Appendiceal fat stranding on CT: a red herring in a post-caesarean section woman with Ogilvie’s syndrome (OS)

Abstract

A 30-year-old woman was referred for a surgical review with abdominal pain and distension 2 days post-caesearean section. Abdominal X-ray showed dilated bowel loops. CT of her abdomen however showed fat stranding around a thickened appendix, suggesting a differential diagnosis of acute appendicitis on top of a postoperative ileus. Failure to respond to intravenous antibiotics led to an emergent surgical exploratory laparotomy, by which time the progressive caecal dilatation had led to patchy necrosis and perforation of the right hemicolon intra-operatively. The patient required a right hemicolectomy and histological examination of the excised bowel supported the diagnosis of Ogilvie’s syndrome. This case highlights the red herrings that one can encounter when faced with a woman with post-caesarean section abdominal pain and aims to raise awareness among clinicians of this condition—where timely diagnosis and management is key.

Ogilvie's syndrome after an emergency caesarean section: A case report

“…Of note, a 2019 case study demonstrated that even in the presence of CT imaging revealing grossly dilated loops of bowel without evidence of mechanical obstruction, the diagnosis of Ogilvie's syndrome can be missed [ 3 ]. In that case study there was concurrent CT evidence of appendiceal thickening and fat stranding leading to the presumed diagnosis and conservative management of acute appendicitis.…”

“…In that case study there was concurrent CT evidence of appendiceal thickening and fat stranding leading to the presumed diagnosis and conservative management of acute appendicitis. The patient's case was complicated by caecal necrosis requiring a right hemicolectomy [ 3 ]. This further highlights the need for increased awareness [ 4 ] of Ogilvie's syndrome and the importance of early diagnosis and management in decreasing morbidity.…”

“…The overall prevalence is estimated to be 1 in 1000 admissions annually [ 2 ]. It can be challenging to identify and distinguish from other causes of postoperative abdominal pain [ 3 ], with resulting delays to diagnosis and treatment therefore increasing morbidity and mortality. There is a low level of general clinician awareness about Ogilvie's syndrome, which can prolong the time from patient development of symptoms to senior clinician review and involvement of a multidisciplinary team [ 4 ].…”