Endoscopic Decompression in Colonic Distension

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Abstract

Background: Acute colonic distension is a medical emergency with high morbidity and mortality. Clinically important causes of colonic distension are acute colonic pseudo-obstruction, colonic volvulus, and malignant obstruction. Endoscopic decompression is one established therapeutic strategy. Summary: This therapeutic review will give an overview of possible therapeutic strategies based on the recently published literature, focusing on endoscopic decompression and summarizing the other therapeutic possibilities. The review discusses separately the therapeutic options of acute colonic pseudo-obstruction, colonic volvulus, and malignant obstruction, providing an evidence-based orientation for clinical use. Key Messages: Endoscopic decompression of colonic distension is an established therapy with high clinical success. The technique and its position in the therapy sequence differ depending on the medical condition, the trigger of the colonic distension, and the local expertise.

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Most cited references 43

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Neostigmine for the treatment of acute colonic pseudo-obstruction.

J Ponec, D Saunders, M Kimmey (1999)

Acute colonic pseudo-obstruction -- that is, massive dilation of the colon without mechanical obstruction -- may develop after surgery or severe illness. Although it may resolve with conservative therapy, colonoscopic decompression is sometimes needed to prevent ischemia and perforation of the bowel. Uncontrolled studies have suggested that neostigmine, may be an effective treatment. We studied 21 patients with acute colonic pseudo-obstruction. All had abdominal distention and radiographic evidence of colonic dilation, with a cecal diameter of at least 10 cm, and had had no response to at least 24 hours of conservative treatment. We randomly assigned 11 to receive 2.0 mg of neostigmine intravenously and 10 to receive intravenous saline. A physician who was unaware of the patients' treatment assignments recorded clinical response (defined as prompt evacuation of flatus or stool and a reduction in abdominal distention), abdominal circumference, and measurements of the colon on radiographs. Patients who had no response to the initial injection were eligible to receive open-label neostigmine three hours later. Ten of the 11 patients who received neostigmine had prompt colonic decompression, as compared with none of the 10 patients who received placebo (P<0.001). The median time to response was 4 minutes (range, 3 to 30). Seven patients in the placebo group and the one patient in the neostigmine group without an initial response received open-label neostigmine; all had colonic decompression. Two patients who had an initial response to neostigmine required colonoscopic decompression for recurrence of colonic distention; one eventually underwent subtotal colectomy. Side effects of neostigmine included abdominal pain, excess salivation, and vomiting. Symptomatic bradycardia developed in two patients and was treated with atropine. In patients with acute colonic pseudo-obstruction who have not had a response to conservative therapy, treatment with neostigmine rapidly decompresses the colon.

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Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2020

Jeanin E van Hooft, Joyce Veld, Dirk Arnold … (2020)

The following recommendations should only be applied after a thorough diagnostic evaluation including a contrast-enhanced computed tomography (CT) scan. 1 ESGE recommends colonic stenting to be reserved for patients with clinical symptoms and radiological signs of malignant large-bowel obstruction, without signs of perforation. ESGE does not recommend prophylactic stent placement. Strong recommendation, low quality evidence. 2 ESGE recommends stenting as a bridge to surgery to be discussed, within a shared decision-making process, as a treatment option in patients with potentially curable left-sided obstructing colon cancer as an alternative to emergency resection. Strong recommendation, high quality evidence. 3 ESGE recommends colonic stenting as the preferred treatment for palliation of malignant colonic obstruction. Strong recommendation, high quality evidence. 4 ESGE suggests consideration of colonic stenting for malignant obstruction of the proximal colon either as a bridge to surgery or in a palliative setting. Weak recommendation, low quality evidence. 5 ESGE suggests a time interval of approximately 2 weeks until resection when colonic stenting is performed as a bridge to elective surgery in patients with curable left-sided colon cancer. Weak recommendation, low quality evidence. 6 ESGE recommends that colonic stenting should be performed or directly supervised by an operator who can demonstrate competence in both colonoscopy and fluoroscopic techniques and who performs colonic stenting on a regular basis. Strong recommendation, low quality evidence. 7 ESGE suggests that a decompressing stoma as a bridge to elective surgery is a valid option if the patient is not a candidate for colonic stenting or when stenting expertise is not available. Weak recommendation, low quality evidence.

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Acute pseudo-obstruction of the colon (Ogilvie's syndrome). An analysis of 400 cases.

V Vanek, M. Salti (1986)

This study analyzes 400 cases of acute pseudo-obstruction of the colon (Ogilvie's syndrome). Seven cases were reported at St. Elizabeth Hospital Medical Center between October 1982 and February 1985; 393 cases were reported in the literature from 1970-1985. Ogilvie's syndrome is most commonly reported in patients in the sixth decade, and is more predominant in men. It is caused by an unknown disturbance to the autonomic innervation of the distal colon, and is associated with different conditions. Plain abdominal roentgenogram is the most useful diagnostic test. If the cecal diameter is 12 cm or greater, or conservative management is unsuccessful, colonoscopic or operative decompression is needed. The mode of treatment, age, cecal diameter, delay in decompression, and status of the bowel significantly influence the mortality rate, which is approximately 15 percent with early appropriate management, compared with 36 to 44 percent in perforated or ischemic bowel.

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Journal

Journal ID (publisher-id): VIS

Journal ID (pmc): VIS

Journal ID (doi): 10.1159/issn.2297-4725

Title: Visceral Medicine

Publisher: S. Karger AG

ISSN (Print): 2297-4725

ISSN (Electronic): 2297-475X

Publication date Subscription-year: 2021

Publication date (Print): March 2021

Publication date (Electronic): 11 February 2021

Volume: 37

Issue: 2

Pages: 142-148

Affiliations

Department of Internal Medicine II, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany

Author notes

*Sebastian Belle, Department of Internal Medicine II, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, DE–68167 Mannheim (Germany), sebastian.belle@umm.de

Article

Publisher ID: 514799 Other ID: Visc Med 2021;37:142–148

DOI: 10.1159/000514799

SO-VID: 418b672a-99e3-4613-a161-390db0ae2198

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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

History

Date received : 17 October 2020

Date accepted : 27 January 2021

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Figures: 1, Tables: 1, Pages: 7

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Endoscopic Decompression in Colonic Distension

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Abstract

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Karger: Gastroenterology

Most cited references 43

Neostigmine for the treatment of acute colonic pseudo-obstruction.

Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2020

Acute pseudo-obstruction of the colon (Ogilvie's syndrome). An analysis of 400 cases.

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