589 d iseases of the c olon & r eCtum V olume 59: 7 (2016) key words

3. Pharmacologic treatment with neostigmine is an appro-

priate next step for ACPO that does not resolve with sup-

portive therapy. Grade of Recommendation: Strong rec-

ommendation based on moderate-quality evidence, 1B.

neostigmine is an antiacetylcholinesterase drug that tran-

siently and reversibly increases acetylcholine levels in the 

synapse of muscarinic receptors of the parasympathetic 

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nervous system.

25

 in the colon, acetylcholine promotes 

contractility and accelerates colon transit.

25,106

 in patients 

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.

32,34,107

 in the landmark study by Ponec 

et al,

32

 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 

and Rogers

108

 included a total of 18 patients treated with 

neostigmine, of which 17 (94%) had immediate clinical 

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% 

to 100%.

34

 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.

28,33,36,109,110

 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.

107

 in patients with aCPo who 

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%.

111

adverse events associated with the use of neostigmine 

for aCPo are attributed to excess acetylcholine and include 

transient abdominal pain (50%–73%), sialorrhea (23%–

38%), vomiting (10%–20%), and bradycardia (5%–9%).

34

 

neostigmine therapy should be administered in a setting 

that allows for continuous monitoring of heart rate, oxygen 

saturation, and frequent blood pressure measurements and 

that has glycopyrrolate or atropine readily available for rapid 

use in cases of bronchospasm or bradycardia.

26,28,32,112

 neo-

stigmine should not be used in aCPo that is complicated by 

colon ischemia or perforation or in the setting of pregnancy, 

uncontrolled cardiac arrhythmias, or severe active broncho-

spasm.

28

 it may be used with caution in patients with brady-

cardia, asthma, chronic obstructive pulmonary disease, renal 

insufficiency, or recent myocardial infarction.

26,112

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.

30,31,33,36,103,113

 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%).

31

 in the 

8 patients (16%) in which a decompression tube was not 

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.

30,31

 additional support 

for the use of a decompression tube in this setting comes 

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 

not used.

114

 similar results were noted in a review in which 

recurrence of colon dilation occurred in 40% of those who 

underwent colonoscopic decompression without place-

ment of a decompression tube.

101

 Commercially available, 

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%.

28,33,36,103,115

 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.

28,33

 if muco-

sal ischemia is identified during colonoscopy, the safety 

of decompression is unclear, although a single small case 

series provided evidence to support this practice.

33,116

 in 

patients with aCPo who have failed supportive, pharma-

cologic, and standard endoscopic therapies and have no 

evidence of colon perforation or ischemia, percutaneous 

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 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.

28,117,118

5. Operative treatment is recommended for ACPO com-

plicated by colon ischemia or perforation or ACPO refrac-

tory to pharmacologic and endoscopic therapies. Grade 

of Recommendation: Strong recommendation based on 

low-quality evidence, 1C.

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-

ment.

26,28,31,33,112

 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.

30,36,101

 Persistent colon dilation re-

fractory to nonoperative measures can be estimated to 

occur in ≈10% of patients.

30–32

 a study of 400 patients 

with aCPo from the “preneostigmine era” included 

179 patients who underwent operative intervention.

30

 

of these patients, 129 (72%) received an ostomy, 25 

(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%.

30

 surgical mor-

tality rates with viable, ischemic, and perforated bowel 

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.

30,102

 intra-

operative decisions in aCPo should be guided by the 

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-

tomy creation.

26,30

 for ischemic or perforated colon, the 

choice of resection with end ostomy or resection with 

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.

100,112

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.

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