Acute Colonic Pseudo-Obstruction: Colonoscopy versus Neostigmine First?

Introduction: Neostigmine (NEO) and decompressive colonoscopy (COL) are two efficacious treatment modalities for acute colonic pseudo-obstruction (ACPO). We hypothesize that a COL first strategy is associated with better outcomes compared to a NEO first strategy. Methods: A single-center retrospective analysis was performed from 2013 to 2020. Patients >= 18 y with a diagnosis of ACPO were included. The outcome was a composite measure of acute operative intervention, 30-day readmission with ACPO, and 30-day ACPO-related mortality. A P-value of <= 0.05 indicated statistical significance. Results: Of 910 encounters in 849 patients, 50 (5.5%) episodes of ACPO in 39 patients were identified after exclusion of one patient with colon perforation on presentation. The me-dian (interquartile range) age was 68 (62-84) y. NEO and COL were administered in 21 and 25 episodes, respectively. In 16 (32%) episodes, no NEO or COL was administered. When pa-tients were given NEO first, COL or additional NEO was required in 12/18 (67%) compared with a COL first strategy where a second COL and/or NEO was given in 5/16 (32%) (P = 0.05). Both strategies had similar outcomes (NEO, 4/18 versus COL, 4/16, P = 0.85). Twenty-two (44%) episodes had an early intervention (<= 48 h) with NEO and/or COL. There was no dif-ference in outcome between those that received an early intervention and those who did not (5/22 versus 5/28, P = 0.71). Conclusions: For patients failing conservative measures, a COL first approach was associated with fewer subsequent interventions, but with similar composite outcomes compared to a NEO first approach. Early (<= 48 h) intervention with NEO and/or COL was not associated with improved outcomes. (c) 2023 Elsevier Inc. All rights reserved.