Acutecol

oni
cpseudo-
obst
ruct
ionaft
ercaesareansecti
onarev
iewand
recommendedmanagemental
gori
thm-ogi
lvi
e”ssyndrome TOG-
summar y

Acutecol
oni
cpseudo-
obstruct
ion(
ACPO),al
soknownasOgi l
vi
e’ssyndr
ome,
isa
rar
ebutseri
ouscompl
icat
ionthatmayoccuraf
tercaesar
eansecti
on

ACPOt ypi
cal
lymanifest
swithpr
ogr
essi
veabdominal
dist
ensionanddi scomfortwit
hin48
hoursofcaesareansect
ionandmaybeaccompani
edbyelectrol
ytedistur
bances
predominant
lyhypokal
aemiaandhy
pomagnesaemiaandrisi
nglev el
sofC- r
eacti
veprot
ein

Pat
hophy
siol
ogy
:Sy
mpat
het
icsy
stem ov
eract
ivi
tyandpar
asy
mpat
het
icunder
act
ivi
ty

r
educt
ioni
nthenumberofi
nter
sti
ti
alcel
l
sofCaj
ali
nresect
edspeci
mens

Specif
ictocaesareansect
ion,i
tispossi
blet
hatischaemi
a,i
nfl
ammat
ionordi
rectdamage
tothesacralpar
asympatheti
csupplytothepel
vi
s

neost
igmi
ne,
apar
asy
mpat
homi
met
icdr
ug,
isof
tensuccessf
uli
ntr
eat
ing.

Anti
chol
iner
gicandsy
mpat
homi
met
ical
pha-
agoni
stsappeart
ober
iskf
act
orsf
ort
he
dev
elopmentofACPO.

I
nci
dence:
Pel
vi
csur
ger
yandcaesar
eansect
ionar
ethemostcommonoper
ati
ons
pr
ecedi
ngACPOandaccountf
orappr
oxi
mat
el10%ofal
lcases

NHSI
nci
dence1i
n1500del
i
ver
ies

mor
tal
i
tyappear
stobel
owi
npost
par
tum womencompar
edwi
tht
hegener
alpopul
ati
on

despi
tehi
ghinci
denceofint
esti
nal
perfor
ati
onandlapar
otomyf
orwomen(
upt
o47%)
,
whichhasbeenassoci
atedwit
ha30-60%r i
skofdeat
h

cl
i
nical
present
ati
on:

Themedi
antimeofonsettof
ir
spresentat
ionofsy
mpt
omsi
nACPOi
s48hour
s,buti
tmay
beasear
lyas6hour
sf ol
l
owingdel
iver
y

si
gni
fi
cantabdominal
dist
ensionwit
hminimalnasogastr
icaspi
rat
es,somedegr
eeofbowel
movement(di
arr
hoeaorpresenceofbowelsounds)andami l
dpyrexi
aorr
isi
ngCRPlevel
wi
thoutanobvi
oussourceofinf
ecti
on.

Pr
ogr
essi
vel
eucocy
tosi
s,r
isi
ngCRPl
evel
sandl
act
icaci
dosi
sar
eindi
cat
iveofwor
seni
ng
col
oni
c

di
l
atat
ion,
bowel
ischaemi
aandper
for
ati
on.

DD:

il
eus-I
tcanbedif
fi
cultt
odiff
erenti
ateil
eusandACPO, buti
l
eustendstopr
esentwi
tha
l
esserdegr
eeofabdominal
distensi
onandi smoreli
kel
ytobeassociat
edwit
hnobowel
soundsandnopassageoff
latus,
invol
vessmallbowel

Mechani
cal
obst
ruct
ion:
cont
rastwoul
dbeexpect
edt
obepr
esentt
hroughoutt
he
wholel
argeboweli
npseudo-
obst
ruct
ion,
theuseofacont
rastenemafol
lowedby
abdomi
nalX-r
aycandi
ffer
ent
iat
ebetweenACPOandmechani cal
obst
ructi
on

I
nACPOabr
uptt
ransi
ti
onpoi
ntsuggest
ingmechani
cal
obst
ruct
ioni
sabsent

Di
agnosi
s/management
:

Themostusef
uli
nit
ial
imagi
ngst
udi
esi
ncl
udeabdomi
nal
andchestX-
ray
s.

A‘cut-
off
’point
,wheredi
l
atat
ionendsatthespl
enicf l
exur
e,hasbeenconsider
eda
speci
fi
csignofACPOi nthepast,
butiti
spossi
blet ohavelargeboweldi
l
atati
on
beyondthi
s,aswellasacut-
offpointpr
oximalt
ot hesplenicfl
exur
e.

cont
rastCToft
heabdomenandpel
vi
smaybeconsi
der
edt
hef
ir
st-
li
nemodeof
i
maging

I
fbowelper
for
ati
oni
ssuspected,
anabdomi
nal
CTwi
thi
ntr
avenouscont
rastshoul
d
beper
for
medinthef
ir
sti
nstance

caecal
diametergr
eat
ert
han14cm (
Figur
e2)hasbeenassoci
atedwi
thagr
eat
er
ri
skofperf
orati
onandmort
ali
ty.

Management
:

Conser vati
vemanagement: Manywomenwi t
hear l
yACPOwi l
li
mprovewit
h
suppor t
ive
care,whi chinvolv
escl oseobservat
ionofvi
talsi
gnsandbloodtest
s,ni
l-
by-
mout h,
nasogast ri
ct ubeinserti
onlef
tonf r
eedrai
nage,gradual
withdr
awalofopi
ates,
rehydrati
onandcor recti
onofelectr
olyt
es

pr
ophy
laxi
sagai
nstv
enoust
hromboembol
i
sm i
simpor
tant
,

medi
cal
(neost
igmi
ne)andsur
gical
(col
onoscopy
)

sy
mpt
omsdonoti
mpr
ovewi
thi
n48–72hour
s,ori
fcaecal
diamet
eri
sst
ati
cor
i
ncreasing,
medicalorendoscopict
reat
mentwoul
dbet
henextst
ep(
unl
esst
her
e
ar
esi gns
i
ndicati
veofint
esti
nalperf
orati
on)

neosti
gmi ne:ashorthal
f -
li
feandi
sconsideredsafewhi
lebr
east
feedi
ng.Car
diac
monitori
ngi sneeded
i
ntravenouslyadminist
ereddoseof2.5mg, usuall
ygi
venover5minut
es.
Thiscanber epeatediftherei
snocli
nicali
mpr ov
ementaft
er3hours

Unpreparedcolonoscopi
cdecompr essionisanot
heropti
onfortr
eat
mentwhen
bowel perf
orat
ionisnotsuspect
ed, caecaldi
ameteri
sgreat
erthan9-
12cm or
supporti
veandmedi calt
herapyhasbeenunsuccessful.
successfuli
n61–95%ofcases, butrecurr
enceoccur
sinupt o40%ofcases,

sur
gical
management
:

Sur
geryi
srecommendedwhenther
eisahighsuspici
onofperf
orati
onorbowel
i
schaemi
a,orconser
vat
ive,
medi
calandcol
onoscopicdecompressi
onhasfai
l
ed

l
apar
otomyshoul
dnormall
ybeundertaken,wi
thresecti
onofnon-
viabl
ebowel
and
pr
imaryanast
omosi
swit
horwithoutdefuncti
oni
ngst omafor
mati
on

compl
icat
ions:
Caecaldi
l
atat
ion,
fol
lowedbyi
schaemi
aandper
for
ati
on,
hav
ebeen
themainf
actor
simpli
catedi
ndeathfr
om ACPO

cecal
diameter
,itisnotacomplet
elyrel
iabl
eindi
cat
orofi
mpendi
ngper
for
ati
onand
thecl
ini
cal
pict
ur eneedstobeconsider
ed.

Concl
usi
on:

Ri
skf act
ors
Emergencycaesar eansecti
on,
Mult
iplepregnancy
Postpart
um haemor r
hage,
Generalanaesthesiaandpostoper
ati
veopi
ateuse.

Mostcasesshouldresol
vewi
thconservat
ivemanagement
,
Medicalt
reat
mentwi t
hneost
igmine
or
boweldecompressi
onv i
acol
onoscopy

Ear
lyi
nvol
vementoft
heacut
egener
alsur
gical
team i
simpor
tant

Par
ti
cul
arat
tent
ionshoul
dbemadet
opr
eventv
enoust
hromboembol
i
sm and
i
nfect
ion.

Pl
easeseeFi
gur
e1on285
Fi
gure3on288

-
DrHar
iPav
ithr
aN