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  • Snapshot
    • 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.
  • Introduction
    • 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
    • Associated conditions
      • hypothyroidism
      • spinal cord injury
  • Epidemiology
    • Often in the elderly
    • Risk factors
      • narcotics
      • anticholinergics
      • recent surgery
      • sepsis
      • malignancy
    • Pathogenesis
      • mechanism unknown
      • possibly due to autonomic nervous system dysfunction
  • Presentation
    • Symptoms
      • bloating
      • abdominal pain
      • nausea and vomiting
    • Physical exam
      • abdominal distention
      • abdomen tender to palpation
      • fever
    • Diagnostic testing
      • abdominal computed tomography scan
        • diagnostic test
        • rule out mechanical obstruction
      • abdominal radiography
        • screening test and for serial monitoring
        • massively dilated cecum and right colon with decompression near splenic flexure
  • Differential
    • 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
  • Treatment
    • 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
  • Complications
    • Ischemic colitis
    • Intestinal perforation
    • Volvulus
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