Caring for people, particularly children, can be very humbling. Just when you think you have a grasp of the potential hazards and pitfalls, a new zebra runs you over. While focusing extensively on “zebras” can be counterproductive, it is useful to know that they do exist. We have previously covered a few “zebras” (ex, Pheochromocytoma, Gradenigo’s Syndrome, Osteosarcoma, Hypertensive Emergency, Cerebral Venous Thrombosis) and hopefully this will help us spot those stripped creatures running with the horses. Another zebra came close to running me over the other day. Let us take a minute to review Colonic Pseudo-Obstruction, Ogilvie’s Syndrome.
Ogilvie’s Syndrome: Basics
- Also known as Acute Colonic Pseudo-Obstruction
- First described by Sir Heneage Ogilvie in 1948.
- Colonic obstruction WITHOUT evidence of an organic / mechanical obstruction.
- It has limited small bowel involvement (which distinguishes it from adynamic ileus).
- Nausea and vomiting
- Abdominal pain
- Obstipation (which sounds terrible)
- Abdominal distension
Pathophysiology is still not clear: [Hooten, 2014; Shukla, 2007]
- May be due to suppression of sacral parasympathetic nerves.
- May be due to increased sympathetic tone inhibiting colonic motility.
- May be due to prostaglandin abnormalities.
Who’s at risk:
- Acutely critically ill patients (ex, Sepsis, Trauma, Metabolic derangements, Peritonitis, Kawasaki Disease) [Shukla, 2007]
- Chronically ill patients (ex, Malignancies, Spinal injury, Diabetes, Sickle Cell Disease) [Khosla, 2008]
- Post-operative patients [Hooten, 2014; Jiang, 2007]
- Medications that affect the bowel (ex, narcotics, sedative/hypnotics, TCAs)
- It is a clinical diagnosis.
- Requires exclusion of other mechanical obstructions.
- No specific laboratory studies.
- Abdominal Plain Films are most useful and show: [Shukla, 2007]
- Colonic and cecal dilation
- Normal austral markings
- Thin colonic wall
- Gasesous distension with little fluid in bowel lumen (so unlike mechanical obstruction with air-fluid levels)
- No established criteria for colonic diameter for pediatric patients. [Shukla, 2007]
Ogilvie’s Syndrome: The Problem
- Despite there being no mechanical obstruction, the condition can lead to significant morbidity and mortality.
- Dilation of the proximal colon leads to retention of large quantities of fecal material and gas.
- This further increases dilation of the colon.
- Intraluminal pressures in the proximal colon increase.
- The increased pressure negatively impacts the capillary blood flow to the intestinal tissue.
- Ischemia, gangrene, and perforation can occur.
Ogilvie’s Syndrome: Treatment
- Ensure that there is not a surgical process first (i.e., rule out mechanical obstruction).
- Treat the underlying medical conditions. (ex, hyponatremia)
- Conservative therapies are preferred: [Shukla, 2007]
- Bowel rest
- Nasogastric decompression
- Rectal tube decompression (if distention extends to sigmoid region)
- Discontinue offending medications
- Neostigmine [Hooten, 2014; Khosla, 2008; Gmora, 2002]
- Erythromycin [Jiang, 2007]
- Colonoscopic decompression is reserved for those who fail conservative therapies and medicines.
- Cecostomy may be required for patients with ischemia, perforation, peritonitis or failure of other therapies.
Moral of the Morsel
- Add this condition to your list of concerns for abdominal distention, particularly in the critically ill or chronically ill.
- While we might not start neostigmine in the ED for this, it is good to know conservative management and bowel decompression are important to start as soon as the bowel distention is noted.