Ogilvies syndrome

acute colonic psuedo obstruction

1. Ogilvie Syndrome (Acute Colon Pseudo-obstruction)

2. Definition First described by British surgeon, William Heneage Ogilvie (1948) A syndrome characterized by a clinical picture suggestive of mechanical obstruction in the absence of any demonstrable evidence of such an obstruction in the intestine.     On the basis of the clinical presentation, can be divided into acute and chronic forms. Acute colonic pseudo-obstruction also referred to as Ogilvie syndrome   The colon is massively dilated; If not decompressed, the patient risks perforation, peritonitis, and death. The mortality rate can be as high as 40% when perforation occurs Coulie B, Camilleri M. Intestinal pseudo-obstruction. Annu Rev Med . 1999. 50:37-55 Ogilvie H. Large-intestine colic due to sympathetic deprivation; a new clinical syndrome. Br Med J . 1948 Oct 9. 2(4579)

3. Characteristics Colonic pseudo-obstruction is characterized by massive dilation of the cecum , with diameter greater than 10 cm on abdominal x-ray

4. Why is the cecum usually the most dilated? Laplace’s law The intraluminal pressure needed to stretch the wall of a hollow tube is inversely proportional to its diameter. The caecum, with its larger diameter, requires less pressure to increase in size and in wall tension. As the wall tension of the colon increases , ischemia with longitudinal splitting of the serosa, herniation of the mucosa, and perforation

5. Pathophysiology The vagus nerve supplies the parasympathetic tone from the upper gastrointestinal (GI) tract up to the splenic flexure. The sacral parasympathetic nerves (S2 to S5) supply the left colon , sigmoid, and rectum. The lower 6 thoracic segments supply the sympathetic tone to the right colon The lumbar segments 1-3 supply the left colon . Sympathetic stimuli result in the inhibition of bowel motility and the contraction of sphincters.

6. Pathophysiology Exact mechanism is unknown Current theories continue to suggest the idea of an imbalance in the autonomic nervous system . Possibly due to ↑ sympathetic tone ↓ parasympathetic tone or a combination of both Manten HD. Pseudo-obstruction. Haubrich WS, Schaffner F, Berk JE eds. Bockus Gastroenterology . Philadelphia: WB Saunders Co; 1995. Vol 2: 1249-67.

7. Support for ↑ sympathetic tone: 1988 study by Lee et al , hypothesized that increased sympathetic tone to the colon results in the inhibition of colonic motility. By using epidural anesthesia to block the splanchnic sympathetics, the y successfully treated several patients , whose acute colonic psuedo- obstruction did not respond to conservative management One more study in 2005 - supported this hypothesis by us ing spinal anesthesia Lee JT, Taylor BM, Singleton BC. Epidural anesthesia for acute pseudo-obstruction of the colon (Ogilvie's syndrome). Dis Colon Rectum. 1988 Sep. 31(9):686-91. Mashour GA, Peterfreund RA. Spinal anesthesia and Ogilvie's syndrome. J Clin Anesth. 2005 Mar. 17(2):122-3.

8. Evidence for ↓ parasympathetic tone Disruption of the sacral innervation may leave the distal colon atonic, resulting in a functional obstruction This hypothesis is consistent with studies showing a transition between dilated and collapsed bowel often at or near the splenic flexure Bachulis BL, Smith PE. Pseudoobstruction of the colon. Am J Surg. 1978 Jul. 136(1):66-72. Christensen J. Intestinal motor physiology. Sleisenger MH, Fordtran JS, eds. Gastrointestinal Disease: Pathophysiology, Diagnosis,Management .

9. Pathophysiology In 1992 , Hutchinson et al reported successfully treating 8 of 11 patients with acute colonic pseudo-obstruction by using the sympathetic adrenergic blocker guanethidine, followed by the cholinesterase inhibitor neostigmine. Hutchinson R, Griffiths C. Acute colonic pseudo-obstruction: a pharmacological approach. Ann R Coll Surg Engl . 1992 Sep. 74(5):364-7

10. Etiology The 3 most common associations Trauma (especially retroperitoneal) Serious infection Cardiac disease (especially myocardial infarction and congestive heart failure)

11. Other causes Recent surgery (abdominal, urologic, gynecologic , orthopedic , cardiac, or neurologic) Spinal cord injury pregnancy; cesarean delivery Neurologic disorders Hypothyroidism Electrolyte imbalances Respiratory disorders Renal insufficiency Medications ( eg , narcotics,TCA , antiparkinsonian drugs, and anesthetic agents)

12. Epidemiology In studies of 13,000 orthopedic and burn patients - pr evalence was 0.29% # Slightly more prominent in males (M:F 1.5:1) A review of more than 400 cases of colonic pseudo-obstruction cases over a period of 15 years - reported a mean patient age of 56.5 years for females and 59.9 years for males . $ Mortality has been documented to be 14% in medically treated patients and 30% in surgically treated patients. # Kadesky K, Purdue GF, Hunt JL. Acute pseudo-obstruction in critically ill patients with burns. J Burn Care Rehabil . 1995 Mar-Apr. 16(2 Pt 1):132-5 $ Vanek VW, Al- Salti M. Acute pseudo-obstruction of the colon (Ogilvie's syndrome). An analysis of 400 cases. Dis Colon Rectum . 1986 Mar. 29(3):203-10.

13. Complications C an lead to ischemic necrosis in the massively dilated intestinal segments Volvulus The most serious complication of colonic pseudo-obstruction is perforation of the cecum. The reported incidence of caecal perforation is 3-40%, and the associated mortality is 40-50%. A caecal diameter greater than 14 cm , a delay in colonic decompression , and advanced age are all predictors of colonic perforation Dorudi S, Berry AR, Kettlewell MG. Acute colonic pseudo-obstruction. Br J Surg. 1992 Feb. 79(2):99-103. [Medline].

14. Clinical Presentation Occurs most commonly in debilitated, hospitalized patients with multiple medical problems  Surgical patients –symptoms usually insidious in onset, an average of 3-5 days postoperatively . Abdominal pain (80%) Nausea and vomiting (80%) Obstipation (40%) 40% may have a recent history of flatus or passage of stool Fever (37%) Alwan MH, van Rij AM. Acute colonic pseudo-obstruction. Aust N Z J Surg . 1998 Feb. 68(2):129-32.

15. Physical Examination Abdominal distention (90-100%) Abdominal tenderness (64%) Hypoactive, high pitched, or absent bowel sounds (60%) Normal or hyperactive bowel sounds (40%) Empty rectum on DRE Guarding and rigidity Vanek VW, Al- Salti M. Acute pseudo-obstruction of the colon (Ogilvie's syndrome). An analysis of 400 cases. Dis Colon Rectum . 1986 Mar. 29(3):203-10.

16. Workup Hyponatremia and  hypokalemia can be present -signify dehydration.   Most useful screening test for intestinal pseudo-obstruction is plain abdominal X-ray The transition between dilated and collapsed bowel is usually near the splenic flexure but can occasionally occur in the distal or sigmoid colon Air-fluid levels are only occasionally observed small bowel dilatation can occur, when the ileocecal valve is incompetent Flexible colonoscopy  can differentiate colonic pseudo-obstruction from mechanical colonic obstruction and can also serve a therapeutic function when colonic decompression is performed Grassi R, Cappabianca S, Porto A, et al. Ogilvie's syndrome (acute colonic pseudo-obstruction): review of the literature and report of 6 additional cases. Radiol Med . 2005 Apr. 109(4):370-5.

17. Abdominal CT scan is very helpful to confirm the diagnosis by excluding mechanical obstruction and toxic megacolon

18. Younger age at the time of diagnosis, Abdominal distention as a chief complaint, Greater caecal diameter - independently associated with poor responses to medical treatment . Lee KJ, Jung KW, Myung SJ, et al. The clinical characteristics of colonic pseudo-obstruction and the factors associated with medical treatment response : a study based on a multicenter database in Korea. J Korean Med Sci . 2014 May . 29 (5):699-703

19. Medical Treatment Conservative therapy: N PO Decompressive nasogastric tube Maintenance IV fluids Bowel regimen – scheduled suppositories / enemas Discontinue offending agents Treatment of infections Incentive spirometry and intermittent positive-pressure breathing may aggravate colonic dilatation and should be avoided if possible. Changing the patient’s position in bed may help mobilize intestinal gas. Manten HD. Pseudo-obstruction. Haubrich WS, Schaffner F, Berk JE eds. Bockus Gastroenterology . Philadelphia: WB Saunders Co; 1995. Vol 2: 1249-67.

20. Neostigmine Neostigmine is effective in treating 85-90% Should be administered only in patients without any mechanical colonic obstruction. Adverse effects salivation, nausea, vomiting, abdominal pain, bradycardia, hypotension, and bronchospasm.   Patients should undergo cardiac monitoring, and atropine should be readily available during the administration. A slow infusion may carry a lower risk of bradycardic episodes than an IV bolus does.   Halverson A. Acute colonic pseudoobstruction . Cameron JL, ed. Current Surgical Therapy . 9th ed. Philadelphia: Mosby-Elsevier; 2008. 192-5.

21. In a prospective placebo-controlled trial Neostigmine infusion was also found to resolve critical illness−related colonic ileus in intensive care unit (ICU) patients with multiple organ failure.   In this trial, neostigmine was administered via continuous IV infusion at a dosage of 0.4-0.8 mg/hr over 24 hours . van der Spoel JI, Oudemans -van Straaten HM, Stoutenbeek CP, Bosman RJ, Zandstra DF. Neostigmine resolves critical illness-related colonic ileus in intensive care patients with multiple organ failure--a prospective, double-blind, placebo-controlled trial. Intensive Care Med . 2001 May.

22. In 1999, Ponec et al conducted the first randomized controlled study using neostigmine. Randomly assigned 21 patients to receive either 2 mg of neostigmine IV or placebo Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med . 1999 Jul 15.

23. Other Medications Lactulose or low-dose polyethylene glycol (both of which are nonabsorbable, nonmetabolized osmotic agents) Daily bisacodyl suppositories helpful to induce rectal emptying and prevent recurrences. Erythromycin , a motilin like agent. Methylnaltrexone , a peripherally acting opioid antagonist , has been reported to be effective in a patient on opioids following surgery Attar A, Lemann M, Ferguson A, et al. Comparison of a low dose polyethylene glycol electrolyte solution with lactulose for treatment of chronic constipation. Gut . 1999 Feb. 44(2):226-30.

24. Colonoscopic Decompression Documented success rates ranging from 77% to 86% with morbidities of only 0.2-2%. A study report that retrospectively assessed 100 patients over a period of 10 years concluded that colonoscopy is superior to neostigmine and should be considered first-line therapy. Any sign of mucosal ischemia ( eg , mucosal ulceration, submucosal hemorrhage, or friable mucosa with yellow exudates) indicates the need for urgent laparotomy   Tsirline VB, Zemlyak AY, Avery MJ, et al. Colonoscopy is superior to neostigmine in the treatment of Ogilvie's syndrome. Am J Surg . 2012 Dec. 204(6):849-55; discussion 855. Fiorito JJ, Schoen RE, Brandt LJ. Pseudo-obstruction associated with colonic ischemia: successful management with colonoscopic decompression. Am J Gastroenterol . 1991 Oct. 86(10):1472-6.

25.  Mean durations of conservative management ranging from 3 days to 6.5 days and have reported even longer periods if clinical signs of perforation were absent and caecal diameters were less than 9 cm Analysis of 1027 cases reported in the literature concluded that a nonoperative approach (including conservative measures and colonoscopic decompression as the initial therapy of choice) was associated with few complications and high efficacy.  # Early recognition and prompt appropriate conservative therapy could lower morbidity and mortality and can reduce the number of cases requiring surgical intervention $ # Wegener M, Borsch G. Acute colonic pseudo-obstruction (Ogilvie's syndrome). Presentation of 14 of our own cases and analysis of 1027 cases reported in the literature. Surg Endosc . 1987. $ Carcoforo P, Jorizzo EF, Maestroni U, Soliani G, Bergossi L, Pozza E. A new approach to the cure of the Ogilvie's syndrome. Ann Ital Chir . 2005 Jan-Feb

26. Surgical Treatment In cases of acute colonic dilatation without perforation or ischemia, tube cecostomy should be considered. This procedure can be performed via an open, a percutaneous, or a laparoscopic approach.   In some patients, this procedure is curative, and the tube may later be removed without the need for subsequent surgical intervention laparotomy is indicated if signs and symptoms of ischemia or perforation are present or if colonoscopy confirms ischemia

27. Percutaneous Emergency Needle Caecostomy for Prevention of Caecal Perforation Alexandra M. Limmer , Zackariah Clement 2017 case report

28. Our Experience