Megacolon and Volvulus in Parkinson's Disease

Abstract

PARKINSON'S disease is a chronic progressive disorder of somatic motor activity, resulting from degenerative changes in the region of the basal ganglia. The visceral manifestations of this disease are few, with chronic constipation and loss of intestinal tone being the most common. These gastrointestinal abnormalities, generally annoying but not serious, tend to be further aggravated by the drugs currently employed to alleviate the somatic muscular rigidity and tremor. It is not generally appreciated that massive dilatation of the colon can occur in these patients and present a clinical picture identical to that of mechanical bowel obstruction. Furthermore, the occurrence of actual mechanical obstruction resulting from a sigmoid volvulus in this type of megacolon has not to our knowledge been previously described. We are reporting 9 cases in patients with known Parkinson's disease in whom megacolon developed. Eight presented clinically with intestinal obstruction. In 4 torsion of a massively dilated sigmoid loop had indeed produced an actual organic obstruction. Clinical Material A summary of our clinical material is presented in Table 1. Of the 9 patients, 6 were male and 3 female, ranging in age from fifty-three to seventy-four years. The time interval between the diagnosis of Parkinson's disease and the onset of abdominal symptoms could be documented in 8 instances, eighteen months being the shortest. The average was twelve years; twenty-eight years was the longest. All patients were on anti-Parkinson medication, singly or in combination, and in dosages which never exceeded the recommended level. These drugs included Artane up to 10 mg daily, Kemadrin up to 20 mg daily, Cogentin up to 6 mg daily, and scopolamine 1.2 mg daily. The duration of such therapy was determined in 6 of the 8 cases and ranged from at least eighteen months to eight years. The initial clinical impression was that of intestinal obstruction in 8 of the 9 cases. No essential difference was seen clinically between the patients with nonobstructive megacolon and those with complicating sigmoid volvulus. In the remaining patient megacolon was not apparent clinically, but was diagnosed by a bariumenema examination performed because of bleeding hemorrhoids. Neither cecal perforation nor any other serious intraabdominal complication was encountered in any of our patients. Therapy consisted of withdrawal of the anti-parkinsonism medication, intubation, occasionally neostigmine administration, and general supportive measures. Surgical detorsion of a volvulated sigmoid loop was necessary in 1 instance, and an elective sigmoid resection was performed in 2 cases. Table I summarizes our 9 cases, 3 of which are reported in detail below. Case Reports CASE I: B. G., a 65-year-old white male, was admitted because of prostatism and acute urinary retention.