Oral pyridostigmine for treatment of postoperative ileus associated with elevated catecholamine levels: A case report

Oral pyridostigmine for treatment of postoperative ileus associated with elevated catecholamine levels: A case report

Sherif Aly, MD 1,2; Gentian Kristo, MD, MPH, FACS1,3.

1Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, MA, USA;
2Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA;
3Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA.

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The etiology of post-operative ileus is usually multifactorial, but increased catecholamines have been implicated as an important cause. We present a case of catecholamine-induced prolonged post-operative ileus treated successfully with Pyridostigmine. A 70-year-old male underwent a low-anterior resection and diverting loop ileostomy for rectal cancer. Immediately post-operatively he developed refractory hypertensive urgency and a small bowel ileus. Biochemical testing revealed markedly elevated 24-hour urinary metanephrines and normetanephrines. However, radiologic studies failed to identify a pheochromocytoma. The ileus persisted despite employing a multimodal regimen consisting of avoidance of narcotic pain medications, gastric decompression via a nasogastric tube, maintenance of normal levels of electrolytes, parenteral nutritional support, and early mobilization. Two weeks after the surgery the patient was treated with oral Pyridostigmine with appropriate return of bowel function. Excessive circulating catecholamines play an important role in the etiology of refractory post-operative ileus, and cholinesterase inhibitors such as Pyridostigmine could be used as an effective treatment in such cases.

Disclosure Statement: The authors have no conflicts of interest or financial disclosures to declare.

Keywords: post-operative ileus; catecholamines; pheochromocytoma; cholinesterase inhibitor

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How to cite this article:

Sherif Aly and Gentian Kristo. Oral pyridostigmine for treatment of postoperative ileus associated with elevated catecholamine levels: A case report. International Journal of Case Reports, 2019 4:77. DOI: 10.28933/ijcr-2019-04-2805


1. Asgeirsson T, El-Badawi KI, Luchtefeld M, Senagore AJ, et al. Postoperative ileus: It costs more than you expect. J. Am. Coll. Surg. 2010, 210, 228–231.
2. Luckey A, Livingston E, Taché Y. Mechanisms and Treatment of Postoperative Ileus. Arch Surg. 2003;138(2):206–214. doi:10.1001/archsurg.138.2.206.
3. Wood JD. Intrinsic neural control of intestinal motility. Annu Rev Physiol. 1981;43:33-51.
4. Wood JD. Neurotransmission at the interface of sympathetic and enteric divisions of the autonomic nervous system. Chin J Physiol. 1999;42:201-10.
5. Wood JD, Mayer CJ. Adrenergic inhibition of serotonin release from neurons in guinea pig Auerback’s plexus. J Neurophysiol. 1979;42:594-603.
6. R. Cruz S, Colwell J. Pheochromocytoma and Ileus. JAMA. 1972. 219. 1050-1051.
7. Noguchi M, Taniya T, Ueno K, Miyazaki I, et al. A case of pheochromocytoma with severe paralytic ileus. Jpn J Surg. 1990 Jul;20(4):448-52.
8. Seung-Joon H, Mi-kwang K, Suk Ch. A case of retroperitoneal paraganglioma manifested as intractable constipation with paralytic ileus and aggravated hyperglycemia. J Korean Endocr Soc. 2008 Dec;23(6):450-455.
9. Thosani S, Ayala-Ramirez M, Roman-Gonzalez A, Jimenez C, et al. Constipation: an overlooked, unmanaged symptom of patients with pheochromocytoma and sympathetic paraganglioma. European Journal of Endocrinology. 2015; 173:377–387.
10. Turner CE. Gastrointestinal pseudo-obstruction due to pheochromocytoma. Am J Gastroenterol. 1983 Apr;78(4):214-7.
11. Sweeney AT, Malabanan AO, Blake AM, Melby JC, et al. Megacolon as the Presenting Feature in Pheochromocytoma. The Journal of Clinical Endocrinology & Metabolism. 2000 Nov;85(11):3968–3972.
12. de Lloyd AC, Munigoti S, Davies JS, Scott-Coombes D. A rare and life-threatening cause of pseudo-obstruction in two surgical patients. BMJ Case Reports 2010.
13. Malekzadeh F, Ansari R, Malekzadeh R. Do you mean: Approach to chronic constipation. Govaresh 2014; 19: 7-13.
14. Sadjadpour K. Pyridostigmine bromide and constipation in Parkinson’s disease. JAMA 1983; 249: 1148-60.
15. Soufi-Afshar I, Moghadamnia A, Bijani A, Shokri-Shirvani J, et al. Comparison of pyridostigmine and bisacodyl in the treatment of refractory chronic constipation. Caspian J Intern Med 2016; 7(1):19-24.
16. Maleknejad A, Khazaei A, Bouya S. Evaluation of the effect of oral pyridostigmine on the ileus after abdominal surgery: a blinded randomized clinical trial. J. Clin. Med. 2018, 7, 104.

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