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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
What is Ogilvie's syndrome?
Ogilvie's syndrome is a syndrome of acute intestinal pseudo-obstruction associated with massive dilation, usually of the colon but also of the small intestine. Mechanical obstruction is absent and there is parasympathetic nerve dysfunction. It was first described by Sir William Heneage Ogilvie in 1948, an English surgeon. The syndrome is also known as acute colonic pseudo-obstruction (ACPO).
Acute colonic distension is a medical emergency with high morbidity and mortality.
How common is Ogilvie's syndrome? (Epidemiology)
- It is a rare condition and the incidence rate is not actually known.
- Oglivie's syndrome is more common in the elderly.
Oglivie's syndrome is often associated with other conditions, including:
- Recent obstetric, gynaecological or pelvic surgery.
- Recent trauma or orthopaedic procedure.
- Underlying infection.
- Recent cardiac events.
- Electrolyte imbalance.
- Medications (eg, opioids, antidepressants).
- Solid organ transplant.
Ogilvie's syndrome symptoms
Although symptoms and signs of a large bowel obstruction commonly occur, Oglivie's syndrome can have a variable clinical presentation. It is important therefore to have a high degree of suspicion.
- Abdominal pain, usually cramping or colicky.
- Bloated feeling.
- Nausea and vomiting.
- Intermittent constipation.
- Massive abdominal distension.
- Normal, reduced or obstructed bowel sounds.
- Minimal tenderness.
- Empty, air-filled rectum on digital rectal examination.
- Mechanical obstruction.
- Colonic adenocarcinoma.
- Scarring, adhesions.
- Inflammatory conditions - peptic ulcer, appendicitis, pancreatitis.
- Irritable bowel syndrome.
- Hirschsprung's disease.
- Parasitic infection - eg, American trypanosomiasis.
- Full history - symptoms, drug history, previous surgery, past medical history and family history, psychiatric history, habits and normal diet.
- Full examination - to identify other conditions and including digital rectal examination.
- Abdominal X-ray often shows massive dilation of the colon (megacolon) with caecal diameters measuring 10-14 cm.
- A CT scan is often undertaken to exclude a mechanical obstruction.
Ogilvie's syndrome treatment and management
Timely recognition and close monitoring are extremely important in the management of this condition. The majority of patients improve with conservative measures.
- If possible, treat the cause.
- Enable the patient to be mobile and, if possible, to exercise.
- Advise adequate fluid intake.
- Nasogastric tube to decompress the stomach and relieve vomiting.
- Antiemetic prokinetics - eg, metoclopramide.
- Intravenous (IV) neostigmine is often given and it is a safe and effective option for patients with Oglivie's syndrome who fail to respond to conservative management. When given as a bolus it can lead to a rapid improvement.
- Intravenous fluids.
- Antibiotics are started if an underlying infection is suspected.
- Perforation, ischaemia and peritonitis necessitate urgent surgical intervention.
- Decompression with flexible colonoscope, especially when caecal dilatation reaches dimensions that are considered a high risk for perforation.
- Surgery undertaken is usually a caecostomy or colectomy.
- Laparotomy is indicated for ischaemia and perforation, or if the diagnosis is not clear.
Acute colonic distension has a high morbidity and mortality. Patients avoiding surgery and perforation make good recovery generally, although recurrence is common.
The age of the patient, maximal caecal diameter and delay in colonic decompression have been shown to have a significant direct correlation to mortality.
Surgery is associated with high rates of morbidity and mortality.
- Avoidance of bed rest.
- Adequate hydration.
- Avoidance of drugs which inhibit parasympathetic gastrointestinal muscle action.
Further reading and references
Pereira P, Djeudji F, Leduc P, et al; Ogilvie's syndrome-acute colonic pseudo-obstruction. J Visc Surg. 2015 Apr152(2):99-105. doi: 10.1016/j.jviscsurg.2015.02.004. Epub 2015 Mar 11.
Belle S; Endoscopic Decompression in Colonic Distension. Visc Med. 2021 Mar37(2):142-148. doi: 10.1159/000514799. Epub 2021 Feb 11.
Jain A, Vargas HD; Advances and challenges in the management of acute colonic pseudo-obstruction (ogilvie syndrome). Clin Colon Rectal Surg. 2012 Mar25(1):37-45. doi: 10.1055/s-0032-1301758.
Underhill J, Munding E, Hayden D; Acute Colonic Pseudo-obstruction and Volvulus: Pathophysiology, Evaluation, and Treatment. Clin Colon Rectal Surg. 2021 Jul34(4):242-250. doi: 10.1055/s-0041-1727195. Epub 2021 Jul 20.
Valle RG, Godoy FL; Neostigmine for acute colonic pseudo-obstruction: A meta-analysis. Ann Med Surg (Lond). 2014 Jun 193(3):60-4. doi: 10.1016/j.amsu.2014.04.002. eCollection 2014 Sep.
Hooten KG, Oliveria SF, Larson SD, et al; Ogilvie's syndrome after pediatric spinal deformity surgery: successful treatment with neostigmine. J Neurosurg Pediatr. 2014 Sep14(3):255-8. doi: 10.3171/2014.6.PEDS13636. Epub 2014 Jul 18.