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Key Features

Essentials of Diagnosis

  • Severe abdominal distention

  • Massive dilation of cecum or right colon

  • Arises in postoperative state or with severe medical illness

  • May be precipitated by electrolyte imbalances, medications

  • Absent to mild abdominal pain; minimal tenderness

General Considerations

  • Spontaneous massive dilation of the cecum and proximal colon in hospitalized patients

  • Progressive cecal dilation may lead to spontaneous perforation

  • Etiology unknown

  • Associated conditions

    • Trauma

    • Respiratory failure

    • Malignancy

    • Myocardial infarction or heart failure

    • Pancreatitis

    • Stroke or subarachnoid hemorrhage

    • Ischemic colitis

    • Use of drugs, eg, opioids, anticholinergics

Demographics

  • Occurs mainly in hospitalized patients with recent trauma, surgery (especially cardiothoracic), or severe medical illness

  • May be precipitated by electrolyte imbalance or opioids

Clinical Findings

Symptoms and Signs

  • Sometimes asymptomatic

  • Constant but mild abdominal pain

  • Nausea and vomiting

  • Abdominal distention

  • Bowel movements may be absent; however, up to 40% of patients continue to pass flatus or stool

  • Abdominal tenderness with some degree of guarding or rebound tenderness; however, signs of peritonitis absent unless perforation has occurred

  • Bowel sounds may be normal or decreased

  • Fever suggests colonic perforation

Differential Diagnosis

  • Mechanical colonic obstruction, eg, malignancy, diverticulitis, volvulus, fecal impaction

  • Toxic megacolon due to inflammatory bowel disease or Clostridium difficile colitis, cytomegalovirus

Diagnosis

Laboratory Tests

  • Obtain complete blood count, serum sodium, potassium, magnesium, phosphorus, and calcium

  • Leukocytosis suggests colonic ischemia or perforation

Imaging Studies

  • Plain radiographs demonstrate colonic dilation, usually cecum and proximal colon

  • Varying amounts of small intestinal dilation and air-fluid levels

  • Cecal diameter > 10–12 cm associated with increased risk of colonic perforation

Diagnostic Procedures

  • CT scan or hypaque (diatrizoate meglumine) enema to exclude distal colonic obstruction, if suspected

Treatment

Medications

  • Discontinue opioids, anticholinergics, and calcium channel blockers, if possible

  • Correct electrolyte abnormalities

  • Oral laxatives are not helpful and may cause perforation

  • Neostigmine 2 mg intravenously as a single dose results in rapid (within 30 minutes) colonic decompression in 75–90% and should be considered for following patients:

    • No improvement or clinical deterioration after 24–48 hours of conservative treatment

    • Cecal dilation > 12 cm

    • Cecal dilation > 10 cm for prolonged period (3–4 days)

Therapeutic Procedures

  • Treat underlying illness

  • Conservative treatment is recommended if no or minimal abdominal tenderness, no fever, no leukocytosis, and a cecal diameter < 12 cm

    • Place a nasogastric tube and a rectal tube

    • Ambulate patients, or roll periodically from side to side and to knee-chest position

    • Judicious administration of enemas if large amounts of stool on radiography

    • Conservative treatment successful in > 80%

  • Colonoscopic decompression in selected patients who do not respond to neostigmine, successful in up ...

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