M. Nguyen1, D. Strosberg1, A. Brown1, E. Abel1, D. Eiferman1 1Ohio State University,Surgery,Columbus, OH, USA
Introduction:
Surgical dogma dictates the necessity of ruling out distal mechanical colonic obstruction prior to using neostigmine to treat suspected colonic pseudo-obstruction (CPO) to avoid the risk for colonic perforation. Gastroenterology guidelines recommend neostigmine as first line therapy for treatment of CPO. Although colonoscopy provides excellent value as a diagnostic and therapeutic modality in CPO, urgent colonoscopy in the setting of an un-prepped and dilated colon also carries the risk of perforation. This study examines if CPO can be safely treated with intravenous neostigmine without prior evaluation with colonoscopy to rule out distal obstruction and examines whether Computed Tomography (CT) scan can adequately assess the distal colon instead of endoscopy.
Methods:
We retrospectively reviewed all patients who received neostigmine for CPO at a tertiary-care academic medical center between 2013 and 2016. Data regarding clinical characteristics including treatment pathways, imaging diagnostics, maximum colonic diameter, clinical response, complications, and need for surgical consultation and/or intervention were collected and analyzed using descriptive methods and student t-test.
Results:
37 patients received neostigmine for the treatment of CPO. Average colonic diameter was 10.6cm prior to any intervention. 13/37 (35%) of patients were not evaluated for distal obstruction prior to neostigmine administration and 29.7% of patients were not evaluated by the surgical service during their hospitalization. CT scan was used to assess for distal obstruction in 21/37 (56.8%) patients and colonoscopy was performed on only 8/37 (21.6%) patients. 76% of patients who received Neostigmine without prior colonoscopy to rule out distal obstruction resulted in improvement of symptoms. Two patients required surgical intervention due to complications unrelated to neostigmine administration. One patient was diagnosed with distal obstruction from a colonic mass. No complications were reported due to neostigmine administration. Mean colonic diameter change was 4.0 cm with decompressive colonoscopy and 2.7 cm with neostigmine (p=0.28).
Conclusion:
Our review suggests that neostigmine can be safely given for CPO without prior endoscopic evaluation nor surgical consultation to rule out distal mechanical obstruction, which challenges traditional surgical dogma. In lieu of colonoscopy, CT scan can be safely utilized to rule out distal obstruction. Administration of neostigmine without colonoscopy can minimize delay in treatment for CPO.