eMedicine Specialties > Gastroenterology > Intestine

Intestinal Pseudo-obstruction, Surgical Treatment: Workup

Author: Burt Cagir, MD, FACS, Assistant Professor of Surgery, State University of New York, Upstate Medical Center; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic
Coauthor(s): Lena M Napolitano, MD, FACS, FCCP, FCCM, Professor of Surgery, University of Michigan School of Medicine; Chief, Surgical Critical Care, Program Director, Surgical Critical Care Fellowship, Associate Chair, Department of Surgery, University of Michigan Health System; James Dunne, MD, Clinical Instructor, Department of Surgery, Trauma/Critical Care, University of Maryland Medical Center
Contributor Information and Disclosures

Updated: May 1, 2008

Workup

Laboratory Studies

  • Laboratory investigations are of little diagnostic value. Mild electrolyte imbalances are often present and typically signify dehydration.7
  • Hyponatremia and hypokalemia can be present and reflect a consequence of the pathologic condition, rather than its etiologic factor.21,27,5,2
  • Leukocytosis can also be present, but it is found in the presence of viable as well as ischemic bowel and is therefore nondiagnostic.27,2

Imaging Studies

  • Plain abdominal radiography  
    • Except for physical examination, the most useful screening test is plain abdominal radiography.30
    • The most common finding is massive colonic dilatation involving the cecum and the ascending and transverse colon.
    • Progressive colonic dilatation can lead to marked increases in cecal distention. Consequently, the cecum is the most common site of perforation in colonic pseudo-obstruction.7,13
      • This observation is based on the Laplace law, which states that the pressure required to stretch the walls of a hollow viscus decreases in inverse proportion to the radius of curvature of the viscus.
      • Accordingly, the tensile strength of the colonic wall is first exceeded in that portion of the colon that has the greatest diameter, that is, the cecum.26
    • Although no agreement has been reached regarding the absolute cecal diameter that results in perforation, most investigators agree that the risk of perforation is markedly increased with cecal diameters in the range of 12-14 cm.26,14,13,27,18 Therefore, frequent abdominal radiographs to assess the diameter of the cecum are useful in the management of these patients.
    • The transition between dilated and collapsed bowel is usually near the splenic flexure but can occasionally occur in the distal or sigmoid colon.7,31,18
    • Air fluid levels are only occasionally observed; small bowel dilatation can occur, but this relies on the incompetency of the ileocecal valve.21,9,32,27,2
    • Other radiologic features include well-defined colonic septa, a smooth contour of the inner lumen, and preservation of haustral markings.32,33,13,18
    • Differentiating colonic pseudo-obstruction from true mechanical colonic obstruction can sometimes be difficult.
      • Low's 1995 study suggests using a prone lateral view of the rectum to aid in confirming the diagnosis.34
      • Low recommends placing the patient in the right lateral decubitus position for several minutes to allow passage of gas into the distal colon.34 This maneuver facilitates the gaseous filling of the rectum when the patient is positioned for a prone lateral view of the pelvis.
      • Low documented a 75% success rate in excluding mechanical obstruction and reported that gaseous filling of the rectum did not occur in any patient with a mechanical obstruction.34

Other Tests

  • Contrast enema  
    • If the diagnosis cannot be confirmed by plain radiography or physical examination, a contrast enema may be used. Common enemas include either barium or diatrizoate meglumine (Gastrografin), but these contrast materials are contraindicated in the presence of perforation.
    • Because of the risk of perforation, the contrast material should be introduced under low pressure. No air is required, and the examination may be terminated when the dilated colon is reached.
    • Diatrizoate meglumine has several advantages over barium because it is clear and water-soluble. Diatrizoate meglumine can be more easily washed away at the time of colonoscopy and can often be therapeutic because of its hyperosmolarity, which results in fluid shifts into the lumen. Furthermore, it removes the risk of peritoneal contamination with barium if a perforation occurs or a laparotomy becomes necessary.35,10,36,37,13

Diagnostic Procedures

  • Flexible colonoscopy can differentiate colonic pseudo-obstruction from mechanical colonic obstruction and can also serve as a therapeutic procedure with colonic decompression performed during the diagnostic colonoscopy procedure. If a mechanical etiology of colonic obstruction is identified as the causative factor during the diagnostic procedure, biopsy of the colonic mass can also be accomplished via flexible colonoscopy.

More on Intestinal Pseudo-obstruction, Surgical Treatment

Overview: Intestinal Pseudo-obstruction, Surgical Treatment
Workup: Intestinal Pseudo-obstruction, Surgical Treatment
Treatment: Intestinal Pseudo-obstruction, Surgical Treatment
Follow-up: Intestinal Pseudo-obstruction, Surgical Treatment
Multimedia: Intestinal Pseudo-obstruction, Surgical Treatment
References
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References

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Further Reading

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Keywords

intestinal pseudoobstruction, colonic pseudo-obstruction, Ogilvie's syndrome, Ogilvie syndrome, large intestinal obstruction, large bowel obstruction, cecal perforation, abdominal distention, abdominal sepsis, anastomotic dehiscence, intestinal fistula, abdominal compartment syndrome

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Contributor Information and Disclosures

Author

Burt Cagir, MD, FACS, Assistant Professor of Surgery, State University of New York, Upstate Medical Center; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic
Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, and Society for Surgery of the Alimentary Tract
Disclosure: Nothing to disclose.

Coauthor(s)

Lena M Napolitano, MD, FACS, FCCP, FCCM, Professor of Surgery, University of Michigan School of Medicine; Chief, Surgical Critical Care, Program Director, Surgical Critical Care Fellowship, Associate Chair, Department of Surgery, University of Michigan Health System
Lena M Napolitano, MD, FACS, FCCP, FCCM is a member of the following medical societies: Alpha Omega Alpha, American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, Association for Academic Surgery, Association of VA Surgeons, Association of Women Surgeons, California Professional Society on the Abuse of Children, Eastern Association for the Surgery of Trauma, Phi Beta Kappa, Shock Society, Society of Critical Care Medicine, and Society of University Surgeons
Disclosure: Nothing to disclose.

James Dunne, MD, Clinical Instructor, Department of Surgery, Trauma/Critical Care, University of Maryland Medical Center
James Dunne, MD is a member of the following medical societies: Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Medical Editor

George Y Wu, MD, PhD, Professor, Department of Medicine, Director, Hepatology Section, Herman Lopata Chair in Hepatitis Research, University of Connecticut School of Medicine
George Y Wu, MD, PhD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, American Medical Association, American Society for Clinical Investigation, and Association of American Physicians
Disclosure: Humana Press Consulting fee Consulting; Novartis Consulting fee Review panel membership

Pharmacy Editor

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

Managing Editor

James L Achord, MD, Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine
James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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