Colonic Pseudo-Obstruction and Caecal Perforation

“Pseudo-obstruction of the colon” refers to a condition in which physical and radiologic findings identical to those associated with mechanical obstruction of the large bowel are found, but no organic cause of colonic distention can be identified. These cases may involve progressive proximal large-intestinal dilation to the point of caecal perforation or necrosis.

A patient was admitted in the Aster Hospital, Al Qusais MICU with viral pneumonia with acute respiratory distress syndrome and was on mechanical ventilation. On day 10, he developed abdominal distention, abdominal pain, vomiting and fever. An X-ray revealed huge colonic dilatation [Image 1] and a diagnosis of ‘Acute Colonic Pseudo-Obstruction’ was made and confirmed with CT scan of the abdomen.

All conservative measures failed and he was taken up for exploratory laparotomy as the patient was clinically deteriorating.

Preoperative, the whole of caecum was gangrenous and perforated, with almost of litre of fecal contaminated fluid in the abdominal cavity. A right hemicolectomy and a thorough peritoneal lavage was administered by Dr. Reji Chandran and patient was shifted back to ICU.

In the ICU, he had a stromy postoperative period requiring continuous mechanical ventilation and cardiac support over a week. He had paralytic ileus for the whole week. On 8th post-operative day he started passing flatus and stools, after which he was off cardiac support and on non invasive ventilation. The abdominal drains were removed in the following day and on day 10, he was totally off ventilation. After two days the patient had mild SSI in the lower part of the laparotomy wound and had minimal superficial wound dehiscence. Since the rectus was intact, the wound dehiscence was managed conservatively. He was discharged after few days and the pathologist confirmed the diagnosis and other caecal pathologies was ruled out.

The most serious complication of colonic pseudo-obstruction is perforation of the caecum. The reported incidence of caecal perforation is 3-40%, and the associated mortality is 40-50%. A caecal diameter greater than 12 cm, a delay in colonic decompression, and advanced age are all predictors of colonic perforation.

Dr. Reji Chandran

General & Laparoscopic Surgeon

Aster Hospital, Al Qusais

Operative Image
Image 1: X-Ray Showing Dilated Colon