Acute colonic pseudo-obstruction (ACPO), known as Ogilvie Syndrome, is an acute dilation of the colon in the absence of an underlying mechanical or anatomic cause. Neostigmine treatment is indicated following failed conservative management of ACPO, however neostigmine has its contraindications. This is a report of a unique case of a patient with a past medical history of symptomatic first degree heart block with a permanent pacemaker who received a bolus dosage of neostigmine treatment for ACPO in an ICU setting.