Acute Colonic Pseudoobstruction (Ogilvie Syndrome/ACPO)

Acute Colonic Pseudoobstruction (Ogilvie Syndrome/ACPO)

Laura Lynn Beck, MD and David Ray Velez, MD

Table of Contents

Definition
Etiology
Presentation and Diagnosis
Management
Neostigmine: Use and Contraindications/Complications

Definition

Definition: Acute Colonic Dilation in the Absence of Mechanical Obstruction

Mortality Risk: 8% (40-45% if Perforated)

Etiology

Most Commonly Presents in Elderly Hospitalized Postoperative Patients with Comorbid Conditions

Medications

  • Opiates – Most Commonly Associated Medication
  • Anticholinergics
  • Dopaminergic Agents
  • Alpha-Adrenergic Agents
  • Calcium Channel Blockers
  • Antipsychotics
  • Cytotoxic Agents
  • Epidural Anesthesia

Surgery

  • Orthopedic Surgery – Particularly Hip Surgery
  • Spine Surgery
  • Pelvic Surgery
  • Cesarean Section
  • Cardiothoracic Surgery

Additional Risk Factors

  • Elderly
  • Dementia
  • Stoke
  • Malignancy
  • Infection
  • Myocardial Infarction
  • Heart Failure
  • Trauma
  • Electrolyte Imbalances
    • Hypokalemia
    • Hypocalcemia
    • Hypomagnesemia

Presentation and Diagnosis

Presentation

  • Abdominal Distention – Primary Clinical Feature
  • Abdominal Pain
  • Nausea and Vomiting
  • Constipation (51%) or Diarrhea (41%)

Symptoms Have an Average Onset 5 Days Postoperatively

Diagnosis: Made by CT Abdomen/Pelvis

  • Demonstrates Proximal Dilation Extending from the Cecum with No Mechanical Source of Obstruction
  • Extends to:
    • Hepatic Flexure: 17%
    • Splenic Flexure: 56% (Most Common)
    • Left Colon: 27%
  • Colon Wall Thickness is Usually Normal – Wall Thickening Raises Concern for Ischemia or Toxic Megacolon
  • Consider Repeat CT with Water-Soluble Rectal Contrast if Obstruction Remains Unclear

Important to Rule Out Mechanical Large Bowel Obstruction and Toxic Megacolon in Diagnostic Evaluation

Can Monitor with Abdominal Plain Film (But Not Specific for Diagnosis)

High-Risk for Perforation if the Cecum is Dilated > 10-12 cm or if Duration is > 6 Days

Acute Colonic Pseudoobstruction

Acute Colonic Pseudoobstruction

Management

The Primary Goal of Management is to Decompress the Colon to Prevent Ischemia and Perforation

Cecum Diameter < 10-12 cm: Initial Trial of Conservative Management and Bowel Rest

  • Fluid Resuscitation
  • Correct Any Electrolyte Derangements
  • Discontinue Any Contributing Medications
  • Serial Abdominal Exams
  • Serial Abdominal Plain Films Every 24 Hours
  • Success Rate: 70-90%

Cecum Diameter > 10-12 cm, Severe Abdominal Pain, or Failure of Conservative Management After 48-72 Hours: Neostigmine

If Neostigmine Contraindicated or Fails: Endoscopic Decompression

  • Endoscopy Done without Prep or Insufflation – Risk for Aspiration or Perforation
  • Extensively Suction Air Once the Most Proximal Extent Accessible is Reached
  • Consider Leaving a Decompression Tube to the Cecum or Transverse Colon for Continued Decompression (Decreases the Risk of Recurrence)

Surgical Intervention

  • Indications:
    • Failure of Medical Management (Neostigmine and Colonoscopic Decompression)
    • Ischemia
    • Perforation
    • Peritonitis
  • Surgery Generally Consists of Cecostomy/Colostomy and/or Resection as Indicated

Cecostomy Tube

  • May Be Considered for Patients Who Fail Medical Management (Neostigmine and Colonoscopic Decompression) as an Alternative to Surgery
  • Can Be Performed Percutaneously by Endoscopy or Interventional Radiology
  • May Be Safe and Effective for Select Patients but Less Well Validated and Can Be Complicated Infection, Bleeding, and Bowel Perforation/Peritonitis

Neostigmine: Use and Contraindications/Complications

Mechanism of Action: Acetylcholinesterase Inhibitor

Dose: 2-5 mg IV Gevin Slowly Over 5 Minutes

Contraindications:

  • Recent Myocardial Infarction
  • Asthma
  • Bradycardia
  • Hypotension
  • Acidosis
  • Beta-Blocker Therapy

Complications:

  • Bradycardia [6%]
  • Hypotension
  • Bronchospasm
  • Seizure
  • Sialorrhea
  • Diarrhea
  • Nausea
  • Abdominal Pain

Give in a “Monitored Setting” to Monitor for Complications

  • Keep Atropine at Bedside for Bradycardia