Ogilvie's syndrome

Background

  • Also known as acute colonic pseudo-obstruction (ACPO)
  • Defined as a large bowel obstruction (LBO) in which no obstructing lesion can be identified
  • No definite etiology identified: suspected to develop secondary to a disbalance of colonic autonomic regulatory control
  • Predisposing factors: recent surgery, underlying neurologic disorders, critical illness
  • First described in 1948 by Sir Ogilvie, in two patients with retroperitoneal malignancy and acute colonic pseudo-obstruction

Clinical Features

History

  • Typically present in patients with concomitant acute comorbid conditions
    • Commonly: significant spinal or retroperitoneal trauma
    • Also: significant electrolyte imbalances, significant opioid exposure
  • Presenting signs and symptoms are the same as large bowel: abdominal pain, distension, obstipation, vomiting
    • In contrast to mechanical obstruction, 40-50% will continue to pass flatus

Physical Exam

  • Dilated bowel may be palpable
  • Findings suggestive of dehydration, sepsis, and gangrene/perforation may be present, depending on the extent of progression
  • Peritoneal signs and fever suggest perforation

Differential Diagnosis

  • Malignancy (commonly, colorectal cancer)
  • Diverticular disease
  • Compression from metastatic disease
  • Impaction
  • Strictures (IBD, chronic colonic ischemia)
  • Adhesions
  • Hernia
  • Toxic megacolon
  • Ischemic colitis
  • Adynamic ileus of the large and small bowel

Diffuse Abdominal pain

Evaluation

Work-up

Same as bowel obstruction

  • Labs:
    • CBC: significant leukocytosis may indicate sepsis/gangrene/perforation
    • Electrolyte Panel: guides rehydration
  • Imaging: See Clinical Features above
    • Abdominal XR
    • CT
    • Water soluble contrast enema
    • Colonoscopy

Evaluation

  • Abdominal XR:
    • distended colon
    • small bowel distension possible
    • cecal diameter >12cm indicates high risk of perforation
  • CT:
    • dilation of the large bowel, often without an abrupt transition point
    • no mechanically obstructing lesion
    • gradual transition point is commonly identified at or near the splenic flexure
  • Water soluble contrast enema:
    • diagnostic: rules out mechanical obstruction
    • may also be therapeutic
  • Colonoscopy: also diagnostic and therapeutic

Management

Cecal distention <12cm, no evidence of gangrene or perforation

consider conservative management

  • Surgical consult
  • Bowel rest/decompression [NPO, NG tube, Rectal tube]
  • Rehydration/Electrolyte Repletion
  • Pain management [No opioids]
  • Management of comorbid conditions
  • Neostigmine then endoscopic decompression may be attempted after 24hrs of failed conservative treatment; surgery for refractory cases
    • Neostigmine for cecal diameter >10cm
    • 2-2.5mg neostigmine IV over 5min[1]
    • Exclude patient with HR<60, low SBP, peritoneal signs

Cecal distension >12cm OR evidence of gangrene/perforation

Disposition

  • Admit

Complications

  • Untreated, Ogilvie’s Syndrome leads to the same pathologic changes as any mechanical large bowel obstruction: increasing bowel dilation and distension, dehydration, edema and eventual ischemia and necrosis of the bowel wall, bacterial translocation and sepsis, and eventual bowel wall perforation.
  • Cecal perforation is rare: 1-3%

See Also

External Links

References

  1. Maloney N and Vargas HD. Acute Intestinal Pseudo-Obstruction (Ogilvie's Syndrome). Clin Colon Rectal Surg. 2005 May; 18(2): 96–101.