Neostigmine is a parasympathomimetic drug that acts as a reversible acetylcholinesterase inhibitor. Clinically it is used in patients with acute colonic pseudo-obstruction (ACPO or Ogilvie’s syndrome, which is a gastrointestinal motility disorder characterized by marked dilatation of the colon in the absence of mechanical obstruction), postoperative ileus, urinary retention, myasthenia gravis, and in anesthesia to reverse the effects of nondepolarizing muscle relaxants. Both bolus and infusion are noted to be effective and lead to prompt evacuation of flatus or stool with a reduction in abdominal distention on physical examination. Median duration is noted to be 4–30 minutes in some trials. Here we present our experience of using 2？mg of intravenous neostigmine to help relieve the severe abdominal distention and ileus in a patient with severe fecal impaction when all conservative measures had been futile. The most frequent side effect of the drug is abdominal pain/cramping, which was noted in our patient as well. Other complications include bradycardia which is very infrequently symptomatic to require atropine. Overall, the drug is a simple, safe, and effective strategy; and as pointed out in the previous studies, the drug appears to be underused in patients who do not have a true contraindication to its use. 1. Case Presentation A 76-year-old man with a past medical history significant for cerebrovascular accident (CVA) with severe residual right-sided hemiplegia/aphasia (bedbound), vascular dementia, HTN, and depression was admitted to our service from a nursing home because of worsening abdominal distention and pain from severe constipation since several weeks apparently. Per nursing home records, patient had been having problems with constipation for the last 2-3 weeks. At the nursing facility, they had tried all kinds of oral stool softeners/laxatives including magnesium citrate, docusate, senna, polyethylene glycol, and prune juices followed by enemas (soap suds enemas and fleet enemas) with no results. Prokinetic drugs (including erythromycin and metoclopramide) were also tried. Methylnaltrexone (Relistor) injections were also administered at the facility as well with no outcome. Given progressive worsening in his abdominal distention/pain, along with ongoing constipation, patient was brought to our tertiary care facility for further care and management. At the time of admission, a computerized tomography (CT) scan of his abdomen was done which unfortunately revealed very severe fecal impaction (Figure 1). According to radiology, significant
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