eMedicine Specialties > Gastroenterology > Colon

Ogilvie Syndrome

Prospere Remy, MD, Assistant Professor of Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Internal Medicine, Bronx-Lebanon Hospital Center
Kavita Kumbum, MD, Fellow, Division of Gastroenterology, Bronx Lebanon Hospital Center, Albert Einstein College of Medicine; Steven Carpenter, MD, Chair, Program Director, Department of Internal Medicine, Memorial Health University Medical Center; Bjorn Holmstrom, MD, Assistant Professor, Department of Internal Medicine, University of South Florida

Updated: Jul 30, 2008

Introduction

Background

Ogilvie syndrome, or acute colonic pseudo-obstruction (ACPO), is a clinical disorder with the signs, symptoms, and radiographic appearance of an acute large bowel obstruction with no evidence of distal colonic obstruction. The colon may become massively dilated; if not decompressed, the patient risks perforation, peritonitis, and death.

In 1948, Ogilvie described 2 patients with metastatic cancer and retroperitoneal spread to the celiac plexus. The patients also had signs and symptoms of colonic obstruction but with no evidence of organic obstruction to the intestinal flow. Ogilvie hypothesized that the etiology of their conditions was an imbalance in the autonomic nervous system with sympathetic deprivation to the colon, leading to unopposed parasympathetic tone and regional contraction, with resulting functional obstruction.

In 1958, Dudley et al used the term pseudo-obstruction to describe the clinical appearance of a mechanical obstruction with no evidence of organic disease during laparotomy.

Pathophysiology

The pathophysiology of Ogilvie syndrome is not clearly understood. Research into the neurophysiology of the colon reveals that Ogilvie's hypothesis was close to the proposed current understanding. The parasympathetic nervous system promotes gut motility. The vagus nerve supplies the parasympathetic tone from the upper GI tract to the splenic flexure, and the sacral parasympathetic nerves (S2 to S5) supply the left colon and the rectum. Sympathetic stimuli result in the inhibition of bowel motility and the contraction of sphincters. The lower 6 thoracic segments supply the sympathetic tone to the right colon, while lumbar segments 1-3 supply the left colon.

An imbalance in the autonomic innervation appears to lead to a functional bowel obstruction, as supported by pharmacologic and spinal blockade studies, metabolic abnormalities, and retroperitoneal trauma. Unlike Ogilvie's hypothesis, some current evidence suggests that an interruption of the sacral parasympathetic nerves occurs, leading to an adynamic distal colon that is similar to Hirschsprung disease, except with normal ganglion cells observable on autopsy. Other research supports the belief that the sympathetic tone increases in these patients, who are usually very ill, leading to inhibition of colonic motility.

The cecum is the usual site of the largest dilatation in patients with Ogilvie syndrome and, thus, is more prone to the risk of perforation. The Laplace law indicates that the intraluminal pressure needed to stretch the wall of a hollow tube is inversely proportional to its diameter. The cecum, with its larger diameter, requires the smallest amount of pressure to increase in size and in wall tension. As the wall tension of the colon increases, ischemia with longitudinal splitting of the serosa, herniation of the mucosa, and perforation can occur.

Frequency

United States

The frequency has not been established.

International

This rare clinical condition makes it difficult to gather solid epidemiological studies, particularly in regard to its frequency.

Mortality/Morbidity

Mortality rates of 15-50% have been reported; however, with increased awareness, better diagnostic tools, and prompt management of this disorder, mortality rates have decreased. The risk of perforation is higher with a larger cecal diameter. Generally, the overall medical status of patients with Ogilvie syndrome is poor. The prognosis in patients successfully treated for this disorder is directly related to the severity of the co-occurring medical conditions.

Race

No data suggest a different frequency according to race.

Sex

No convincing data suggest a different frequency according to sex; however, some researchers suggest that this illness may have a slight male predominance, possibly by a ratio of 1.5:1.

Age

Ogilvie syndrome is generally a disease of elderly patients, usually older than 60 years; however, this disorder may occur in younger patients, particularly those with underlying spinal cord disorders.

Clinical

History

Patients with Ogilvie syndrome present with abdominal distention and generally have obstipation. Up to 40% may have a recent history of flatus or passage of stool. Presenting symptoms are as follows:

• Abdominal pain (80%)
• Nausea and vomiting (80%)
• Obstipation (40%)
• Fever (37%)

Physical

• Abdominal distention (90-100%)
• Abdominal tenderness (64%)
• Bowel sounds
• Normal or hyperactive (40%)
• Hypoactive, high pitched, or absent (60%)

Causes

Ogilvie syndrome usually occurs in a setting of a recent serious medical illness or surgical procedure. The 3 most common associations are trauma, infection, and cardiac disease, especially myocardial infarction and congestive heart failure. 

• Recent surgery
  • Abdominal
  • Orthopedic
  • Neurologic
  • Urologic
  • Cardiac
• Severe pulmonary disease
• Severe electrolyte disturbance
  • Hyponatremia
  • Hypokalemia
  • Hypocalcemia or hypercalcemia
  • Hypomagnesemia
• Severe cardiovascular disease
• Severe constipation
• Malignancy
• Systemic infection
• Medications
  • Narcotics
  • Anticholinergics
  • Clonidine
  • Amphetamines
  • Phenothiazines
  • Steroids

Differential Diagnoses

Other Problems to Be Considered

Colonic volvulus may manifest in a fashion similar to colonic pseudo-obstruction. The following conditions should also be considered:

• Peritonitis
• Colonic perforation
• Electrolyte disturbances
• Adverse reaction to medication

Workup

Laboratory Studies

• CBC count: Leukocytosis should raise concerns for possible impending or frank perforation.
• Electrolytes: Disorders of potassium, sodium, calcium, and magnesium may be the underlying cause of the problem. Patients with colonic pseudo-obstruction are commonly dehydrated and frequently exhibit prerenal azotemia or renal insufficiency.
• Liver function profile

Imaging Studies

• Plain abdominal films
  • This is the most useful diagnostic tool for this disorder. Plain and upright abdominal films show a dilated colon, often from the cecum to the splenic flexure and occasionally to the rectum. Haustral markings remain normal. Serial films may be used to follow the clinical course and the response to treatment.
  • Specific attention to the diameter of the colon is important. If the colonic diameter exceeds 10 cm, decompression of the colon must be considered and expedited. In addition to cecal diameter, the duration of distension also appears to be an important factor in perforation risk, with the risk lowest in patients who undergo decompression within less than 4 days of onset.
• CT scan: While a CT scan is not required to establish a diagnosis, it may be helpful in excluding the presence of frank perforation, obstruction, and toxic megacolon.

Other Tests

• Gastrografin enema: Gastrografin is water-soluble and has a high osmolarity; therefore, this contrast medium tends to cause a fluid shift into the colon and may subsequently increase colonic motility. A Gastrografin enema may be both diagnostic and therapeutic for this disorder.
• Barium enema: Given the nature of pseudo-obstruction, air should not be instilled into the colon if this procedure is performed.

Procedures

• Colonoscopy
  • This examination may be helpful diagnostically and therapeutically.
  • This single procedure can help exclude an obstructive process and decompress the colon.
  • This may be technically difficult because of the difficulty in adequately preparing the colon in order to allow good endoscopic visualization.

Treatment

Medical Care

Diagnosis and management of colonic pseudo-obstruction require that mechanical bowel obstruction be completely excluded. Initial management requires an evaluation for signs of bowel ischemia or perforation; if present, these problems must be addressed immediately.

• Addressing basic issues of supportive care prior to initiating specific medical therapy is critical.
  • Aggressively treat any reversible underlying medical condition (eg, respiratory failure, congestive heart failure [CHF], systemic infection).
  • Administer intravenous fluids to correct any volume deficit.
  • Correct electrolyte imbalances.
  • Nasogastric suction or decompression can be helpful; furthermore, rectal tube decompression can be therapeutic in some cases.
  • Promptly discontinue any medications that might precipitate or exacerbate this problem (eg, narcotics, anticholinergics).
• Colonoscopic decompression of the colon
  • Colonoscopic decompression is a very useful method to remove air from the colon and, hopefully, to reduce the risk of subsequent colonic perforation; however, this procedure may be difficult to perform because of poor colonic preparation in most patients.
  • Colonoscopy is successful in reducing colonic air in 70-85% of patients.
  • Decompression may be facilitated by placement of a decompression tube.
  • Passage of the endoscope to the hepatic flexure is usually sufficient to decompress the cecum.
  • If a decompression tube is placed, flush the tube every 2-4 hours with enough saline to maintain patency.
  • The main risk of decompressive colonoscopy is perforation. Maintain great care to avoid excessive air insufflation during endoscope insertion.
  • The risk of perforation is probably higher in patients with significant colonic ischemia.
  • Although colonoscopic decompression is usually successful, cecal distention often recurs. The literature indicates recurrence rates of 22-41%.

Surgical Care

A small percentage of patients with Ogilvie syndrome may require surgical intervention.

• Tube cecostomy
  • This procedure allows for colonic venting in patients with Ogilvie syndrome. In some patients, this procedure is curative, and the tube may later be removed without the need for subsequent surgical intervention.
  • Reserve cecostomy for patients with impending cecal perforation.
  • Generally, a cecostomy is performed via open technique.
  • Percutaneous cecostomy may also be performed via CT guidance.
  • A laparoscopically assisted cecostomy using T-bars to anchor the cecum to the anterior abdominal wall is another acceptable intervention.
• Subtotal colectomy
  • In patients with subsequent perforation, a subtotal colectomy may be required.
  • Generally, patients with perforation require temporary diversion, with plans for a second operation to establish bowel continuity at a later date.
  • Potential complications include abscess formation, ileus, and bleeding.

Consultations

• Gastroenterologists
• General surgeons

Diet

In general, patients with Ogilvie syndrome are not allowed to have anything by mouth until the disorder is reversed.

Activity

If the patient is able, ambulation can have beneficial aspects on colonic motility patterns. However, patients with acute Ogilvie syndrome typically are not ambulatory.

Medication

Prior to medical therapy, a mechanical bowel obstruction must be excluded. Ensure that colonic air is found in all colonic segments, including the rectosigmoid, prior to consideration of neostigmine therapy. If air is not demonstrable on abdominal films, a mechanical obstruction should be excluded via contrast enema.

Acetylcholinesterase inhibitors

Ponec et al demonstrated the utility of neostigmine in colonic pseudo-obstruction.¹

Neostigmine (Prostigmin)

Inhibits destruction of acetylcholine by acetylcholinesterase, which facilitates transmission of impulses across myoneural junction.

Dosing

Adult

1-2 mg IV/SC; may repeat in 3 h if needed

Pediatric

Not established

Interactions

Atropine antagonizes muscarinic effects of neostigmine; effects of neuromuscular agents are increased; other agents that cause bradycardia, including beta-blockers and calcium channel blockers, should not be coadministered

Contraindications

Documented hypersensitivity; GI or GU obstruction; baseline heart rate <60 bpm or systolic blood pressure <90 mm Hg; sick sinus syndrome or history of second- or third-degree A-V block without a pacemaker; active bronchospasm requiring medication

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal failure, epilepsy, asthma, bradycardia, hyperthyroidism, cardiac arrhythmias, or peptic ulcer; anticholinesterase insensitivity can develop for brief or prolonged periods; patients with renal impairment may have an increased or prolonged response after administration; monitor carefully for bradycardia (should be on a heart monitor during administration); keep atropine (0.6-1.2 mg IV) on hand as an antidote for muscarinic adverse effects

Enema therapies

Can be helpful in some circumstances. This therapy may cleanse the colon and gently enhance colonic motility, thereby correcting the underlying problem. The cleansing effect may also make subsequent attempts at colonoscopic decompression easier.

Polyethylene glycol (GoLYTELY)

Laxative with strong electrolyte and osmotic effects that has cathartic actions in GI tract.

Dosing

Adult

1 adult enema PR

Pediatric

Not established

Interactions

Reduces effectiveness and absorption of oral medications

Contraindications

Documented hypersensitivity, colitis, megacolon, bowel perforation, gastric retention, GI obstruction

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in ulcerative colitis and hot loop polypectomy

Tap water enema

Lubricates the bowel and softens the stool. Can be used as a retention enema.

Dosing

Adult

1 adult enema PR

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in leukemia or thrombocytopenia

Follow-up

Further Inpatient Care

• Treatment of the underlying medical condition: As previously mentioned, colonic pseudo-obstruction is usually precipitated by an important underlying condition. Appropriately replace electrolytes and promptly manage infections with adequate antimicrobial therapy.

Further Outpatient Care

• In general, further outpatient care is dictated by the patient's underlying medical condition(s).
• Outpatient care can usually be managed by the primary care physician.

Inpatient & Outpatient Medications

• Constipation: If the patient shows a tendency toward colonic inertia, outpatient treatment is necessary. Osmotic laxatives and fiber can be useful to provide adequate stool frequency.

Transfer

• If endoscopic or surgical expertise in the area does not allow for patient management in a timely manner, consider transferring the patient to another facility.

Complications

• Colonic perforation: If the colon is not decompressed before it reaches critical diameter, the patient is at risk for colonic perforation. Once again, this complication may be prevented by timely diagnosis and management of the problems at hand.

Prognosis

• Prognosis is determined by the underlying medical and/or surgical problems that placed the patient at risk for colonic pseudo-obstruction.

Patient Education

• Advise the patient and family members of the signs and symptoms of recurrent pseudo-obstruction. Inform them that recurrent abdominal distention is an indication to seek prompt medical attention.

Miscellaneous

Medicolegal Pitfalls

• Failure to arrive at the accurate diagnosis in a timely fashion. Ogilvie syndrome should be considered in all patients with significant abdominal distention.
• Delay in appropriate therapy: Once the colon reaches 10 cm in diameter (usually the cecum), a risk of perforation exists; therefore, initiate therapy in a timely fashion once the diagnosis is confirmed.

References

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2. Armstrong DN, Ballantyne GH, Modlin IM. Erythromycin for reflex ileus in Ogilvie's syndrome. Lancet. Feb 9 1991;337(8737):378. [Medline].

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Keywords

Ogilvie syndrome, Ogilvie's syndrome, acute colonic pseudo-obstruction, ACPO, colonic pseudoobstruction, bowel obstruction, colonic obstruction, acute large bowel obstruction, colonic perforation, intestinal perforation, peritonitis, nontoxic megacolon, bowel motility, adynamic distal colon, Hirschsprung disease, abdominal distention, obstipation, cecal perforation, cecostomy, colonoscopy, colonoscopic decompression, colectomy

Contributor Information and Disclosures

Author

Prospere Remy, MD, Assistant Professor of Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Internal Medicine, Bronx-Lebanon Hospital Center
Prospere Remy, MD is a member of the following medical societies: American College of Physicians and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Coauthor(s)

Kavita Kumbum, MD, Fellow, Division of Gastroenterology, Bronx Lebanon Hospital Center, Albert Einstein College of Medicine
Kavita Kumbum, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Steven Carpenter, MD, Chair, Program Director, Department of Internal Medicine, Memorial Health University Medical Center
Steven Carpenter, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Bjorn Holmstrom, MD, Assistant Professor, Department of Internal Medicine, University of South Florida
Bjorn Holmstrom, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Medical Association, Medical Association of Georgia, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Douglas M Heuman, MD, FACP, Director of Hepatology, McGuire Veterans Affairs Medical Center, Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine
Douglas M Heuman, MD, FACP is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

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