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Pseudo-obstruction

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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
    • ~15% of patients

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


©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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