Review Topic
  • A 71-year-old man with coronary artery disease, diabetes, chronic obstructive lung disease, lung cancer, and arthritis is admitted for septic arthritis of his right knee after a recent steroid injection. He undergoes treatment with antibiotics and incision and drainage of the right knee. He reports feeling better with good pain control with hydrocodone; however, on postoperative day 3, he develops acute abdominal distention that is slightly tender to palpation. Abdominal radiography demonstrates cecal dilation to 11 cm.
  • Clinical definition
    • acute dilation of the large intestine in the absence of mechanical obstruction, also known as acute colonic pseudo-obstruction (ACPO)
    • most often involves right colon and cecum
  • Epidemiology
    • often in the elderly
    • risk factors
      • narcotics
      • anticholinergics
      • recent surgery
      • sepsis
      • malignancy
  • Pathogenesis
    • mechanism unknown
    • possibly due to autonomic nervous system dysfunction
  • Associated conditions
    • hypothyroidism
    • spinal cord injury
  • Symptoms
    • bloating
    • abdominal pain
    • nausea and vomiting
  • Physical exam
    • abdominal distention
    • abdomen tender to palpation
    • fever
  • Diagnostic testing
    • imaging
      • abdominal radiography
        • screening test and for serial monitoring
        • massively dilated cecum and right colon with decompression near splenic flexure
      • abdominal computed tomography scan
        • diagnostic test
        • rule out mechanical obstruction
  • Toxic megacolon
    • distinguishing factors
      • associated severe colitis
      • systemic toxicity such as tachycardia, fever, and altered mental status
  • Large bowel obstruction
    • distinguishing factor
      • mechanical obstruction present
  • First line
    • discontinue offending medications
    • conservative care
      • intravenous fluids and electrolyte repletion
      • nasogastric tube decompression
  • Second line
    • neostigmine
      • if no resolution with 24-48 hours of conservative care
      • atropine for possible bradyarrhythmia
  • Third line
    • colonoscopic decompression
      • if no resolution after neostigmine
  • Fourth line
    • cecostomy
      • if no resolution after colonoscopic decompression
  • Ischemic colitis
  • Intestinal perforation
  • Volvulus

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