Info
Management of Intestinal Pseudo-obstruction
- Conservative management for 48-72 hours is the preferred initial management if cecal diameter is < 12 cm and there are no signs of ischemia, perforation, or peritonitis (Strong recommendation) which includes:
- nothing by mouth
- intravenous hydration and/or correction of fluid and electrolyte imbalances
- discontinuation of narcotic, sedative, calcium-channel blocker, or anticholinergic medications
- placement of nasogastric tube for proximal intestinal decompression
- aggressive use of body positioning and ambulation
- placement of rectal tube (with or without use of limited tap water enemas)
- With conservative management, monitor the patient every 12-24 hours for electrolytes, leukocyte count, and cecal diameter (with supine and dependent abdominal x-ray) and treat any emergent complications.
- Give neostigmine 2 mg IV over 3-5 minutes (with cardiac monitoring) in patients with intestinal psuedo-obstruction who have failed conservative therapy, are at risk for perforation, and have no contraindications (Strong recommendation).
- Consider octreotide to stimulate motility, but may worsen gastroparesis.
- In patients with contraindications to neostigmine and those failing other medical management (prokinetics or octreotide), consider colonoscopy with decompression tube placement (Weak recommendation).
- Consider prokinetic agents, such as metoclopramide, erythromycin, or prucalopride, but they are not clearly shown to be beneficial and their use is limited by adverse effects and drug interactions.
- In patients with SIBO, consider rifaximin 550 mg 3 times daily for 14 days.
- Surgery should be used in patients with overt perforation or signs of peritonitis (Strong recommendation).
- For patients unresponsive to maximal pharmacological and endoscopic therapy but also considered unfit for surgery, consider percutaneous endoscopic colostomy of the cecum as an alternate method of decompression.
- Consider venting/feeding gastrostomy and/or jejunostomy patients with chronic intestinal pseudo-obstruction, or isolated small bowel or multivisceral transplantation in patients who develop life threatening total parenteral nutrition (TPN)-associated complications such as intestinal failure associated liver disease.