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Colonic Obstruction
Graded EBD +/-Intralesional
steroid injections
FCEMS
Endoscopic incisional
therapies- needle knife
LAMS
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Bridge to surgery
219
SEMS
Malignant
Emergency Surgery
FIG. 4 Summary of management of colonic obstruction/stricture.
Palliative therapy
Extrinsic compression
TABLE 1 Contraindications to SEMS Placement
Contraindication
Absolute
Relative • Distalrectallesionswith5cmfromthedentateline(stentscrossingtheanalvergecaninduceseverepain,
Special
considerations
SEMS, Self-expandable metal stent
• Colonicperforationorseverecolonicischemiawithimpendingnecrosis
tenesmus, bleeding, and risk of migration)
• Presenceofdiffuseperitonealcarcinomatosis(higherfailurerate)
• Persistentseverecoagulopathy(riskofbleeding)
• Patientsonchemotherapywithantiangiogenicdrugs(suchasbevacizumab)
• Tumorsclosetotheanalverge(<5cm)
have a higher failure rate)
• Theuseofprophylacticstentsinpatientswithmetastaticdiseasetopreventpotentialobstructionisnotrecommended.
• Right-sidedorproximalcoloniclesionsarebettermanagedwithsurgicalresectionwithprimaryanastomosisor
stoma creation. Although SEMS placement is performed in some palliative cases, it is not recommended given the
technical challenges and non-inferiority to surgery.
TABLE 2 Various Types of Colonic Stents
Manufacturer Model Name Stent Covering
Boston Scientific WallFlex colonic* Uncovered TTS, 10F Nitinol 22, 25/27, 30 60, 90, 120
Taewoong Medical Niti-S enteral
Ultraflex preci-
sion colonic*
Wallstent colonic
and duodenal
endoprosthesis*
colonic D type*
Niti-S Enteral
Colonic S-type*
Delivery
System Material
Uncovered Non-TTS,
Nitinol 25/30 (proximal
OTW, 16F
Uncovered TTS, 10F Stainless
Uncovered TTS, 10F Nitinol 18, 20, 22, 24, 26, 28/,
Body Diameter/Flange
Diameter (mm) Length (mm)
flange)
20, 22/Minimal, no
steel
flare
57, 87, 117
60, 90, 120
60, 80, 100, 120
no flare
Partially covered TTS, 10F Nitinol 20, 22/28, 30 60, 80, 100,120
Partially covered NON-TTS Nitinol 22, 24, 26, 28/30, 32, 34 60, 80, 100, 120
Continued
220 ENTERAL STENTS IN THE TREATMENT OF COLONIC OBSTRUCTION
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TABLE 2 Various Types of Colonic Stents—cont’d
Delivery
Manufacturer Model Name Stent Covering
Cook Endoscopy Evolution colonic* Uncovered TTS Nitinol 25/30 60, 80,100
M.I. Tech Hanarostent
colon/rectum*
Choostent
colon/rectum
(CCC)
EndoChoice Bonastent Uncovered/partially
ELLA-CS SX-ELLA colorec-
tal (Enterella)
S & G Biotech EGIS colorectal Covered single or double TTS, 10F Nitinol 20, 22 60, 80, 100, 120
Hercules SP col-
orectal stent
dual type
Leufen Medizintechnik
OHG
MICRO-TECH
Europe (Dusseldorf,
Germany)
Ecostent Uncovered Non-TTS Nitinol 30/36 both ends flared 8, 10
MICRO-TECH
colon and rectum stent
Uncovered and fully
covered
Fully covered NON-TTS Nitinol 22, 24/30, 32, both
covered
Uncovered and
covered
Inner uncovered, outer
partially covered
Composed of two
separate stents
sequentially deployed
Uncovered and par-
tially covered
System Material
TTS: 10.2F, 10.5F;
NON-TTS 24F
TTS, 10F and
12F
Non-TTS, 15F
(uncovered),
18F (covered)
Non-TTS Nitinol 28 outer, 18 inner 110, 130,
TTS, non-TTS Nitinol 30/36
Nitinol 20, 22, 24/26, 28, 30 60, 70, 80, 90, 100,
Nitinol 22, 24, 26 60, 80, 100
Nitinol 20, 22, 25 82, 90, 113, 135
Body Diameter/Flange
Diameter (mm) Length (mm)
110, 120, 130,
140, 150, 160
100, 180
ends flanged; available symmetric and
asymmetric
150, 170,
190(outer)
8, 10, 12
25/30(covered)
*FDA approved
Stent Dimensions
The uncovered stents in the United States come in sizes that fall between
5.7 and 12 cm in length and mid-body diameters of 20 to 30 mm (with
variably flanged ends that are wider than the width of the stent body)
after deployment. They come within a 10Fr catheter that fits through the
accessory channel of an adult colonoscope or a therapeutic gastroscope
(with a channel diameter of at least 3.7 mm), which allows for the stent
to be placed using both endoscopic and fluoroscopic visualization.
Stent Material
SEMS are composed of a radiopaque, woven, metal mesh with a
cylindrical shape that exerts self-expansion forces. In their unexpanded form, they fit through the channel of an endoscope. Following deployment to the desired location, they expand to oppose the
luminal surface of interest. Although the basic delivery system and
deployment mechanism are identical, stents are classified based on
their coating and manufacture material.
Stents are made from stainless steel or other alloys such as Nitinol (comprising nickel and titanium) or Elgiloy (comprising cobalt,
chromium, and nickel). Nitinol is the most widely used metal alloy.
Its main advantage over other stent materials is its malleability at low
temperatures and strong radial forces at body temperature without
losing its flexibility (Fig. 5). Stainless steel stents are relatively stiff
and may affect the quality of imaging studies such as MRI. Stents
made of Elgiloy are thinner, more elastic, and more flexible, and they
are MRI-compatible with less imaging artifact.
Covered versus Uncovered Stents
Uncovered stents have bare wires, while covered stents have a silicone
membrane over the bare wires. Covered stents can be subdivided into
fully and partially covered stents. Although covered stents reduce the risk
of tumor ingrowth and can be used to seal fistulas, fully covered stents
have less anchoring power and an increased risk of migration compared
with uncovered stents. Partially covered stents with flared uncovered segments at both ends were developed to overcome migration risk. Patency
rates between uncovered and covered SEMS are thought to be similar,
however more data are required to validate these findings. In a systemic
review and meta-analysis by Mashar et al. (1 RCT and 9 observational
studies including 753 patients) comparing covered and uncovered stents
in management of MBO, uncovered stents were associated with a lower
risk of complications (RR 0.57, 95% CI 0.44–0.74, P<0.0001), tumor
overgrowth (RR 0.29, 95% CI 0.09–0.93,P
(RR 0.29, 95% CI 0.17–0.48,P< 0.00001); longer duration of patency
(MD 18.47, 95% CI 10.46–26.48, P < 0.00001); lower need for stent
reinsertion (RR 0.38, 95% CI 0.17–0.86,P
tumor ingrowth (RR 4.53, 95% CI 1.92–10.69, P = 0.0008). Rates of
technical success (RR 1.02, 95% CI 0.99–1.04,P = 0.21), clinical success
(RR 1.03, 95% CI 0.98–1.08,P = 0.32), perforation (RD 0.01, 95% CI
0.03–0.02, p = 0.65), bleeding (RD 0.00, 95% CI 0.03–0.03, P = 0.98),
stool impaction (RR 0.56, 95% CI 0.12–2.04, P = 0.38), and stent
obstruction (RR 2.23, 95% CI 0.94–5.34,P = 0.97) were similar. These
results concluded that uncovered stents were superior in the management of MBO. It is worth mentioning that only uncovered colonic
SEMS are available in the United States.
= 0.04), and stent migration
= 0.02); and higher risk of
Technical Aspects of Stent Deployment (Box 1)
Pre-stent placement
Before performing colonic SEMS placement, one should assess the
location and morphology of the stricture (Fig. 6). The imaging modalities commonly used include a retrograde water-soluble contrast enema
(barium enema or Gastrografin) (Bracco Diagnostics Inc., Monroe
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FIG. 5 Various types of self-expandable uncovered metal colonic stents. (From Baron TH, Wong Kee Song LM, Repici A. Role of self-expandable stents for patients
with colon cancer (with videos). Gastrointest Endosc. 2012;75:653–662.)
Township, NJ) or cross-sectional imaging (CT scan). These imaging
modalities can help delineate the anatomy (number, length, location,
and degree of stricturing) and in some cases reveal synchronous proximal lesions and rule out the presence of a leak or perforation. CT scans
can also assist with defining the surrounding soft tissue, lymph nodes,
and more distant organs, which can be critical in cases of mass lesions,
as well as in inflammatory bowel disease, which can be further complicated by fistulas or abscesses. Patients are usually given one or two
cleansing enemas to prepare the distal colon. Oral bowel prep should be
avoided as it may worsen the symptoms of obstruction. In some cases,
BOX 1 Technical Aspects of Stent Placement
Prerequisites
Thorough history and physical examination; rule out perforation
Assess location and morphology of stricture with contrasted
imaging:
Retrograde barium/Gastrografin enema or CT with contrast
Avoid oral mechanical bowel prep; consider enemas
Diagnostic colonoscopy (some cases)
a diagnostic colonoscopy is warranted in determining the etiology of a
stricture as it can help obtain sampling for pathologic diagnosis.
In patients with complete obstruction and dilated colon proximally, prophylactic intravenous antibiotic therapy is recommended
by the surgical societies. It is postulated that during insufflation for
stent deployment, the increase of wall tension and intestinal barrier
damage may cause microperforations resulting in bacterial translocation. However, several studies report a negligible risk of infection
within 48 hours post-stenting. Likewise, Kim et al. performed a propensity score-matched analysis of prophylactic antibiotics for colonic
stenting that did not show significant differences in infectious
complications (such as fever, bacteremia, and systemic inflamma-
Intraprocedural
Endoscopy suite or operating room
General anesthesia preferred
Left lateral position
Therapeutic gastroscope or colonoscope (depending on location)
CO
insufflation
2
Stent Deployment
Combined endoscopy and fluoroscopy technique
TTS stent deployment with guidewire
tory response syndrome) between patients who received antibiotic
prophylaxis and those who did not. The ESGE and ASGE do not
recommend the routine use of antibiotic prophylaxis.
Stent Deployment Process
Post-stent care
Confirm large bowel decompression on endoscopy
Post-procedure imaging (x-ray or CT)
Repeat x-ray in 2 days to confirm stent expansion and position
The procedure is usually carried out in the endoscopy suite or operating room depending on the physician performing the procedure.
TTS, Through the scope.
222 ENTERAL STENTS IN THE TREATMENT OF COLONIC OBSTRUCTION
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A
FIG. 6 Morphology of colonic stricture with apple core lesion, pathognomic for colonic adenocarcinoma. (A) Barium enema showing morphology of colonic
stricture. (B) CT abdomen and pelvis (sagittal view) with intravenous and intraluminal contrast showing a colonic stricture (arrow). (From Copland AP, Wang AW.
Clinical Gastrointestinal Endoscopy 3rd ed. Chapter 40: Colonic Strictures.)
B
FIG. 7 Through-the-scope (TTS) colonic self-expandable metal stent placement process. The endoscope is passed to the lesion, and a guidewire is
advanced across the obstruction (far left).(A) The catheter is advanced across the lesion. (B) The predeployed stent is advanced through the endoscope
channel and across the lesion. (C) The restraining sheath is withdrawn. (D) The stent is fully deployed. (From Baron TH, Wong Kee Song LM, Repici A. Role of
self-expandable stents for patients with colon cancer (with videos). Gastrointest Endosc. 2012;75:653–662.)
Anesthesia choice is based on physician preference, but intubation
is recommended in cases of acute colonic obstruction given the risk
of aspiration during the procedure. Patients are placed in the left
lateral position to facilitate passage of the endoscope. For left-sided
colonic strictures, a therapeutic gastroscope is often the instrument
of choice, but for more proximal or right-sided strictures, an adult
colonoscope may be required. CO
as CO
is more rapidly absorbed and leads to reduced abdominal
2
discomfort and may decrease the risk of perforation.
A SEMS can be loaded using two different delivery systems:
through-the-scope (TTS) stents or over-the-wire (OTW) stents. TTS
insufflation is preferred over air
2
stents are traditionally loaded into 10Fr catheters, introduced over
the guidewire, and placed across the stricture under endoscopic and
fluoroscopic guidance. OTW stents are passed over the guidewire and
placed under fluoroscopic visualization. The use of simultaneous sideby-side endoscopy with a small-caliber endoscope is recommended
in some cases but not mandatory. This technique is preferred in case
of rectal or sigmoid strictures, acute angulations, or other conditions
with poor endoscopic visualization. Both fluoroscopic and endoscopic
guidance is preferred as fluoroscopy not only assists in defining the
stricture but also adjunctively guides stent placement. TTS colonic
SEMS placement is illustrated in Figure 7 and Video 1.
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TABLE 3 Technical Tips for Stent Deployment and Guidewire Passage
Instrument Technical Tip
Triple-lumen biliary
occlusion (stone
retrieval) catheter
Guidewires Using hydrophilic biliary guidewires (e.g., Glidewire; Boston Scientific)
Cap, sphincterotome For lesions at flexures or corners, a clear cap to obtain a more en face view and a sphincterotome, preferably a
Stent deployment SEMS should be of suitable length to bridge the stricture and extend at least 2 cm on each side of the
On reaching the stricture, a guidewire with a hydrophilic soft/
floppy tip (typically a 0.035-inch-diameter guidewire for added stiffness) is passed across the stricture. Careful guidewire passage and
measuring the appropriate stricture length are key steps to technical
success of the stent deployment process. A few additional technical
tips are described in Table 3.
Deployment of TTS uncovered or covered metal stents follows
similar principles and involves an assistant deploying the stent
while the endoscopist pulls back on the restraining catheter until
the stent is released. The stent is then deployed by withdrawing the
constraining sheath or unraveling string (depending on the device).
Most colonic SEMSs deploy from a proximal (oral) to distal (rectal)
fashion. Although there is no validated rule for stent deployment,
it is recommended that the SEMS should be of suitable length to
bridge the stricture and extend at least 2 cm on each side of the
obstruction once the stent is deployed. One must also account for
the degree of shortening that occurs during deployment and stent
migration away from the endoscope. If stent coverage is inadequate, an additional stent can be deployed overlapping the existing
stent. It is important to keep the wire in place across the lesion
until the final position of the stent is assessed radiographically
because passing a wire through a newly deployed stent can be technically challenging. In patients who present with complete colonic
obstruction, consideration should be given to leaving the guidewire
in place after stent deployment to pass a colonic decompression
tube through the stent and into the proximal bowel if immediate
passage of stool does not occur after stent placement. For rightsided colonic obstruction, stents can also be successfully placed
proximally, although the lesions typically require a TTS SEMS
placed via an adult colonoscope.
After stent deployment, additional balloon dilation is not recommended because it is associated with a high risk of perforation.
Because of the nature of the self-expansion, stents are allowed to
slowly expand over time. The peristaltic movements of the colon
after decompression may facilitate full expansion. Immediately after
stent placement, the enema examination can be repeated to document post-stenting patency and correct positioning, although this is
not always needed.
FOLLOW-UP CARE
Immediately following stent placement, large bowel decompression,
confirmed on endoscopy, is suggestive of successful deployment of
a stent. If a nasogastric tube is present, it can often be removed the
following day. A postprocedural abdominal radiograph or CT is
Method 1: Catheter with the balloon inflated to 12–15 mm and positioned just distal to or impacted at the
obstruction site followed by stricturogram
Method 2: Biliary stone retrieval balloon passed beyond the stricture and then inflated to a large-diameter 12–15
mm, and balloon is withdrawn until it abuts the proximal shelf of the stricture meeting resistance. The endoscopist then holds the catheter at the biopsy port. The balloon is deflated and withdrawn while keeping the finger position on the catheter. When the balloon is seen endoscopically on the distal aspect of the stricture, the
distance from the endoscopist’s fingers to the biopsy port corresponds to the length of the stricture.
rotatable sphincterotome (e.g., Autotome RX; Boston Scientific), are used to orient the catheter in the direction of the lumen.
obstruction.
Keep in mind the degree of SEMS shortening during deployment and stent migration away from the endoscope.
FIG. 8 Postprocedural abdominal radiograph demonstrating a well-posi-
tioned transverse colon stent across a malignant stricture.
obtained immediately after stent placement to confirm position and
exclude free air (Fig. 8). An abdominal x-ray is repeated within 24 to
48 hours when full expansion of the stent is expected. A liquid diet
can typically be initiated within 24 to 48 hours of stent placement in
most patients. Several days are needed for complete decompression
to a normal-sized colon.
OUTCOMES AND ADVERSE EVENTS
The mortality rate of colonic stenting is roughly 1.5% to 3%.
Technical success (immediate or short-term success) is defined
223
224 ENTERAL STENTS IN THE TREATMENT OF COLONIC OBSTRUCTION
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FIG. 9 (A) Endoscopic view of carcinoma ingrowth with obstruction
of stent 6 months after initial deployment. (B) Successful fulguration
of carcinoma ingrowth inside the stent using argon plasma coagulation.
(C) Rectosigmoid resection specimen reveals stent erosion.
as the ability to safely deploy and properly position the stent across
the stricture without any immediate complication. Clinical success
(long-term success) is defined as the ability to achieve long-term
decompression without the need for operative intervention to treat
long-term failure of the stent or related complications. Colonic stenting has a high technical success of 80% to 100% and clinical success
of 70% to 100%. The rates of complications are variable across studies
but can be broadly divided into early (<2 weeks) and late (>2 weeks)
complications, with an overall complication rate of 10% to 15%.
Early Complications
Perforation
The most feared complication is perforation. The rate of perforation
in malignant obstruction is 6% across various studies, while that of
silent or microperforations is up to 14%. Angiogenesis inhibitors (e.g.,
bevacizumab) are independent risk factors of perforation, even in the
absence of stenting, and are known to increase the rate of perforation
to 12.8%. The ESGE does not recommend the combination therapy of
stent with antiangiogenic drugs (Fig. 9). Perforation rates are highest
in colonic SEMS deployment for benign strictures (18%). When large
perforations occur, they are best managed operatively. Microperforations may be managed with bowel rest and intravenous antibiotics.
(inadequate stricture coverage), incomplete expansion, or undetected synchronous tumors. Stent migration rates are determined by
the type of stent deployed, the degree of stenosis, the proximal and
distal clearance, and the flare diameter. Short stents, smaller-diameter stents (<25 mm), and covered stents have higher rates of migration. SEMS migration can typically be managed endoscopically by
removing the migrated stent with the goal of either placing a larger
stent or a different type of stent that might be less prone to migration.
Other alternatives to replacing a migrated SEMS include observation
(particularly if the stricture has become more patent following stenting) or more definitive surgical intervention.
Abdominal/Rectal Pain and Incontinence
Abdominal/rectal pain and incontinence may occur if stents are
placed within 5 cm of the anal verge. Pain is also commonly caused
by mucosal irritation from the stent itself. Bleeding may occur in
up to 5% of patients. This is usually mild to moderate in severity,
however endoscopic interventions are recommended before surgery.
Late Complications
Late stent migration can be seen in cases following chemotherapy or
radiotherapy with subsequent tumor shrinkage.
Stent Migration and Failure
Failure of the stent to resolve the obstruction and early stent migration (seen in 4%–11.7%) should raise suspicion for stent malposition
Occlusion by Fecal Impaction and/or Tumor Ingrowth
Tumor ingrowth has been reported in 15% of patients. Although
most patients currently treated with palliative stents succumb to their
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225
disease before obstructing, the impact of newer chemotherapeutic
agents on long-term survival may affect the rate of this long-term
complication. Tumor ingrowth and fecal impaction of the stent can
be managed endoscopically by placing another stent through the
occluded stent.
CONCLUSION
Colonic SEMS are an important part of the treatment armamentarium of managing obstructing colorectal cancer. It is a
relatively safe and effective procedure that is used for palliation
of obstruction and as a bridge to a safer, less morbid surgery. As
newer technologies and medical therapies continue to evolve, surgeons and gastroenterologists must work in close collaboration to
appropriately select patients who would most benefit from these
interventions.
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226 MANAGEMENT OF ACUTECOLONIC PSEUDO-OBSTRUCTION (OGILVIE’S SYNDROME)
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Management of
AcuteColonic
Pseudo-Obstruction
(Ogilvie’s Syndrome)
Marshall S. Bedine, MD
cute colonic pseudo-obstruction (ACPO), often known as Ogilvie’s
syndrome, is a condition of sudden onset associated with an acute
A
dilation of the colon with no evidence of mechanical obstruction. The
syndrome was first reported by William Ogilvie in 1948.
Pathogenesis of ACPO has been thought to be related to
impairment of the autonomic nervous system leading to an atonic
distal colon and functional obstruction. When this occurs, colonic
diameter increases with a rise in tension on the colonic wall. This,
in turn, increases the risk of colonic ischemia and perforation as
the colon dilates and cecal diameter exceeds 10 to 12 cm. Ischemia
with or without perforation increases rapidly as the colon dilates,
particularly if the duration of distention exceeds 6 days.
ACPO most often occurs in hospitalized or institutionalized
patients usually with severe comorbid illness. Associated conditions include infection, cardiac disease, and inoperative trauma
as well as orthopedic procedures including hip and spine surgery
or after pelvic surgery. In one study, 92% of postpartum cases of
ACPO were in patients following cesarean section after complicated pregnancies. The incidence of ACPO is approximately 1:1000
of hospitalized patients. If colonic ischemic or perforation occur,
the mortality may be as high as 50%.
CLINICAL MANIFESTATIONS AND
DIAGNOSIS
Clinical manifestations of ACPO may occur gradually or rapidly
with abdominal pain occurring in 80% of patients associated with
distention. Nausea and vomiting are frequent, and constipation or
even diarrhea has been reported in 40% to 50%.
Physical examination reveals a protuberant abdomen that is
tympanic to percussion and associated with bowel sounds in up
to 90% of patients. Fever, abdominal tenderness, and peritoneal
signs are worrisome and suggest colonic ischemia or impending
perforation.
The diagnosis of ACPO is made on imaging studies. CT of the
abdomen and pelvis typically demonstrate proximal colon dilation
with an intermediate transition zone near the splenic flexure (Fig. 1).
Occasional dilation may extend to the rectum. This will exclude a
mechanical obstruction. Plain abdominal films can be used to monitor interval changes of colonic dilation (Fig. 2). Contrast enemas
can be hazardous and may increase the risk of perforation. Stool
cultures and stool evaluation for Clostridioides difficile toxin should
be obtained. Hypokalemia, hypocalcemia, and hypomagnesemia are
common and should be corrected. The differential diagnoses include
acute mechanical obstruction, toxic megacolon, and chronic intestinal pseudo-obstruction.
MANAGEMENT
Initial management of ACPO should include keeping the patient
NPO, attempting decompression with nasogastric and rectal tube
suction, and avoiding inciting medications such as opioids, anticholinergics, antipsychotics, cytotoxic drugs, calcium channel blockers,
and clonidine (Fig. 3). Fluid and electrolyte imbalance should be
corrected. Mobilizing the patient, if possible, should be considered.
Positioning the patient in a prone position with hips elevated can
be helpful in allowing the patient to pass gas for relief of distention.
These maneuvers should be considered for 24 to 48 hours as long
as the patient is undergoing frequent physical examinations and
abdominal films at 12-hour intervals. The response to conservative
management may vary between 20% and 92%. A surgical consultation should be obtained as soon as a diagnosis has been made to
guarantee optimal care (Box 1).
When conservative management is ineffective, pharmacologic agents
should be considered. The primary pharmacologic treatment of ACPO
A B
FIG. 1 CT images of colonic dilation, with arrows denoting transition point in the absence of mechanical obstruction (A), consistent with Ogilvie’s syn-
drome, and a ruler demonstrating cecal diameter at the typical threshold of concern for perforation (12 cm) (B). (From Pereira etal. Ogilvie’s syndrome—acute
colonic pseudo-obstruction. J Visceral Surg. 2015;152:99–105.)
122.50 mm
+
+
LARGE BOWEL
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227
A
B
FIG. 2 Upright abdominal plain films demonstrating acute colonic pseudo-obstruction before (A) and after (B) placement of a decompression tube.
(From Saunders MD. Acute colonic pseudo-obstruction. Best Pract Res Clin Gastroenterol. 2007;21:671–687.)
Clinical and radiologic features consistent
with acute colonic pseudo-obstruction
No complications, cecal
diameter <12 cm
Supportive care
(bowel rest, fluids,
mobilization, correction of
underlying causes)
Persistent or progressive
distension
Cecal diameter >12 cm
IV neostigmine
Persistent or progressive
distension
Evidence of mechanical
obstruction, ischemia, or
perforation
Surgery
Sustained response
Daily low-dose
polyethylene glycol
Colonoscopic
decompression
Persistent or progressive
distension
Percutaneous
cecostomy
Persistent distension or
pending perforation
FIG. 3 Algorithmic approach to stepwise therapy in acute colonic pseudo-obstruction.
228 MANAGEMENT OF ACUTECOLONIC PSEUDO-OBSTRUCTION (OGILVIE’S SYNDROME)
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BOX 1 Conservative Management
1. Correct metabolic abnormalities
2. Follow CBC, electrolytes, serum lactate
3. Check stool for Clostridioides difficile
4. Decompression with nasogastric and rectal tubes
5. NPO with intravenous hydration
6. Serial imaging and physical examinations
7. Avoid opiates, anticholinergics, calcium channel blockers, and
antipsychotics
is the use of neostigmine, an anticholinesterase parasympathomimetic
agent. This is indicated in patients with ACPO with a cecal diameter of
12 cm who have failed conservative management. Neostigmine (2 mg)
is given intravenously over a 5-minute period with constant monitoring
of vital signs and electrocardiography. Patients should be supine on a
bedpan as they may respond quickly with passage of gas and stool. A
response will generally occur within 30 minutes. Glycopyrrolate should
be available to treat bradycardia. Response to neostigmine will occur in
up to 94% with the initial dose. There is a recurrence rate of about 31%.
A second dose can be given no sooner than 8 hours but up to 24 hours
later, which may lead to a further response of 40% to 100%. Three placebo-controlled, double-blind, randomized trials have demonstrated the
effectiveness of neostigmine (Box 2).
Risk factors for neostigmine failure include male gender, younger
age, electrolyte imbalance, and postsurgical status. It is recommended that regular administration of polyethylene glycol via nasogastric tube may also increase the effectiveness of treatment with
neostigmine.
Neostigmine has most often been administered intravenously in
a bolus, but studies have shown success with subcutaneous neostigmine or continuous infusion of 0.4 mg/h in saline over 24 hours.
Subcutaneous neostigmine has been shown to result in passage of
stool within a median of 29 hours. Continuous infusion of neostigmine was associated with greater bowel diameter reduction in
24 hours, and adverse events may also be diminished by continuous
infusion. In one study, subcutaneous neostigmine was found to be
safe and effective. Response to a bolus infusion is more rapid.
Bradyarrhythmias may occur in 5% to 10% of patients with
other potential side effects being bronchoconstriction, hypotension,
agitation, abdominal cramps, nausea and vomiting, salivation, and
diaphoresis. Glycopyrrolate 0.4 mg may attenuate some of these side
effects. Mechanical intestinal obstruction, urinary tract obstruction,
or peritonitis are absolute contraindications. Particular care must
be taken in patients with heart rates of <60 beats per minute, systolic blood pressure of <90 mm Hg, reactive airway disease, recent
myocardial infarction, and concomitant β-blocker use. The usage of
neostigmine in the setting of pregnancy has not been studied.
Other pharmacologic agents have been used with varied response.
Anecdotal reports have recommended the use of erythromycin,
metoclopramide, and cisapride (not available in the United States).
These drugs have yielded inconsistent results. Oral pyridostigmine,
a long-acting acetylcholinesterase inhibitor, has been successful in
treating some patients refractory to neostigmine. In one report,
a patient was treated with methylnaltrexone, a -opioid-receptor
antagonist. This is an option for treatment of patients who have been
on opioid treatment. Prucalopride has also been reported to be successful. These drugs will require further studies before routine use
can be considered.
COLONOSCOPIC DECOMPRESSION
When patients do not improve with either conservative management
or infusion of neostigmine, endoscopic colonic decompression should
be considered. The procedure should be done without prior preparation to decrease the risk of perforation. The risks of colonoscopic
decompression include a perforation rate of 2% and mortality of 1%.
The procedure can be performed without air insufflation preferably
using small amounts of CO
through a large-bore suction channel. The ascending colon and cecum
may not be well perfused and appear ischemic. Adequate decompression can be obtained when the colonoscope is passed to the proximal
transverse colon under fluoroscopic guidance. Decompression may be
effective in 50% by suction of air and liquid. Most endoscopists will
pass a guidewire through the accessory channel of the colonoscope
and slowly withdraw the scope under fluoroscopic guidance. A decompression tube can then be passed over the guidewire followed by low
intermittent suction with saline flushes every 4 to 6 hours to decrease
obstruction of the decompression tube. Repeat colonoscopy is often
required due to a recurrence rate of 40%. Randomized controlled trials
are not available supporting the use of decompression tubes. The use of
polyethylene glycol after endoscopic decompression is recommended.
There is limited data suggesting that colonoscopic decompression
is superior to neostigmine infusion. Other studies suggest that both
modalities are equivalent (Box 3).
. Air and liquid stool can be aspirated
2
PERCUTANEOUS CECOSTOMY
Among patients who are at high perioperative risk and have failed
conservative, pharmacologic, and endoscopic decompression, percutaneous cecostomy (PEC cecum) may be considered for colon
decompression. PEC-cecum tubes can be placed endoscopically
or through interventional radiology techniques with an excellent
response rate. However, this is an invasive procedure with serious
adverse events that include wound infection, bleeding, perforation,
granuloma, and buried bumper necrosis. Such procedures should
be managed by experts in interventional radiology and therapeutic
endoscopy. Adequate studies of these procedures are lacking.
BOX 2 Neostigmine Therapy
1. 2 mg intravenously over 5 minutes with available glycopyrrolate
or atropine
2. Consider 0.4 mg/h IV continuous infusion
3. Monitor EKG, oxygen saturation, and blood pressure
4. Adjust for renal failure if:
• Creatinineclearancelessthan50mL/min50%
• Creatinineclearanceoflessthan10mL/hr75%
5. Avoid if:
• Mechanical,intestinal,orurinarytractobstruction
• Bradycardialessthan60bpmorsystolicbloodpressureless
than 90 mm Hg
• Recentmyocardialinfarction
• Peritonitis
• β-Blockeruse
BOX 3 Endoscopic Decompression
1. Failure to respond to conservative management and trial of
neostigmine
2. Persistent ACPO
3. Colonoscope passed to hepatic flexure or cecum
• Avoidair-limitedCO2 infusion
• Largeboresuctionofairinstool
• Guidewireplacementthroughaccessorychannelunder
uoroscopy
• Decompressiontubeplacedoverguidewire
4. Low intermittent suction
5. Flush tube with saline every 4–6 hours
6. 72-hour limit then remove tube
7. Avoid with ischemic mucosa, perforation, or peritonitis
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