Ogilvie syndrome

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Ogilvie syndrome

• Case report paper review
• 2004/08/02 Ri ???

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Case summary

• 59 y/o female
• Past history
• Idiopathic liver cirrhosis for 10 years
• PPU (6 year ago)
• LVH (07/12 LVEF 91.5)

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Clinical course

• 03/29 Left femoral neck fracture
• 03/30 ORIF
• 05/29 Remove of implant debridement
• 07/07 Abdominal CT IHD, CBD stones, distended T
  colon, pneumatosis at cecum
• 07/10 Intubation 6 trials--gt 4C1
• 07/13 Hypaque study distal colon not opacified
• 07/15 Colon fiberoscopy no definite obstructive

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17 Hr
3 Hr
8 Hr
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Clinical course

• 07/16 Neostigmine X 3 days
• 07/19 KUB massive colonic and intestinal gas
• 07/20 on rectal tube
• 07/21 remove of rectal tube
• 07/27 NPO
• 08/01 NG feeding with Nupep 1500kcal/1500ml

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Ogilvie syndrome

• Acute colonic pseudo-obstruction
• Definition
• Colonic dilation without mechanical obstruction
• s/s abdominal distension without pain
• Plain film massive colonic dilation, esp. of the
  cecum and right colon
• If not decompressed the colon, patient risks
  perforation, peritonitis, and death.

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Pathophysiology

• not clearly understood
• It is thought to result from an imbalance in the
  regulation of colonic motor activity by the
  autonomic nervous system.
• parasympathetic nervous dysfunction

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Causes

• Ogilvie syndrome is usually associated with a
  recent, significant medical illness or surgical
  procedure.
• Recent surgery
• Severe pulmonary disease
• Severe cardiovascular disease
• Severe electrolyte disturbance
• Severe constipation
• Malignancy
• Systemic infection
• Medications

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Treatment

• Medical Care
• Supportive care (NPO, NG decompression, fluid
  resuscitation, enema)
• neostigmine
• Colonoscopic decompression of the colon
• Surgical Care
• Tube cecostomy
• Subtotal colectomy

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Neostigmine for the treatment of acute colonic
pseudo-obstruction

• NEJM 1999 341 (3)137

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Patients and Methods

• Patient en-roll criteria
• Abdominal distention and radiographic evidence of
  colonic dilation (cecal diameter gt 10 cm)
• had no response to at least 24 hours of
  conservative treatment.
• Exclusion criteria
• Basal HR lt 60 bpm, SBP lt 90 mmHg
• active bronchospasm
• pregnancy
• a history of colon cancer or partial colonic
  resection
• active GI bleeding
• signs of bowel perforation

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Patients and methods

• Randomly assigned 11 to receive neostigmine (2mg,
  iv) and 10 to receive saline.
• Assessment of Outcomes
• clinical response
• prompt evacuation of flatus or stool
• a reduction in abdominal distention
• measurements of the colon on radiographs
• Patients who had no response to the initial
  injection were eligible to receive openlabel
  neostigmine three hours later.

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Conclusion Discussion

• The use of neostigmine should be careful in
  patient underlying
• bradyarrhythmias
• bronchospasm
• renal impairment
• The effect of neostigmine treatment, compare with
• conservative therapy
• Colonoscopy
• Surgery

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Discussion

• Even though the elimination half-life of
  neostigmine is short, most patients had sustained
  improvement.
• Concomitant treatment with neostigmine and the
  anticholinergic agent glycopyrrolate has been
  reported to diminish the central cholinergic
  effects of neostigmine without reducing the
  increases in colonic motility.

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Ogilvie Syndrome as a Postoperative Complication

• Arch Surg. 2000135682-687

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Patients and methods

• Trauma or operation between 1989 and 1998
• Radiographic findings
• colonic distention greater than 8 cm without
  evidence of mechanical obstruction
• Patients who had small-bowel dilation in addition
  to colonic dilation were considered to have a
  postoperative ileus and were excluded from the
  study

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Patients and methods

• Type of operation
• Postoperative day of diagnosis of Ogilvie
  syndrome
• Interval from diagnosis to resolution or death
• Treatment

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Results
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Results
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Results

• Conservative treatment (nasogastric tube
  placement, fluid resuscitation, and enemas) was
  successful in 19 patients (53).
• 12 of the 13 patients (92) had successful
  decompression of the colon after the initial
  colonoscopy
• The mortality rate
• Total14 (5/36)
• Required operative intervention 60 (3/5)

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Thanks for your attention