UNASSIGNED: Pneumoperitoneum is a well-known consequence of gastrointestinal perforations but can also be a consequence of medical diseases such as asthma exacerbations or interventions such as mechanical ventilation. Tension pneumoperitoneum is a rare, life-threatening form of large volume pneumoperitoneum that can cause cardiovascular and respiratory compromise due to increased intra-abdominal pressure.
METHODS: We present a case report where an 86-year-old male was diagnosed with large volume pneumoperitoneum with compression of the inferior vena cava and intra-abdominal hollow and solid organs due to a suspected splenic flexure perforation in the setting of an acute colonic pseudo-obstruction that was able to be successfully managed solely with bedside needle decompression.
UNASSIGNED: Large volume pneumoperitoneum and tension physiology requires early diagnosis and prompt intervention. Patients are often critically ill and require major abdominal surgery if secondary to gastrointestinal perforation.
CONCLUSIONS: Select patients and clinical presentations of tension pneumoperitoneum can be managed successfully with bedside needle decompression if diagnosis and intervention is prompt.

Several gastrointestinal complications have been reported in patients with COVID-19, including motility disorders, such as acute colonic pseudo-obstruction (ACPO). This affection is characterized by colonic distention in the absence of mechanical obstruction. ACPO in the context of severe COVID-19 may be related to neurotropism and direct damage of SARS-CoV-2 in enterocytes.
We conducted a retrospective study of patients who were hospitalized for critical COVID-19 and developed ACPO between March 2020 and September 2021. The diagnostic criteria to define ACPO was the presence of 2 or more of the following: abdominal distension, abdominal pain, and changes in the bowel movements, associated with distension of the colon in computed tomography. Data of sex, age, past medical history, treatment, and outcomes were collected.
Five patients were detected. All required admission to the Intensive Care Unit. The ACPO syndrome developed with a mean of 33.8 days from the onset of symptoms. The mean duration of the ACPO syndrome was 24.6 days. The treatment included colonic decompression with placement of rectal and nasogastric tubes, endoscopy decompression in two patients, bowel rest, fluid, and electrolytes replacement. One patient died. The remaining resolved the gastrointestinal symptoms without surgery.
ACPO is an infrequent complication in patients with COVID-19. It occurs especially in patients with critical condition, who require prolonged stays in intensive care and multiple pharmacological treatments. It is important to recognize its presence early and thus establish an appropriate treatment, since the risk of complications is high.

Neostigmine (NEO) and decompressive colonoscopy (COL) are two efficacious treatment modalities for acute colonic pseudo-obstruction (ACPO). We hypothesize that a COL first strategy is associated with better outcomes compared to a NEO first strategy.
A single-center retrospective analysis was performed from 2013 to 2020. Patients ≥18 y with a diagnosis of ACPO were included. The outcome was a composite measure of acute operative intervention, 30-day readmission with ACPO, and 30-day ACPO-related mortality. A P-value of ≤ 0.05 indicated statistical significance.
Of 910 encounters in 849 patients, 50 (5.5%) episodes of ACPO in 39 patients were identified after exclusion of one patient with colon perforation on presentation. The median (interquartile range) age was 68 (62-84) y. NEO and COL were administered in 21 and 25 episodes, respectively. In 16 (32%) episodes, no NEO or COL was administered. When patients were given NEO first, COL or additional NEO was required in 12/18 (67%) compared with a COL first strategy where a second COL and/or NEO was given in 5/16 (32%) (P = 0.05). Both strategies had similar outcomes (NEO, 4/18 versus COL, 4/16, P = 0.85). Twenty-two (44%) episodes had an early intervention (≤48 h) with NEO and/or COL. There was no difference in outcome between those that received an early intervention and those who did not (5/22 versus 5/28, P = 0.71).
For patients failing conservative measures, a COL first approach was associated with fewer subsequent interventions, but with similar composite outcomes compared to a NEO first approach. Early (≤48 h) intervention with NEO and/or COL was not associated with improved outcomes.

Acute colonic pseudo-obstruction (ACPO) is a functional disorder of the large intestine distinguished by colonic dysmotility resulting in colonic distension in the absence of mechanical obstruction. The underlying pathophysiology of ACPO remains unclear despite technological advances in understanding the physiology of colonic motility, such as spatio-temporal mapping and high-resolution manometry. In many ways, the management of ACPO has remained relatively unchanged for 40 years. Patients with perforation or suspected ischemia undergo operative intervention, while patients without undergo initial conservative management with bowel rest, correction of electrolyte disturbances, and mobilization. Patients who fail conservative management or have prominent cecal dilatation undergo decompression with either neostigmine or colonoscopy. A subset of patients with ACPO will have recurrent symptoms despite endoscopic and medical management. For these patients who are difficult to manage, an underlying colonic functional disorder, such as slow-transit dysmotility or chronic intestinal pseudo-obstruction may be considered. The following review of ACPO aims to provide a concise update of the causes, diagnosis, and management of this emergency surgical condition.

Acute colonic pseudo-obstruction (ACPO) is a severe form of colonic dysmotility and is associated with considerable morbidity. The pathophysiology of ACPO is considered to be multifactorial but has not been clarified. Although colonic motility is commonly assumed to be hypoactive, there is little direct pathophysiological evidence to support this claim.
A 56-year-old woman who developed ACPO following spinal surgery underwent 24 h of continuous high-resolution colonic manometry (1 cm resolution over 36 cm) following endoscopic decompression. Manometry data were analyzed and correlated with a three-dimensional colonic model developed from computed tomography (CT) imaging.
The distal colon was found to be profoundly hyperactive, showing near-continuous non-propagating motor activity. Dominant frequencies at 2-6 and 8-12 cycles per minute were observed. The activity was often dissociated and out-of-phase across adjacent regions. The mean amplitude of motor activity was higher than that reported from pre- and post-prandial healthy controls. Correlation with CT imaging suggested that these disordered hyperactive motility sequences might act as a functional pseudo-obstruction in the distal colon resulting in secondary proximal dilatation.
This is the first detailed description of motility patterns in ACPO and suggests a novel underlying disease mechanism, warranting further investigation and identification of potential therapeutic targets.

OBJECTIVE: Corticobasal syndrome (CBS) is one of an atypical parkinsonian syndromes characterized by extrapyramidal features as well as cortical involvement signs. A variety of factors may lead to delirium in older adults with chronic progressive life-limiting neurological illnesses like CBS. Ogilvie\'s syndrome (OS) is an acute colonic pseudo-obstruction in which abdominal distension, nausea, vomiting, and constipation can be seen. We report a case of OS identified as the underlying possible cause of delirium in an 80-year-old woman with CBS. We also discuss the importance of holistic approach which is essential to manage the underlying cause and to preserve the quality of life in particular for the frail geriatric population who potentially needs palliative care or already benefits from palliative care.
METHODS: An older patient with CBS presented with symptoms similar to that of acute colonic obstruction and subsequently developed delirium. The patient was found to have colonic pseudo-obstruction (OS).
RESULTS: Neostigmin infusion was therefore given to treat it and delirium was resolved.
CONCLUSIONS: To the best of our knowledge, clinical manifestation of delirium as OS in a patient with CBS has not been previously reported. OS may be superimposed to CBS in older patients, and OS in such patients may play a role as a precipitating factor for the development of delirium. Given the fact that CBS is progressive and rare neurodegenerative disease and almost all of these patients need palliative care, eventually, health-care professionals, especially in palliative care, should be aware of distinctive challenges of life-limiting chronic neurological illnesses, such as conditions that may lead to the development of acute colonic pseudo-obstruction because the rapid treatment of them prevents the use of potentially harmful drugs, surgical procedures, or inappropriate interventions.

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Intravenous neostigmine is a well-established treatment for acute colonic pseudo-obstruction (ACPO). Its use is hampered by the perceived requirement for continuous cardiac monitoring, and patients are often transferred to high-dependency units for close observation during treatment. Subcutaneous neostigmine has the potential to minimize adverse cardiovascular effects while maintaining efficacy. This study aims to assess the safety of subcutaneous neostigmine on ward inpatients with ACPO monitored with standard nursing care.
This is a retrospective case series of 30 patients with ACPO who were treated with subcutaneous neostigmine between August 2008 and October 2012. Data were collected prospectively. All patients were diagnosed using clinical examination and radiology and were assessed for contraindications to neostigmine. Patients were treated on regular wards and monitored with standard nursing observations. The main outcomes were time to flatus and bowels working and complications.
No serious complications such as clinically evident bradycardia were encountered. Ninety-three percent of patients had clinically successful resolution of ACPO. Two patients (7%) developed caecal tenderness and proceeded to colonoscopic decompression, which was successful in both instances.
Subcutaneous neostigmine appears to be safe for the treatment of ACPO. No clinically evident serious adverse events occurred, meaning continuous cardiac monitoring as a routine may not be necessary. In our cohort, we achieved similar success rates compared with reported rates using intravenous neostigmine.

Acute colonic pseudo-obstruction (ACPO), also known as Ogilvie\'s syndrome, is defined by poor peristaltic activity of the colon that mimics mechanical obstruction in the absence of any mechanical occlusive gut lesion. This case report is the first to be published on ACPO occurring after robotic-assisted radical hysterectomy. Given that robotic-assisted laparoscopic surgery has become the next major stage of advancement for a range of operations, especially in gynecologic oncology surgery, this report emphasizes the importance of recognizing precipitating factors associated with this syndrome, including minimally invasive surgery.

BACKGROUND: Ogilvie\'s Syndrome or Acute Colonic Pseudo-Obstruction (ACPO) is a rare condition characterized by massive dilatation of the colon in the absence of mechanical obstruction. About 10% of all reported cases are related to Obstetric and Gynaecological procedures, Caesarean section being the commonest associated factor. Acute intestinal dilatation, if not treated, may lead to perforation and faecal peritonitis with consequent high morbidity and mortality.
METHODS: An electronic literature searches were performed in PubMed, EMBASE, Google scholar and hand searches for relevant references were included without any language restriction. All the records reported after year 2002 were included for the full review. We analyzed the quality of the reports and the data was further analyzed for their respective risk factors, clinical features, management methods, morbidity and mortality.
RESULTS: The results from our searches included a total of 125 cases of postpartum ACPO. A total of 66 cases were reported in 37 publications after year 2002. Details of delivery were recorded in 13(19%), clinical manifestations in 49(69%), imaging results in 43(65%) and management described in 100% of the cases. Although 62(92%) cases were following caesarean section, no specific antepartum or intrapartum factors were associated with ACPO. The caesarean sections performed for indications of preeclampsia, multiple pregnancy, antepartum haemorrhage/placenta previa were more in this group of patients who developed ACPO compared to caesarean sections performed for same indication in general population of England and Wales. Abdominal distension and pain were the commonest symptoms, followed by vomiting. Fever was common in patients with perforation. Twenty eight (43%) patients had intestinal perforation or impending perforation, and 31(47%) patients required laparotomy. Conservative management was successful in 33(50%) patients. All patients with a caecal diameter of more than 12cm perforated compared to 3/17 with a diameter of less than 9cm. Most perforations were diagnosed between postoperative day 3 and day 5. Only one case of mortality has been recorded (1.5%).
CONCLUSIONS: No specific risk factors could be identified for postpartum ACPO. A postpartum patient with abdominal distension and pain should have appropriate imaging to rule out colonic dilatation and/or perforation. Perforation may occur with a caecal diameter of less than 9cm but it is more likely if the diameter exceeded 12cm. The mortality risk appears to be low in the postpartum group compared to other patients with ACPO. There is a need for establishing national level databases to capture all the relevant data in a consistent manner, to understand this rare disease process.