Isaac Ingersoll, DO1, Phillip C. Lindholm, MD2, Erin Gorton, DO3; 1Madigan Army Medical Center, Lacey, WA; 2Uniformed Services University of the Health Sciences, JBLM, WA; 3Madigan Army Medical Center, JBLM, WA
Introduction: Acute Colonic Pseudo obstruction (ACPO) is a condition involving significant colonic dilation in the absence of mechanical obstruction. It is associated with post-operative states, electrolyte abnormalities and critical illness. Up to 10% of ACPO cases have some degree of colonic ischemia. Current guidelines recommend surgical intervention with evidence of ischemia due to risk of perforation. However, not all patients are appropriate surgical candidates. We present a case of ACPO with right-sided ischemia that was successfully managed with non-surgical interventions.
Methods: The patient is an 81 year old male with CAD and CABG, heart failure and Sjogren’s who underwent L4-L5 surgery for spinal stenosis. On post-operative day (POD) 2, he developed colonic dilation of 9 cm with nausea and vomiting. Serum potassium, sodium and phosphorous were low. Infectious work-up was negative. NG tube decompression and electrolyte optimization was unsuccessful and colonic dilation increased to 14 cm. Neostigmine was not given due to the patient’s prior symptomatic bradycardia. Colonoscopy with right colon biopsies were consistent with ischemia. A colonic decompression tube was placed distally under with fluoroscopy. General surgery declined colectomy or venting cecostomy due to his comorbidities. Improvement from colonic tube decompression was short lived. Early ambulation, intermittent NG decompression and TPN were employed with resolution over two weeks. He was discharged on POD 26 with resolution of colonic dilation and no sequalae of ischemia. Discussion: Though surgery is recommend with ischemia due to high rates of perforation, up to 90% of patients with non-ischemic ACPO are successfully treated conservatively. Surgery itself can be associated with 50% mortality. Colonoscopic decompression is also associated with elevated risks of perforation. Therefore, each treatment modality is associated with unique risks that must be balanced with patient needs. We demonstrated that ischemia can be managed with conservative therapy. We question if mild ischemia is under-recognized as few patients undergo colonoscopy but up to 10% have signs of ischemia on colonoscopy. Prior case reports demonstrate a similar success in patients with ischemic ACPO managed without surgical intervention. We recommend prudent observation of guidelines yet consideration of medical management for ischemic ACPO when peri-operative risk is unacceptable.
14 cm dilation.
Right colon ischemia.
Disclosures: Isaac Ingersoll indicated no relevant financial relationships. Phillip Lindholm: Gilead – Stockholder/Ownership Interest (excluding diversified mutual funds). Erin Gorton indicated no relevant financial relationships.