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Intestinal Pseudo-Obstruction Workup

  • Author: Burt Cagir, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Dec 28, 2015
 

Approach Considerations

Laboratory investigations generally are of little diagnostic value for intestinal pseudo-obstruction (also referred to as acute colonic pseudo-obstruction [ACPO] or Ogilvie syndrome]). The diagnosis is based largely on the clinical signs and symptoms, the natural history of the condition, and the findings from radiographic studies.[42]

Plain radiography is the most useful diagnostic tool in this setting. If plain radiography fails to confirm the diagnosis, a contrast enema may be used. Contrast enema should also be used in cases to rule out mechanical colonic obstruction. Although computed tomography (CT) is not required to establish a diagnosis, it may be helpful for excluding the presence of frank perforation, obstruction, and toxic megacolon.[43]

Colonoscopy may be helpful not only diagnostically but also therapeutically. This procedure can help exclude an obstructive process and decompress the colon.

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Laboratory Studies

A complete blood count (CBC) is indicated. A finding of leukocytosis should raise concerns for possible impending or frank perforation. However, it should be kept in mind that leukocytosis is found in the presence of viable as well as ischemic bowel and is therefore nondiagnostic of intestinal pseudo-obstruction.[2, 14]

Mild electrolyte imbalances are often present and typically signify dehydration.[27] Hyponatremia and hypokalemia can be present and reflect a consequence of the pathologic condition, rather than its etiologic factor.[2, 8, 14, 25] Patients frequently exhibit prerenal azotemia or renal insufficiency.

A liver function profile may be helpful.

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Plain Abdominal Radiography

Aside from physical examination, the most useful screening test for intestinal pseudo-obstruction is plain abdominal radiography.[41] Films show a dilated colon, with dilatation often extending from the cecum to the splenic flexure and occasionally to the rectum (see the images below). Serial films may be used to follow the clinical course and the response to treatment.

Abdominal radiographs confirm acute colonic pseudo Abdominal radiographs confirm acute colonic pseudo-obstruction after hip surgery. Note extensive, diffuse colonic dilation with no evidence of transition point.
Ogilvie syndrome. Ogilvie syndrome.

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. By the Laplace law, the tensile strength of the colonic wall will be exceeded first in that portion of the colon that has the greatest diameter—namely, the cecum.[13] Thus, the cecum is the most common site of perforation in colonic pseudo-obstruction.[16, 27]

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.[13, 14, 16, 33, 37] 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.[27, 37, 44]

Air-fluid levels are only occasionally observed; small bowel dilatation can occur, but this relies on the incompetency of the ileocecal valve.[2, 8, 14, 29, 45]

Other radiologic features include well-defined colonic septa, a smooth contour of the inner lumen, and preservation of haustral markings.[16, 37, 45, 46]

Differentiating colonic pseudo-obstruction from true obstruction is sometimes difficult. A 1995 study suggested using a prone lateral view of the rectum to help confirm the diagnosis.[47] Placing patients in the right lateral decubitus position for several minutes to allow gas to pass into the distal colon facilitated gaseous filling of the rectum when patients were positioned for a prone lateral view of the pelvis. This approach had a 75% success rate in excluding mechanical obstruction, and gaseous filling did not occur in any patients with mechanical obstruction.[47]

An abdominal CT scan is very helpful to confirm the diagnosis by excluding mechanical obstruction and toxic megacolon.

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Contrast Enema

If the diagnosis cannot be confirmed by means of plain radiography or physical examination, a contrast enema may be used. Common enemas include barium and diatrizoate meglumine. Both of 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 advantages over barium in that it is clear and water-soluble. In addition, it 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 and may subsequently increase colonic motility. Furthermore, it removes the risk of peritoneal contamination with barium if a perforation occurs or a laparotomy becomes necessary.[16, 30, 48, 49, 50]

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Colonoscopy

Flexible colonoscopy can differentiate colonic pseudo-obstruction from mechanical colonic obstruction and can also serve a therapeutic function when colonic decompression is performed during diagnostic colonoscopy. If a mechanical condition is identified as the cause of colonic obstruction during the diagnostic procedure, biopsy of the colonic mass can also be accomplished via flexible colonoscopy. The procedure may be challenging to perform in many patients because of the difficulty of accomplishing adequate bowel preparation.

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Contributor Information and Disclosures
Author

Burt Cagir, MD, FACS Clinical Professor of Surgery, The Commonwealth Medical College; Attending Surgeon, Assistant Program Director, Robert Packer Hospital; Attending Surgeon, Corning Hospital

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, 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 is a member of the following medical societies: Alpha Omega Alpha, American Society for Parenteral and Enteral Nutrition, California Professional Society on the Abuse of Children, Eastern Association for the Surgery of Trauma, Association of Women Surgeons, 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, Association for Academic Surgery, Association of VA Surgeons, Phi Beta Kappa, Shock Society, Society of Critical Care Medicine, Society of University Surgeons

Disclosure: Nothing to disclose.

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, American Society for Gastrointestinal Endoscopy

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.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, 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, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Acknowledgements

Steven Lee Carpenter, MD, FACP, AGAF, FASGE Academic Chair, Associate Professor of Medicine, Department of Internal Medicine, Internal Medicine Program Director, Mercer University School of Medicine; Senior Partner, The Center for Digestive and Liver Health, The Endoscopy Center

Steven Lee Carpenter, MD, FACP, AGAF, FASGE 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.

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of GI, Hepatology, and Nutrition at North Shore University Hospital/Long Island Jewish Medical Center; Professor, Department of Medicine, Hofstra North Shore-LIJ School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF 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: Novartis Grant/research funds Other; Bayer Grant/research funds Other; Otsuka Grant/research funds None; Bristol Myers Squibb Grant/research funds Other; Scynexis None None; Salix Grant/research funds Other; MannKind Other

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.

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

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 & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Kavitha Kumbum, MD Associate Program Director and Attending Physician, Gastroenterology Fellowship Program, Division of Gastroenterology, Bronx Lebanon Hospital Center, Albert Einstein College of Medicine

Kavitha Kumbum, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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: Springer Consulting fee Consulting; Gilead Consulting fee Review panel membership; Gilead Honoraria Speaking and teaching; Bristol-Myers Squibb Honoraria Speaking and teaching; Springer Royalty Review panel membership

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Abdominal radiographs confirm acute colonic pseudo-obstruction after hip surgery. Note extensive, diffuse colonic dilation with no evidence of transition point.
Treatment algorithm for intestinal pseudo-obstruction.
Ogilvie syndrome.
 
 
 
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