New ASGE Guideline on Endoscopy and Management of ACPO and Colonic Volvulus
Douglas K. Rex, MD, FASGE reviewing Naveed M, et al. Gastrointest Endosc 2019 Nov 29.
Some of the key and/or interesting findings in the new American Society for Gastrointestinal Endoscopy guideline on management of volvulus and acute colonic pseudo-obstruction (ACPO) are:
- Endoscopy with a decompression tube, if possible, is still a first-line treatment for uncomplicated sigmoid volvulus, but surgical consultation should be obtained in the index admission because of high recurrence rates.
- Cecal volvulus should be managed surgically from the outset, as there is a high risk of perforation with endoscopy.
- In uncomplicated ACPO, conservative therapy (eg, withdrawing offending drugs, correcting underlying risk factors) is appropriate for 48 to 72 hours, with administration of neostigmine to those without a contraindication (2 mg over 3-5 minutes) in a monitored setting and a second dose if the first dose fails.
- Several studies suggest that continuous infusion of neostigmine by subcutaneous or intravenous routes may be superior to the usual bolus methods.
- Patients who failed neostigmine therapy should undergo colonoscopic decompression by an expert endoscopist, using nonopioid sedation, carbon dioxide, and decompression tube placement.
COMMENT
This is an informative and useful set of recommendations, though the paper suggests that uncomplicated ACPO includes a cecal diameter <12 cm, while much of the literature actually suggests that a diameter ≥12 cm defines ACPO, and that many patients with larger diameters can be successfully treated by nonsurgical approaches, including the usual sequence of pharmacologic therapy and colonoscopic decompression.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
Douglas K. Rex, MD, FASGE
CITATION(S)
Naveed M, Jamil LH, Fujii-Lau LL, et al. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus. Gastrointest Endosc 2019 Nov 29. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2019.09.007)
