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Acute colonic pseudo-obstruction

Definition
ACPO is a syndrome of massive dilation of the colon without mechanical obstruction and an identifiable cause.
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Pathophysiology
The pathophysiology is not completely understood but is thought to result from an imbalance in the autonomic regulation of colonic motor function. Metabolic or pharmacological factors, as well as spinal or retroperitoneal trauma, may alter the autonomic regulation of colonic function, leading to excessive parasympathetic suppression or sympathetic stimulation. This imbalance results in colonic atony and dilation.
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Epidemiology
The incidence of ACPO is estimated at 100 cases per 100,000 admissions.
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Disease course
Clinically, it presents as a syndrome of massive dilation of the colon without mechanical obstruction. The condition can lead to significant complications, including ischemia and perforation.
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Prognosis and risk of recurrence
The prognosis is serious, with significant morbidity and mortality. Complications such as ischemia or perforation can occur, particularly when the cecal diameter exceeds 12 cm and when the distention has been present for > 6 days. The mortality rate is estimated at 40% when these complications occur.
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Key sources
The following summarized guidelines for the evaluation and management of acute colonic pseudo-obstruction are prepared by our editorial team based on guidelines from the American Society for Gastrointestinal Endoscopy (ASGE 2020), the European Society of Gastrointestinal Endoscopy (ESGE 2020), and the American Society of Colon and Rectal Surgeons (ASCRS 2016).
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Guidelines

1.Diagnostic investigations

Initial assessment: elicit a focused history, perform physical examination, and obtain the following tests in the initial evaluation of patients with suspected colonic volvulus:
CBC
serum electrolytes
renal function tests
diagnostic imaging
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2.Medical management

Conservative management: as per ASGE 2020 guidelines, initiate conservative therapy as the preferred initial management, including identifying and correcting potentially contributing metabolic, infectious, and pharmacologic factors, in patients with uncomplicated ACPO (absence of ischemia, peritonitis, cecal diameter < 12 cm, and/or significant abdominal pain).
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3.Therapeutic procedures

Endoscopic decompression: as per ASGE 2020 guidelines, consider performing colonic decompression with decompression tube placement as an alternative in patients with ACPO not being candidates for conservative therapy or failed conservative therapy (up to 72 hours) and having no contraindication to endoscopy.
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4.Surgical interventions

Indications for surgery: as per ASGE 2020 guidelines, perform surgery in patients with ACPO with overt perforation or signs of peritonitis.
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