Ogilvie syndrome

Case report & paper review2004/08/02 Ri 林哲生

Case summary

59 y/o female Past history:

Idiopathic liver cirrhosis for 10+ years PPU (6 year ago) LVH (07/12 LVEF 91.5%)

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--> 4C1 07/13 Hypaque study: distal colon not opacified 07/15 Colon fiberoscopy: no definite obstructive

3 Hr 8 Hr 17 Hr

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

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.

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

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

Treatment

Medical Care Supportive care (NPO, NG decompression, fluid

resuscitation, enema) neostigmine Colonoscopic decompression of the colon

Surgical Care Tube cecostomy Subtotal colectomy

Neostigmine for the treatment of acute colonic pseudo-obstruction

NEJM 1999; 341 (3):137

Patients and Methods Patient en-roll criteria:

Abdominal distention and radiographic evidence of colonic dilation (cecal diameter > 10 cm)

had no response to at least 24 hours of conservative treatment.

Exclusion criteria: Basal HR < 60 bpm, SBP < 90 mmHg active bronchospasm pregnancy a history of colon cancer or partial colonic resection active GI bleeding signs of bowel perforation

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.

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

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.

Ogilvie Syndrome as a Postoperative Complication

Arch Surg. 2000;135:682-687

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

Patients and methods

Type of operation Postoperative day of diagnosis of Ogilvie

syndrome Interval from diagnosis to resolution or death Treatment

Results

Results

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 Total=14% (5/36) Required operative intervention= 60% (3/5)

Thanks for your attention