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Johnny CS, Schlegel RN, Balachandran M, Casey L, Mathew J, Carne P, Varma D, Ban EJ, Fitzgerald MC. Acute colonic pseudo-obstruction in polytrauma patients. J Trauma Acute Care Surg 2024; 97:614-622. [PMID: 38769618 DOI: 10.1097/ta.0000000000004392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Acute colonic pseudo-obstruction (ACPO) is characterized by severe colonic distension without mechanical obstruction. It has an uncertain pathogenesis and poses diagnostic challenges. This study aimed to explore risk factors and clinical outcomes of ACPO in polytrauma patients and contribute information to the limited literature on this condition. METHODS This retrospective study, conducted at a Level 1 trauma center, analyzed data from trauma patients with ACPO admitted between July 2009 and June 2018. A control cohort of major trauma patients was used. Data review encompassed patient demographics, abdominal imaging, injury characteristics, analgesic usage, interventions, complications, and mortality. Statistical analyses, including logistic regression and correlation coefficients, were employed to identify risk factors. RESULTS There were 57 cases of ACPO, with an incidence of 1.7 per 1,000 patients, rising to 4.86 in major trauma. Predominantly affecting those older than 50 years (75%) and males (75%), with motor vehicle accidents (50.8%) and falls from height (36.8%) being the commonest mechanisms. Noteworthy associated injuries included retroperitoneal bleeds (RPBs) (37%), spinal fractures (37%), and pelvic fractures (37%). Analysis revealed significant associations between ACPO and shock index >0.9, Injury Severity Score >18, opioid use, RPBs, and pelvic fractures. A cecal diameter of ≥12 cm had a significant association with cecal ischemia or perforation. CONCLUSION This study underscores the significance of ACPO in polytrauma patients, demonstrating associations with risk factors and clinical outcomes. Clinicians should maintain a high index of suspicion, particularly in older patients with RPBs, pelvic fractures, and opioid use. Early supportive therapy, vigilant monitoring, and timely interventions are crucial for a favorable outcome. Further research and prospective trials are warranted to validate these findings and enhance understanding of ACPO in trauma patients. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Cecil S Johnny
- From the Trauma Service (C.S.J., R.N.S., M.B., L.C., J.M., E.-J.B., M.C.F.), Emergency and Trauma Centre (C.S.J., J.M.), and National Trauma Research Institute (C.S.J., J.M., E.-J.B., M.C.F.), The Alfred Hospital; Department of Surgery (C.S.J., J.M., M.C.F.), Central Clinical School, Monash University; Colorectal Unit, Department of Surgery (P.C.), Department of Radiology (D.V.), and Acute General Surgery Unit (E.-J.B.), The Alfred Hospital, Melbourne, Victoria, Australia
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Clozapine and Ogilvie syndrome in Schizophrenia: Case report of a successful rechallenge. Asian J Psychiatr 2022; 77:103249. [PMID: 36095882 DOI: 10.1016/j.ajp.2022.103249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/12/2022] [Accepted: 08/26/2022] [Indexed: 11/22/2022]
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Xu S, Sharma S, Jadbabaie F. Management of acute colonic pseudo-obstruction in a neutropenic patient. BMJ Case Rep 2022; 15:e250633. [PMID: 35793843 PMCID: PMC9260809 DOI: 10.1136/bcr-2022-250633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2022] [Indexed: 12/16/2022] Open
Abstract
Acute colonic pseudo-obstruction, also known as Ogilvie's syndrome, is a rare condition involving acute large bowel dilatation without mechanical obstruction. Management begins with conservative treatment and may include pharmacological therapy, colonoscopic decompression and surgery. Timely resolution is important due to the increased risk of bowel perforation and ischaemia associated with colonic dilatation. However, conditions such as neutropenia that place patients at an elevated risk of infection may limit treatment options. We report a case of acute colonic pseudo-obstruction in a neutropenic elderly man resistant to conservative measures and neostigmine and discuss the additional management considerations in an immunocompromised patient.
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Affiliation(s)
- Suzanne Xu
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shreyak Sharma
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Farid Jadbabaie
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Pedroza Pinheiro R, Ribeiro Nascimento L, Rodrigo Tavares Costa H, Luiz Aparecido Defino H. OGILVIE SYNDROME FOLLOWING SPINAL SURGERY. SANAMED 2022. [DOI: 10.24125/sanamed.v16i3.523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Joechle K, Guenzle J, Utzolino S, Fichtner-Feigl S, Kousoulas L. Ogilvie's syndrome-is there a cutoff diameter to proceed with upfront surgery? Langenbecks Arch Surg 2022; 407:1173-1182. [PMID: 35020083 PMCID: PMC9151542 DOI: 10.1007/s00423-021-02407-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/08/2021] [Indexed: 11/04/2022]
Abstract
Purpose Although Ogilvie’s syndrome was first described about 70 years ago, its etiology and pathogenesis are still not fully understood. But more importantly, it is also not clear when to approach which therapeutic strategy. Methods Patients who were diagnosed with Ogilvie’s syndrome at our institution in a 17-year time period (2002–2019) were included and retrospectively evaluated regarding different therapeutical strategies: conservative, endoscopic, or surgical. Results The study included 71 patients with 21 patients undergoing conservative therapy, 25 patients undergoing endoscopic therapy, and 25 patients undergoing surgery. However, 38% of patients (n = 8) who were primarily addressed for conservative management failed and had to undergo endoscopy or even surgery. Similarly, 8 patients (32%) with primarily endoscopic treatment had to proceed for surgery. In logistic regression analysis, only a colon diameter ≥ 11 cm (p = 0.01) could predict a lack of therapeutic success by endoscopic treatment. Ninety-day mortality and overall survival were comparable between the groups. Conclusion As conservative and endoscopic management fail in about one-third of patients, a cutoff diameter ≥ 11 cm may be an adequate parameter to evaluate surgical therapy.
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Affiliation(s)
- Katharina Joechle
- Department of General and Visceral Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Jessica Guenzle
- Department of General and Visceral Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Stefan Utzolino
- Department of General and Visceral Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Lampros Kousoulas
- Department of General and Visceral Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany.
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Wells CI, Paskaranandavadivel N, Du P, Penfold JA, Gharibans A, Bissett IP, O'Grady G. A novel mechanism for acute colonic pseudo-obstruction revealed by high-resolution manometry: A case report. Physiol Rep 2021; 9:e14950. [PMID: 34231325 PMCID: PMC8261480 DOI: 10.14814/phy2.14950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Acute colonic pseudo-obstruction (ACPO) is a severe form of colonic dysmotility and is associated with considerable morbidity. The pathophysiology of ACPO is considered to be multifactorial but has not been clarified. Although colonic motility is commonly assumed to be hypoactive, there is little direct pathophysiological evidence to support this claim. METHODS A 56-year-old woman who developed ACPO following spinal surgery underwent 24 h of continuous high-resolution colonic manometry (1 cm resolution over 36 cm) following endoscopic decompression. Manometry data were analyzed and correlated with a three-dimensional colonic model developed from computed tomography (CT) imaging. RESULTS The distal colon was found to be profoundly hyperactive, showing near-continuous non-propagating motor activity. Dominant frequencies at 2-6 and 8-12 cycles per minute were observed. The activity was often dissociated and out-of-phase across adjacent regions. The mean amplitude of motor activity was higher than that reported from pre- and post-prandial healthy controls. Correlation with CT imaging suggested that these disordered hyperactive motility sequences might act as a functional pseudo-obstruction in the distal colon resulting in secondary proximal dilatation. CONCLUSIONS This is the first detailed description of motility patterns in ACPO and suggests a novel underlying disease mechanism, warranting further investigation and identification of potential therapeutic targets.
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Affiliation(s)
- Cameron I. Wells
- Department of SurgeryFaculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | | | - Peng Du
- Auckland Bioengineering InstituteThe University of AucklandAucklandNew Zealand
| | - James A. Penfold
- Department of SurgeryFaculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | - Armen Gharibans
- Department of SurgeryFaculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
- Auckland Bioengineering InstituteThe University of AucklandAucklandNew Zealand
| | - Ian P. Bissett
- Department of SurgeryFaculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | - Greg O'Grady
- Department of SurgeryFaculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
- Auckland Bioengineering InstituteThe University of AucklandAucklandNew Zealand
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Incidence and Risk Factors for the Development of Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome) in Total Joint Arthroplasty Patients. J Am Acad Orthop Surg 2021; 29:159-166. [PMID: 32501855 DOI: 10.5435/jaaos-d-20-00096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/01/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Acute colonic pseudo-obstruction (Ogilvie syndrome [OS]) is a rare but devastating condition that can develop in orthopaedic patients postoperatively. The objective of this study was to identify the risk factors for developing OS after total hip arthroplasty (THA) or total knee arthroplasty (TKA) and to compare the outcomes between patients who did and did not develop OS postoperatively. METHODS This was a retrospective review using the National Inpatient Sample, a national database incorporating inpatient hospitalization information. ICD-9 codes were used to identify patients who underwent primary and revision THA or TKA. Patients were separated based on the diagnosis of OS. Primary outcomes assessed included patient mortality, postoperative complications, length of stay, and cost during index hospitalization. RESULTS From 2001 to 2014, a total of 12,541,169 patients underwent primary and revision THA or TKA. Of those, 3,182 patients (0.03%) developed OS postoperatively. There was an increased incidence of OS in revision THA and TKA compared with primary THA and TKA. Fluid and electrolyte disorders were associated with the largest increased adjusted risk of OS. Patients with OS had an increased adjusted risk of overall postoperative complications and being discharged to skilled nursing facility. Patients with OS had an increased average length of stay and hospitalization cost compared with patients without OS. DISCUSSION Given our findings, the risk factors for the development of OS, including revision surgery, should be identified and minimized during the perioperative period to prevent the development of this morbid and potentially life-threatening complication. LEVEL OF EVIDENCE III (Retrospective cohort study).
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Ahmad MU, Riley KD, Ridder TS. Acute Colonic Pseudo-Obstruction After Posterior Spinal Fusion: A Case Report and Literature Review. World Neurosurg 2020; 142:352-363. [PMID: 32659357 DOI: 10.1016/j.wneu.2020.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Acute colonic pseudo-obstruction (ACPO) or Ogilvie's syndrome occurs in 0.22%-7% of patients undergoing surgery, with a mortality of up to 46%. ACPO increased median hospital days versus control in spinal surgery (14 vs. 6 days; P < 0.001). If defined as postoperative ileus, the incidence was 7%-13.4%. Postoperative ileus is associated with 2.9 additional hospital days and an $80,000 increase in cost per patient. We present a case of ACPO in an adult patient undergoing spinal fusion for correction of scoliosis and review the available literature to outline clinical characteristics and surgical outcomes. CASE DESCRIPTION The patient was a 31-year-old woman with untreated advanced scoliosis with no history of neurologic issues. T2-L3 spinal instrumentation and fusion was completed. Plain abdominal radiography showed of dilated cecum 11 cm and the department of general surgery was consulted. Neostigmine administration was planned after conservative treatment failure after transfer to the intensive care unit. The patient was discharged home with no recurrence >60 days. Thirty cases were found in our literature review using PubMed and Embase databases and summarized. CONCLUSIONS Of 30 cases reviewed, only 3 cases of ACPO were specific to patients undergoing spinal fusion for scoliosis. According to the literature, 20% of patients had resolution with conservative treatment, 40% with neostigmine, and 30% with surgical intervention. Other noninvasive treatments may have similar efficacy in preventing complications leading to surgical invention. Sixty clinical trials and 9 systematic reviews were summarized with an updated management algorithm.
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Affiliation(s)
- M Usman Ahmad
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - Keyan D Riley
- Trauma and Acute Care Surgery, Memorial Hospital, University of Colorado Health, Colorado Springs, Colorado, USA
| | - Thomas S Ridder
- Pediatric and Adult Neurosurgery, UCHealth Brain & Spine Clinic, Children's Hospital of Colorado, Colorado Springs, Colorado, USA
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Harnsberger CR. Acute colonic pseudo-obstruction (Ogilvie's syndrome). SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1016/j.scrs.2019.100690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Wells CI, O’Grady G, Bissett IP. Acute colonic pseudo-obstruction: A systematic review of aetiology and mechanisms. World J Gastroenterol 2017; 23:5634-5644. [PMID: 28852322 PMCID: PMC5558126 DOI: 10.3748/wjg.v23.i30.5634] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 06/29/2017] [Accepted: 07/22/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To critically review the literature addressing the definition, epidemiology, aetiology and pathophysiology of acute colonic pseudo-obstruction (ACPO). METHODS A systematic search was performed to identify articles investigating the aetiology and pathophysiology of ACPO. A narrative synthesis of the evidence was undertaken. RESULTS No consistent approach to the definition or reporting of ACPO has been developed, which has led to overlapping investigation with other conditions. A vast array of risk factors has been identified, supporting a multifactorial aetiology. The pathophysiological mechanisms remain unclear, but are likely related to altered autonomic regulation of colonic motility, in the setting of other predisposing factors. CONCLUSION Future research should aim to establish a clear and consistent definition of ACPO, and elucidate the pathophysiological mechanisms leading to altered colonic function. An improved understanding of the aetiology of ACPO may facilitate the development of targeted strategies for its prevention and treatment.
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Abstract
Ogilvie syndrome is defined as colonic pseudo-obstruction due to nonmechanical causes. Mortality of nearly 50% is associated with perforation of the distended, pseudo-obstructed colon. While conservative medical therapy has proven to be beneficial in a majority of cases, >3% of patients have significant distention or perforation of the colon that warrants surgical resection. The case of a 48-year-old male with progressive abdominal discomfort and distention 12 days following knee replacement surgery is presented. He was subsequently diagnosed with colonic pseudo-obstruction and definitively treated with subtotal colectomy and colostomy. We propose that a more conservative approach to treatment of colonic pseudo-obstruction may prevent the need for colostomy, significantly improving quality of life.
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Affiliation(s)
- Daniel Galban
- Trinity School of Medicine, Alpharetta, Georgia, USA
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Acute colonic pseudo-obstruction in an infant after retroperitoneal pyeloplasty successfully treated with rectal irrigation. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2016. [DOI: 10.1016/j.epsc.2015.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Pervaiz O. Ogilvie's syndrome after rectal prolapse repair and total hemorrhoidectomy: Case report and Discussion. Clin Case Rep 2016; 4:154-7. [PMID: 26862413 PMCID: PMC4736515 DOI: 10.1002/ccr3.474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 08/21/2015] [Accepted: 11/12/2015] [Indexed: 11/12/2022] Open
Abstract
This case highlights the rare diagnosis of Ogilvie's syndrome after minor surgery in a private hospital where facilities and expertise are generally sparse. It shows the importance of knowledge of the subject, proper assessment, accurate diagnosis, and early input from seniors is crucial to prevent ischemia and perforation of colon that carries high mortality.
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Affiliation(s)
- Omer Pervaiz
- Spire Elland Hospital Elland Lane West Yorkshire HX5 9EB UK
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Bernardi MP, Warrier S, Lynch AC, Heriot AG. Acute and chronic pseudo-obstruction: a current update. ANZ J Surg 2015; 85:709-14. [PMID: 25943300 DOI: 10.1111/ans.13148] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2015] [Indexed: 12/13/2022]
Abstract
Acute colonic pseudo-obstruction (ACPO) and chronic intestinal pseudo-obstruction (CIPO) are distinct clinical entities in which patients present similarly with symptoms of a mechanical obstruction without an occlusive lesion. Unfortunately, they also share the issues related to a delay in diagnosis, including inappropriate management and poor outcomes. Advancements have been made in our understanding of the aetiologies of both conditions. Several predisposing factors linked to critical illness have been implicated in ACPO. CIPO is a functional motility disorder, historically misdiagnosed, with unnecessary surgery being performed in many patients with dire consequences. This review discusses the pathophysiology, clinical and diagnostic features, and treatment of each. For ACPO, a safer pharmacological approach to treatment is presented in a modified up-to-date algorithm. The importance of CIPO as a differential diagnosis when seeing patients with recurrent admissions for abdominal pain and distention is also discussed, as well as specific indications for surgery. While surgery is often a last resort, the role of the surgeon in the management of both ACPO and CIPO cannot be undervalued. By characterizing each condition in a common review, the knowledge gleaned aims to optimize outcomes for these frequently complex patients.
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Affiliation(s)
- Maria-Pia Bernardi
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Satish Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A Craig Lynch
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Pereira P, Djeudji F, Leduc P, Fanget F, Barth X. Pseudo-obstruction colique aiguë ou syndrome d’Ogilvie. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.jchirv.2015.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
Ogilvie's syndrome describes an acute colonic pseudo-obstruction (ACPO) consisting of dilatation of part or all of the colon and rectum without intrinsic or extrinsic mechanical obstruction. It often occurs in debilitated patients. Its pathophysiology is still poorly understood. Since computed tomography (CT) often reveals a sharp transition or "cut-off" between dilated and non-dilated bowel, the possibility of organic colonic obstruction must be excluded. If there are no criteria of gravity, initial treatment should be conservative or pharmacologic using neostigmine; decompression of colonic gas is also a favored treatment in the decision tree, especially when cecal dilatation reaches dimensions that are considered at high risk for perforation. Recurrence is prevented by the use of a multiperforated Faucher rectal tube and oral or colonic administration of polyethylene glycol (PEG) laxative. Alternative therapeutic methods include: epidural anesthesia, needle decompression guided either radiologically or colonoscopically, or percutaneous cecostomy. Surgery should be considered only as a final option if medical treatments fail or if colonic perforation is suspected; surgery may consist of cecostomy or manually-guided transanal pan-colorectal tube decompression at open laparotomy. Surgery is associated with high rates of morbidity and mortality.
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Jain A, Vargas HD. Advances and challenges in the management of acute colonic pseudo-obstruction (ogilvie syndrome). Clin Colon Rectal Surg 2013; 25:37-45. [PMID: 23449274 DOI: 10.1055/s-0032-1301758] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Although acute colonic pseudo-obstruction (ACPO), also known as Ogilvie syndrome, is a well-known clinical entity, in many respects it remains poorly understood and continues to challenge physicians and surgeons alike. Our understanding of ACPO continues to evolve and its epidemiology has changed as new conditions have been identified predisposing to ACPO with critical illness providing the common thread among them. A physician must keep ACPO high in the list of differential diagnoses when dealing with the patient experiencing abdominal distention, and one must be prepared to employ and interpret imaging studies to exclude mechanical obstruction. Rapid diagnosis is the key, and institution of conservative measures often will lead to resolution. Fortunately, when this fails pharmacologic intervention with neostigmine often proves effective. However, it is not a panacea: consensus on dosing does not exist, administration techniques vary and may impact efficacy, contraindications limit its use, and persistence and or recurrence of ACPO mandate continued search for additional medical therapies. When medical therapy fails or is contraindicated, endoscopy offers effective intervention with advanced techniques such as decompression tubes or percutaneous endoscopic cecostomy providing effective results. Operative intervention remains the treatment of last resort; surgical outcomes are associated with significant morbidity and mortality. Therefore, a surgeon should be aware of all options for decompression-conservative, pharmacologic, and endoscopic-and use them in best combination to the advantage of patients who often suffer from significant concurrent illnesses making them poor operative candidates.
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Affiliation(s)
- Arpana Jain
- Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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Abstract
Bowel obstruction and abdominal hernia are commonly observed in patients seeking emergency care for abdominal pain. This article discusses bowel obstruction, adynamic ileus, acute colonic pseudo-obstruction, and abdominal hernias, with particular emphasis on the management of patients in the emergency department (ED). Although the diagnostic approach to bowel obstruction often requires imaging, abdominal hernia may be identified in most circumstances by history and physical examination alone. Urgent surgical consultation is indicated when there is a concern for bowel ischemia, strangulation, or complete obstruction. This article reviews an ED-based approach to the patient presenting with symptoms of bowel obstruction or hernia.
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Affiliation(s)
- Geoffrey E Hayden
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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Shakir AJ, Sajid MS, Kianifard B, Baig MK. Ogilvie's syndrome-related right colon perforation after cesarean section: a case series. Kaohsiung J Med Sci 2011; 27:234-8. [PMID: 21601169 DOI: 10.1016/j.kjms.2010.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 11/24/2010] [Indexed: 12/13/2022] Open
Abstract
The objective of this article is to discuss and report three cases of right colon perforation secondary to postcesarean Ogilvie's syndrome (OS; colonic pseudo-obstruction) requiring right hemicolectomy. We retrospectively reviewed the case notes of three patients who underwent caesarean section and postoperatively developed OS. OS is an uncommon problem in patients undergoing caesarean section. Abdominal X-ray and water-soluble contrast enema are the main diagnostic modalities. Drip-suck therapy along with endoscopic or pharmacological decompression should be performed in early stages. In a significant percentage of patients, diagnosis is delayed resulting in bowel ischemia and perforation requiring surgical resection and adding significant mortality/morbidity. We recommend our obstetric colleagues to involve surgical team in earlier stages to avoid surgery-related mortality and morbidity. We also advocate general surgeons to be aware of OS in patients after caesarean section and recommend a stepwise systematic approach toward the diagnosis and management of OS.
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Affiliation(s)
- Ali Jabbir Shakir
- Department of Colorectal Surgery, Worthing Hospital, Worthing, West Sussex, United Kingdom
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Mainguy Le Gallou C, Eboué C, Vardon D, Von Théobald P, Dreyfus M. [Ogilvie's syndrome following cesarean section: Just think! Report of two cases and review of the literature]. JOURNAL DE GYNECOLOGIE, OBSTETRIQUE ET BIOLOGIE DE LA REPRODUCTION 2011; 40:557-63. [PMID: 21257272 DOI: 10.1016/j.jgyn.2010.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Revised: 11/03/2010] [Accepted: 11/17/2010] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To identify clinical and radiological signs of the post-cesarean Ogilvie's syndrome in order to establish the appropriate treatment. PATIENTS AND METHODS Based on the Medline research, we listed 41 cases of Ogilvie's syndrome after cesarean section. We analyzed the patient's age, the clinical and radiological signs, the time to diagnosis, and the treatments and their efficiency. RESULTS The clinical signs generally appear in the first 72 h after cesarean. Diagnosis of Ogilvie's syndrome is based on a clinical picture of acute obstruction of the large bowel and by X-ray showing a large caecum without pathological lesion. If the caecal diameter is under 12 cm, conservative treatment is done with colonoscopic decompression when necessary, however if there are signs of peritonitis surgery is recommended. CONCLUSION Ogilvie's syndrome after cesarean section is uncommon. Diagnosis must be fast in order to avoid the caecum to burst causing faecal peritonitis, which carries slight mortality rate.
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Affiliation(s)
- C Mainguy Le Gallou
- Service gynécologie-obstétrique et médecine de la reproduction, CHU Caen, avenue Côte-de-Nacre, 14033 Caen cedex 9, France.
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RAWLINGS C. Management of postcaesarian Ogilvie’s syndrome and their subsequent outcomes. Aust N Z J Obstet Gynaecol 2010; 50:573-4. [DOI: 10.1111/j.1479-828x.2010.01214.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Dejou-Bouillet L, Bourdel N, Slim K, Vernis L, Bazin JE, Bonnin M, Rabischong B, Tran X, Mage G, Canis M. [Ogilvie's syndrome after cesarean section: a case report]. ACTA ACUST UNITED AC 2010; 38:347-9. [PMID: 20430677 DOI: 10.1016/j.gyobfe.2010.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Accepted: 01/29/2010] [Indexed: 01/24/2023]
Abstract
We report a case of acute postcesarean colonic pseudo-obstruction (Ogilvie's syndrome). We report the treatment algorithm we followed. Recording to this algorithm may improve the treatment of this pathology and perhaps avoid surgical treatment in emergency.
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Affiliation(s)
- L Dejou-Bouillet
- Département de gynécologie obstétrique, CHU Estaing Clermont-Ferrand, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand cedex 1, France
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Abstract
AbstractBackgroundAcute colonic pseudo-obstruction is characterized by clinical and radiological evidence of acute large bowel obstruction in the absence of a mechanical cause. The condition usually affects elderly people with underlying co-morbidities, and early recognition and appropriate management are essential to reduce the occurrence of life-threatening complications.MethodsA part-systematic review was conducted. This was based on key publications focusing on advances in management.Results and conclusionsAlthough acute colonic dilatation has been suggested to result from a functional imbalance in autonomic nerve supply, there is little direct evidence for this. Other aetiologies derived from the evolving field of neurogastroenterology remain underexplored. The rationale of treatment is to achieve prompt and effective colonic decompression. Initial management includes supportive interventions that may be followed by pharmacological therapy. Controlled clinical trials have shown that the acetylcholinesterase inhibitor neostigmine is an effective treatment with initial response rates of 60–90 per cent; other drugs for use in this area are in evolution. Colonoscopic decompression is successful in approximately 80 per cent of patients, with other minimally invasive strategies continuing to be developed. Surgery has thus become largely limited to those in whom complications occur. A contemporary management algorithm is provided on this basis.
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Affiliation(s)
- R De Giorgio
- Department of Clinical Medicine and Centro Unificato di Ricerca BioMedica Applicata, University of Bologna, Bologna, Italy
| | - C H Knowles
- Centre for Academic Surgery, Royal London Hospital, London, UK
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25
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Delgado-Aros S, Ilzarbe Sánchez L. [Gastrointestinal endoscopy. Is decompressive endoscopy indicated as the first-line measure in patients with acute colonic pseudoobstruction, also known as Ogilvie syndrome?]. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:620-1. [PMID: 19091255 DOI: 10.1157/13128306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Ileus and colonic pseudo-obstruction cause functional obstruction of intestinal transit, without mechanical obstruction, because of uncoordinated or attenuated intestinal muscle contractions. Ileus usually arises from an exaggerated intestinal reaction to abdominal surgery that is often exacerbated by numerous other conditions. Colonic pseudo-obstruction is induced by numerous metabolic disorders, drugs that inhibit intestinal motility, severe illnesses, and extensive surgery. It presents with massive colonic dilatation with variable, moderate small bowel dilatation. Both conditions are initially treated with supportive measures that include intravenous rehydration, correction of electrolyte abnormalities, discontinuation of antikinetic drugs, and treatment of other contributing disorders. Specific therapies for colonic pseudo-obstruction include neostigmine (an anticholinesterase) for pharmacologic colonic decompression and colonoscopic decompression.
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Affiliation(s)
- Mihaela Batke
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, MOB 233, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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McNamara R, Mihalakis MJ. Acute colonic pseudo-obstruction: rapid correction with neostigmine in the emergency department. J Emerg Med 2008; 35:167-70. [PMID: 18242923 DOI: 10.1016/j.jemermed.2007.06.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2007] [Accepted: 06/12/2007] [Indexed: 11/30/2022]
Abstract
Ogilvie's syndrome, now known as acute colonic pseudo-obstruction, is characterized by massive dilatation of large bowel in the absence of mechanical obstruction. It is found in a variety of patients, although elderly and immobile patients make up a large portion of the afflicted population. This article discusses the case of a 64-year-old bedridden, paraplegic, male nursing home resident who presented to the Emergency Department with a chronic history of abdominal distention that acutely worsened on the day of his arrival. A diagnosis of acute colonic pseudo-obstruction was made and 2 mg of intravenous neostigmine was administered, with resolution of the patient's condition allowing for subsequent Emergency Department discharge. This report discusses the utilization of neostigmine, an acetylcholinesterase inhibitor, for patients with colonic pseudo-obstruction. We also briefly review the literature on this condition and other therapeutic options.
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Affiliation(s)
- Robert McNamara
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA
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28
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Cowlam S, Watson C, Elltringham M, Bain I, Barrett P, Green S, Yiannakou Y. Percutaneous endoscopic colostomy of the left side of the colon. Gastrointest Endosc 2007; 65:1007-14. [PMID: 17531635 DOI: 10.1016/j.gie.2007.01.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2006] [Accepted: 01/04/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND Percutaneous endoscopic colostomy (PEC) on the left side of the colon is a minimally invasive endoscopic technique, increasingly used to treat lower-GI conditions. OBJECTIVE To evaluate the efficacy and safety of a PEC tube insertion at a single unit. DESIGN Retrospective data collection. SETTING District general and teaching hospital in the United Kingdom. PATIENTS Data collected from patients with lower-GI disorders who had a PEC tube inserted. INTERVENTIONS Data collection. MAIN OUTCOME MEASUREMENTS Incidence of complications and patient outcome. RESULTS Between 2001 and 2005, 31 patients presented for a PEC. Insertion was possible in 27 patients. Indications included functional constipation (n=8), recurrent sigmoid volvulus (n=8), colonic pseudo-obstruction (n=5), and neurologic constipation (n=6). In 22 patients (81%), symptoms were markedly improved after insertion. Sigmoid volvulus did not recur with a PEC tube in place. The mean (standard error of the mean) duration with tubes in situ was 9.5+/-1.6 months. Only 2 patients still had a PEC tube in situ. A total of 77% of patients had episodes of infection. Infective episodes led to tube removal in 44% of the total group. Other complications included buried internal bolster, fecal leakage, and pain. Mortality was high (26%), with 7 deaths: 5 from unrelated causes and 2 deaths from fecal peritonitis. LIMITATIONS This was a retrospective study. A prospective study in our unit is unlikely because of these results. CONCLUSIONS Symptoms were effectively controlled by a PEC tube insertion, and recurrent sigmoid volvulus was prevented. Recurrent complications caused significant morbidity. Infection necessitated tube removal in the majority of patients. Fatal fecal peritonitis occurred in 2 patients. Indiscriminate use of a PEC in the left side of the colon is not recommended. A PEC should only be considered in carefully selected cases.
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Affiliation(s)
- Simon Cowlam
- Department of Medicine, University Hospital of North Durham, North Road, Durham, UK
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29
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Mehta R, John A, Nair P, Raj VV, Mustafa CP, Suvarna D, Balakrishnan V. Factors predicting successful outcome following neostigmine therapy in acute colonic pseudo-obstruction: a prospective study. J Gastroenterol Hepatol 2006; 21:459-461. [PMID: 16509875 DOI: 10.1111/j.1440-1746.2005.03994.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIM To evaluate predictors of neostigmine response in patients with acute colonic pseudo-obstruction. METHODS Twenty-seven patients with acute colonic pseudo-obstruction were enrolled in the study. All patients had received initial conservative management such as nil orally, nasogastric suction, rectal tube placement and correction of electrolyte imbalance for the first 24 h. Those who did not resolve with conservative management received 2 mg neostigmine intravenously. The same dose was repeated after 24 h in patients who did not response to the first dose (initial non-responders), or in those patients who relapsed after an initial response (initial responders). All non-responders to neostigmine underwent colonoscopic decompression followed by 2 mg neostigmine infusion for 30 min. A sustained response was defined as the resolution of symptoms and colonic dilatation on a plain radiograph. RESULTS The study enrolled 27 patients; 18 were male (67%), and the median age was 60 years (range 18-78 years). Eight (30%) patients had spontaneous resolution. Initial response with neostigmine was observed in 16 (84%) patients, of which 10 (63%) had a sustained response. Nine patients (three initial non-responders and six initial responders) had received a second dose of neostigmine. A sustained response was seen only in five initial responders. Four patients who did not respond to neostigmine underwent colonoscopic decompression followed by neostigmine infusion and had a sustained response. Neostigmine responders were more likely to be postoperative patients (11 of 15 (73%) vs one of four (25%), P = 0.07), less likely to have electrolyte imbalance and to be on antimotility agents (three of 15 (20%) vs four of four (100%), P = 0.009 and two of 15 (13%) vs four of four (100%), P = 0.003). CONCLUSIONS Electrolyte imbalance and usage of anti-motility agents are factors associated with a poor response, while postoperative patients showing good response to neostigmine therapy.
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Affiliation(s)
- Rajiv Mehta
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Cochin, Kerala, India.
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30
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Kalu E, Fakokunde A, Jesudason M, Whitlow B. Acute colonic pseudo-obstruction (Ogilvie's Syndrome) following caesarean section for triplets. J OBSTET GYNAECOL 2005; 25:299-300. [PMID: 16147743 DOI: 10.1080/01443610500105928] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- E Kalu
- Assisted Conception Unit, St Helier University Hospital, Wrythe Lane, Carshalton, Surrey, UK.
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31
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Abstract
A 32-year-old patient developed pseudo-obstruction of the large bowel following elective caesarean section. The association of this rare postoperative complication with anaesthesia is discussed. Pseudo-obstruction of the large bowel (Ogilvie's Syndrome), is characterised by an adynamic mechanically unobstructed bowel which may progress to marked dilatation of the caecum. The reported mortality varies from 14-30% rising to 40-50% if there is caecal perforation. The underlying mechanism is thought to be an imbalance of the autonomic nervous system.
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Affiliation(s)
- M A Dickson
- Department of Anaesthetics, Edinburgh Royal Infirmary, Edinburgh, UK
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32
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33
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Suri S, Hillman K. Neostigmine for treatment of acute colonic pseudo-obstruction. Indian J Crit Care Med 2005. [DOI: 10.4103/0972-5229.17094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Hamilton SW, Jabbar AA. Ogilvie's syndrome: a rare complication of inguinal hernia repair. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2004; 65:562-3. [PMID: 15449496 DOI: 10.12968/hosp.2004.65.9.15989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
A 49-year-old man had an open, tension-free, mesh (Lichtenstein) repair performed under general anaesthetic for a left-sided direct inguinal hernia. His immediate postoperative recovery was uneventful and he was discharged the following day. He was readmitted as an emergency 2 days later with intermittent abdominal pain, nausea and complete constipation. On examination his abdomen was slightly distended, but was not tender. X-ray (Figure 1) showed dilated loops of small bowel with gas in the colon and rectum. He was managed conservatively. However, over the next 24 hours his symptoms became worse with increasing abdominal pain and vomiting. He was still passing no flatus. His abdomen became more distended and generally tender to light palpation. Repeat X-ray (Figure 2) revealed markedly distended small bowel and a grossly distended caecum. He proceeded to theatre as the caecal distension was increasing and he had developed signs of peritoneal irritation. At laparotomy his bowel was free from the left hernia repair and no mechanical cause for the obstruction was found. The colon was distended to the rectum and the caecum was 10 cm in diameter with tearing almost imminent. It was therefore decompressed with an aspiration needle and on-table sigmoidoscopy. Appendicectomy was performed and the stump used to place a caecostomy. Recovery was slow but he was discharged home 2 weeks after readmission.
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Affiliation(s)
- S W Hamilton
- Department of Orthopaedic Surgery, Aberdeen Royal Infirmary, Aberdeen
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35
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Abstract
The gastroenterologist is frequently involved in the care of patients with bowel obstruction and pseudo-obstruction. In the case of obstruction, the central problem is determining which patients should be managed surgically. In both SBO and LBO, evidence of vascular compromise to the gut mandates surgical intervention. Most patients with pseudo-obstruction respond to conservative therapy or neostigmine. Endoscopic decompression is indicated in recalcitrant cases, with surgery reserved as a last resort.
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Affiliation(s)
- Charles J Kahi
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, 550 North University Boulevard, UH 4100, Indianapolis, IN 46202-5121, USA
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36
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Pokorny H, Plöchl W, Soliman T, Herneth AM, Scharitzer M, Pokieser P, Berlakovich GA, Mühlbacher F. Acute colonic pseudo-obstruction (Ogilvie’s-syndrome) and Pneumatosis intestinalis in a kidney recipient patient. Wien Klin Wochenschr 2003; 115:732-5. [PMID: 14650951 DOI: 10.1007/bf03040892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Acute colonic pseudo-obstruction (Ogilvie's syndrome) is a clinical entity characterized by massive nontoxic dilatation of the colon in the absence of mechanical obstruction and is associated with increased morbidity and mortality in the immunosuppressed patient. We present a case of a kidney transplant recipient developing a life-threatening condition with acute colonic pseudo-obstruction associated with radiologic findings of a linear pneumatosis intestinalis (PI). Urgent laparotomy and resection of the dilated cecum, colon ascendens and transversum was performed because of bowel necrosis with multiple serosal defects. Stool cultures and special stains for microorganisms were all negative, and there was no evidence for viral or fungal infection. The patient was discharged 31 days after transplantation with normal renal function. In conclusion, this steroid-induced ileus (pseudo-obstruction) is a potentially malignant early form of colonic dysmotility rarely reported in transplant recipients. Awareness and early recognition of the condition are critical for a successful outcome. Colonoscopic decompression can achieve reversal of colonic dilatation in most cases, but in some patients prophylactic laparotomy is indicated for prevention of the catastrophic consequences of perforation.
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Affiliation(s)
- Herwig Pokorny
- Division of Transplantation, Department of Surgery, University Hospital Vienna, Vienna, Austria.
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37
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Abstract
Intestinal pseudo-obstruction is defined as a clinical syndrome characterized by impairment of intestinal propulsion, which may resemble intestinal obstruction, in the absence of a mechanical cause. It may involve the small and/or the large bowel, and may present in acute, subacute or chronic forms. We have performed a systematic review of acute pseudo-obstruction, also referred to as Ogilvie's syndrome in the literature, and focused on proposed mechanisms, manifestations and management of post-surgery and critically ill patients who suffer from one or more underlying clinical conditions. The hallmark of the syndrome is massive intestinal distension, which is detected on clinical inspection and plain abdominal radiography. The underlying pathophysiological mechanisms are not fully understood. Therefore, treatment focuses on preventing intestinal perforation, which is associated with an average 21% mortality rate.
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Affiliation(s)
- Silvia Delgado-Aros
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, 200 First Street SW, Charlton 8-110, Rochester, MN 55905, USA
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38
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Abstract
Intestinal pseudo-obstruction is defined as a clinical syndrome characterized by impairment of intestinal propulsion, which may resemble intestinal obstruction, in the absence of a mechanical cause. It may involve the small and/or the large bowel, and may present in acute, subacute or chronic forms. We have performed a systematic review of acute pseudo-obstruction, also referred to as Ogilvie's syndrome in the literature, and focused on proposed mechanisms, manifestations and management of post-surgery and critically ill patients who suffer from one or more underlying clinical conditions. The hallmark of the syndrome is massive intestinal distension, which is detected on clinical inspection and plain abdominal radiography. The underlying pathophysiological mechanisms are not fully understood. Therefore, treatment focuses on preventing intestinal perforation, which is associated with an average 21% mortality rate.
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Affiliation(s)
- Silvia Delgado-Aros
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, 200 First Street SW, Charlton 8-110, Rochester, MN 55905, USA
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Delgado-Aros S, Camilleri M. Manejo clínico de la seudoobstrucción aguda de colon en el enfermo hospitalizado: revisión sistemática de la bibliografía. GASTROENTEROLOGIA Y HEPATOLOGIA 2003; 26:646-55. [PMID: 14670240 DOI: 10.1016/s0210-5705(03)70426-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Intestinal pseudoobstruction is a clinical syndrome characterized by impairment of intestinal propulsion, which may resemble intestinal obstruction, in the absence of a mechanical cause. It usually affects the colon but the small intestine may also be involved, and may present in acute, subacute or chronic forms. We have performed a systematic review of the acute form of pseudoobstruction, also referred to as Ogilvie's syndrome. We discuss proposed pathophysiological mechanisms, manifestations and management of this clinical condition in post-surgery and critically ill patients. The hallmark of the syndrome is massive intestinal distension, which is detected on clinical inspection and plain abdominal radiography. The underlying pathophysiological mechanisms are not fully understood. Therefore, treatment has focussed on preventing intestinal perforation, which is associated with a 21% mortality rate.
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Affiliation(s)
- S Delgado-Aros
- Clinical Enteric Neuroscience Translational & Epidemiological Research (CENTER) Program. Mayo Clinic. Rochester. United States.
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Loftus CG, Harewood GC, Baron TH. Assessment of predictors of response to neostigmine for acute colonic pseudo-obstruction. Am J Gastroenterol 2002; 97:3118-22. [PMID: 12492198 DOI: 10.1111/j.1572-0241.2002.07108.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Acute colonic pseudoobstruction (ACPO) most commonly develops after surgery, with narcotic administration, or in association with severe illness. Most cases resolve with conservative management. Colonoscopic decompression may be required in patients failing to respond to conservative treatment. Neostigmine has been proposed as an effective treatment for ACPO as an alternative to colonoscopic decompression. We sought to identify factors associated with spontaneous resolution of ACPO and to identify variables associated with a response to i.v. administration of neostigmine for the treatment of ACPO. METHODS Retrospective analysis of Mayo Clinic's diagnostic index revealed all patients who developed ACPO between July, 1999 and September, 2001 at the Mayo Clinic Medical Center. We separately analyzed those patients who did not resolve ACPO with conservative management and to whom i.v. neostigmine was administered. Patient records were abstracted for demographic data, etiology of ACPO, management, and response to treatment. RESULTS A total of 151 patients were identified with ACPO between July, 1999 and September, 2001; 117 patients (77%) had spontaneous resolution of symptoms. Of the 34 "nonresolvers," 18 patients received neostigmine, whereas 16 did not receive neostigmine. Of those 16 patients, 11 required colonoscopic decompression, two underwent surgery, and three died of underlying illness. "Spontaneous resolvers" were less likely to be taking narcotics (59% vs 74%, p = 0.08). Of the 16 nonresolvers who did not receive neostigmine, only one had a contraindication to neostigmine use. Of the 18 patients that who received neostigmine, 16 patients (89%) had prompt evacuation (<30 min) of flatus or stool. Sustained clinical response to neostigmine was noted in 11 of 18 (61%); the remaining seven patients (39%) required colonoscopic decompression or surgery for recurrent or persistent colonic dilation. Neostigmine-responders were more likely to be older (mean age, 76 yr vs 54 yr, p = 0.03), than nonresponders. Preneostigmine cecal diameter did not differ significantly between responders (median, 12 cm) and nonresponders (median, 13 cm), p = 0.9. Median time to resolution of ACPO in spontaneous resolvers was 4 days compared to 2 days in patients responding to neostigmine; p = 0.038. CONCLUSIONS Most patients with ACPO respond to conservative treatment. Female gender and older age are associated with a response to neostigmine in those patients who do not respond to conservative management. Neostigmine appears to be under-used in patients with ACPO who do not have a true contraindication to its use.
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Affiliation(s)
- Conor G Loftus
- Division of Gastroenterology and Hepatology, Mayo Medical Center, Rochester, Minnesota, USA
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Chevallier P, Marcy PY, Francois E, Peten EP, Motamedi JP, Padovani B, Bruneton JN. Controlled transperitoneal percutaneous cecostomy as a therapeutic alternative to the endoscopic decompression for Ogilvie's syndrome. Am J Gastroenterol 2002; 97:471-4. [PMID: 11866290 DOI: 10.1111/j.1572-0241.2002.05457.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute colonic pseudo-obstruction, the so-called Ogilvie's syndrome, results in massive colonic dilation without mechanical obstruction. In most cases, a conservative treatment with or without endoscopic decompression is sufficient. In rare cases of relapses or failures, a cecostomy has to be performed. A surgical cecostomy is associated with high morbidity and mortality. However, a percutaneous cecostomy could be an interesting alternative treatment. We report the case of a 67-yr-old male with colonic pseudoobstruction for which both the conservative and the endoscopic treatments were unsuccessful. A percutaneous cecostomy was performed, and for the first time in this indication, a transperitoneal access was used with the help of nylon T-fasteners.
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Affiliation(s)
- Patrick Chevallier
- Department of Radiology, Centre Hospitalier Régional et Universitaire de Nice, Hĵpital Archet II, France
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Sheikh RA, Prindiville T, Yasmeen S. Haloperidol and benztropine interaction presenting as acute intestinal pseudo-obstruction. Am J Gastroenterol 2001; 96:934-5. [PMID: 11280595 DOI: 10.1111/j.1572-0241.2001.03660.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Acute pseudo-obstruction may manifest clinically in one of three forms--acute gastroparesis, ileus, and acute colonic pseudo-obstruction (Ogilvie's syndrome). Though formerly associated primarily with the postoperative state, these entities are increasingly recognized in association with a wide variety of major medical problems. There are few controlled studies to guide the clinician in the management of these disorders. Treatment remains largely empirical, and time-honored, based primarily on "bowel rest," nasogastric decompression, and supportive care. While a wide variety of pharmacologic approaches have been advocated, few have been subjected to, or survived, the rigors of a properly controlled trial. Neostigmine is a notable exception, and has been shown to be effective in Ogilvie's syndrome. Perforation is a significant threat in megacolon; colonoscopic, or surgical decompression may, therefore, be indicated. Both are associated with significant risks in this context, but may prevent progression to perforation with its attendant mortality. New approaches seek to exploit current concepts in the pathophysiology of ileus and megacolon but have not, as yet, achieved efficacy in human studies.
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Trevisani GT, Hyman NH, Church JM. Neostigmine: safe and effective treatment for acute colonic pseudo-obstruction. Dis Colon Rectum 2000; 43:599-603. [PMID: 10826417 DOI: 10.1007/bf02235569] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ogilvie's syndrome, or acute colonic pseudo-obstruction, is a common and relatively dangerous condition. If left untreated, it may cause ischemic necrosis and colonic perforation, with a mortality rate as high as 50 percent. Neostigmine enhances excitatory parasympathetic activity by competing with acetylcholine for attachment to acetylcholinesterase at sites of cholinergic transmission and enhancing cholinergic action. We hypothesized that neostigmine would restore peristalsis in patients with acute colonic pseudo-obstruction. METHODS Twenty-eight patients at Fletcher Allen Health Care and The Cleveland Clinic Foundation were treated for acute colonic pseudo-obstruction with neostigmine 2.5 mg IV over 3 minutes while being monitored with telemetry. Mechanical obstruction had been excluded. RESULTS Complete clinical resolution of large bowel distention occurred in 26 of the 28 patients. Time to pass flatus varied from 30 seconds to 10 minutes after administration of neostigmine. No adverse effects or complications were noted. Of the two patients who did not resolve, one had a sigmoid cancer that required resection and one patient died from multiorgan failure. CONCLUSION This study supports the theory that acute colonic pseudo-obstruction is the result of excessive parasympathetic suppression rather than sympathetic overactivity. We have shown that neostigmine is a safe and effective treatment for acute colonic pseudo-obstruction.
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Affiliation(s)
- G T Trevisani
- Cleveland Clinic Foundation, Department of Colorectal Surgery, Ohio, USA
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Shapiro AMJ, Bain VG, Preiksaitis JK, Ma MM, Issa S, Kneteman NM. Ogilvie's syndrome associated with acute cytomegaloviral infection after liver transplantation. Transpl Int 2000. [DOI: 10.1111/j.1432-2277.2000.tb01034.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Pham TN, Cosman BC, Chu P, Savides TJ. Radiographic changes after colonoscopic decompression for acute pseudo-obstruction. Dis Colon Rectum 1999; 42:1586-91. [PMID: 10613478 DOI: 10.1007/bf02236212] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Colonoscopy has been the principal tool for decompression in acute colonic pseudo-obstruction, known as Ogilvie's syndrome. The objectives of this study were to determine the immediate effect of colonoscopy on the cecal diameter (measured on supine radiographs) and to delineate possible correlations in the diameters of dilated segments of the colon. METHODS The charts and radiographs of 24 patients who had colonoscopic decompression for acute colonic pseudo-obstruction between 1992 and 1997 at the San Diego Veterans Affairs Medical Center and the University of California, San Diego Hospitals were reviewed. We measured cecal, transverse, descending, and sigmoid colon diameters on serial radiographs up to the point of clinical resolution. RESULTS Mean +/- standard deviation cecal diameter change (between initial and post-decompression films) was -2+/-3.4 cm at four hours and -2.2+/-3.3 cm one day after decompression. On the daily radiographs between colonoscopic decompression and clinical resolution, there was a close correlation between the diameter of the cecum and that of the transverse colon (P<0.05). There was no correlation between the cecal diameter and that of the descending or sigmoid colon. CONCLUSIONS Colonoscopic decompression only causes a small decrease in cecal size in the patient with acute colonic pseudo-obstruction. Dilation patterns of the cecum and transverse colon are significantly correlated in acute colonic pseudo-obstruction. This correlation provides additional support to the contention that the same pathophysiology affects these two segments of the colon.
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Affiliation(s)
- T N Pham
- Department of Surgery, San Diego Veterans Affairs Healthcare System and University of California, USA
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Abstract
We present a case of recurrent acute colonic pseudo-obstruction (ACPO) in a burn patient that responded to a postural change which has not been previously reported.
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Affiliation(s)
- C M Estela
- Department of Burns and Plastic Surgery, Frenchay Hospital, Bristol, UK
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48
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Abstract
BACKGROUND Acute colonic pseudo-obstruction -- that is, massive dilation of the colon without mechanical obstruction -- may develop after surgery or severe illness. Although it may resolve with conservative therapy, colonoscopic decompression is sometimes needed to prevent ischemia and perforation of the bowel. Uncontrolled studies have suggested that neostigmine, may be an effective treatment. METHODS We studied 21 patients with acute colonic pseudo-obstruction. All had abdominal distention and radiographic evidence of colonic dilation, with a cecal diameter of at least 10 cm, and had had no response to at least 24 hours of conservative treatment. We randomly assigned 11 to receive 2.0 mg of neostigmine intravenously and 10 to receive intravenous saline. A physician who was unaware of the patients' treatment assignments recorded clinical response (defined as prompt evacuation of flatus or stool and a reduction in abdominal distention), abdominal circumference, and measurements of the colon on radiographs. Patients who had no response to the initial injection were eligible to receive open-label neostigmine three hours later. RESULTS Ten of the 11 patients who received neostigmine had prompt colonic decompression, as compared with none of the 10 patients who received placebo (P<0.001). The median time to response was 4 minutes (range, 3 to 30). Seven patients in the placebo group and the one patient in the neostigmine group without an initial response received open-label neostigmine; all had colonic decompression. Two patients who had an initial response to neostigmine required colonoscopic decompression for recurrence of colonic distention; one eventually underwent subtotal colectomy. Side effects of neostigmine included abdominal pain, excess salivation, and vomiting. Symptomatic bradycardia developed in two patients and was treated with atropine. CONCLUSIONS In patients with acute colonic pseudo-obstruction who have not had a response to conservative therapy, treatment with neostigmine rapidly decompresses the colon.
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Affiliation(s)
- R J Ponec
- Division of Gastroenterology, University of Washington Medical Center, Seattle 98195, USA
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O'Malley KJ, Flechner SM, Kapoor A, Rhodes RA, Modlin CS, Goldfarb DA, Novick AC. Acute colonic pseudo-obstruction (Ogilvie's syndrome) after renal transplantation. Am J Surg 1999; 177:492-6. [PMID: 10414701 DOI: 10.1016/s0002-9610(99)00093-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Acute colonic pseudo-obstruction (Ogilvie's syndrome) in the immunosuppressed patient is associated with increased morbidity and mortality. Renal transplant recipients possess several comorbidities that increase the risk of acute pseudo-obstruction of the colon. The aims of this study were to present our experience with this syndrome and to evaluate the potentiating factors in these patients. A review of the literature for pseudo-obstruction following renal transplantation is presented. METHODS Seven patients who developed Ogilvie's syndrome were identified in a retrospective review of 550 kidney-only transplants. Pretransplant data, potential risk factors, presentation, management, and outcome details were retrieved. The medical literature was reviewed using Medline. RESULTS Seventy-eight patients with Ogilvie's syndrome in the early posttransplant period have been reported. The associated morbidity and mortality was heightened in this immunocompromised population. Obese transplant recipients (body mass index >30 kg/m2) were at significantly increased risk for developing this syndrome. CONCLUSION A broad armamentarium of treatment options is available, but the key to successful resolution lies in early recognition.
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Affiliation(s)
- K J O'Malley
- Department of Urology, Cleveland Clinic Foundation, Ohio 44195, USA
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Abstract
Gastrointestinal surgical problems often mimic symptoms and signs of nonsurgical conditions that occur during pregnancy. This mimicry presents a particular challenge to diagnosis because avoiding a delay in treatment is critical to successful management. Some of these conditions, such as acute appendicitis and biliary colic, are common in younger women; however, the anatomic and physiologic changes of pregnancy can alter their usual manner of presentation. Many elective and urgent operations can be performed during pregnancy with minimal risk to the mother and fetus. The mother's condition should always take priority because her proper treatment usually benefits the fetus as well.
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Affiliation(s)
- M S Firstenberg
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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