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Essentials of Diagnosis
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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
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General Considerations
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Occurs mainly in hospitalized patients with recent trauma, surgery (especially cardiothoracic), or severe medical illness
May be precipitated by electrolyte imbalance or opioids
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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
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Differential Diagnosis
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Mechanical colonic obstruction, eg, malignancy, diverticulitis, volvulus, fecal impaction
Toxic megacolon due to inflammatory bowel disease or Clostridioides difficile colitis, cytomegalovirus
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Obtain complete blood count, serum sodium, potassium, magnesium, phosphorus, and calcium
Leukocytosis suggests colonic ischemia or perforation
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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
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Diagnostic Procedures
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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:
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Therapeutic Procedures
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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 ...