A 76-year-old woman, bedridden after a fractured neck of femur, develops gross abdominal distension over three days. She passes flatus minimally but has no pain or vomiting. Plain radiograph shows a colon dilated to 11 cm at the caecum with air down to the rectum and no transition point. CT excludes mechanical obstruction. Electrolytes are normal. What is the most appropriate next step?

• A Colonoscopic decompression as first-line therapy
• B Emergency subtotal colectomy
• C Intravenous neostigmine under cardiac monitoring ✓
• D Oral polyethylene glycol bowel preparation

Explanation

This is acute colonic pseudo-obstruction (Ogilvie syndrome), a parasympathetic autonomic dysfunction seen in immobilised, postoperative and frail patients. With caecal diameter above 10 cm and no peritonitis, intravenous neostigmine is the recommended first intervention because it produces rapid colonic decompression in most patients; its cholinergic effects mandate cardiac monitoring and atropine availability. Colonoscopy is reserved for neostigmine failure, and surgery is reserved for perforation or ischaemia.

Reference: Sabiston Textbook of Surgery, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.