Practice Management

A 65-year-old female is hospitalized following right hip replacement three days ago. A GI consult is requested for evaluation of abdominal distention. She has poor oral intake. She's receiving regularly scheduled intravenous (IV) morphine for hip pain. She has been immobile for the last two days. Yesterday she noted abdominal distention. Her last bowel movement was three to four days ago. She last passed flatus one day ago. Complete blood cell count (CBC) and electrolytes are normal. Abdominal films reveal a dilated right-side colon, air in the rectum and normal small bowel. A CT scan of the abdomen and pelvis reveals proximal colonic dilation to 8 centimeters, normal to mildly dilated left-side colon, air in the rectum and no obstruction.

The most likely diagnosis is:

A) Acute colonic pseudo-obstruction (Ogilvie syndrome)
B) Mechanical colon obstruction
C) Small-bowel obstruction
D) Small-bowel ileus
E) Gastroparesis

The correct answer is A, acute colonic pseudo-obstruction (Ogilvie syndrome).

PRACTICE PEARLS

Epidemiology

• Acute colonic pseudo-obstruction typically involves the cecum and right side of the colon, occasionally extending to the rectum.¹
• Acute colonic pseudo-obstruction most often occurs in patients with severe illness or injury and those with recent surgery, including abdominal surgery, heart surgery and, especially, knee and hip surgery.^1,2  Additional factors include medications (e.g., opiates, anticholinergics and calcium channel blockers), neurologic disorders and electrolyte abnormalities.^1,2
• The precise mechanism by which colonic dilation occurs is unknown.¹

Clinical Manifestations

• Clinical manifestations include abdominal distension (most common symptom), abdominal pain, nausea, vomiting, constipation and paradoxical diarrhea.^1,2 Nearly half of patients with Ogilvie syndrome will report passing flatus.
• Abdominal distension occurs gradually over three to seven days; however, symptoms can begin as early as 24 to 48 hours.¹
• Upon examination, the abdomen is tympanic to percussion. Typically, bowel sounds are present. Approximately 65% of patients have abdominal tenderness.^1,2   The presence of fever, marked abdominal tenderness and peritoneal signs suggests colonic ischemia or perforation.¹

Diagnostic Approach

• Laboratory evaluations includes CBC, comprehensive metabolic panel (CMP), serum lactate and thyroid-stimulating hormone.
• Abdominal films typically reveal right-side colon distension with air in the rectum (Image 1).
• A CT scan of the abdomen and pelvis reveals proximal colon dilation that may extend to the rectum while ruling out colonic obstruction. When a CT scan is not available, a contrast enema using water soluble contrast can be used, providing there is no evidence of perforation on examination.¹

Management-Cecal Diameter < 12 cm¹

• Initial management is conservative with supportive care: treat the underlying cause, discontinue medications associated with acute colonic pseudo-obstruction, nasogastric tube decompression and cautious administration of tap water enemas.
• Patients should be monitored with physical examination every 12 to 24 hours, plain abdominal films every 12 to 24 hours and laboratory tests, including CBC and CMP.¹

Management-Cecal Diameter > 12 cm, Severe Abdominal Pain or Failed Conservative Management¹

• Neostigmine is the recommended initial treatment, provided there are no contraindications to neostigmine (e.g., recent myocardial infarction, asthma, bradycardia or therapy with beta-blockers).¹ Neostigmine is administered by slow IV infusion over five minutes. Patients should be kept supine on a bedpan, atropine should be available at the bedside, continuous monitoring of vital signs and electrocardiogram for 30 minutes and continuous clinical assessment for 15 to 30 minutes.^1,3
• Complications of neostigmine include bradycardia, bronchoconstriction, hypotension and abdominal cramps.
• Most patients respond adequately to therapy, with resolution of acute colonic pseudo-obstruction in up to 89 percent of patients. Patients who fail to respond to the first dose of neostigmine can receive a second dose 24 hours after the first dose.¹
• Colonic decompression is performed in patients who failed therapy with neostigmine or who have contraindications to neostigmine. Colonic decompression is a technically difficult procedure to perform and has a perforation rate of approximately 2 percent.¹
• A decompression tube, placed over a guidewire, can be placed during colonic decompression with colonoscopy.
• Surgical management is reserved for patients with refractory symptoms, ischemia, perforation or peritonitis.

• Authors
• References

Sarah Enslin, PA-C

University of Rochester Medical Center

Rochester, NY

Stacia Sackmaster, APN-BC

University of Rochester Medical Center

Rochester, NY

Joseph Vicari, MD, MBA, FASGE

Rockford Gastroenterology Associates

Rockford, IL

Sarah Enslin, PA-C, is a physician assistant at the University of Rochester Medical Center in Rochester, NY, with over 10 years of experience as a practicing PA in GI. Sarah serves on several national GI committees and is a member of the ASGE Practice Operations Committee and ASGE APP Task Force.

Stacia Sackmaster, APN-BC, is a family nurse practitioner at Rockford Gastroenterology Associates, Ltd., in Rockford, IL.

Joseph Vicari, MD, FASGE, joined Rockford Gastroenterology in 1997 and has served as managing partner. He previously served as chair of the ASGE Practice Operations Committee and currently serves as councilor on the ASGE Governing Board and co-chair of the ASGE APP Task Force.

1. Camilleri M. Acute colonic pseudo-obstruction (Olgilvie’s syndrome). Updated May 31, 2023. UpToDate. https://www.uptodate.com.
2. Symptoms and causes of intestinal pseudo-obstruction. National Institute of Diabetes and Digestive and Kidney Diseases. Last Reviewed October 2021. https://www.niddk.nih.gov/health-information/digestive-diseases/intestinal-pseudo-obstruction/symptoms-causes
3. Naveed M, Jamil LH, Fujii-Lau LL, et al. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus. Gastrointest Endosc. 2020;91:228-235
4. Valle RGL, Godoy FL. Neostigmine for acute colonic pseudo-obstruction: A meta-analysis. Ann Med Surg (Lond). 2014;3:60-64.
5. Kayani B, Spalding DR, Jiao LR, Habib NA, Zacharakis E. Does neostigmine improve time to resolution of symptoms in acute colonic pseudo-obstruction? Int J Surg. 2012;10:453-457.