Treatment of anticholinergic-induced ileus with neostigmine

A 33-year-old man with a history of recreational benztropine abuse presente d to the emergency department with confusion, abdominal pain, and distentio n. An abdominal radiograph revealed gross fecal loading. He was initially t reated with intravenous fluids and opiate analgesia. Subsequently, a diagno sis of anticholinergic poisoning was made, based on tachycardia, dry mucosa , and reduced bowel sounds. Treatment delirium with tacrine reversed the de lirium, and a history of repeated benztropine use was obtained. Persistent ileus was treated with repeated doses of neostigmine, and gastrointestinal motility returned with prompt defecation. Neostigmine appears to be useful in reversing ileus caused by anticholinergic drug overdose. Theoretically, it may be useful in reversing anticholinergic ileus resulting from acute dr ug overdose, allowing or enhancing decontamination, but the safety and pote ntial efficacy of neostigmine in this scenario have not been established.