From the Guidelines
In patients with a distended colon, flexible endoscopy should be performed as the first line of treatment to decompress the colon, as long as there is no suspicion of ischemia or perforation clinically and/or radiologically. This approach is based on the most recent and highest quality study available, which recommends urgent endoscopic detorsion as the initial treatment for sigmoid volvulus, with a success rate of 60-95% and a low morbidity and mortality rate 1.
Key Considerations
- The treatment of a distended colon depends on the underlying cause, but flexible endoscopy is a crucial diagnostic and therapeutic tool in many cases.
- The procedure allows for the assessment of the mucosa to evaluate the viability of the sigmoid colon and the placement of a decompression flatus tube to maintain the reduction and facilitate continued colonic decompression 1.
- After successful endoscopic detorsion, long-term recurrence is a significant concern, with rates ranging from 43% to 75%, and operative intervention should be considered to prevent future episodes of volvulus and its attendant risks 1.
Important Details
- Flexible endoscopy is preferred over rigid endoscopy due to its superior diagnostic performance, particularly in assessing ischemia, and its lower perforation rate 1.
- The literature supports the use of flexible endoscopy, with a large retrospective series demonstrating improved outcomes with the introduction of flexible endoscopic decompression, including higher success rates and lower morbidity and mortality rates 1.
- In cases where advanced mucosal ischemia, perforation, or impending perforation of the colon are discovered during endoscopy, the procedure should be aborted, and emergency colectomy is warranted 1.
From the Research
Treatment Options for Distended Colon
- Endoscopic decompression is an established therapeutic strategy for treating colonic distension, with high clinical success rates 2.
- The technique and position of endoscopic decompression in the therapy sequence differ depending on the medical condition, trigger of colonic distension, and local expertise 2.
- For acute megacolon, treatment options include:
- Toxic megacolon: coordinated intensive medical and surgical management, including vigorous resuscitation, parenteral corticosteroids, broad-spectrum antibiotics, and close monitoring 3.
- Ogilvie's syndrome: supportive therapy, including nasogastric suction, correction of fluid and electrolyte imbalances, stopping potentially aggravating medications, and decompressing the colon with a rectal tube and positional changes 3.
- For chronic megacolon, goals of therapy are to cleanse the colon, prevent impaction, and minimize stool volume and gas buildup, with options including surgical exclusion of the colon, decompression and antegrade enemas via cecostomy, or subtotal or segmental resection 3.
- Nasogastric tube decompression may not be necessary for all patients with small bowel obstruction, and its use has been associated with increased risk of pneumonia and respiratory failure, as well as longer time to resolution and hospital length of stay 4.
Specific Therapies
- Intravenous neostigmine is a pharmacologic agent with proven efficacy for treating Ogilvie's syndrome 3.
- Colonoscopic decompression is an alternative for patients who do not respond to neostigmine or have conditions that contraindicate its use 3.
- Daily oral administration of polyethylene glycol electrolyte solutions may decrease the relapse rate after initial decompression is achieved 3.
- Administration of Gastroview (GV) via nasogastric tube has diagnostic and therapeutic value for adhesive small bowel obstruction, and can facilitate early recognition of complete obstruction 5.