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 obstruction:
- Abdominal pain/distension
- Obstipation
- In contrast to mechanical obstruction, 40-50% will continue to pass flatus
- Vomiting
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
- Abdominal aortic aneurysm
- Acute gastroenteritis
- Aortoenteric fisulta
- Appendicitis (early)
- Bowel obstruction
- Bowel perforation
- Diabetic ketoacidosis
- Gastroparesis
- Hernia
- Hypercalcemia
- Inflammatory bowel disease
- Mesenteric ischemia
- Pancreatitis
- Peritonitis
- Sickle cell crisis
- Spontaneous bacterial peritonitis
- Volvulus
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 Xray
- 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
- Abdominal Xray
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
- Emergent surgical consult
- Antibiotics
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
- ↑ Maloney N and Vargas HD. Acute Intestinal Pseudo-Obstruction (Ogilvie's Syndrome). Clin Colon Rectal Surg. 2005 May; 18(2): 96–101.