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American Society for Gastrointestinal EndoscopyGastroenterology2020advanced

Role of Endoscopy in the Management of Acute Colonic Pseudo-Obstruction and Colonic Volvulus

Published by American Society for Gastrointestinal Endoscopy

10Recommendations
70References
1Figures

Summary

AI-generated

Colonic volvulus and acute colonic pseudo-obstruction (ACPO) are two causes of benign large-bowel obstruction. Colonic volvulus occurs most commonly in the sigmoid colon from bowel twisting, whereas ACPO stems from altered autonomic regulation of colonic motility resulting in dilation without a mechanical cause. Prompt diagnosis and intervention improve outcomes for both conditions.

colonic volvulusacute colonic pseudo-obstructionACPOASGEgastroenterologyguidelinesneostigmineendoscopic decompression

Key Takeaways

  • 1
    Endoscopy is the suggested initial treatment modality for uncomplicated sigmoid volvulus, while surgery is recommended for cecal volvulus.
  • 2
    Surgical consultation should occur during the index admission for sigmoid volvulus due to high recurrence rates.
  • 3
    Surgical management is recommended for both colonic volvulus and ACPO if there are signs of peritonitis or overt perforation.
  • 4
    Conservative therapy is the preferred first-line management for uncomplicated ACPO.
  • 5
    Neostigmine is the recommended pharmacologic agent for ACPO patients who fail or are ineligible for conservative therapy.
  • 6
    Colonic decompression via endoscopy is an alternative for ACPO when conservative therapy fails and no contraindications are present.

What's New in This Version

This document is a focused update on the role of endoscopy in the management of colonic volvulus and acute colonic pseudo-obstruction (ACPO), updating the preceding 2010 comprehensive guideline.

Key Recommendations

RECOMMENDATIONS

  • 1

    For patients with uncomplicated sigmoid volvulus, we suggest endoscopy as the initial treatment modality. After successful detorsion, placement of decompression tube should be considered to maintain reduction and decrease risk of recurrence.

    þþTreatment
  • 2

    For patients with sigmoid volvulus, we suggest surgical consultation during index admission given the high risk of recurrent volvulus and high morbidity and mortality associated with each episode.

    þþþManagement
  • 3

    For patients with cecal volvulus, we recommend pursuit of surgical management as initial treatment modality and avoidance of endoscopic intervention given the high risk of perforation.

    þþþTreatment
  • 4

    For patients with colon volvulus with overt perforation or signs of peritonitis, we recommend surgical management.

    þþþTreatment
  • 5

    For patients with uncomplicated ACPO (absence of ischemia, peritonitis, cecal diameter <12 cm, and/or significant abdominal pain), we recommend conservative therapy as the preferred initial management including identifying and correcting potentially contributing metabolic, infectious, and pharmacologic factors.

    þþþTreatment
  • 6

    For patients with ACPO who are not candidates for conservative therapy, have failed conservative therapy (up to 72 hours), or are at risk for perforation and have no contraindication to its use, we recommend pharmacologic therapy with neostigmine (2 mg over 3-5 minutes) with appropriate cardiovascular monitoring.

    þþþTreatment
  • 7

    For patients with ACPO who do not respond to a first dose of neostigmine, we suggest the administration of a second dose of neostigmine.

    þTreatment
  • 8

    For patients with ACPO refractory to bolus dosing of neostigmine, we suggest alternative routes of neostigmine administration including subcutaneous or continuous intravenous infusion.

    þTreatment
  • 9

    For patients with ACPO who are not candidates for conservative therapy or have failed conservative therapy (up to 72 hours) and have no contraindication to endoscopy, we suggest colonic decompression with decompression tube placement as an alternative.

    þþTreatment
  • 10

    For patients with ACPO with overt perforation or signs of peritonitis, we recommend surgical management.

    þþþTreatment

Scope & Objectives

Clinical Topic

Colonic volvulus and acute colonic pseudo-obstruction (ACPO)

Objectives

To provide an update on the evaluation and endoscopic management of sigmoid volvulus and acute colonic pseudo-obstruction (ACPO).

Target Patient Population

Patients with suspected or known colonic volvulus or acute colonic pseudo-obstruction.

Diagnostic Criteria

Diagnosis is established via plain-film abdominal radiography or contrast-enhanced CT (showing colonic dilation, possible transition zone, and excluding mechanical obstructions, or mesenteric whirl sign for volvulus).

Target Providers

GastroenterologistsEndoscopistsSurgeons

Patient Criteria & Setting

Therapeutic Area

Gastrointestinal Disorders

Guideline Scope

EvaluationManagementEndoscopic Treatment

Care Settings

HospitalInpatientEmergency Setting

Special Populations

ElderlyPediatricDebilitated

Safety & Contraindications

Contraindications

  • Peritonitis
  • Perforation
  • Intestinal or urinary obstruction
  • Hypersensitivity to neostigmine

Monitoring Guidance

Continuous monitoring of cardiac rhythm and respiratory status and immediate access to atropine in the event of bradycardia are required during neostigmine administration.

Authors & Contributors

Mariam NaveedLaith H. JamilLarissa L. Fujii-LauMohammad Al-HaddadJames L. BuxbaumDouglas S. FishmanTerry L. JueJoanna K. LawJeffrey K. LeeBashar J. QumseyaMandeep S. SawhneyNirav ThosaniAndrew C. StormAudrey H. CalderwoodMouen A. KhashabSachin B. Wani

Guideline Features

Dosing informationFlowcharts includedBased on systematic review

Learning Context

Difficulty

advanced

Learning Paths

GastroenterologyEndoscopyColonic VolvulusAcute Colonic Pseudo-obstructionOgilvie's Syndrome