Acute Colonic Pseudo-Obstruction (ACPO): An Expanding Colon with Unusual Risk Factors

The distention of the colon without mechanical or anatomical obstruction, Acute Colonic Pseudo-obstruction (ACPO), is a common condition occurring in the critically ill. ACPO in the setting of an acute pulmonary embolism and embolic stroke is a rarity. A 76-year-old female with shortness of breath, left hemiparesis and right-sided paresthesias presented with acute pulmonary embolism and acute infarcts of the left caudate nucleus, thalamus and occipital lobe. Her hospitalization was complicated with persistent distention of the large bowel without dilation of the small bowel. Empiric antibiotics were initiated without improvement and laboratory studies including Clostridium difficile were negative. She underwent nasogastric decompression and two decompressive colonoscopies with a resolution of her symptoms. This case illustrates an example of acute abdominal distension, without underlying etiology, in the setting of acute embolism of the pulmonary and cerebral vasculature. Early identification and action with decompressive colonoscopy were key to preventing further bowel damage or rupture.

Acute colonic pseudo-obstruction: A systematic review of aetiology and mechanisms

To critically review the literature addressing the definition, epidemiology, aetiology and pathophysiology of acute colonic pseudo-obstruction (ACPO). METHODSA systematic search was performed to identify articles investigating the aetiology and pathophysiology of ACPO. A narrative synthesis of the evidence was undertaken. RESULTSNo consistent approach to the definition or reporting of ACPO has been developed, which has led to overlapping investigation with other conditions. A vast array of risk factors has been identified, supporting a multifactorial aetiology. The pathophysiological mechanisms remain unclear, but are likely related to altered autonomic regulation of colonic motility, in the setting of other predisposing factors. CONCLUSIONFuture research should aim to establish a clear and consistent definition of ACPO, and elucidate the pathophysiological mechanisms leading to altered colonic function. An improved understanding of the aetiology of ACPO may facilitate the development of targeted strategies for its prevention and treatment.

Chronic intestinal pseudo-obstruction

Chronic intestinal pseudo-obstruction (CIPO) is a se- vere digestive syndrome characterized by derangement of gut propulsive motility which resembles mechanical obstruction, in the absence of any obstructive process. Although uncommon in clinical practice, this syndrome represents one of the main causes of intestinal failure and is characterized by high morbidity and mortality. It may be idiopathic or secondary to a variety of diseases. Most cases are sporadic, even though familial forms with either dominant or recessive autosomal inheritance have been described. Based on histological features in- testinal pseudo-obstruction can be classified into three main categories:neuropathies, mesenchymopathies, and myopathies, according on the predominant involvement of enteric neurones, interstitial cells of Cajal or smooth muscle cells, respectively. Treatment of intestinal pseu- do-obstruction involves nutritional, pharmacological and surgical therapies, but it is often unsatisfactory and the long-term outcome is generally poor in the majority of cases.

Intestinal pseudo-obstruction in patients with systemic lupus erythematosus: A real diagnostic challenge

Intestinal pseudo-obstruction secondary to systemic lupus erythematosus(SLE) is a rare syndrome described in recent decades. There are slightly over 30 published cases in the English language literature, primarily associated with renal and hematological disease activity. Its presentation and evolution are a diagnostic challenge for the clinician. We present four cases of intestinal pseudo-obstruction due to lupus in young Mexican females. One patient had a previous diagnosis of SLE and all presented with a urinary tract infection of varying degrees of severity during their evolution. We consider that recognition of the disease is of vital importance because it allows for establishing appropriate management, leading to a better prognosis and avoiding unnecessary surgery and complications.

Severe delayed complication after percutaneous endoscopic colostomy for chronic intestinal pseudo-obstruction: A case report and review of the literature

Percutaneous endoscopic colostomy （PEC） is increasingly proposed as an alternative to surgery to treat various disorders, including acute colonic pseudo-obstruction, chronic intestinal pseudo-obstruction and relapsing sigmoid volvulus. We report on a severe complication that occurred two months after PEC placement. A 74-year-old man with a history of chronic intestinal pseudo-obstruction evolving since 8 years was readmitted to our hospital and received PEC to provide long-standing relief. The procedure was uneventful and greatly improved the patient＇s quality of life. Two months later, the patient developed acute stercoral peritonitis. At laparotomy, the colostomy flange was embedded in the abdominal wall but no pressure necrosis was found at the level of the colonic wall. This complication was likely related to inadvertent traction of the colostomy tube. Subtotal colectomy with terminal ileostomy was performed. We review the major features of 60 cases of PEC reported to date, including indications and complications.

Intestinal pseudo-obstruction caused by herpes zoster:Case report and pathophysiology

Herpes zoster(HZ) infection occurs in approximately 10% to 30% of individuals. Visceral neuropathies secondary to HZ can cause cystitis and urinary retention. But colonic pseudo-obstruction can also occur. Peripheral neuropathy may reveal segmental motor paresis of either upper or lower limbs, the abdominal muscles or the diaphragm. We report the case of a 62-year-old male patient who presented with abdominal distention and cutaneous vesicular eruption on the left side of the abdominal wall. Plain X-rays and computed tomography scan showed distended small bowel. A diagnosis of intestinal pseudo-obstruction was made secondary to segmental paresis of the small intestine and visceral neuropathy. Conservative management was successful and the patient was discharged uneventfully. Intestinal pseudo-obstruction ought to be consideredwhen dealing with non-obstructive(adynamic) conditions of the digestive tract associated with HZ infection; since early recognition may help to avoid unnecessary surgery.

Latest developments in chronic intestinal pseudo-obstruction

Chronic intestinal pseudo-obstruction(CIPO)is a type of intestinal dysfunction presenting as symptoms of intestinal obstruction but without actual mechanical obstruction.An extremely low incidence,non-specific clinical symptoms,strong heterogeneity,and no definitive cause in some patients make CIPO very difficult to diagnose correctly.Imaging and gastrointestinal manometry are commonly used.Most patients have progressive worsening of their symptoms and require intervention,and nutritional assessment and treatment are very important to determine the prognosis.With improvements in surgical techniques,small bowel transplantation is a feasible treatment option for patients with advanced CIPO;however,the long-term prognosis for CIPO patients remains unsatisfactory.Generally,the disease is rare and difficult to diagnose,which leads to clinicians’lack of understanding of the disease and results in a high rate of misdiagnosis.This review describes the characteristics of CIPO and the latest developments in diagnosis and treatment,in detail.The goal of our review is to improve clinicians'understanding of CIPO so that the disease is identified quickly and accurately,and treated as early as possible to improve patients’quality of life.

Intestinal pseudo-obstruction in inactive systemic lupus erythematosus: An unusual finding

Chronic intestinal pseudo-obstruction (CIP) is an infre-quent complication of an active systemic lupus erythema-tosus (SLE). We illustrate a case of SLE inactive-related CIP. A 51-year old female with inactive SLE (ECLAM score 2) was hospitalized with postprandial fullness, vomiting, abdominal bloating and abdominal pain. She had had no bowel movements for five days. Plain abdominal X-ray revealed multiple fluid levels and dilated small and large bowel loops with air-fluid levels. Intestinal contrast radiology detected dilated loops. CIP was diagnosed. The patient was treated with prokinetics, octreotide, claritromycin, rifaximin, azathioprine and tegaserod without any clinical improvement. Then methylprednisolone (500 mg iv daily) was started. After the first administration, the patient showed peristaltic movements. A bowel movement was reported after the second administration. A plain abdominal X-ray revealed no air-fluid levels. Steroid therapy was slowly reduced with complete resolution of the symptoms. The patient is still in a good clinical condition. SLE-related CIP is generally reported as a complication of an active disease. In our case, CIP was the only clinical demonstration of the SLE.

Abnormal layering of muscularis propria as a cause of chronic intestinal pseudo-obstruction:A case report and literature review

Visceral myopathy is one of the causes of chronic intestinal pseudo-obstruction. Most cases pathologically reveal degenerative changes of myocytes or muscularis propia atrophy and fibrosis. Abnormal layering of muscularis propria is extremely rare. We report a case of a 9-mo-old Thai male baby who presented with chronic intestinal pseudo-obstruction. Histologic findings showed abnormal layering of small intestinal muscularis propria with an additional oblique layer and aberrant muscularization in serosa. The patient also had a short small bowel without malrotation, brachydactyly,and absence of the 2nd to 4th middle phalanges of both hands. The patient was treated with cisapride and combined parenteral and enteral nutritional support.He had gradual clinical improvement and gained body weight. Subsequently, the parenteral nutrition was discontinued. The previously reported cases are reviewed and discussed.

Resolution of herpes zoster-induced small bowel pseudo-obstruction by epidural nerve block:A case report

BACKGROUND When herpes zoster is complicated with paralytic ileus,this mostly involves acute intestinal pseudo-obstruction of Ogilvie’s syndrome manifesting as obvious dilatation of the cecum and right colon;small intestinal obstruction is rare.Here,we present a patient with a very rare case of small bowel pseudo-obstruction.CASE SUMMARY A 76-year-old female patient complained of right upper quadrant pain.Two days later,a blistering,right-sided rash of the thoracoabdominal dermatome(T5-T10) emerged in conjunction with small intestinal dilatation and the inability to defecate.Computed tomography of the abdomen confirmed small bowel pseudoobstruction.Antiviral therapy,gastrointestinal decompression,and enemas proved unproductive.After 4 d of stagnation,an epidural block was performed for pain relief and prompted the passage of gas and stool,resolving the obstructive problem.Three days later,the rash appeared dry and crusted,and the pain diminished.After 5 d,no abnormality was visible by gastroenteroscopy,and the patient was discharged on day 7.CONCLUSION This case shows that herpes zoster may induce small bowel pseudo-obstruction in addition to colonic pseudo-obstruction.Epidural block can not only treat intercostal neuralgia but also resolve small bowel pseudo-obstruction caused by herpes zoster.

Intestinal pseudo-obstruction:An uncommon condition with heterogeneous etiology and unpredictable outcome

Intestinal pseudo-obstruction (IPO) either acute or chronic is a condition including features of intestinal ileus in absence of mechanical obstruction. Our paper presents such a rare case of idiopathic IPO in a 53-year-old male patient with recurrent episodes of pseudo-obstruction, which were successfully resolved by anticholinesterase agents, motilin agonists or colonic decompression. However, the patient finally underwent total colectomy. Huge colonic dilatation was identified intraoperatorily, while histology showed a neuropathic variant of chronic intestinal pseudo-obstruction. Etiologic mechanisms and current therapeutic methods are reviewed in this paper, which concludes that IPO is a condition in which conservative treatment usually fails. Total colectomy with ileoanal pouch may be the only solution in these situations.

characteristics of intestinal pseudo-obstruction in patients with mitochondrial diseases

AIM: To reveal the frequency, characteristics and prognosis of chronic intestinal pseudo-obstruction (CIP) in mitochondrial disease patients. METHODS: Between January 2000 and December 2010, 31 patients (13 males and 18 females) were di-agnosed with mitochondrial diseases at our hospital. We conducted a retrospective review of the patients' sex, subclass of mitochondrial disease, age at onset of mitochondrial disease, frequency of CIP and the age at its onset, and the duration of survival. The age at onset or at the first diagnosis of the disorder that led to the clinical suspicion of mitochondrial disease was also examined. RESULTS: Twenty patients were sub-classified with mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS), 8 with chronic progressive external ophthalmoplegia (CPEO), and 3 with myoclonus epilepsy associated with ragged-red fibers (MERRF). Nine patients were diagnosed with CIP, 8 of the 20 (40.0%) patients with MELAS, 0 of the 8 (0.0%) patients with CPEO, and 1 of the 3 (33.3%) patients with MERRF. The median age (range) at the diagnosis and the median age at onset of mitochondrial disease were 40 (17-69) and 25 (12-63) years in patients with CIP, and 49 (17-81) and 40 (11-71) years in patients without CIP. During the survey period, 5 patients (4 patients with MELAS and 1 with CPEO) died. The cause of death was cardiomyopathy in 2 patients with MELAS, cerebral infarction in 1 patient with MELAS, epilepsy and aspiration pneumonia in 1 patient with MELAS, and multiple metastases from gastric cancer and aspiration pneumonia in 1 patient with CPEO. CONCLUSION: Patients with CIP tend to have disorders that are suspected to be related to mitochondrial diseases at younger ages than are patients without CIP.

Pseudopneumoperitoneum in chronic intestinal pseudo-obstruction:A case report

Chronic intestinal pseudo-obstruction(CIPO) is a rare disease due to a severe gastrointestinal motility disorder which may mimic,on both clinical and radiological grounds,mechanical obstruction.We report a case of a 26-year-old woman who presented to our institution for plain abdominal radiography for referred long-lasting constipation with recurrent episodes of abdominal pain and distension.At X-ray,performed both in the upright and supine position,an isolated air-fluid level was depicted in the left flank,together with a number of radiological signs suggestive of pneumoperitoneum.First,subphrenic radiolucency could be observed in the upright film.Second,the intestinal wall of some jejunal loops appeared to be outlined in the right flank.Third,the inferior cardiac border was clearly depicted in the upright film.The patient however had no evidence ofperitoneal signs but only hypoactive bowel movements.Unenhanced multi-detector computed tomography(MDCT) of the abdomen and pelvis was therefore performed.MDCT revealed abnormal air-driven distension of the small and large bowel,without evidence of extraluminal air.All radiological signs of pneumoperitoneum turned out to be false-positive results.The patient was submitted to pan-colonoscopy and to anorectal manometry to rule out Hirshprung's disease,and was finally discharged with a diagnosis of CIPO.

Jejunal diverticulosis found in a patient with long-standing pneumoperitoneum and pseudo-obstruction on imaging:a case report

Small bowel diverticulosis is a rare finding within the general population and jejunal diverticulosis,specifically,is even rarer.Clinical manifestations can range from post-prandial pain,constipation and malabsorption to serious complications,such as gastro-intestinal hemorrhage,perforation and acute intestinal obstruction.Here we describe the case of an 81-yearold gentleman who presented with a three-year history of abdominal pain and weight loss.Despite unremarkable physical examination and laboratory tests,persistent pneumoperitoneum and dilated loops of small bowel were found on imaging.Having been given a diagnosis of small bowel bacterial overgrowth,the patient underwent capsule endoscopy study for further evaluation of his small bowel.The capsule did not reach the colon and the patient never noted passing the capsule in his stool so,six months post-procedure,a computed tomography(CT)scan seemed to reveal the retained capsule.Subsequent exploratory laparotomy revealed 200 cm of atonic,dilated jejunum with impressive diverticula along the antimesenteric border.This case report is an example of an unusual set of presenting signs and symptoms of jejunal diverticulosis,including persistent pneumoperitoneum,pseudo-obstruction and small bowel bacterial overgrowth.A literature review has revealed that these signs have been present in other cases of jejunal diverticulosis,although the etiology and pathophysiology is not clearly understood.

Bowel function and inflammation: Is motility the other side of the coin?

Digestion and intestinal absorption allow the body to sustain itself and are the emblematic functions of the bowel.On the flip side,functions also arise from its role as an interface with the environment.Indeed,the gut houses microorganisms,collectively known as the gut microbiota,which interact with the host,and is the site of complex immune activities.Its role in human pathology is complex and scientific evidence is progressively elucidating the functions of the gut,especially regarding the pathogenesis of chronic intestinal diseases and inflammatory conditions affecting various organs and systems.This editorial aims to highlight and relate the factors involved in the pathogenesis of intestinal and systemic inflammation.

Gastrointestinal motility and absorptive disorders in patients with inflammatory bowel diseases: Prevalence, diagnosis and treatment

Inflammatory bowel diseases(IBD),Crohns disease and ulcerative colitis,are chronic conditions associated with high morbidity and healthcare costs.The natural history of IBD is variable and marked by alternating periods of flare and remission.Even though the use of newer therapeutic targets has been associated with higher rates of mucosal healing,a great proportion of IBD patients remain symptomatic despite effective control of inflammation.These symptoms may include but not limited to abdominal pain,dyspepsia,diarrhea,urgency,fecal incontinence,constipation or bloating.In this setting,commonly there is an overlap with gastrointestinal(GI)motility and absorptive disorders.Early recognition of these conditions greatly improves patient care and may decrease the risk of mistreatment.Therefore,in this review we describe the prevalence,diagnosis and treatment of GI motility and absorptive disorders that commonly affect patients with IBD.

Enteric neuropathology of congenital intestinal obstruction:A case report

Experimental evidence indicates that chronic mechanical sub-occlusion of the intestine may damage the enteric nervous system （ENS）, although data in humans are lacking. We here describe the first case of enteric degenerative neuropathy related to a congenital obstruction of the gut. A 3-year and 9-mo old girl began to complain of vomiting, abdominal distension, constipation with air-fluid levels at plane abdominal radiology. Her subsequent medical history was characterized by 3 operations： the first showed dilated duodeno-jejunal loops in the absence of occlusive lesions; the second （2 years later） was performed to obtain full-thickness biopsies of the dilated intestinal loops and revealed hyperganglionosis at histopathology; the third （9 years after the hyperganglionosis was identified） disclosed a Ladd＇s band which was removed and the associated gut malrotation was corrected. Repeated intraoperative full-thickness biopsies showed enteric degenerative neuropathy along with reduced interstitial cells of Cajal network in dilated loops above the obstruction and a normal neuromuscular layer below the Ladd＇s band. One year after the latest surgery the patient tolerated oral feeding and did well, suggesting that congenital （partial） mechanical obstruction of the small bowel in humans can evoke progressive adaptive changes of the ENS which are similar to those found in animal models of intestinal mechanical occlusion. Such ENS changes mimic neuronal abnormalities observed in intestinal pseudoobstruction.

Acupuncture for Treating Postoperative Enteroparalysis

Postoperative enteroparalysis refers to dysfunction of the intestinal tract after abdominal surgery, which is manifested by abdominal distension, failure of aerofluxus from the anus etc.

A case report of abdominal distention caused by herpes zoster

Gastrointestinal complications caused by herpes zoster are extremely rare. Here, we described a case of abdominal distention caused by herpes zoster. The patient was a 59-year-old female who suffered from unexplained paroxysmal and a burning pain on the right part of her waist and abdomen, accompanied by abdominal distention. Intestinal pseudo-obstruction was diagnosed by abdominal radiography. Distention of the right abdominal wall was still apparent after one month. In this report, we found that recovery from abdominal distention caused by herpes zoster is difficult and may require surgical intervention.

New techniques in the tissue diagnosis of gastrointestinal neuromuscular diseases

Gastrointestinal neuromuscular diseases are a clinically heterogeneous group of disorders of children and adults in which symptoms are presumed or proven to arise as a result of neuromuscular (including interstitial cell of Cajal) dysfunction. Common to most of these diseases are symptoms of impaired motor activity which manifest as slowed or obstructed transit with or without evidence of transient or persistent radiological visceral dilatation. A variety of histopathological techniques and allied investigations are being increasingly applied to tissue biopsies from such patients. This review outlines some of the more recent advances in this fi eld, particularly in the most contentious area of small bowel disease manifesting as intestinal pseudo-obstruction.