From the 2024 HVPA National Conference
Timothy Graziano DO (Lehigh Valley Health Network Department of Medicine), Tinsa Varughese DO, Kathryn Zaffiri MPH, Amy Slenker MD, Shashin Shah MD, Travis Magdaleno DO
Acute colonic pseudo-obstruction (ACPO) is a functional motility disorder defined by marked dilation of the colon. Also termed Ogilvie’s syndrome, mechanical obstruction is characteristically absent. Its annual incidence is approximately 100 per 100,000 admissions. Clinical practice guidelines published by the American Society for Gastrointestinal Endoscopy recommend that uncomplicated cases be treated with conservative measures for the first 48 to 72 hours. This initial approach includes supportive care, nil per os (NPO) status, electrolyte correction, and nasogastric decompression. In refractory cases, pharmacologic management with the anticholinesterase parasympathomimetic neostigmine is recommended. This agent effectively decreases resolution time but can also precipitate serious adverse events, including bronchospasm and bradycardia. It is imperative, therefore, to ensure that ACPO cases are managed appropriately to avoid unnecessary risks of advanced therapies.
This Quality Assessment sought to (1) quantify the incidence of complicated ACPO throughout one 900-bed community hospital and three smaller (150- to 200-bed) satellite hospitals necessitating neostigmine utilization and (2) determine whether such cases are initially managed according to guideline recommendations.
The records of patients admitted between January 2022 and April 2023 with an associated K59 ICD-10 diagnosis code were collected, totaling 1,278 encounters. This sample was narrowed to include a neostigmine order associated with each encounter. Inpatient consult orders to Gastroenterology and Colorectal Surgery were recorded for informative purposes but not designated as inclusion criteria. Corresponding patient encounters were then manually reviewed to determine whether a patient was diagnosed with ACPO and if so, whether neostigmine was administered for the purpose of treating ACPO, and whether conservative measures were attempted for at least 48-72 hours prior to treatment. Findings were recorded on a secure Excel spreadsheet.
Of the 57 patient encounters meeting all inclusion criteria within the designated time range, 5 contained a formal diagnosis of ACPO and 3 were administered therapeutic neostigmine. In all cases, guideline-directed supportive measures were attempted for at least 48 hours prior to neostigmine initiation. All cases contained a formal consult to either Gastroenterology or Colorectal Surgery. Notably, in 1 separate encounter, neostigmine was administered to a patient with ileus in an intensive care setting, with a K59 code (“slow-transit constipation”) but no formal diagnosis of ACPO; in this case, conservative measures were attempted appropriately, General Surgery was consulted and symptoms resolved following neostigmine administration. There were 14 additional cases with a K59 diagnosis specific to ACPO for which neostigmine was never administered.
Though rare, ACPO is a serious phenomenon. Its complications and treatments pose additional risks to patient safety. By incorporating the strategy developed through this assessment, patient encounters can be efficiently pinpointed to examine inpatient ACPO management. An annual incidence of complicated ACPO within the studied health network can also be deduced. Fortunately, all cases reviewed during this assessment were found to be managed appropriately according to guidelines. Of note, given that evaluation necessitated manual chart review, this study was heavily influenced by precise provider documentation and updated problem lists. Should this strategy be replicated, these potential pitfalls should be considered.
A successful strategy has been identified to quantify and evaluate cases of ACPO, which can be internally replicated should re-assessment be warranted. It can also be utilized by other health networks interested in duplicating this quality assessment.