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Pseudo-obstruction of the colon: incidence and treatment in a transplant population.
DJ Vargo, M Reichelderfer, SJ Knechtle.
Department of Surgery, University of Wisconsin Hospital & Clinics, Madison, WI.

We have reviewed the kidney and liver transplant experience at the University of Wisconsin through 6/30/95 in an attempt to generate an incidence and evaluate treatment options in this patient population. Of 3079 kidney transplants, 40 (1.3%) were diagnosed with pseudo-obstruction, while 2 of 558 liver transplant patients (0.36%) developed the disorder. Of the 42 patients, 3 were diagnosed with perforations at the time pseudo-obstruction was recognized and were immediately taken to surgery. The remaining 39 patients were categorized into three groups based on treatment given: 1) conservative therapy only, which consisted of one or more of the following: NPO, decrease steroids, rectal tube, motility agents, enemas, GI lavage, and correction of electrolytes (8 patients); 2) conservative therapy, followed by colonoscopic decompression (20 patients); and 3) immediate colonoscopy (11 patients). No significant differences were noted between the three groups with regards to age, number of days postoperatively the diagnosis was made, cecal size, maximum cecal size, electrolyte imbalances, presence of rejection, or immunosupressive regimens. Of the 28 patients treated conservatively initially, 7 did not require colonoscopy, for a success rate of 25%. 1 of 28 patients perforated (3.6%), but this was in the precolonoscopic decompression era. Of the remaining 31 patients, 42 colonoscopies were performed. 23 patients required only one procedure, for an initial success rate of 65%. There was no significant correlation between distance colonoscope could be advanced and resolution of colonic distention. In addition, roentgenographic findings pre- and post-colonoscopy did not correlate with resolution of distention. The colonoscopy groups had 2 perforations (2/42, 5%), one with the initial procedure and one during a third colonoscopy. One of these patients died. The colonoscopy groups had resolution of symptoms in 6.6 days on average, compared to 8.1 days for the conservative group alone, the difference being not statistically significant. We have evaluated a large transplant population for incidence of pseudo-obstruction of the colon and potential treatment options. There was no increase in complications associated with a trial of conservative therapy. Colonoscopy lead to a faster rate of recovery, but was associated with a higher complication rate than is generally reported for the procedure (0.2%). We believe that in transplant patients with a diagnosis of pseudo-obstruction, a trial of conservative therapy is warranted. If unsuccessful, colonoscopy is indicated to prevent complications of conservative therapy, namely colonic wall ischemia, necrosis, and perforation.