Ten-year management of acute colonic pseudo-obstruction in a single UK center: a retrospective cohort study

Background: Acute colonic pseudo-obstruction (ACPO) is a rare but clinically significant cause of acute colonic dilatation without mechanical obstruction. Older adults and patients living with frailty are particularly vulnerable to complications, including perforation, sepsis, and death. Despite guideline recommendations, variability persists in diagnostic pathways and therapeutic decision-making. This study reports a 10-year experience of ACPO management at a large UK tertiary referral center and evaluates the relationship between frailty, treatment escalation, and mortality. An exploratory cohort of ACPO cases associated with COVID-19 infection was also examined to explore how highly monitored critical care settings may influence treatment patterns. Materials and Methods: A retrospective cohort study identified adults with radiologically confirmed ACPO between January 2009 and March 2019. Demographic, clinical, management, and outcome data were extracted from electronic health records and imaging systems. The primary outcome was 30-day all-cause mortality. Secondary outcomes included escalation of care (endoscopy or surgery), resolution following conservative or pharmacological therapy, recurrence within 12 months, and 6-month mortality. Frailty was retrospectively assessed using the Clinical Frailty Scale (CFS) in patients aged ≥65 years ( n = 27), consistent with institutional frailty assessment practices. Multivariable logistic regression was used to examine associations between CFS, cecal diameter, escalation of care, and early mortality. A separate exploratory cohort of critically ill patients who developed ACPO during COVID-19 infection between 2020 and 2021 was analyzed descriptively. Results: Forty-eight patients met the inclusion criteria (median age 81 years; 56.0% women), and 71.0% developed ACPO during hospitalization. Endoscopic decompression was performed in 52.0% of patients, with a success rate of 72.0%. Neostigmine was administered in 12.5% of cases despite 37 patients meeting eligibility criteria; treatment success was 83.0%. Surgery was required in 10.0% of cases, mainly due to perforation or ischemia. Among patients aged ≥65 years with available frailty assessments, higher frailty was associated with increased 30-day mortality (44.0% with CFS ≥ 6 vs 8.0% with CFS < 6). In multivariable analysis, increasing CFS (aOR 1.42 per point, 95% CI 1.05–1.93) and cecal diameter ≥12 cm (aOR 3.08, 95% CI 1.01–9.41) were independently associated with early mortality. In the exploratory COVID-19 cohort ( n = 11), all patients received neostigmine, and none required surgery. Conclusions: Higher frailty and greater cecal dilatation were associated with early mortality in patients with ACPO. Neostigmine use in routine practice appeared inconsistent outside highly monitored settings. These observations suggest that a structured, frailty-informed management approach may support clinical decision-making; however, prospective studies are required to determine whether such pathways improve outcomes in older and multimorbid patients.