Advances and Challenges in the Management of Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome)

Abstract

Objectives: On completion of this article, the reader should be able to review diagnostic testing confirming diagnosis of acute colonic pseudo-obstruction, identify initial conservative treatment measures, and discuss pharmacologic and endoscopic options for decompression.Acute colonic pseudo-obstruction (ACPO) is a syndrome of massive distension of colon without mechanical obstruction. Ischemia and perforation remain the endpoint of progressive untreated distension and early recognition and timely intervention is of utmost importance. The diagnosis of ACPO depends on excluding mechanical bowel obstruction and its subsequent management has evolved with improved understanding of its pathophysiology and pharmacologic and endoscopic treatment options. Historical BackgroundACPO is also known by the eponym Ogilvie syndrome. Sir William Heneage Ogilvie described two patients diagnosed with colonic pseudo-obstruction in 1948.1 Both patients had Keywords► acute colonic pseudoobstruction ► ogilvie syndrome AbstractAlthough acute colonic pseudo-obstruction (ACPO), also known as Ogilvie syndrome, is a well-known clinical entity, in many respects it remains poorly understood and continues to challenge physicians and surgeons alike. Our understanding of ACPO continues to evolve and its epidemiology has changed as new conditions have been identified predisposing to ACPO with critical illness providing the common thread among them. A physician must keep ACPO high in the list of differential diagnoses when dealing with the patient experiencing abdominal distention, and one must be prepared to employ and interpret imaging studies to exclude mechanical obstruction. Rapid diagnosis is the key, and institution of conservative measures often will lead to resolution. Fortunately, when this fails pharmacologic intervention with neostigmine often proves effective. However, it is not a panacea: consensus on dosing does not exist, administration techniques vary and may impact efficacy, contraindications limit its use, and persistence and or recurrence of ACPO mandate continued search for additional medical therapies. When medical therapy fails or is contraindicated, endoscopy offers effective intervention with advanced techniques such as decompression tubes or percutaneous endoscopic cecostomy providing effective results. Operative intervention remains the treatment of last resort; surgical outcomes are associated with significant morbidity and mortality. Therefore, a surgeon should be aware of all options for decompression-conservative, pharmacologic, and endoscopic-and use them in best combination to the advantage of patients who often suffer from significant concurrent illnesses making them poor operative candidates.

Acute Colonic Pseudo-Obstruction Associated with Parkinson’s Disease

“…The incidence of Ogilvie's syndrome is uncertain and its exact pathogenesis is also unknown, but it is due to a functional disturbance in colonic motility which is multifactorial [3,5]. Most studies indicate that elderly patients are at greatest risk of developing ACPO and usually suffer preexisting medical condition.…”

“…Many conditions are associated with ACPO: medical or surgical causes and some medications. ACPO is characterized by abdominal distension, pain, nausea and/or vomiting [1,3]. Delays in diagnosis or misdiagnosis can lead to mural ischemia; perforation and peritonitis requiring emergency laparotomy associated to high mortality.…”

Distensão Abdominal Aguda em Paciente com Síndrome Consumptiva

“…A pseudo obstrução colônica aguda, também denominada Síndrome de Ogilvie, é caracterizada por uma intensa dilatação do ceco e do cólon direito, podendo ainda estender-se para o reto, sem que haja uma causa obstrutiva de natureza mecânica para explicar a parada do trânsito intestinal [1][2][3][4] . A patogênese exata da dilatação do colón é ainda desconhecida, porém acredita-se que resulte de um desequilíbrio entre sistema nervoso autônomo simpático e parassimpático 1 .…”

“…O diagnóstico, porém, só é estabelecido através de exames de imagem. A colonoscopia não deve ser utilizada como ferramenta diagnóstica, uma vez que a insuflação com ar poderá distender ainda mais o colón, com risco de perfuração 1,2,6 . O enema opaco ou tomografia computadorizada de abdome podem ser realizados para a detecção de alguma obstrução mecânica.…”

What’s new in medical management strategies for raised intra-abdominal pressure: evacuating intra-abdominal contents, improving abdominal wall compliance, pharmacotherapy, and continuous negative extra-abdominal pressure

“…Prokinetics, neostigmine and enemas have all been used successfully to manage postoperative ileus. However, in patients not responding to maximal supportive and pharmacologic therapy, endoscopic decompression should be considered [12].…”