68-year-old man with progressive abdominal distension
A 68-year-old man who is a retired civil engineer undergoes an uncomplicated elective revision right total hip arthroplasty. On the fourth hospital day after surgery, his wife alerts nursing staff that he has progressive abdominal fullness and has passed neither flatus nor stool for over 48 hours. Initial management of suspected hypomotility with oral intake restriction, intravenous fluid administration, nasogastric suction, electrolyte repletion, and discontinuation of opioid analgesics was initiated 36 hours ago. Despite these interventions, abdominal distension has worsened. He reports mild diffuse abdominal discomfort and mild nausea without vomiting. He has no personal or family history of gastrointestinal disease, and his chronic medications include atorvastatin and tamsulosin. On physical examination, temperature is 37.1 C (98.8 F), pulse is 72/min, blood pressure is 128/76 mm Hg, and respirations are 16/min. Oxygen saturation is 98% while breathing ambient air. The abdomen is markedly distended and tympanitic to percussion. There is mild diffuse tenderness without guarding, rigidity, or rebound. Bowel sounds are absent. The surgical wound dressing over the right hip is clean and dry. Laboratory studies show a leukocyte count of 9,200/mm3, hemoglobin of 12.8 g/dL, serum sodium of 139 mEq/L, serum potassium of 4.3 mEq/L, serum chloride of 102 mEq/L, serum bicarbonate of 24 mEq/L, serum magnesium of 2.2 mg/dL, serum creatinine of 1.0 mg/dL, and serum lactate of 1.1 mmol/L. An abdominal computed tomography scan with intravenous contrast reveals massive colonic dilation with a cecal diameter of 12.4 cm and gradual caliber tapering near the splenic flexure. There is no mechanical intraluminal mass, stricture, bowel wall thickening, pneumatosis intestinalis, or free intraperitoneal air. Which of the following is the most appropriate next step in management?
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B
Explanation
Clinical Pearl:
In acute colonic pseudo-obstruction (Ogilvie syndrome), intravenous neostigmine under continuous cardiac monitoring is the recommended first-line therapy when conservative management fails or the cecal diameter exceeds 12 cm in the absence of peritonitis or bowel ischemia.
Explanation:
This patient has acute colonic pseudo-obstruction (Ogilvie syndrome), evidenced by severe progressive abdominal distension and massive colonic dilation with a cecal diameter of 12.4 cm without mechanical blockage on computed tomography following orthopedic surgery. Professional gastrointestinal endoscopy and colorectal surgical guidelines recommend intravenous neostigmine with continuous cardiac monitoring as the primary pharmacologic therapy when cecal diameter exceeds 12 cm or when conservative measures fail after 24 to 48 hours, provided there is no evidence of bowel ischemia, perforation, or peritonitis. Exploratory laparotomy with right hemicolectomy is reserved for patients who demonstrate signs of bowel perforation, peritonitis, or transmural ischemia, none of which are present given this patient's soft abdomen, normal leukocyte count, and normal serum lactate level. Oral polyethylene glycol solution is contraindicated because administering an osmotic laxative proximal to a severely dilated, non-propulsive colon markedly increases intraluminal hydrostatic pressure and heightens the risk of cecal rupture. Intravenous metoclopramide accelerates gastric emptying and small intestinal transit through dopamine antagonism and 5-HT4 receptor agonism, but it exerts minimal colonic prokinetic effect and does not resolve colonic pseudo-obstruction. Water-soluble contrast enema provides no therapeutic decompression and is unnecessary for diagnosis because intravenous contrast-enhanced computed tomography has already excluded mechanical obstruction, volvulus, and extraluminal air while posing an unnecessary risk of barotrauma.
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