A best evidence topic was written according to a structured protocol. In [patients with acute colonic pseudo-obstruction] is [neostigmine] superior to [conservative treatment] with respect to [duration of symptoms and complications]. In total 51 papers were found using the reported search, and ten of these represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. We conclude that intravenous neostigmine is associated with significantly reduced duration of acute colonic pseudo-obstruction (ACPO) compared to conservative treatment alone. Neostigmine infusion should be administered with continuous cardiac monitoring for possible bradycardia, which may require treatment with atropine. Seven prospective analyses and one retrospective study showed that intravenous neostigmine reduces time to resolution of clinical and radiological features of ACPO. One prospective study showed that neostigmine is only effective in improving duration of ACPO when it is combined with proponalol. One prospective study showed no difference in time to resolution of ACPO between neostigmine and conservative treatment but this study was limited by small sample size, lack of radiological examinations and poor reporting of adverse effects. In four separate studies patients experienced bradycardia with intravenous neostigmine and this required treatment with atropine. No other significant adverse effects were reported. Overall, intravenous neostigmine is associated with a significant reduction in duration of ACPO. In addition to regularly reviewing patients for antic-cholinergic side effects, patients should undergo continuous cardiac monitoring for bradycardia. The wide variety in methodology and measurement of outcomes reinforce the need for higher power studies to improve patient selection and monitoring of outcomes.
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