of action(1–20 min) short duration (1–2 h) The elimination half-life averages 80 min

Medical therapy

Contraindications to its use include

mechanical obstruction,presence of ischemia or perforation, pregnancy, uncontrolled cardiac arrhythmias, severe active bronchospasm, and renal insufficiency (serum creatinine >3 mg/dL).

Neostigmin

Colonic decompression is the initial invasive

procedure of choice for patients with marked cecal distention (>10 cm) of significant duration (>3–4 days), not improving after 24–48 h of supportive therapy, and who have contraindications to or fail neostigmine.

It should not be performed if overt peritonitis or perforation are present

Colonoscopic decompression

there are case reports of patients with

ischemia in ACPO being successfully managed with colonoscopic decompression

Oral laxatives and bowel preparations should not be administered prior to colonoscopy

Prolonged attempts at cecal intubation are notnecessary because reaching the hepatic flexure usually suffices

Colonoscopic decompression

Colonoscopic decompression

Eff icacy successful colonoscopic decompression has

been reported in many retrospective series In the series reported by Geller et al:Acute colonic pseudo-obstruction was diagnosed in 50 patients; . Forty-one patients (82%) had one colonoscopic decompression with clinical success in 39 (95%). Nine patients (18%) required multiple (2 to 4) colonoscopic decompressions with clinical success in 5 (56%)

Colonoscopic decompression

the overall clinical success of colonoscopic

decompression was 88%. However, in procedures where a decompression tube was not placed the clinical success was poor (25%).

Colonoscopic decompression

Safety: The complication rate of decompression

colonoscopy in ACPO ranges from approximately 1 to 5%

Perforation is the most complication

Colonoscopic decompression

can be considered in high surgical risk

patients reserved for patients failing neostigmine and

colonoscopic decompression who have no evidence of ischemia or perforation and who are felt to be at high risk for surgery.

Percutaneous cecostomy

Surgical management is reserved for patients

with signs of colonic ischemia or perforation or who fail endoscopic and pharmacologic effort

Without perforated or ischemic bowel, cecostomy is the procedure of choice.

In cases of ischemic or perforated bowel,segmental or subtotal resection is indicated

Surgical therapy

Everyone can enjoy of life but

just some of them can pick up

a scalple and save the lifes.