eMedicine Specialties > Gastroenterology > Colon

Ogilvie Syndrome: Treatment & Medication

Author: Prospere Remy, MD, Assistant Professor of Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Internal Medicine, Bronx-Lebanon Hospital Center
Coauthor(s): 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
Contributor Information and Disclosures

Updated: Jul 30, 2008

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.

Adult

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

Pediatric

Not established

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

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

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.

Adult

1 adult enema PR

Pediatric

Not established

Reduces effectiveness and absorption of oral medications

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

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.

Adult

1 adult enema PR

Pediatric

Not established

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

More on Ogilvie Syndrome

Overview: Ogilvie Syndrome
Differential Diagnoses & Workup: Ogilvie Syndrome
Treatment & Medication: Ogilvie Syndrome
Follow-up: Ogilvie Syndrome
References
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References

  1. Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med. Jul 15 1999;341(3):137-41. [Medline].

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

  3. Baraza W, Brown S, McAlindon M, et al. Prospective analysis of percutaneous endoscopic colostomy at a tertiary referral centre. Br J Surg. Nov 2007;94(11):1415-20. [Medline].

  4. Bharucha AE, Phillips SF. Megacolon: Acute, Toxic, and Chronic. Curr Treat Options Gastroenterol. Dec 1999;2(6):517-523. [Medline].

  5. Bode WE, Beart RW Jr, Spencer RJ, et al. Colonoscopic decompression for acute pseudoobstruction of the colon (Ogilvie's syndrome). Report of 22 cases and review of the literature. Am J Surg. Feb 1984;147(2):243-5. [Medline].

  6. Camilleri M, Malagelada JR, Abell TL, et al. Effect of six weeks of treatment with cisapride in gastroparesis and intestinal pseudoobstruction. Gastroenterology. Mar 1989;96(3):704-12. [Medline].

  7. Cherta I, Forne M, Quintana S, et al. Prolonged treatment with neostigmine for resolution of acute colonic pseudo-obstruction. Aliment Pharmacol Ther. Jun 1 2006;23(11):1678-9. [Medline].

  8. Datta SN, Stephenson BM, Havard TJ, et al. Acute colonic pseudo-obstruction. Lancet. Mar 13 1993;341(8846):690. [Medline].

  9. Dorudi S, Berry AR, Kettlewell MG. Acute colonic pseudo-obstruction. Br J Surg. Feb 1992;79(2):99-103. [Medline].

  10. Fiorito JJ, Schoen RE, Brandt LJ. Pseudo-obstruction associated with colonic ischemia: successful management with colonoscopic decompression. Am J Gastroenterol. Oct 1991;86(10):1472-6. [Medline].

  11. Geller A, Petersen BT, Gostout CJ. Endoscopic decompression for acute colonic pseudo-obstruction. Gastrointest Endosc. Aug 1996;44(2):144-50. [Medline].

  12. Harig JM, Fumo DE, Loo FD, et al. Treatment of acute nontoxic megacolon during colonoscopy: tube placement versus simple decompression. Gastrointest Endosc. Jan-Feb 1988;34(1):23-7. [Medline].

  13. Jetmore AB, Timmcke AE, Gathright JB Jr, et al. Ogilvie's syndrome: colonoscopic decompression and analysis of predisposing factors. Dis Colon Rectum. Dec 1992;35(12):1135-42. [Medline].

  14. Johnston G, Vitikainen K, Knight R, et al. Changing perspective on gastrointestinal complications in patients undergoing cardiac surgery. Am J Surg. May 1992;163(5):525-9. [Medline].

  15. Laine L. Management of acute colonic pseudo-obstruction. N Engl J Med. Jul 15 1999;341(3):192-3. [Medline].

  16. Longo WE, Vernava AM 3rd. Prokinetic agents for lower gastrointestinal motility disorders. Dis Colon Rectum. Jul 1993;36(7):696-708. [Medline].

  17. Lynch CR, Jones RG, Hilden K, et al. Percutaneous endoscopic cecostomy in adults: a case series. Gastrointest Endosc. Aug 2006;64(2):279-82. [Medline].

  18. McNamara R, Mihalakis MJ. Acute Colonic Pseudo-Obstruction: Rapid Correction With Neostigmine In The Emergency Department.

  19. Mehta R, John A, Nair P, et al. Factors predicting successful outcome following neostigmine therapy in acute colonic pseudo-obstruction: a prospective study. J Gastroenterol Hepatol. Feb 2006;21(2):459-61. [Medline].

  20. Nelson JD, Urban JA, Salsbury TL, et al. Acute colonic pseudo-obstruction (Ogilvie syndrome) after arthroplasty in the lower extremity. J Bone Joint Surg Am. Mar 2006;88(3):604-10. [Medline].

  21. Ogilvie WH. Large intestine colic due to sympathetic deprivation: a new clinical syndrome. BMJ. 1948;2:671-3.

  22. Rovira A, Lopez A, Cambray C, et al. Acute colonic pseudo-obstruction (Ogilvie's syndrome) treated with erythromycin. Intensive Care Med. Jul 1997;23(7):798. [Medline].

  23. Saunders MD. Acute colonic pseudo-obstruction. Best Pract Res Clin Gastroenterol. 2007;21(4):671-87. [Medline].

  24. Saunders MD, Cappell MS. Endoscopic management of acute colonic pseudo-obstruction. Endoscopy. Aug 2005;37(8):760-3. [Medline].

  25. Saunders MD, Kimmey MB. Acute colonic pseudo-obstruction. Current Perspectives in Gastroenterology. 2000;3:156-62.

  26. [Best Evidence] Sgouros SN, Vlachogiannakos J, Vassiliadis K, et al. Effect of polyethylene glycol electrolyte balanced solution on patients with acute colonic pseudo obstruction after resolution of colonic dilation: a prospective, randomised, placebo controlled trial. Gut. May 2006;55(5):638-42. [Medline].

  27. Shrestha BM, Darby C, Fergusson C, et al. Cytomegalovirus causing acute colonic pseudo-obstruction in a renal transplant recipient. Postgrad Med J. Jul 1996;72(849):429-30. [Medline].

  28. Sloyer AF, Panella VS, Demas BE, et al. Ogilvie's syndrome. Successful management without colonoscopy. Dig Dis Sci. Nov 1988;33(11):1391-6. [Medline].

  29. Stephenson BM, Morgan AR, Drake N, et al. Parasympathomimetic decompression of acute colonic pseudo-obstruction. Lancet. Nov 6 1993;342(8880):1181-2. [Medline].

  30. Stephenson BM, Morgan AR, Salaman JR, et al. Ogilvie's syndrome: a new approach to an old problem. Dis Colon Rectum. Apr 1995;38(4):424-7. [Medline].

  31. Stieger DS, Cantieni R, Frutiger A. Acute colonic pseudoobstruction (Ogilvie's syndrome) in two patients receiving high dose clonidine for delirium tremens. Intensive Care Med. Jul 1997;23(7):780-2. [Medline].

  32. Turegano-Fuentes F, Munoz-Jimenez F, Del Valle-Hernandez E, et al. Early resolution of Ogilvie's syndrome with intravenous neostigmine: a simple, effective treatment. Dis Colon Rectum. Nov 1997;40(11):1353-7. [Medline].

  33. Vanek VW, Al-Salti M. Acute pseudo-obstruction of the colon (Ogilvie's syndrome). An analysis of 400 cases. Dis Colon Rectum. Mar 1986;29(3):203-10. [Medline].

  34. vanSonnenberg E, Varney RR, Casola G, et al. Percutaneous cecostomy for Ogilvie syndrome: laboratory observations and clinical experience. Radiology. Jun 1990;175(3):679-82. [Medline].

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Further Reading

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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

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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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