Acute Intestinal Pseudo-obstruction

Overview and Recommendations

Background

● Acute intestinal pseudo-obstruction (colonic ileus) is disturbed intestinal motor function leading to
massive dilation of the intestinal tract in the absence of mechanical obstruction.

● It is usually associated with surgery, medications, and/or underlying medical conditions.

● Suspect colonic ileus in a patient with slowly developing distension of abdomen and mild, di use
abdominal pain. Nausea and vomiting may occur more than half the time. The cessation of passage of
atus and stool occurs about half the time.

Evaluation

● A plain abdominal x-ray will show massive colonic dilation.

● Exclude mechanical obstruction with any of the following:

⚬ computed tomography (CT)

⚬ water-soluble or barium contrast enema of the rectum and colon
⚬ magnetic resonance imaging (MRI)
⚬ abdominal ultrasound

● Consider performing abdominal CT, MRI, or ultrasound to evaluate the colonic dilation, and
complications such as perforation.

● Exclude toxic megacolon due to Clostridium di cile infection with a stool test.

● Blood tests should include a basic metabolic panel, complete blood count, thyroid studies, and
calcium, magnesium, and phosphate tests.

● Consider obtaining blood cultures if sepsis is suspected.

Management

● Conservative management for 24-48 hours is the preferred initial management if cecal diameter is <
12 cm and there are no signs of ischemia, perforation, or peritonitis (Strong recommendation) which
includes:
⚬ nothing by mouth
⚬ intravenous hydration and/or correction of uid and electrolyte imbalances
⚬ discontinuation of narcotic, sedative, or anticholinergic medications
⚬ placement of nasogastric tube for proximal intestinal decompression
⚬ aggressive use of body positioning and ambulation
⚬ placement of rectal tube (with or without use of limited tap water enemas)

● With conservative management, monitor the patient every 12-24 hours for electrolytes, leukocyte
count, and cecal diameter (with supine and dependant abdominal x-ray) and treat any emergent
complications.
● Give neostigmine (Prostigmin) 2 mg IV over 3-5 minutes (with cardiac monitoring) in patients who
have failed conservative therapy, are at risk for perforation, and have no contraindications (Strong
recommendation).

● Consider using prokinetic agents in refractory cases, but they are not clearly shown to be bene cial
and their use is limited by adverse e ects and drug interactions.

● Consider colonoscopy with decompression tube placement in patients with contraindications to

neostigmine and those failing other medical management (Weak recommendation).

● Surgery should be used in patients with overt perforation or signs of peritonitis (Strong
recommendation).

Related Summaries

● Small bowel obstruction

● Malignant large bowel obstruction

● Gastroparesis

● Prevention and management of postoperative ileus

General Information

Description

● disturbed intestinal motor function (due to uncoordinated, nonperistaltic, or attenuated muscle

contractions), leading to massive dilation of intestinal tract in absence of mechanical
obstruction 1 , 2 , 3 , 4

Also called

● Ogilvie's syndrome

● intestinal pseudo-obstruction

● acute colonic pseudo-obstruction

● acute nontoxic megacolon

● colonic ileus

Epidemiology

Who is most affected

● acute colonic pseudo-obstruction occurs most commonly in 1 , 4

⚬ patients > 60 years old

⚬ men
⚬ hospitalized or institutionalized patients
 ⚬ obese patients

Incidence/Prevalence

● acute intestinal pseudo-obstruction usually associated with surgery, medication, and/or underlying

medical conditions, and reported to occur in 1 , 4

⚬ 1% of hospitalized patients undergoing orthopedic procedures
⚬ 0.3% of patients with severe burns

Etiology and Pathogenesis

Causes

● medications associated with acute colonic pseudo-obstruction 1 , 2 , 3 , 4

⚬ opiates
⚬ calcium channel blockers
⚬ antidepressants
⚬ phenothiazines
⚬ anti-Parkinsonian medications
⚬ clonidine
⚬ theophylline
⚬ baclofen
⚬ chemotherapy and chemoradiation therapy
⚬ corticosteroids
⚬ medications reported in 48 patients with colonic pseudo-obstruction included narcotics (56%), H2
blockers (52%), phenothiazines (42%), calcium channel blockers (27%), steroids (23%), tricyclic
antidepressants (15%) and epidural analgesics (6%) (Dis Colon Rectum 1992 Dec;35(12):1135 )
⚬ case report of paralytic ileus in elderly patient with diabetes treated with voglibose (an alpha-
glucosidase inhibitor used in Japan) can be found in J Am Geriatr Soc 2006 Jan;54(1):182

● trauma associated with acute colonic pseudo-obstruction 1 , 2 , 4

⚬ pelvic trauma
⚬ thoracic trauma
⚬ spinal cord trauma
⚬ long bone fracture

● neoplasms associated with acute colonic pseudo-obstruction 1 , 4

⚬ hematologic malignancy such as leukemia

⚬ retroperitoneal tumor
⚬ pelvic radiation therapy
⚬ paraneoplastic syndrome, such as

– thymoma (Ann R Coll Surg Engl 2011 Sep;93(6):e61 )

– small cell lung cancer in case reports (Clin Oncol (R Coll Radiol) 2004 Feb;16(1):71 ,
Gastroenterol Clin Biol 1998 Mar;22(3):346 )
⚬ multiple myeloma

● connective tissue diseases, such as scleroderma, systemic lupus erythematosus (SLE), vasculitis 1
● surgery (see also Prevention and management of postoperative ileus) 1 , 2 , 3 , 4

● infections associated with acute colonic pseudo-obstruction 1 , 2 , 3 , 4

⚬ acute cholecystitis
⚬ meningitis
⚬ pelvic abscess
⚬ herpes zoster
⚬ pneumonia
⚬ cytomegalovirus (CMV) infection
⚬ sepsis
⚬ intestinal pseudo-obstruction may be due to Kawasaki disease, case report cites about 15 other
cases reported in the literature (Pediatrics 2004 May;113(5):e504 full-text )
⚬ case report of Ogilvie syndrome in woman with severe dengue can be found in Lancet 2013 Feb
23;381(9867):698

● neurological diseases associated with acute colonic pseudo-obstruction 1 , 2 , 3 , 4

⚬ Parkinson disease
⚬ Alzheimer dementia
⚬ multiple sclerosis (MS)
⚬ lower spinal cord disease
⚬ Guillain-Barre syndrome
⚬ meningioma
⚬ diabetic peripheral neuropathy
⚬ neuro bromatosis
⚬ familial visceral neuropathy
⚬ stroke (Clin Med 2013 Dec;13(6):623 )

● metabolic disturbances associated with acute colonic pseudo-obstruction 1 , 2 , 3 , 4

⚬ electrolyte imbalance, such as hypokalemia, hypocalcemia, hypomagnesemia

⚬ renal insu ciency
⚬ hepatic insu ciency
⚬ diabetes mellitus
⚬ alcohol abuse
⚬ electrolyte abnormalities in 48 patients with colonic pseudo-obstruction included hypocalcemia
(63%), hyponatremia (38%), hypokalemia (29%), hypomagnesemia (21%) and hypophosphatemia
(19%) (Dis Colon Rectum 1992 Dec;35(12):1135 )

● cardiovascular disease associated with acute colonic pseudo-obstruction 1 , 2 , 3 , 4

⚬ acute myocardial infarction

⚬ congestive heart failure, ileus present in 14% of older heart failure patients in study of 109 patients
(mean age 74) admitted with heart failure compared to 3% of 114 controls admitted with hip
fracture (J Am Geriatr Soc 1999 Feb;47(2):258 )
⚬ cerebrovascular attack

● other medical causes associated with acute colonic pseudo-obstruction 1 , 3

⚬ mechanical ventilation
⚬ pulmonary disease
 ⚬ acute pancreatitis
⚬ retroperitoneal hemorrhage
⚬ pregnancy
⚬ renal transplantation
⚬ toxicity, such as drug overdose, Amanita phalloides ingestion, pesticides
⚬ hypothyroidism
⚬ thyrotoxic periodic paralysis (case report can be found in J Am Geriatr Soc 2005 Dec;53(12):2237
)
⚬ hypopituitarism
⚬ sickle cell disease
⚬ postcolonoscopy
⚬ familial visceral myopathy (see chronic intestinal pseudo-obstruction below)

● acute intestinal pseudo-obstruction may be an exacerbation/presentation of chronic intestinal

pseudo-obstruction (also called chronic idiopathic intestinal pseudo-obstruction, CIIP, CIP, or pseudo-
obstruction syndrome)
⚬ CIP is a heterogeneous group of severe gut motility disorders of impaired gastrointestinal
propulsion in absence of mechanical obstruction, with an estimated adult prevalence of 0.9/
100,000
⚬ CIP presents non-speci cally with symptoms of bowel obstruction such as abdominal pain (chronic
or acute), dysphagia, distension, vomiting, constipation or diarrhea, or bowel perforation
– ultimately causes unintentional weight loss and malnourishment due to inability to meet
normal nutritional requirements
– may cause severe, life-threatening complications
– course is reported to be chronic and intermittent

⚬ onset has been reported anytime from infancy to age 89 years

⚬ diagnosis requires imaging, and is often delayed to nonspeci c and varied presentations, and
rareness of disorder
⚬ categorized as primary CIP (intrinsic myopathy or neuropathy a ecting gastrointestinal passage) or
secondary CIP (dysfunction due to underlying non-gastrointestinal disorder)
– primary CIP is either myopathic (weakened or absent contractions) or neuropathic
(unsynchronized contractions), and is caused by a variety of acquired and genetic disorder (may
also be idiopathic); further subsets include
● congenital (sometimes due to fetal insults or toxins)
● familial (may be inherited as autosomal dominant, autosomal recessive, or an X-linked trait)

⚬ includes familial visceral myopathy and familial visceral neuropathy

⚬ 20-year-old man presenting with megaduodenum due to familal visercal myopathy
reported in case report and review (Acta Chir Belg 2016 Oct;116(5):305 )
● sporadic

– secondary CIP has been associated with

● medical conditions

⚬ collagen vascular diseases (autoimmune conditions) - scleroderma, lupus,

dermatomyositis, mixed connective tissue disorder, rheumatoid arthritis
⚬ endocrine disorders - diabetes mellitus, hypothyroidism or hypoparathyroidism
⚬ neurological disorders - Parkinson disease, multiple system atrophy, Hirschsprung
disease
⚬ cancers including small cell carcinoma of the lung
 ⚬ myopathies such as Duchenne muscular dystrophy or myotonic dystrophy
⚬ other conditions including amyloidosis, Celiac disease, Ehlers-Danlos syndrome, or
mitochondrial neurogastrointestinal encephalopthy (MNGIE)
● infectious causes including Chagas disease, Epstein Bar virus, or cytomegalovirus
● medications or drugs including tricyclic antidepressants, anticholingergic agents or narcotics

⚬ currently no speci c therapy; treatment is symptom-based and individualized

– for primary CIP treatment may include dietary adjustments, total parenteral nutrition, enteral
feeding, medications (antibiotics for infection, diarrhea, and bloating; anti-emetics, prokinetics,
and/or low-dose tricyclic antidepressants or gabapentin for chronic pain), or surgery
– secondary CIP is managed by treating underlying condition

⚬ References - Endoscopy 2014 Jun;46(6):533 , National Organization for Rare Disorders Chronic
intestinal pseudo-obstruction

Pathogenesis

● poorly understood, probably multifactorial 1 , 4

● theories for colonic pseudo-obstruction include 1 , 4

⚬ imbalance of autonomic in uences that produces hypertonic bowel, possibly through increased
sympathetic activity or decreased parasympathetic activity
⚬ overstimulation of splanchnic nerves
⚬ sacral parasympathetic de ciency with unopposed sympathetic activity, causing bowel hypotonia
and resulting in luminal stasis and colonic dilatation through ine cient expulsion of intraluminal
gas and stool

History and Physical

History

Chief concern (CC)

● common clinical presentation includes 1 , 3 , 4

⚬ abdominal pain, nausea, vomiting

⚬ abdominal distension
⚬ inability to pass atus or stool

History of present illness (HPI)

● symptoms may develop slowly over several days, with gradual distension of abdomen and mild,

di use abdominal pain 1 , 3

● nausea and vomiting may occur more than half the time 1 , 3

● cessation of passage of atus and stool occurs about half the time 1 , 3 , 4

Medication history

● ask about previous intake or current use of medications associated with acute colonic pseudo-

obstruction 1 , 2 , 3 , 4
Past medical history (PMH)

● ask about medical conditions associated with acute colonic pseudo-obstruction 1 , 2 , 3 , 4

Family history (FH)

● ask about familial visceral neuropathy or myopathy 1

Social history (SH)

● ask about history of substance use 1 , 2 , 3 , 4

Physical

General physical

● check for 1 , 3 , 4

⚬ fever
⚬ tachycardia

Abdomen

● assess for 1 , 3 , 4

⚬ abdominal distension
⚬ tympanic percussion
⚬ reduced, high-pitched, or absent bowel sounds
⚬ tenderness

Rectal

● perform rectal examination for signs of bleeding 1

Diagnosis

Making the diagnosis

● abdominal x-ray to determine extent of distension 1 , 3 , 4

● large bowel obstruction must be ruled out to make diagnosis of acute colonic ileus; this can be done

with 1 , 2 , 4
⚬ computed tomography (CT)
⚬ water-soluble or barium contrast enema of rectum and colon
⚬ magnetic resonance imaging (MRI)
⚬ abdominal ultrasound

● exclude toxic megacolon due to Clostridium di cile infection with stool test in patients with abdominal
distension 1 , 4

Differential diagnosis

● mechanical obstruction 1 , 2 , 4

● toxic megacolon, which frequently presents as acute illness with 1 , 2 , 4

 ⚬ fever, tachycardia, and abdominal tenderness
⚬ diarrhea that may be bloody
⚬ see also Ulcerative colitis topic for de nition and management

● ischemic colitis 1

● volvulus (Dis Colon Rectum 1986 Mar;29(3):203 )

● Hirschsprung disease

● Gastroparesis

● fecal impaction (Dis Colon Rectum 1986 Mar;29(3):203 )

● malignant large bowel obstruction (Dis Colon Rectum 1986 Mar;29(3):203 )

● gallstone ileus (case report in HPB Surg 2010;2010:153740 full-text )

Testing overview

● blood tests

⚬ can help determine precipitating events and look for signs of ischemia or perforation
⚬ check CBC, leukocyte count, metabolic panel and liver function tests (BUN, creatinine, electrolytes
(Na, K, Cl), magnesium, phosphate, calcium, thyroid function tests, and blood cultures

● plain abdominal x-ray

● tests to help exclude obstruction

⚬ water-soluble or barium contrast enema

⚬ computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound

● colonoscopy may be performed for diagnostic or therapeutic purposes in absence of clinical signs of
peritonitis or perforation

● stool study for Clostridium di cile toxin A

Blood tests

● initial blood tests to help determine precipitating factors and help rule out ischemia or perforation

include 1
⚬ complete blood count (CBC), abnormalities may suggest systemic toxicity, ischemia, or sepsis
⚬ leukocyte count, leukocytosis may suggest ischemia
⚬ metabolic panel and liver function (sodium, potassium, calcium, magnesium, phosphorus, blood
urea nitrogen [BUN], creatinine, and liver function), severe electrolyte imbalances, renal failure,
liver failure, and diabetes mellitus may precipitate pseudo-obstruction
⚬ thyroid function tests, both thyrotoxicosis and hypothyroidism may cause gastrointestinal paralysis
⚬ blood culture (if sepsis suspected)

Stool studies

● stool study for Clostridium di cile toxin A may help diagnose toxic megacolon 1
 ⚬ see Ulcerative colitis topic for toxic megacolon de nition and management

Imaging studies

● abdominal x-ray 1 , 3 , 4

⚬ signs suggestive of colonic pseudo-obstruction

– colonic distension, may be limited to area proximal to splenic exure

– air- lled colon extending distally to rectosigmoid
– right colon distension often greater than left colon
– retention of haustral markings
– simultaneous, though lesser, distension of small bowel
– thumbprinting on x-ray may suggest ischemia

IMAGE 1 OF 1

Gastrointestinal Pseudo-obstruction

A at plate X-ray of the abdomen reveals small

intestine and colonic dilation in a patient with di use
cutaneous systemic sclerosis with pseudo-
obstruction.

● to exclude obstruction

⚬ contrast enema

– contrast enema (either barium or water-soluble contrast) 1 , 2 , 4

● may occasionally be therapeutic

● barium enema may rarely cause perforation
● water-soluble contrast may cause dehydration

STUDY
– SUMMARY
acute contrast enema may help rule out colonic obstruction in patients with distended
colon DynaMed Level 2

DIAGNOSTIC COHORT STUDY: Clin Radiol 1992 Oct;46(4):273

Details
● based on retrospective diagnostic cohort study without blinding of reference standard or test
under investigation
● 140 patients were referred for acute contrast enema for suspected colonic obstruction
(based on clinical ndings plus plain abdominal x-ray)
● reference standard was clinical outcome
 ● 39.3% had colonic obstruction by reference standard
● diagnostic performance of plain x-ray was

⚬ sensitivity 84%
⚬ speci city 72%

● diagnostic performance of acute contrast enema was

⚬ sensitivity 96%
⚬ speci city 98%

● Reference - Clin Radiol 1992 Oct;46(4):273

⚬ abdominal computed tomography (CT)

– may help identify potential complications and may help di erentiate mechanical obstruction

from pseudo-obstruction 1 , 4
– CT may allow most accurate measurement of bowel diameter and better appraisal of condition

of mucosa 1 , 4
– fast helical multidetector CT may be useful in frail or uncooperative patients 1

STUDY
– SUMMARY
computed tomography with contrast appears able to rule out obstruction in patients with
suspected large bowel obstruction

DIAGNOSTIC COHORT STUDY: ANZ J Surg 2007 Mar;77(3):160

Details
● based on diagnostic cohort study without independent validation
● 44 adults (mean age 71 years) with clinical and abdominal x-ray signs suggesting either ileus
or large bowel obstruction were examined by computed tomography (CT) with either IV or
oral contrast
● 3 reference standards used

⚬ surgery
⚬ further imaging
⚬ clinical course

● 50% had large bowel obstruction by reference standard

● diagnostic performance of CT with contrast for determining large bowel obstruction

⚬ sensitivity 90.9%
⚬ speci city 100%
⚬ positive predictive value 100%
⚬ negative predictive value 91.6%

● Reference - ANZ J Surg 2007 Mar;77(3):160

● colonoscopy 1 , 2 , 4

⚬ may also be therapeutic

⚬ may be performed at bedside with unprepared colon, but low-pressure normal saline enema may
help visualization
⚬ contraindicated with any signs of peritonitis or perforation
⚬ abort with any signs of colonic ischemia
⚬ signs suggestive of pseudo-obstruction
 – dilated, amotile, compliant colon
– absence of point of obstruction
– absence of intrinsic colonic lesion

⚬ sign suggestive of Clostridium di

cile infection are pseudomembranes (2mm-8mm yellowish
nodules of adherent exudate overlying mucosa)
⚬ signs suggestive of ischemic colitis

– de novo segmental colitis, usually rectal sparing

– hemorrhagic nodules caused by intramural hemorrhage and edema
– friable and ulcerated mucosa
– gray or dusky mucosa

Management

Management overview

● treat underlying disorder if applicable 1 , 2 , 4

● give antibiotics if sepsis suspected 1

● conservative management for 24-48 hours is preferred initial management if cecal diameter < 12 cm

and no signs of ischemia, perforation, or peritonitis (ASGE Moderate quality evidence) 1 , 2

⚬ nothing by mouth
⚬ intravenous hydration and/or correction of uid and electrolyte imbalances (such as hypokalemia,
hypocalcemia, and hypomagnesia)
⚬ discontinuation of narcotic, sedative, or anticholinergic medications
⚬ placement of nasogastric tube for proximal intestinal decompression
⚬ aggressive use of body positioning and ambulation
⚬ placement of rectal tube (with or without use of limited tap water enemas)

● with conservative management, monitor patient every 12-24 hours for electrolytes, leukocyte count,
and cecal diameter (with supine and dependant abdominal x-ray) and treat emergent
complications 1 , 2

● give neostigmine (Prostigmin) 2 mg IV over 3-5 minutes (with cardiac monitoring) in patients who have
failed conservative therapy, are at risk for perforation, and have no contraindications (ASGE High
quality evidence) 1 , 2

● consider prokinetic agents in refractory cases but not clearly shown to be bene cial and use limited

by adverse e ects and drug interactions 1 , 2 , 3

● consider colonoscopy with decompression tube placement in patients with contraindications to

neostigmine and those failing other medical management (ASGE Low quality evidence) 2

● surgery should be used in patients with overt perforation or signs of peritonitis (ASGE Moderate

quality evidence) 2

● follow-up for symptoms and signs of sepsis and/or worsening distension

Diet

● nothing by mouth, as part of conservative approach 1 , 2

● total parenteral nutrition (TPN) or peripheral parenteral nutrition (PPN)

⚬ may be appropriate for prolonged ileus with oral intake limited by vomiting
⚬ American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines for use of parenteral and
enteral nutrition in adult and pediatric patients can be found in JPEN J Parenter Enteral Nutr 2002
Jan-Feb;26(1 Suppl):1SA , correction can be found in JPEN J Parenter Enteral Nutr 2002 Mar-
Apr;26(2):144

● Academy of Nutrition and Dietetics (AND) evidence-based nutrition practice guideline on critical illness
can be found at AND Evidence Analysis Library 2012 Sep

Activity

● encourage and facilitate getting out of bed and ambulating as tolerated 1 , 2

Medications

Neostigmine

● neostigmine (anticholinesterase parasympathomimetic agent) shows consistent positive results 1 , 2 , 3

⚬ response may be more favorable in women and older persons

⚬ response may be attenuated in patients with electrolyte imbalances or who have taken antimotility
agents
⚬ monitor cardiac activity during and immediately after administration

● contraindications 1 , 2 , 3

⚬ bradycardia
⚬ severe cardiac disease, including recent myocardial infarction
⚬ intestinal obstruction
⚬ peptic ulcer disease
⚬ therapy with beta-blockers
⚬ hypotension
⚬ active bronchospasm requiring medication or asthma
⚬ renal insu ciency
⚬ pregnancy

● dose reported 2 mg IV associated with mean response time 4 minutes (reduce dose if adverse e ects

are concern), second dose after 4 hours may be used if necessary 1 , 3

● possible adverse e ects (may co-administer glycopyrrolate 0.1 mg IV every 4 hours 3-4 times per day

to minimize cholinergic adverse e ects or atropine to treat adverse e ects) 1 , 2 , 3

⚬ asystole
⚬ bradycardia
⚬ bronchospasm
⚬ bronchoconstriction
⚬ seizures
⚬ hypotension
 ⚬ crampy abdominal pain
⚬ vomiting
⚬ diarrhea
⚬ restlessness
⚬ tremor
⚬ hyperhidrosis
⚬ excessive salivation

STUDY
● SUMMARY
neostigmine associated with rapid decompression of colon in acute colonic pseudo-obstruction
DynaMed Level 2

RANDOMIZED TRIAL: N Engl J Med 1999 Jul 15;341(3):137

Details
⚬ based on small randomized trial
⚬ 21 patients with acute colonic pseudo-obstruction and no response to ≥ 24 hours of conservative
treatment were randomized to neostigmine 2 mg vs. saline IV
⚬ colonic pseudo-obstruction de ned as abdominal distention, cecal diameter > 10 cm on x-ray,
mechanical obstruction ruled out by air in rectosigmoid colon or by radiographic contrast enema
⚬ median time to response 4 minutes (range 3-30 minutes)
⚬ 2 patients initially responsive to neostigmine required colonoscopic decompression for recurrence
(1 ultimately had subtotal colectomy)
⚬ side e ects included

– abdominal pain
– excess salivation
– vomiting
– symptomatic bradycardia (treated with atropine)

⚬ 8 patients (7 placebo and 1 non-responder) received open-label neostigmine and all had response
⚬ Reference - N Engl J Med 1999 Jul 15;341(3):137 , editorial can be found in N Engl J Med 1999 Jul
15;341(3):192 , commentary can be found in N Engl J Med 1999 Nov 18;341(21):1622 , ACP J
Club 2000 Jan-Feb;132(1):19

STUDY
● SUMMARY
neostigmine infusion promotes defecation in critically ill patients with colonic ileus
DynaMed Level 2

RANDOMIZED TRIAL: Intensive Care Med 2001 May;27(5):822

Details
⚬ based on small randomized trial
⚬ 30 ventilated patients with multiple organ failure and critical illness-related colonic ileus for > 3
days were randomized to neostigmine 0.4-0.8 mg/hour vs. placebo by continuous infusion over 24
hours, 24 patients (80%) were evaluated
⚬ at 24 hours, 11 of 13 neostigmine patients vs. none of 11 placebo patients passed stools (p < 0.001,
NNT 1.2)
⚬ non-responders given neostigmine or placebo, 8 of 11 neostigmine patients vs. no placebo patients
then passed stools
 ⚬ no acute serious adverse e ects but 3 patients had ischemic colonic complications 7-10 days after
treatment
⚬ Reference - Intensive Care Med 2001 May;27(5):822

STUDY
● SUMMARY
neostigmine IV may help resolve distension in patients with acute colonic pseudo-obstruction
who fail conservative treatment

COHORT STUDY: Dis Colon Rectum 2000 May;43(5):599

Details
⚬ based on prospective cohort study
⚬ 28 patients with acute colonic pseudo-obstruction who failed conservative treatment were given
neostigmine 2.5 mg IV over 3 minutes after mechanical obstruction was ruled out
⚬ complete resolution of large bowel distention occurred in 26 patients with time to pass atus
between 30 seconds and 10 minutes after administration
⚬ no adverse events or complications occurred
⚬ Reference - Dis Colon Rectum 2000 May;43(5):599 , commentary can be found in Dis Colon
Rectum 2000 Oct;43(10):1454

● neostigmine relapse occurs in about 35% of patients 1

STUDY
⚬ SUMMARY
polyethylene glycol solution via nasogastric tube may decrease risk of relapse in patients
treated with neostigmine or colonoscopic decompression DynaMed Level 3

RANDOMIZED TRIAL: Gut 2006 May;55(5):638 | Full Text

Details
– based on small randomized trial without clinical outcomes
– 15 patients with resolution of colonic ileus by neostigmine or endoscopy decompression
randomized to polyethylene glycol (PEG) 29.5 g in 500 mL vs. placebo delivered twice daily orally
or via nasogastric tube
– relapse de ned as cecal diameter ≥ 8 cm with concomitant ≥ 10% increase over baseline on x-
ray
– relapse in 0 patients received PEG vs. 33.3% receiving placebo (p < 0.05, NNT 3)
– Reference - Gut 2006 May;55(5):638 full-text

Prokinetic agents

● erythromycin 1 , 2 , 3

⚬ no evaluation by randomized studies, but relatively safe

⚬ dose reported 250-500 mg orally or IV 3-4 times per day

STUDY
⚬ SUMMARY
erythromycin 500 mg orally 4 times per day reported to resolve within 24 hours acute colonic
pseudo-obstruction secondary to spinal injury in 2 men DynaMed Level 3

CASE REPORT: Lancet 1991 Feb 9;337(8737):378

 Details
– based on case report
– Reference - Lancet 1991 Feb 9;337(8737):378

STUDY
⚬ SUMMARY
erythromycin 250 mg in 250 mL saline IV every 8 hours for 3 days reported to resolve acute
colonic pseudo-obstruction secondary to Guillain-Barre syndrome in 69 year old woman
DynaMed Level 3

CASE REPORT: J Clin Gastroenterol 1991 Aug;13(4):475

Details
– based on case report
– Reference - J Clin Gastroenterol 1991 Aug;13(4):475 , commentary can be found in J Clin
Gastroenterol 1992 Sep;15(2):169

● prucalopride 4 mg twice daily orally reported to resolve acute intestinal pseudo-obstruction in patient
with mitochondrial disease in case report (Neurology 2014 May 27;82(21):1932 )

● other options

⚬ mu receptor opioid antagonists (alvimopan and methylnaltrexone) 1

⚬ kappa-receptor opioid antagonists (asimadoline) 1

STUDY
⚬ SUMMARY
polyethylene glycol may maintain resolution after initial resolution of colonic ileus
DynaMed Level 2

RANDOMIZED TRIAL: Gut 2006 May;55(5):638

Details
– based on small randomized trial
– 30 patients who had abdominal distension, colonic dilation (cecal diameter ≥ 10 cm) and
resolution of colonic dilation were randomized to polyethylene glycol 29.5 g/day vs. placebo for
7 days
– open-label polyethylene glycol given if relapse (de ned as cecal diameter 8 cm or higher), or
10% or greater increase after successful therapeutic intervention
– 25 patients received neostigmine (successful in 88%), 8 patients had successful endoscopic
decompression
– recurrent cecal dilation occurred in no polyethylene glycol vs. 5 (33%) placebo patients (p = 0.04,
NNT 3)
– Reference - Gut 2006 May;55(5):638

Surgery and procedures

Surgery

● consider cecostomy or colostomy for critically ill patients who do not respond to medical or

colonoscopic therapy 1 , 2 , 3
 ⚬ percutaneous transperitoneal cecostomy under uoroscopic, colonoscopic, or laparoscopic
guidance
– possible adverse events

● catheter leakage
● abdominal wall cellulitis
● sepsis

⚬ perforation may require total colectomy with ileostomy

⚬ see also Colorectal surgery considerations

Procedures

● colonoscopic decompression therapy 1 , 2 , 3

⚬ preferred over other invasive procedures

⚬ contraindications are overt peritonitis or perforation
⚬ perform without oral laxatives or bowel preparation
⚬ sedation using benzodiazepines alone preferred due to narcotic inhibition of colonic motility
⚬ decompression at level of proximal hepatic exure usually su cient
⚬ guidewire may be placed through instrument channel, followed by colonoscope withdrawal with
regular suction and passage of decompression tube over wire with uoroscope guidance or
decompression tube through colonoscope without uoroscope guidance
⚬ large-channel colonoscope may facilitate decompression by allowing more rapid evacuation of
stool and gas and allows passage of larger-diameter decompression tube
⚬ use of long decompression tube may decrease recurrence rate
⚬ place decompression tube to gravity drainage and ush every 4-6 hours to prevent clogging
⚬ administration of polyethylene glycol afterwards may help prevent relapse
⚬ possible adverse events

– perforation
– ischemia

STUDY
⚬ SUMMARY
addition of tube placement to colonoscopic decompression reduces recurrence risk

COHORT STUDY: Gastrointest Endosc 1988 Jan-Feb;34(1):23

Details
– based on prospective cohort study
– 20 patients with acute colonic pseudo-obstruction had colonoscopic decompression, 11 with
decompression followed by tube placement (enteroclysis tube with side holes in distal 20 cm)
vs. 9 with single decompression
– recurrence rate 0% vs. 44% (p < 0.05)
– Reference - Gastrointest Endosc 1988 Jan-Feb;34(1):23

Other management

● conservative treatment often successful 1 , 2 , 4

STUDY
⚬ SUMMARY
77% of patients with acute colonic pseudo-obstruction may improve with conservative
treatment
 COHORT STUDY: Am J Gastroenterol 2002 Dec;97(12):3118

Details
– based on retrospective cohort study
– records from 151 patients (mean age 67.1 years) with acute colonic pseudo-obstruction (with
cecal diameter ≥ 10 cm) between 1999-2001 were reviewed for treatment and outcomes
– 77% of patients resolved pseudo-obstruction with conservative management (nothing by
mouth, nasogastric suction, and uid and electrolyte replacement), the remaining patients were
treated with neostigmine, colonoscopic decompression, or surgery after failing conservative
therapy
– compared to patients requiring medication, colonoscopy, or surgery, patients who resolved with
conservative management were less likely
● postoperative, 44% vs. 29% (p = 0.01)
● taking narcotics, 74% vs. 59% (p = 0.08)

– Reference - Am J Gastroenterol 2002 Dec;97(12):3118

STUDY
⚬ SUMMARY
96% of patients with acute colonic pseudo-obstruction may improve with conservative
treatment

COHORT STUDY: Dig Dis Sci 1988 Nov;33(11):1391

Details
– based on retrospective cohort study
– records from 25 patients with acute colonic pseudo-obstruction between 1982-1985 were
reviewed for clinical presentation, treatment, and outcome
– 24/25 (96%) patients were managed conservatively, 1 patient had laparotomy for prophylactic
cecostomy
– 96% of patients treated conservatively improved within mean 3 days, remaining patient died
– cecal diameter range 9-18 cm, no colonic perforations
– Reference - Dig Dis Sci 1988 Nov;33(11):1391

● if possible, alternation of prone position with hips elevated on pillow, knee-chest position with hips
high, and right and left lateral decubitus positions every hour may help with spontaneous evacuation
of atus 2

Follow-up

● monitor for symptoms and signs of sepsis and/or worsening distension 4

⚬ perform x-ray and blood tests every 12-24 hours

⚬ check for overt abdominal tenderness

Complications and Prognosis

Complications

● complications associated with cecal diameters > 10-12 cm, transverse colon diameters > 9 cm, or

duration of distension > 6 days 1 , 2 , 4

 ⚬ intestinal perforation
⚬ intestinal ischemia and necrosis
⚬ peritonitis

Prognosis

● prognosis varies according to underlying disease processes and interventions

⚬ mortality 1 , 2 , 4

STUDY
– SUMMARY
factors associated with mortality in acute colonic pseudo-obstruction include surgical
treatment, delay > 7 days before colonic decompression, and cecal diameter > 14 cm

COHORT STUDY: Dis Colon Rectum 1986 Mar;29(3):203

Details
● based on retrospective cohort study
● records from 393 patients (mean age 56.5 years) with acute colonic pseudo-obstruction from
1970-1985 were reviewed for associated conditions, laboratory and imaging results,
treatment, and outcomes
● mortality rate by treatment (no p values reported)

⚬ 14% for conservative treatment (insertion of nasogastric tube plus nothing by mouth)
⚬ 13% for colonoscopy
⚬ 30% for surgery

● mortality by number of days after diagnosis until decompression (no p values reported)

⚬ 15% for < 4 days

⚬ 27% for 4-7 days
⚬ 73% for > 7 days

● mortality by cecal diameter (no p values reported)

⚬ 7% for < 12 cm
⚬ 7% for 12-14 cm
⚬ 14% for > 14 cm

● Reference - Dis Colon Rectum 1986 Mar;29(3):203

⚬ perforation

STUDY
– SUMMARY
bowel perforation usually not observed until cecal diameter ≥ 12 cm

COHORT STUDY: Dis Colon Rectum 1986 Mar;29(3):203

Details
● based on retrospective cohort study
● records from 393 patients (mean age 56.5 years) with acute colonic pseudo-obstruction from
1970-1985 were reviewed for associated conditions, laboratory and imaging results,
treatment, and outcomes
● perforation incidence by cecal diameter

⚬ 0% for < 12 cm
 ⚬ 7% for 12-14 cm
⚬ 23% for > 14 cm

● Reference - Dis Colon Rectum 1986 Mar;29(3):203

STUDY
– SUMMARY
cecal diameter may not indicate risk of bowel perforation

COHORT STUDY: AJR Am J Roentgenol. 1985 Dec;145(6):1211 | PDF

Details
● based on retrospective cohort study
● bedside radiographs in supine position from 46 patients (age range 14-85 years old) with
cecal dilatation ≥ 10 cm collected over 3 years were reviewed for diagnosis (cecal or colonic
ileus, mechanical obstruction, volvulus, or unclassi able), treatment, and outcomes
● 84.8% were diagnosed with cecal or colonic ileus
● perforation incidence by treatment (no p values reported)

⚬ 12.8% for conservative treatment (nasogastric suction, rectal tubes, enemas, and
cathartics)
⚬ 2.6% for colonoscopy
⚬ 0% for surgical resection

● diameter of cecum did not correlate with incidence of perforation, range 11 cm - 18 cm

(mean 15 cm) for patients with perforation vs. 10 cm-19 cm (mean 14 cm) for patients
without perforation
● Reference - AJR Am J Roentgenol. 1985 Dec;145(6):1211 PDF

Prevention and Screening

● avoid medications that may have caused symptoms

● see Prevention and management of postoperative ileus for additional information

Guidelines and Resources

Guidelines

● American Society of Colon and Rectal Surgeons (ASCRS) clinical practice guideline on colon volvulus
and acute colonic pseudo-obstruction can be found at ASCRS 2016 PDF or in Dis Colon Rectum
2016 Jul;59(7):589

● American Society for Gastrointestinal Endoscopy (ASGE) guideline on roloe of endoscopy in

management of acute colonic pseudo-obstruction and colonic volvulus can be found in Gastrointest
Endosc 2020 Feb;91(2):228

● American Society for Gastrointestinal Endoscopy (ASGE) guideline on role of endoscopy in

management of patients with known and suspected colonic obstruction and pseudo-obstruction can
be found in Gastrointest Endosc 2010 Apr;71(4):669

● Academy of Nutrition and Dietetics (AND) evidence-based nutrition practice guideline on critical illness
can be found at AND Evidence Analysis Library 2012 Sep
Review articles

● review of colonic pseudo-obstruction can be found in Singapore Med J 2009 Mar;50(3):237 PDF

● case presentation of acute megacolon (Ogilvie syndrome) due to clozapine-induced gastrointestinal

hypomotility can be found in N Engl J Med 2009 Oct 8;361(15):1487 , correction can be found in N
Engl J Med 2010 Dec 16;363(25):2474

● case presentation of Ogilvie syndrome in a pregnant woman presenting as abdominal pain and
constipation can be found in Obstet Gynecol 2012 Feb;119(2 Pt 1):374

● review of intestinal pseudo-obstruction syndrome in systemic lupus erythematosus can be found in

Lupus 2011 Oct;20(12):1324

● review of intestinal and anorectal motility and functional disorders can be found in Best Pract Res Clin
Gastroenterol 2009;23(3):407

● review of gastrointestinal motility disorders in children can be found in Gastroenterol Hepatol (N Y)

2014 Jan;10(1):16 PDF

MEDLINE search

● to search MEDLINE for (Colonic ileus) with targeted search (Clinical Queries), click therapy ,
diagnosis , or prognosis

Patient Information

● handout on intestinal pseudo-obstruction from National Digestive Diseases Information

Clearinghouse PDF

● handout on intestinal obstruction from Mayo Clinic

● technical information on intestinal obstruction and ileus from Patient Plus PDF

● handout on Ogilvie syndrome (acute colonic pseudo-obstruction) from National Organization for Rare
Disorders

ICD Codes

ICD-10 codes

● K56.0 paralytic ileus

● K56.3 gallstone ileus

● K56.4 other impaction of intestine

● K56.5 intestinal adhesions (bands) with obstruction

● K56.6 other and unspeci ed intestinal obstruction

● K56.7 ileus, unspeci ed

References

General references used

1. Batke M, Cappell MS. Adynamic ileus and acute colonic pseudo-obstruction. Med Clin North Am. 2008
May;92(3):649-70

2. American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee. The role of
endoscopy in the management of patients with known and suspected colonic obstruction and
pseudo-obstruction. Gastrointest Endosc. 2010 Apr;71(4):669-79 PDF

3. Quigley EM. Acute Intestinal Pseudo-obstruction. Curr Treat Options Gastroenterol. 2000 Aug;3(4):273-
286

4. De Giorgio R, Knowles CH. Acute colonic pseudo-obstruction. Br J Surg. 2009 Mar;96(3):229-39 full-
text

Recommendation grading systems used

● American Society for Gastrointestinal Endoscopy (ASGE)

⚬ levels of evidence

– High quality - further research very unlikely to change con dence in estimate of e ect
– Moderate quality - further research likely to have important impact on con dence in estimate of
e ect and may change estimate
– Low quality - further research very likely to have important impact on con dence in estimate of
e ect and likely to change estimate
– Very low quality - estimate of e ect very uncertain

⚬ Reference - ASGE guideline on role of endoscopy in management of patients with known and
suspected colonic obstruction and pseudo-obstruction (Gastrointest Endosc 2010 Apr;71(4):669
PDF )

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