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Acute colonic pseudo-obstruction (ACPO) known as Ogilvie's syndrome is characterized by massive dilatation of the colon without a mechanical obstruction with unclear pathophysiology. The ACPO is associated with wide variety of medical and surgical conditions, especially the pregnancy, the cesarean section, and the trauma. Usually, the conservative therapy of 2-3 days is enough for its treatment. However, if it shows no effect, colonoscopic decompression is recommended. As an alternative, neostigmine has been reported to be effective in the treatment of ACPO. Here, we report a case of idiopathic ACPO treated with neostigmine. The initial treatment was conservative but showed no effect, and thus colonoscopic decompression was followed. After decompression, symptoms were improved. However, 10 days after decompression, abdominal distension was recurred. Thus, we injected 2.0 mg of neostigmine intravenously for 3 minutes. It improved the symptom. Seven days later, the symptoms were aggravated, so 1.0 mg of neostigmine was administrated twice. However, it made no response. The patient transferred for exploration, and total colectomy was carried out. After 7 days from the colectomy, the patient died of sepsis.