Acute colonic pseudo-obstruction
Also known as Ogilvie's syndrome
Characterised by massive dilatation of the colon in the absence of mechanical
obstruction. More common in the elderly.
Causes and precipitants
- Post operative
- intra-abdominal surgery
- spinal surgery (especially lumbar)
- other orthopaedic surgery
- gynaecological surgery
- urological surgery
- trauma
- retroperitoneal
- spinal cord injury
- Medical
- sepsis
- neurological disorders
- hypothyroidism
- viral infections (herpes, varicella zoster)
- cardiac or respiratory disorders
- electrolyte imbalance
- hypokalaemia
- hypocalcaemia
- hypomagnesaemia
- drugs
- narcotics
- anticholinergic agents
- tricyclic antidepressants
- phenothiazines
- anti-Parkinsonian drugs
- anaesthetic agents
- renal insufficiency
Complications
- perforation
- most commonly caecal
- associated with caecal diameter >10-12 cm and distension for >6
days
- 3-15% of patients with mortality rate of ~50%
- colonic ischaemia
Investigations
- vital to exclude mechanical obstruction. If there is any suspicion that
the patient has mechanical obstruction a water soluble contrast enema of
rectum and distal colon should be obtained
- exclude intra-abdominal infection
- regular abdominal X-rays to monitor caecal diameter
- WCC and electrolytes
- other investigations to determine cause or precipitants
Management
- correct precipitating factors
- serial examination for development of abdominal tenderness or other signs
of peritonitis
- AXR every 12 h
Conservative measures
- can be used alone for 24-48 hours for patients without significant
abdominal pain or signs of peritonitis and who have one or more potential
underlying factors that are reversible
- NG tube for gut decompression
- rectal tube
- body positioning (if feasible)
- prone with hips elevated on a pillow or knee-chest position with hips
held high. These positions often aid the spontaneous evacuation of
flatus
- alternate hourly with right and left lateral decubitus position
- active intervention indicated for:
- patients who deteriorate despite conservative measures
- clinical features of ischaemia or perforation
- significant pain
- fever
- leucocytosis
- respiratory compromise
Drug therapy
- although several drugs have been tried (eg metoclopramide, erythromycin)
the only neostigmine produces consistently positive results
- 2 mg intravenously
- parasympathetic stimulation can also induce:
- bradycardia, asystole
- hypotension
- restlessness
- fits
- tremor
- miosis
- bronchoconstriction
- hyperperistalsis
- nausea, vomiting
- salivation
- diarrhoea
- sweating
Invasive measures
Indicated for patients who fail or who have contraindications to neostigmine
treatment
Endoscopic treatment
- Colonoscopic decompression with placement of decompression tube
- preferred invasive method of decompression with success rate of 61-78%
on initial procedure and ultimate succcess after 1 or more procedures o
73-88%
- recurrence (18-33%) appears to be more likely if decompression tube
not placed
- complications in 0-4% and perforation rate of up to 3%
- colonic ischaemia may be a contra-indication
Surgical decompression
- caecostomy or colectomy
- reserved for patients who fail endoscopic decompression and
neostigmine or who have other indications for laparotomy
Further reading
American
Society of Gastrointestinal Endoscopy. Acute colonic pseudo-obstruction.
Gastrointestinal Endoscopy, 2002; 56:789-92
Ponec
RJ et al.Neostigmine for the Treatment of Acute Colonic Pseudo-Obstruction. N
Engl J Med, 1999; 341:137-141
Useful link
Napolitano
L, Dunne J. Intestinal pseudo-obstruction: Surgical Perspective
Created April 2004 | 
