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Colonic pseudoobstruction in patients with stroke.

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NOTES AND LETTERS
Colonic Pseudoobstruction
in Patients with Stroke
Barbara J. Reynolds, MD,
and Sven G. Eliasson, MD, PhD
T h e syndrome of pseudoobstruction of the colon has been
recognized among surgeons for some time [ 1-41 but has not
as y e t become well known among the nonsurgical
specialists, including neurologists. Within the last year we
have seen 4 cases.
A 54-year-old man was admitted after being found unconscious at home. Angiography showed occlusion of the left
vertebral and distal basilar arteries. O n the fourth hospital
day a guaiac-positive nasogastric aspirate was obtained, and
he was started on a regimen of magnesium and aluminum
hydroxides. Seventeen days after admission abdominal distention was noted. The patient was passing liquid stools, and
the abdomen was diffusely tender with rebound. O n the
twenty-first day the patient suffered a hypotensive episode,
and a roentgenogram showed free air in the abdomen. An
emergency exploratory laparotomy was performed, and a
cecal perforation was found approximately 10 cm from the
ileocecal valve. No mechanical obstruction was found; a
cecostomy was performed, but, the patient died three days
later. On postmortem examination the cerebral vessels were
found to be patent.
A second patient, a 49-year-old man, had a pontine
hemorrhage. O n the eleventh day abdominal distention was
noted, and serial abdominal roentgenograms showed increasing cecal diameter. The cecum continued to expand
and was over 15 cm in diameter when the patient underwent
cecostomy to decompress the colon. At operation serosal
tears were seen, hut perforation was not complete. H e
recovered and was discharged essentially well.
The third patient, a 75-year-old man, had left hemiparesis
and dysphasia. Ten days after admission he was noted to
have abdominal distention. The abdomen was tympanitic,
with normal bowel sounds. The distention did not resolve,
and when the cecal diameter was shown by roentgenogram
to be about 18 cm, the patient underwent exploratory
laparoromy. The cecum was found to b e markedly dilated,
with two serosal tears but no complete perforation, and a
cecostomy was performed. The patient was discharged from
the hospital about seven weeks after the operation.
A 33-year-old woman without a history of trauma gradually became comatose due to bilateral internal carotid artery
occlusion. The patient’s bowel function was regular until t h e
eleventh day after admission, and then there were no bowel
movements for six days. The next day abdominal distention
was noted, and the patient .was passing large amounts of
From the Deparrment o f Neurology, Washington University
School of Medicine, St Louis, MO.
Accepted for publication Sept 20, 1976.
Address reprint requests to Dr Eliasson, Department o f Neurology, Washington LJniversity School of Medicine, Sr Louis, MO
63110.
diarrheal stools. O n e day later roentgenograms showed
massive pneumoperitoneum, and at operation a perforation
was found on the anterior surface of the cecum. The patient
recovered from her peritonitis but not from the coma.
Colonic pseudoobstruction is characterized by progressive abdominal distention following avariable time course in
the absence of mechanical obstruction. The seriousness of
the distention may not be appreciated early, since it is often
associated with the passage of stools and gas, absence of
tenderness, normal bowel sounds, and a normal blood electrolyte picture. The syndrome is best diagnosed by an
abdominal flat-plate roentgenogram rhat shows a dilated
colon with or without associated small bowel involvemenr.
The dilatation is usually gaseous hut may show air-fluid
levels. I t involves the proximal colon in a segmental manner,
with a characteristic cutoff point beyond which the bowel
size appears normal. The transition point is usually at the
splenic flexure but may be at the hepatic or sigmoid flexures.
Barium studies show n o obstructing lesion in the bowel. It
has been suggested that both the cecal diameter and the rate
ofcecal dilation must be monitored carefully [l-41. A cecal
diameter greater than 12 cm or lack ofimprovement within
7 2 hours is an indication for operation. The possibility of
pseudoobstruction must be kept in mind when dealing with
stroke patients if the potentially fatal complication of cecal
perforation and ensuing peritonitis is to be avoided.
Supported in part by NI NDS Grant 05378
Stuart Weiss, MD, called our attention to 1 of the described cases.
The neuropathological study i n the first patient was done by
William Schlaepfer, MD.
References
1. Adams JT: Adynamic ileus o f the colon: an indication for
cecostomy. Arch Surg 109:503-507, 1974
2. Ogilvie H: Large-intestine colic due to sympathetic deprivarioti:
a new clinical syndrome. Br Med J 2:671-673, 1948
3. MacFarlane JA, Kay SK: Ogilvie’s syndrome of false rolonic
obstruction: is it a new clinical entity? Br Med J 2:1267-1269,
1949
4. Wanebo H, Mathewson C, Conolly B: Pseudo-obstruction of
the colon. Surg Gynecol Obstet 133:44-48, 1971
Fits, Faints, and
the IUD
To the Editor:
While syncope is an infrequenr hut recognized coniplication
ofintrauterine itevice (IUD)insertion [ l ,21, the occurrence
of corivulsions following IUD placement has not often been
observed. Conrad et a1 [ 11, in the only report documenting
the association, described 3 patients who developed fits i n
relation to I U D insertion. Although the frequency of convulsions in Conrad’s series was less than 1 in 2,000, we have
seen 3 such patients during a six-month period.
Each of our patients had generalizecl c h i c movements
lasting 10 to 30 seconds during the insertion of an IUD
305
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