Ogilvie's syndrome

Background

• Ogilvie syndrome is 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 narcotic exposure
• Presenting signs and symptoms are the same as LBO: 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

Imaging:

• 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

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%

Differential Diagnosis

Bowel obstruction

• Malignancy (commonly, colorectal cancer)
• Volvulus
• 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
• Abdominal pain ddx

Diagnosis

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

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 narcotics]
• Management of comorbid conditions
• Neostigmine then endoscopic decompression may be attempted after 24hrs of failed conservative treatment; surgery for refractory cases

Cecal distension >12cm or evidence of gangrene/perforation:

• Emergent surgical consult
• Antibiotics

Disposition

• Admission

References

• Rocco V. Acute and Chronic Constipation In: Tintinalli's Emergency Medicine. 7th ed. McGraw-Hill. 2011: Chapter 77