Colonic perforation associated with neostigmine administration
The patient, a 34-year-old female, developed symptoms consistent with pseudo-obstruction on Day 3 post-emergency Caesarean section, which was performed for foetal distress and possible placenta abruption. An abdominal X-ray was performed which showed a significantly dilated colon (Fig. ), and the diagnosis of pseudo-obstruction was again confirmed on computer tomography (CT) scan of the abdomen which showed a caecum measuring 9.8 cm transversely (Fig. ). Emergency colonoscopic decompression with the insertion of a flatus tube was performed and medical management, including cessation of opioids, anticholinergics and correction of electrolyte abnormalities, was commenced.\nThe patient failed to have a return of normal bowel function post-decompression and after 3 days was administered 500 µg of neostigmine via subcutaneous injection in an attempt to improve bowel motility. That evening she developed fever, and abdominal pain and erect chest X-ray confirmed free gas under her diaphragms (Fig. ). She was taken to theatre for emergency laparotomy. At operation she was found to have two sites of caecal perforation with a moderate faecal contamination in the right paracolic gutter. A right hemicolectomy with primary anastomosis was performed. She was discharged home on post-operative Day 7 without further complication. It is possible that the serosal tears of the caecum had occurred secondary to either administration of neostigmine or dilatation in the post-Caesarean period.