We treated a 49-yr-old man with neostigmine, who had liver cirrhosis, acute hepatic encephalopathy, and acute intestinal pseudoobstruction. He was admitted in a state of hepatic confusion. On physical examination, the abdomen was distended; and bowel sound was absent. Plain abdomen film revealed multiple airfluid levels and distention of bowel loops. Initially, we gave him lactulose enemas every 6 hr for one day without improvement in his mental state. Furthermore, he became to a state of coma. Therefore, we gave him 0.5 mg of neostigmine subcutaneously to improve his peristaltic movement, and 2 L of polyethylene glycol electrolyte solution through a nasogastric tube for 4 hr to reduce the production and absorption of gutderived toxins of nitrogenous compounds. After these treatments, the venous ammonia level decreased to the normal range within 12 hr, and the coma disappeared after 2 days. We suggest that neostigmine may be one of the most effective treatments to initiate peristaltic movement and bowel cleansing in cirrhotic patients with acute hepatic encephalopathy and acute intestinal pseudoobstruction.
Air ; Ammonia/metabolism ; Blood Pressure ; Cholinesterase Inhibitors/*pharmacology ; Electrolytes/pharmacology ; Enema ; Fibrosis/*drug therapy ; Hepatic Encephalopathy/*diagnosis/*drug therapy/radiography ; Humans ; Intestinal Pseudo-Obstruction/*diagnosis/*drug therapy/radiography ; Lactulose/pharmacology ; Liver/metabolism ; Male ; Middle Aged ; Neostigmine/*pharmacology ; Peristalsis ; Polyethylene Glycols/pharmacology ; Time Factors