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TIPS & EXPERT ADVICE ON ESSAYS, PAPERS & COLLEGE APPLICATIONS

A
74-year-old woman is 2 days status post hip surgery for a fracture after a
fall. Her only

Medication
prior to admission was a calcium supplement, and she has no prior surgical
history. Over the past 24 hours, she has had increasing abdominal discomfort
and distension. She received a dose of cefazolin prior to surgery but no other
antibiotics. On physical examination, she is afebrile with blood pressure of
140/80 mmHg, heart rate of 110 bpm, respiratory rate of 16 breaths/min, and
oxygen saturation of 100% on 2 L of nasal oxygen. She has a distended tympanic
abdomen with absent bowel sounds. There is no rebound tenderness. The
radiograph shows massively dilated colon extending to the rectum with small
bowel air-fluid levels. There is presence of gas in the colon. No
extraintestinal air. Which of the following is the
most likely diagnosis?

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A.
Atropine

B.
Laparotomy

C.
Morphine

D.
Neostigmine

E.
Vancomycin

 

EXPLANATION:

This
radiograph described is consistent with colonic pseudo-obstruction or Ogilvie
syndrome. Ogilvie syndrome may be seen in elderly patients after nonabdominal
surgery or in patients with underlying autonomic dysfunction. The presence of
gas in the colon makes small bowel obstruction unlikely. There is no
extraintestinal air that would be suggestive of small or large bowel
perforation. Small bowel ileus is characterized by multiple small bowel
air-fluid levels on radiograph. The differential for extensive colonic dilation
includes toxic megacolon due to C difficile infection. In this case, that is
less likely given the recent surgery and lack of antibiotic treatment.
Neostigmine is an acetylcholinesterase inhibitor that increases cholinergic
(parasympathetic) activity and can stimulate colonic motility. Some studies
have shown it to be moderately effective in alleviating acute colonic
pseudo-obstruction. It is the most common therapeutic approach and can be used
once it is certain that there is no mechanical obstruction. Cardiac monitoring
is required, and atropine should be immediately available for symptomatic
bradycardia. Intravenous administration induces defecation and flatus within 10
minutes in the majority of patients who will respond. Surgical therapy may be
necessary in cases of bowel perforation or impending perforation. Morphine,
with its anticholinergic side effects, may worsen small or large bowel
pseudo-obstruction. Oral vancomycin is the treatment for C difficile infection.

 

REFERENCE:

https://www.evidence.nhs.uk/Search?ps=30&q=colonic+pseudo+obstruction

 http://www.annalsjournal.com/article/S2049-0801(14)00037-5/abstract

 

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