neostigmine is an antiacetylcholinesterase drug that tran-
siently and reversibly increases acetylcholine levels in the
synapse of muscarinic receptors of the parasympathetic
oGel et al:
in the colon, acetylcholine promotes
with aCPo, placebo-controlled, randomized prospective
trials of intravenous administration of neostigmine have
shown that this drug leads to resolution of colon dilation
in ≈90% of cases.
in the landmark study by Ponec
patients with aCPo who received 2 mg of neostig-
mine intravenously over a period of 2 to 5 minutes experi-
enced a clinical response, defined as the passage of flatus or
stool and decreased abdominal distension in 10 (91%) of
11 cases at a median interval of 4 minutes (range, 3–30 min-
utes). in addition, serial abdominal radiographs revealed a
greater median decrease in cecal diameter compared with
the placebo group (5- vs 2-cm decrease). although the
authors considered neostigmine to have failed in 3 (27%)
of 11 cases, 1 of the 3 initial nonresponders subsequently
responded to a second dose of neostigmine, whereas the
other 2 required colonoscopic decompression. in 7 of the
10 patients who received open-label neostigmine after
failure of placebo, a clinical and radiographic response
occurred in 100%, and there were no recurrences. a sub-
sequent and similarly designed trial performed by amaro
included a total of 18 patients treated with
response and 16 (89%) had sustained colon decompres-
sion. a recent review of the randomized and nonran-
domized trials of neostigmine for aCPo reported that a
single intravenous dose of 2 to 5 mg administered over 1 to
5 minutes was successful in 60% to 94%, with a recurrence
rate of 0% to 31% and overall long-term response in 69%
in initial nonresponders or partial responders
to neostigmine, a second dose has proven effective in 40%
to 100% of patients and therefore may be considered after
an interval that exceeds the normal 80-minute elimination
half-life of the drug.
as an alternative to rapid
intravenous administration of neostigmine, a single, ran-
domized prospective trial of 24-hour neostigmine infusion
for patients with ileus rather than aCPo has led to suc-
cessful resolution of the condition in 85%, with no acute
harmful adverse effects.
respond to neostigmine, a small, randomized, placebo-
controlled trial demonstrated that the oral administration
of polyethylene glycol resulted in no recurrence of colonic
dilation, whereas placebo resulted in recurrence in 33%.
for aCPo are attributed to excess acetylcholine and include
transient abdominal pain (50%–73%), sialorrhea (23%–
38%), vomiting (10%–20%), and bradycardia (5%–9%).
neostigmine therapy should be administered in a setting
saturation, and frequent blood pressure measurements and
that has glycopyrrolate or atropine readily available for rapid
use in cases of bronchospasm or bradycardia.
colon ischemia or perforation or in the setting of pregnancy,
uncontrolled cardiac arrhythmias, or severe active broncho-
it may be used with caution in patients with brady-
cardia, asthma, chronic obstructive pulmonary disease, renal
insufficiency, or recent myocardial infarction.
4. Endoscopic decompression of the colon should be
considered in patients with ACPO in whom neostigmine
therapy is contraindicated or ineffective. Grade of Rec-
ommendation: Strong recommendation based on mod-
erate-quality evidence, 1B.
in patients with aCPo who have not been treated with
neostigmine, endoscopic decompression of the colon has
been shown to result in initial colon decompression in
61% to 95% of cases and sustained decompression in the
70% to 90% range.
to prevent the recurrence
of colon dilation, more than 1 endoscopic decompression
procedure and/or endoscopic placement of a decompres-
sion tube is often required. in a study of 50 patients with
aCPo, 41 (82%) had 1 colonoscopic decompression with
clinical success in 39 (95%), and 9 (18%) required multiple
(2–4) procedures with clinical success in 5 (56%).
placed, clinical success was achieved in only 2 (25%). the
overall clinical success of colonoscopic decompression was
88% (44 of 50), a percentage similar to the 82% success rate
for the 125 patients who underwent colonoscopy in the
large review by Vanek and al-salti.
from a nonrandomized study in which there were no recur-
rences of colon dilation in the 11 patients who underwent
decompression tube placement and a 36% (4 of 11) recur-
rence in those patient in whom a decompression tube was
similar results were noted in a review in which
underwent colonoscopic decompression without place-
ment of a decompression tube.
through-the-scope colonoscopic decompression kits that
include guide wires are available. ideally, the decompres-
sion tube is placed in the proximal ascending colon.
Colonoscopy in aCPo has a reported perforation rate
of 1% to 3%.
it is performed without mechani-
cal bowel preparation of the colon using carbon dioxide
or minimal air insufflation while avoiding or minimizing
the use of narcotics. the goal of the colonoscopy in this
setting is to intubate the right colon rather than the cecum
and to place a suitable decompression tube while remov-
ing as much gas as possible from the colon.
of decompression is unclear, although a single small case
series provided evidence to support this practice.
patients with aCPo who have failed supportive, pharma-
cologic, and standard endoscopic therapies and have no
evidence of colon perforation or ischemia, percutaneous
iseases of the
endoscopic colostomy may be considered as a last step
before surgical therapy. although this procedure has been
performed safely, its overall success and role in the man-
agement of aCPo remain to be determined.
the effectiveness of nonoperative, pharmacologic, and
endoscopic therapy for aCPo has reduced the need for
surgery to cases complicated by colon ischemia or per-
foration or dilation refractory to nonoperative manage-
Colon ischemia or perforation occurs
in 3% to 10% of patients with aCPo who have risk
factors including cecal diameter >12 cm and duration
of dilation >6 days.
Persistent colon dilation re-
fractory to nonoperative measures can be estimated to
occur in ≈10% of patients.
with aCPo from the “preneostigmine era” included
179 patients who underwent operative intervention.
(14%) had a resection, and 25 (14%) had other opera-
tions performed, with an overall mortality rate of 30%.
among the 129 patients treated with tube cecostomy
(n = 34), cecostomy (n = 61), and ileostomy or colostomy
(n = 34), successful decompression was achieved in
100%, 95%, and 73%, with mortality of 15%, 21%, and
41%, and morbidity of 9%, 3%, and 3%.
were 26%, 44%, and 36%. for comparison, the mortal-
ity rates for patients treated with supportive therapy
alone and endoscopically treated patients were 14% and
13%. additional risk factors for death in aCPo were ad-
vanced patient age, cecal diameter >14 cm, prolonged
periods (>4 days) of unrelieved colonic distension, and
the requirement for operative intervention.
condition of the colon and the condition of the patient.
With viable, dilated colon, tube cecostomy or cecostomy
is successful in 95% to 100% of patients with no com-
parative data available to guide the preferred type of os-
for ischemic or perforated colon, the
anastomosis with or without proximal diversion is de-
termined on a case-by-case basis and follows the general
principles applicable to all bowel surgeries.
APPENDIX A: CONTRIBUTING MEMBERS OF THE AS-
CRS CLINICAL PRACTICE GUIDELINES COMMITTEE
Janice Rafferty, m.D.; ian Paquette, m.D.; Daniel herzig,
M.D.; Fergal Fleming, M.B.B.Ch.
1. Guyatt G, Gutterman D, Baumann MH, et al. Grading strength
of recommendations and quality of evidence in clinical guide-
lines: report from an american College of Chest Physicians
task force. Chest. 2006;129:174–181.
2. lopez-Kostner f, hool GR, lavery iC. management and
causes of acute large-bowel obstruction. Surg Clin North Am.
3. Yeo hl, lee sW. Colorectal emergencies: review and con-
troversies in the management of large bowel obstruction.
4. halabi WJ, Jafari mD, Kang CY, et al. Colonic volvulus in the
united states: trends, outcomes, and predictors of mortality.
Ann Surg. 2014;259:293–301.
5. Raveenthiran V, madiba te, atamanalp ss, De u. Volvulus of
the sigmoid colon. Colorectal Dis. 2010;12(7 online):e1–e17.
6. akinkuotu a, samuel JC, msiska n, mvula C, Charles aG. the
role of the anatomy of the sigmoid colon in developing sigmoid
volvulus: a case-control study. Clin Anat. 2011;24:634–637.
7. Ballantyne GH, Brandner MD, Beart RW Jr, Ilstrup DM.
Volvulus of the colon: incidence and mortality. Ann Surg.
8. Gingold D, murrell Z. management of colonic volvulus. Clin
9. Grossmann em, longo We, stratton mD, Virgo Ks, Johnson
fe. sigmoid volvulus in Department of Veterans affairs
medical Centers. Dis Colon Rectum. 2000;43:414–418.
10. Swenson BR, Kwaan MR, Burkart NE, et al. Colonic volvulus:
presentation and management in metropolitan minnesota,
united states. Dis Colon Rectum. 2012;55:444–449.
11. Yassaie o, thompson-fawcett m, Rossaak J. management
of sigmoid volvulus: is early surgery justifiable? ANZ J Surg.
12. Ballantyne GH. Review of sigmoid volvulus: clinical patterns
and pathogenesis. Dis Colon Rectum. 1982;25:823–830.
13. hiltunen Km, syrjä h, matikainen m. Colonic volvulus:
14. Bruzzi M, Lefèvre JH, Desaint B, et al. Management of acute
sigmoid volvulus: short- and long-term results. Colorectal Dis.
15. Friedman JD, Odland MD, Bubrick MP. Experience with co-
lonic volvulus. Dis Colon Rectum. 1989;32:409–416.
16. Lau KC, Miller BJ, Schache DJ, Cohen JR. A study of
large-bowel volvulus in urban australia. Can J Surg.
17. o’mara Cs, Wilson th Jr stonesifer Gl, stonesifer Gl,
term follow-up. Ann Surg. 1979;189:724–731.
18. Oren D, Atamanalp SS, Aydinli B, et al. An algorithm for the
management of sigmoid colon volvulus and the safety of pri-
mary resection: experience with 827 cases. Dis Colon Rectum.
19. theuer C, Cheadle WG. Volvulus of the colon. Am Surg.
20. Rabinovici R, simansky Da, Kaplan o, mavor e, manny J.
Cecal volvulus. Dis Colon Rectum. 1990;33:765–769.
21. tejler G, Jiborn h. Volvulus of the cecum: report of 26 cases and
review of the literature. Dis Colon Rectum. 1988;31:445–449.
22. lou Z, Yu eD, Zhang W, meng RG, hao lQ, fu CG. appropriate
treatment of acute sigmoid volvulus in the emergency setting.
World J Gastroenterol. 2013;19:4979–4983.
23. madiba te, thomson sR. the management of cecal volvulus.
24. Chudzinski aP, thompson eV, ayscue Jm. acute colonic pseu-
doobstruction. Clin Colon Rectal Surg. 2015;28:112–117.
25. De Giorgio R, Barbara G, Stanghellini V, et al. Review article:
the pharmacological treatment of acute colonic pseudo-ob-
struction. Aliment Pharmacol Ther. 2001;15:1717–1727.
26. De Giorgio R, Knowles Ch. acute colonic pseudo-obstruction.
Br J Surg. 2009;96:229–239.
27. ogilvie h. large-intestine colic due to sympathetic depriva-
tion; a new clinical syndrome. Br Med J. 1948;2:671–673.
28. saunders mD. acute colonic pseudo-obstruction. Gastrointest
29. spira ia, Rodrigues R, Wolff Wi. Pseudo-obstruction of the co-
lon. Am J Gastroenterol. 1976;65:397–408.
30. Vanek VW, al-salti m. acute pseudo-obstruction of the co-
lon (ogilvie’s syndrome): an analysis of 400 cases. Dis Colon
31. Geller A, Petersen BT, Gostout CJ. Endoscopic decompres-
sion for acute colonic pseudo-obstruction. Gastrointest Endosc.
32. Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the
treatment of acute colonic pseudo-obstruction. N Engl J Med.
33. harrison me, anderson ma, appalaneni V, et al. the role
of endoscopy in the management of patients with known
and suspected colonic obstruction and pseudo-obstruction.
34. Valle RG, Godoy fl. neostigmine for acute colonic pseudo-ob-
struction: a meta-analysis. Ann Med Surg (Lond). 2014;3:60–64.
35. Rex DK. acute colonic pseudo-obstruction (ogilvie’s syn-
drome). Gastroenterologist. 1994;2:233–238.
36. Saunders MD, Kimmey MB. Systematic review: acute co-
lonic pseudo-obstruction. Aliment Pharmacol Ther.
37. anderson JR, Welch Gh. acute volvulus of the right colon: an
analysis of 69 patients. World J Surg. 1986;10:336–342.
38. atamanalp ss. sigmoid volvulus: diagnosis in 938 patients over
45.5 years. Tech Coloproctol. 2013;17:419–424.
39. Burrell HC, Baker DM, Wardrop P, Evans AJ. Significant plain
film findings in sigmoid volvulus. Clin Radiol. 1994;49:317–319.
40. Javors BR, Baker SR, Miller JA. The northern exposure sign:
a newly described finding in sigmoid volvulus. AJR Am J
41. Levsky JM, Den EI, DuBrow RA, Wolf EL, Rozenblit AM.
Ct findings of sigmoid volvulus. AJR Am J Roentgenol.
42. Rosenblat JM, Rozenblit AM, Wolf EL, DuBrow RA, Den
ei, levsky Jm. findings of cecal volvulus at Ct. Radiology.
43. agrez m, Cameron D. Radiology of sigmoid volvulus. Dis
44. Ericksen AS, Krasna MJ, Mast BA, Nosher JL, Brolin RE. Use of
gastrointestinal contrast studies in obstruction of the small and
large bowel. Dis Colon Rectum. 1990;33:56–64.
45. Consorti et, liu th. Diagnosis and treatment of caecal volvu-
lus. Postgrad Med J. 2005;81:772–776.
46. Delabrousse E, Sarliève P, Sailley N, Aubry S, Kastler BA. Cecal
volvulus: Ct findings and correlation with pathophysiology.
47. Vandendries C, Jullès MC, Boulay-Coletta I, Loriau J, Zins
m. Diagnosis of colonic volvulus: findings on multidetec-
tor Ct with three-dimensional reconstructions. Br J Radiol.
48. Renzulli P, Maurer CA, Netzer P, Büchler MW. Preoperative
colonoscopic derotation is beneficial in acute colonic volvulus.
Dig Surg. 2002;19:223–229.
49. Bruusgaard C. Volvulus of the sigmoid colon and its treatment.
50. atamanalp ss. treatment of sigmoid volvulus: a single-center
experience of 952 patients over 46.5 years. Tech Coloproctol.
51. Ghazi a, shinya h, Wolfe Wi. treatment of volvulus of the co-
lon by colonoscopy. Ann Surg. 1976;183:263–265.
52. turan m, sen m, Karadayi K, et al. our sigmoid colon volvulus
experience and benefits of colonoscope in detortion process.
53. Dülger M, Cantürk NZ, Utkan NZ, Gonullu NN. Management
of sigmoid colon volvulus. Hepatogastroenterology.
54. tan KK, Chong Cs, sim R. management of acute sigmoid vol-
vulus: an institution’s experience over 9 years. World J Surg.
55. Welch Gh, anderson JR. acute volvulus of the sigmoid colon.
56. madiba te, thomson sR. the management of sigmoid volvu-
lus. J R Coll Surg Edinb. 2000;45:74–80.
57. Ballantyne GH. Review of sigmoid volvulus: history and results
of treatment. Dis Colon Rectum. 1982;25:494–501.
58. ifversen aK, Kjaer DW. more patients should under-
59. tsai ms, lin mt, Chang KJ, Wang sm, lee Ph. optimal inter-
val from decompression to semi-elective operation in sigmoid
volvulus. Hepatogastroenterology. 2006;53:354–356.
60. akcan a, akyildiz h, artis t, Yilmaz n, sozuer e. feasibility
of single-stage resection and primary anastomosis in patients
with acute noncomplicated sigmoid volvulus. Am J Surg.
61. Bagarani M, Conde AS, Longo R, Italiano A, Terenzi A, Venuto
G. sigmoid volvulus in West africa: a prospective study on sur-
gical treatments. Dis Colon Rectum. 1993;36:186–190.
62. Bhatnagar BN, Sharma CL, Gautam A, Kakar A, Reddy DC.
Gangrenous sigmoid volvulus: a clinical study of 76 patients.
63. Coban s, Yilmaz m, terzi a, et al. Resection and primary anas-
tomosis with or without modified blow-hole colostomy for sig-
moid volvulus. World J Gastroenterol. 2008;14:5590–5593.
64. Kuzu ma, aşlar aK, soran a, Polat a, topcu o, hengirmen s.
emergent resection for acute sigmoid volvulus: results of 106
consecutive cases. Dis Colon Rectum. 2002;45:1085–1090.
65. safioleas m, Chatziconstantinou C, felekouras e, et al. Clinical
considerations and therapeutic strategy for sigmoid volvu-
lus in the elderly: a study of 33 cases. World J Gastroenterol.
66. majeski J. operative therapy for cecal volvulus combining re-
section with colopexy. Am J Surg. 2005;189:211–213.