What is the best course of action for a 65-year-old gentleman with post-operative ileus (intestinal obstruction), abdominal distension, and hypokalemia (low potassium), who has undergone recent hip fracture repair and has a medical history of Parkinson's disease, dementia, and type 2 diabetes mellitus, and is currently afebrile with no rebound tenderness?

From the Research

I recommend a trial of intravenous neostigmine for this patient. The clinical presentation strongly suggests acute colonic pseudo-obstruction (Ogilvie's syndrome), characterized by massive colonic dilation without mechanical obstruction. The patient's risk factors include recent hip surgery, immobility, electrolyte abnormalities (hypokalemia and hypomagnesemia), and medications that decrease gut motility. With a cecal diameter of 12 cm and worsening distension despite 40 hours of conservative management (NPO status, avoiding narcotics, electrolyte repletion), the risk of perforation is increasing. Neostigmine, a cholinesterase inhibitor, increases acetylcholine at the neuromuscular junction, stimulating colonic motility and often providing rapid decompression. The typical dose is 2 mg IV administered over 3-5 minutes with continuous cardiac monitoring due to potential bradycardia, as supported by the study by 1. If successful, the patient should experience rapid passage of flatus and stool with reduction in abdominal distension. Conservative management has already failed, and the increasing cecal diameter makes colonoscopic decompression or surgery higher risk interventions that should be reserved if neostigmine fails or is contraindicated.

Some key points to consider in this case include:

• The patient's clinical presentation and risk factors, which suggest a high likelihood of acute colonic pseudo-obstruction
• The failure of conservative management, which increases the risk of perforation and necessitates further intervention
• The potential benefits and risks of neostigmine, including its efficacy in stimulating colonic motility and the risk of bradycardia, as noted in the study by 2
• The importance of continuous cardiac monitoring during neostigmine administration, as highlighted in the study by 3
• The potential for neostigmine to reduce the need for more invasive interventions, such as colonoscopic decompression or surgery, as suggested by the study by 1.

Overall, the use of intravenous neostigmine in this patient is supported by the most recent and highest quality evidence, including the study by 1, which demonstrated its efficacy and safety in the treatment of acute colonic pseudo-obstruction.