NEOSTIGMINE TREATMENT FOR REFRACTORY COLONIC PSEUDO-OBSTRUCTION IN AN 85 YEAR-OLD FEMALE WITH SERIOUS COMORBIDITIES IN INTENSIVE CARE UNIT

AA ANGELES, MD, JL GOPEZ-CERVANTES, MD
Institute of Digestive and Liver Diseases, St. Luke’s Medical Center — Quezon City Metro Manila, Philippine

Significance: Acute Colonic Pseudo-obstruction (ACPO) is common in patients with serious comorbidities especially in Intensive Care Unit. The acetylcholinesterase inhibitor neostigmine is considered treatment to unresponsive to conservative management but not sufficiently used with the fear of side effects. This case demonstrated the safety and effectiveness of Neostigmine as treatment option.

Clinical Presentation: This is a case of an 85-year-old female, admitted at ICU and being managed as case of Septic shock from UTI and CAP, ARF secondary to CAP on mechanical ventilator and fentanyl, Cardiogenic shock secondary to ACS on Norepinephrine and Acute Kidney Injury. On the 7th day of admission, had an episode of vomiting and abdominal distention.

Management: Serial SFA done showed progressive increase in cecal diameter from 8.2cm to 11.1cm despite 3 days of conservative management with bowel rest and prokinetic. Whole abdominal CT scan showed dilated cecum with air and fluid-filled small and large bowel segments from the proximal jejunum up to the transverse colon without discrete transition point. Patient was then managed as case of colonic pseudo-obstruction with colonic decompression twice, rectal tube for 5 days however, no resolution of symptoms was observed. Neostigmine bolus was administered and patient subsequently improved. Patient was maintained on Polyethylene glycol and Bisacodyl with observed sustained response.

Recommendation: When conservative methods fail, Neostigmine is recommended pharmacological treatment of Colonic Pseudo-obstruction. Favorable clinical-radiologic response can be achieved but recurrence rate is high as 33% due to multifactorial factors that will newly arise. Hence maintenance with Polyethylene Glycol and Bisacodyl can be used for the sustained response.

Keywords: ACPO, Neostigmine,

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