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A case of cholinergic crisis caused by distigmine bromide administered for paralytic ileus Toshihiro Sakurai, Shu Yamada, Maki Kitada, Satoshi Hashimoto, Shoko Hashimoto, Fumihiko Kimura, Masahiro Harada, Takeshi Takahashi Department of Emergency and Critical Care Medicine, National Hospital Organization Kumamoto Medical Center 1-5 Ninomaru, Chuo-ku, Kumamoto, Kumamoto 860-0008 Japan Distigmine bromide, an anticholinesterase, is available for the treatment of strangury. Because this drug was reported to cause cholinergic crisis as a severe side effect, the clinical dose has been limited. However, cases of cholinergic crisis are still reported. We experienced a case of shock caused by severe pneumonia and paralytic ileus. Initially, the condition was considered as septic shock. However, it was later, diagnosed as cholinergic crisis because the patient took distigmine bromide and the serum cholinesterase level decreased significantly. Because most of the drug is excreted in the feces, drug concentration in the blood increases when gastrointestinal peristalsis decreases, which is observed in conditions such as paralytic ileus, we must be aware that cholinergic crisis may occur in patients with paralytic ileus.