Correspondence

Neostigmine for Acute Colonic Pseudo-Obstruction

N Engl J Med 1999; 341:1622-1623November 18, 1999

Article

To the Editor:

Ponec et al. (July 15 issue)1 reported that treatment with neostigmine rapidly decompresses the colon in patients with acute colonic pseudo-obstruction who have not had a response to conservative therapy. Symptomatic bradycardia, however, developed in two patients.

Because bradycardia is a well-recognized and important complication of neostigmine therapy, use of neostigmine for reversal of neuromuscular blockade in the operating room is always accompanied by administration of an antimuscarinic anticholinergic agent such as atropine or glycopyrrolate. Although the authors recognized that administration of glycopyrrolate has not been shown to decrease colonic motility, they did not administer it prophylactically. Vital signs were monitored before the injection of neostigmine and 5 and 30 minutes after injection. Since vital signs were not continuously monitored, asymptomatic bradycardia might not have been detected, and thus the true incidence of important bradycardia might have been underestimated. Moreover, even if bradycardia is treated, the effects of neostigmine may outlast those of glycopyrrolate or atropine.

We recommend that patients who are given neostigmine for colonic pseudo-obstruction also receive either atropine or glycopyrrolate prophylactically and that they be monitored continuously by electrocardiography and blood-pressure measurement for one hour after neostigmine administration.

Monica S. Vavilala, M.D.
Arthur M. Lam, M.D.
University of Washington School of Medicine, Seattle, WA 98104

1 References

1. 1

   Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med 1999;341:137-141
   Full Text | Web of Science | Medline

To the Editor:

We have been using neostigmine to treat patients with acute colonic pseudo-obstruction for more than six years and have found it to be extremely effective and safe.1 However, we are concerned that some patients in the study by Ponec et al. — specifically, those with air in the rectosigmoid colon on plain abdominal radiography — did not receive radiographic contrast enemas to rule out a mechanical obstruction. In our experience and that of others,2 the presence of air at the presumed rectosigmoid junction in association with dilatation of the proximal colon can be misleading and can wrongly imply the absence of an obstructing lesion. Such a false sense of reassurance can lead to incorrect diagnosis and treatment of a patient with a potent colonic stimulant such as neostigmine.3 This can have severe adverse consequences.

We believe that a water-soluble contrast enema should be used for all patients with possible acute colonic pseudo-obstruction when pharmacologic treatment with neostigmine is considered. Also, over the past four years, we have used a combination of glycopyrrolate and neostigmine (Robinul-Neostigmine, Wyeth Laboratories) (500 μg and 2.5 mg, respectively) to good effect in seven consecutive patients in the intensive care unit who had acute colonic pseudo-obstruction.4 None had even a transient bradycardia.

Faisal Abbasakoor, F.R.C.S.
Alison Evans, M.B., B.Ch.
Brian M. Stephenson, F.R.C.S.
Royal Gwent Hospital, Newport, NSW NP20 2UB, Australia

4 References

1. 1

   Stephenson BM, Morgan AR, Drake N, Salaman JR, Wheeler MH. Parasympathomimetic decompression of acute colonic pseudo-obstruction. Lancet 1993;342:1181-1182
   CrossRef | Web of Science | Medline

2. 2

   Stewart J, Finan PJ, Courtney DF, Brennan TG. Does a water soluble contrast enema assist in the management of acute large bowel obstruction: a prospective study of 117 cases. Br J Surg 1984;71:799-801
   CrossRef | Web of Science | Medline

3. 3

   Trevisani G, Hyman N, Church J. Neostigmine: a new treatment for Ogilvie's syndrome. Dis Colon Rectum 1998;41:A29-A29 abstract.
   

4. 4

   Stephenson BM, Morgan AR, Salaman JR, Wheeler MH. Ogilvie's syndrome: a new approach to an old problem. Dis Colon Rectum 1995;38:424-427
   CrossRef | Web of Science | Medline

To the Editor:

I was surprised by the enrollment of an obviously very sick patient in the study by Ponec et al. The authors stated that “one patient, who was subsequent-ly randomly assigned to the placebo group, was enrolled after only 18 hours of conservative therapy, when the consulting gastroenterologist determined that urgent decompression was warranted.” I wonder how they justify their disregard of the patient's consultant, who obviously assessed the situation as urgent. What was the outcome for this patient?

Claus A. Pierach, M.D.
Abbott Northwestern Hospital, Minneapolis, MN 55407

To the Editor:

In 1948, Ogilvie described two cases of large-intestine colic due to sympathetic deprivation associated with abdominal carcinoma.1 No massive distention was found. To refer to massive distention of the colon without mechanical obstruction as “Ogilvie's syndrome” is not appropriate.

David Nicholson, M.D.
117 Colonial Ct., Little Rock, AR 72205-4221

1 References

1. 1

   Ogilvie H. Large-intestine colic due to sympathetic deprivation: a new clinical syndrome. BMJ 1948;2:671-673
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We appreciate the comments of Abbasakoor and colleagues and acknowledge that the report by Stephenson et al.1 was one of the reasons we performed our controlled study. We also are concerned about the use of neostigmine in the presence of mechanical obstruction and agree that contrast radiography should be used to rule out obstruction if plain abdominal radiographs do not have the classic appearance of acute colonic pseudo-obstruction. We cannot agree, however, that contrast radiography must be performed in all cases, since in the right clinical setting, plain abdominal radiographs with classic findings are seldom incorrect.

Vavilala and Lam discuss the importance of monitoring patients when they are given neostigmine. We agree with this and monitor all our patients continuously with portable electrocardiographic and automated blood-pressure equipment for 30 minutes after infusion of neostigmine. Our protocol called for atropine for patients who had symptomatic bradycardia. We are very interested in the potential application of glycopyrrolate as a means of avoiding this adverse effect of neostigmine, as suggested by both Abbasakoor et al. and Vavilala and Lam, and look forward to the results of a controlled trial to prove its efficacy.

Pierach raises an important point with regard to the use of neostigmine. Patients whose cardiovascular or respiratory condition is unstable should probably not receive neostigmine. Thus, we adhered to the strict inclusion and exclusion criteria listed in the Methods section of our article. With regard to the specific patient mentioned, he was offered entry into the study early because the consulting gastroenterologist did not believe that he should wait for an additional 6 hours to allow the 24 hours of conservative therapy otherwise required before study entry. According to our protocol, patients who did not have decompression three hours after infusion of the study drug were offered open-label neostigmine, as was this particular patient, who had a response to open-label treatment. The protocol was designed in this manner specifically to avoid the ethical dilemma described by Pierach.

Finally, as Nicholson points out, it may be a misnomer to use the term “Ogilvie's syndrome” to refer to acute colonic pseudo-obstruction. In his original report of two patients with widespread cancer, Ogilvie called attention to the importance of a balanced autonomic nervous system for maintenance of colonic function. His patients, however, actually presented with chronic symptoms. Ironically, today we would probably not diagnose acute colonic pseudo-obstruction in his two patients.

Robert J. Ponec, M.D.
Michael D. Saunders, M.D.
Michael B. Kimmey, M.D.
University of Washington Medical Center, Seattle, WA 98195

1 References

1. 1

   Stephenson BM, Morgan AR, Drake N, Salaman JR, Wheeler MH. Parasympathomimetic decompression of acute colonic pseudo-obstruction. Lancet 1993;342:1181-1182
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Mark A. Korsten, Alan S. Rosman, Anthony Ng, Erdal Cavusoglu, Ann M. Spungen, Miroslav Radulovic, Jill Wecht, William A. Bauman. (2005) Infusion of Neostigmine-Glycopyrrolate for Bowel Evacuation in Persons with Spinal Cord Injury. The American Journal of Gastroenterology 100:7, 1560-1565
   CrossRef

2. 2

   R. De Giorgio, G. Barbara, V. Stanghellini, M. Tonini, V. Vasina, B. Cola, R. Corinaldesi, G. Biagi, F. De Ponti. (2001) The pharmacological treatment of acute colonic pseudo-obstruction. Alimentary Pharmacology and Therapeutics 15:11, 1717-1727
   CrossRef