That is the problem!!!!
INTRODUCTION

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?
PATHOGENESIS

 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
Predisposing factors

 In comparison to control patients, patients who
developed ACPO had significantly lower
postoperative serum sodium, a higher serum urea
and remained in hospital longer

CLINICAL
PRESENTATION

 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 features

 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
DIAGNOSIS

 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

MANAGEMENT

outcome

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.
Treatment

 Treatment options for ACPO include appropriate
supportive measures, pharmacologic therapy,
colonoscopic decompression, and surgery
Supportive therapy

Treatment

 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
Medical therapy

 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
Neostigmin

 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).
Colonoscopic
decompression

 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
Percutaneous cecostomy

 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.
Surgical therapy

 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
Everyone can enjoy of life

but just some of them can
pick up a scalple and save
the lifes.