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
  • Aortocaval fistula
• Acute gastroenteritis
• Aortoenteric fisulta
• Appendicitis (early)
• Bowel obstruction
  • Large bowel obstruction
    • Ogilvie's syndrome
  • Small bowel obstruction
  • Malignant bowel obstruction
• Bowel perforation
• Diabetic ketoacidosis
• Gastroparesis
• Hernia
• Hypercalcemia
• Inflammatory bowel disease
• Mesenteric ischemia
  • Mesenteric vein thrombosis
• Pancreatitis
• Peritonitis
• Sickle cell crisis
• Spontaneous bacterial peritonitis
• Volvulus

Evaluation

CT-Scan showing a coronal section of the abdomen of an elderly woman with Ogilvie syndrome.

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

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
  • 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

• Abdominal Pain
• Bowel Obstruction