What is Ogilvie Syndrome?
Acute colonic pseudo-obstruction (ACPO), also known as Ogilvie syndrome, is a special case where the colon – the part of the digestive system where waste material is stored – becomes enlarged but there’s no physical blockage causing it. In most cases, only a part of the colon gets enlarged, usually near the curve in the colon located near the spleen. This syndrome often occurs in older adults who already have different health issues but can also happen in healthy individuals after a severe injury or surgical operation.
It’s crucial to recognize that diagnosing ACPO comes down to ruling out other more common reasons for an enlarged bowel. Usually, the symptoms of this health issue appear over 3 to 5 days but, on occasion, they can develop more rapidly, sometimes within 2 days. The condition is considered severe if the patient shows signs of a lack of blood supply to the bowel, inflammation of the abdominal lining, or a hole in the bowel. The possibility of serious issues increases with the degree of enlargement of the colon part, and the duration of the illness.
The main treatment for people with uncomplicated ACPO is supportive care involving careful monitoring. However, early use of medication is becoming more popular. More aggressive treatments, like invasive procedures or surgery, are only necessary for stubborn cases or if a patient’s initial condition is severe. With the right treatment, many patients do recover, although the chances of serious illness or death rise substantially in people who face complications at any point during treatment.
What Causes Ogilvie Syndrome?
Acute colonic pseudo-obstruction is a condition that we can’t predict or pin to a definite cause. However, certain situations or health conditions seem to increase its risk. For instance, older people, those with health problems that affect their electrolyte balance (the right amount of certain chemicals in the body) or require multiple medications, and those with limited movement or overall poor health are more likely to develop it.
Elderly people who have been in the hospital, even if they didn’t have surgery, are also more at risk. A study looked back at 400 patients with this condition and noted that non-operative trauma (injury without having surgery), severe infection, and having heart disease increased their risk, each accounted for around 10% of the cases.
While all surgeries do increase the risk of a related condition called ileus (a temporary stagnation of bowel movements), the types of surgery that seem to have the strongest association with pseudo-obstruction are major orthopedic surgeries (related to bones or muscles) and procedures connected with childbirth.
A connection to cesarean section (C-section) surgeries has also been seen, but the exact reason for this is not currently clear. Lastly, it’s also important to note that not everyone who gets pseudo-obstruction will be in the hospital. The risk is higher in elderly patients being cared for in long-term care facilities or nursing homes, in those with progressive neurological diseases that get worse over time, or in those who have recently had abdominal surgery.
Risk Factors and Frequency for Ogilvie Syndrome
This disease is reported to occur around 100 times for every 100,000 hospital admissions each year, though the exact number might be a little higher due to underreporting. Men seem to be slightly more likely to get this disease than women, but we don’t know why. Most people who are diagnosed with this disease are around 60 years old. It is also mainly seen in patients with multiple existing health conditions, especially those who are already dependent on others for their day-to-day tasks. People who have recently had surgery are usually diagnosed with this disease between 3 to 5 days after their operation.
- This disease is reported in about 100 in 100,000 hospital admissions per year. However, it may be underreported.
- Men appear to be a bit more likely to develop this disease, but the reason for this is not known.
- People are usually around 60 years old when they are diagnosed with this disease.
- Patients who have multiple other health problems, especially those who depend on others for basic functions, are more commonly diagnosed with this disease.
- Patients who have recently had surgery are most often diagnosed between 3 to 5 days after their operation.
Signs and Symptoms of Ogilvie Syndrome
Acute colonic pseudo-obstruction is a condition that gradually causes an increase in the size of the abdomen and some discomfort. Many people also experience nausea, vomiting, and changes in their bowel habits. Even though blockages in the bowel are often associated with constipation, some individuals with this condition can still experience a degree of bowel movement, and can sometimes have diarrhea caused by excess water secretion. It’s essential to note that most of these people also suffer from severe ongoing health conditions or temporary worsening of chronic diseases, which can make their condition’s history unreliable.
During a physical exam, a swollen abdomen is typically noted. The abdomen usually sounds hollow when tapped, and high-pitched bowel sounds can be heard using a stethoscope. There might be some tenderness when the abdomen is touched, and the presence of a fever or serious abdominal pain, especially when signs of inflammation in the lining of the abdomen are present, could indicate the emergency conditions of low blood flow or a tear in the bowel. If the signs of inflammation in the lining of the abdomen are present together with abnormal vital signs, it could be suggestive of severe infection.
Testing for Ogilvie Syndrome
Acute colonic pseudo-obstruction, also known as Ogilvie’s syndrome, is a rare cause of blockage in the bowel and is typically diagnosed once other possibilities have been ruled out. To officially determine if a person has this condition, a detailed assessment, including various imaging tests using dye or “contrast”, are required. It is also important to check for possible problems that may be causing this condition, or complications such as tissue damage (ischemia) or tears (perforation) in the bowel.
Some blood tests, although not directly linked to this condition, can help with a full evaluation. In absence of any other known disease, higher levels of white blood cells (leukocytosis), inflammation marker C-Reactive Protein (CRP), or a compound called lactate in the blood could indicate damage to the bowel. Various other tests like liver function, lipase and human chorionic gonadotropin (HCG) could help rule out other causes of severe belly pain. It’s also common to see changes in electrolytes like magnesium and calcium levels in such patients, especially after surgery. A thyroid function test may be needed if there isn’t a recent one available. Patients with diarrhea should be tested for Clostridium difficile toxin. Blood cultures could be considered in patients who appear septic, meaning they may have a severe infection.
Performing the correct imaging tests is crucial for diagnosing and managing this condition. Plain X-rays of the abdomen, while standing and lying down, might be done. These could show some swelling in the large intestine, normal folds or haustra in the bowel wall and lack of signs of mechanical blockage like a twisted bowel (volvulus). Presence of air in the belly area on these X-rays can raise concern for a tear in the bowel, although it does not rule it out. An important use of these X-rays is to understand the degree of bowel swelling initially and to keep track of changes over time after the diagnosis.
The best imaging test for diagnosis is a CT scan with oral and injectable contrast. Rectal contrast could be used but it has been known to sometimes cause a tear in the bowel. Instead, a safer, water-soluble contrast is preferred. A CT scan can rule out certain causes of blockage such as a physical block or other causes of swelling like a hematoma (bruise) behind the abdomen or abscesses in the belly. It can also show signs of bowel wall damage like wall thickening, swelling under the mucosal-lining, or presence of gas. Typically, this condition on a CT scan presents as swelling limited to the large intestine, primarily affecting the first part (cecum) and the part that rises upwards (ascending colon), and tapering or “cutting off” near the spleen (splenic flexure).
If a CT scan cannot be performed and if the patient does not have inflammation of the abdomen lining (peritonitis) during the exam, a contrast enema study, where the contrast is introduced through the rectum, might be performed. This test has up to 96% accuracy in diagnosing this condition. Importantly, diagnostic colonoscopy, where a tube is inserted into the rectum to examine the colon, should not be used in patients with a suspicion of this condition as the air inflated during the procedure can increase the risk of perforation or a tear in the bowel.
Treatment Options for Ogilvie Syndrome
When dealing with acute colonic pseudo-obstruction (ACPO), the main goal of treatment is to quickly reduce the amount of pressure in the bowel. This can be achieved in a few ways, like observation, using medication, or using endoscopy techniques. In some cases, when these treatments aren’t successful or if complications such as a blocked or ruptured bowel arise, surgical intervention might be required. These treatment guidelines follow the recommendations released by the American Society of Colon and Rectal Surgeons in 2016.
If ACPO isn’t too serious, the patient will need to be kept in the hospital for careful monitoring. Initially, some of the steps which are taken include stopping the patient from eating or drinking, placing a nasal gastric tube to help reduce pressure in the stomach, giving the patient fluids, and correcting any electrolyte imbalances. Any medications that can affect bowel movement, like painkillers and anticholinergics, should be stopped, and the use of laxatives is discouraged. Patients are encouraged to walk around as much as they comfortably can, and when lying in bed, to change positions regularly to help release trapped gas. Regular tests are needed to monitor the patient’s blood count and electrolyte levels, as well as imaging tests to keep an eye on the size of the cecum, a part of the colon. If the cecum hasn’t increased beyond 12 cm in diameter after three days of this treatment, there’s a high chance (up to 90%) of full recovery.
If there’s no progress after 72 hours, and the patient has had ACPO for more than 4 days or has a cecal diameter of more than 12 cm, medication may be necessary. Neostigmine is usually the go-to medication for treating ACPO. Side effects of neostigmine include abdominal discomfort, increased saliva production, and vomiting, which are usually harmless and short-lived. The patient’s heart and lung functions need to be closely monitored during and after the medication is given, to watch for any adverse effects, and other medications should be on hand in case the side effects need to be addressed.
People who can’t tolerate neostigmine or don’t respond to the medication might need an endoscopy, which involves using a flexible tube with a camera to examine and relieve the blockage in the colon. The procedure can be technically challenging, and success rates often depend on the experience of the medical team. A small tube may be placed into the colon to help remove air and result in decompression. However, there’s a small risk of unintentionally puncturing the colon during this procedure, which might necessitate further treatment.
Traditional surgical methods might be required if the above treatments aren’t successful, or if complications arise, such as restricted blood flow to the bowel or a rupture in the bowel. Different procedures might be performed depending on the patient’s condition, such as creating an opening in the cecum to remove excess air or removal of a section of the colon if damage is too severe. However, surgeries come with high mortality rates and complications, so every effort should be made to manage this condition with more conservative methods.
What else can Ogilvie Syndrome be?
When trying to diagnose ACPO, or acute colonic pseudo-obstruction, doctors have a list of different conditions they need to consider. These might have similar symptoms but are not ACPO. The conditions they need to check for are:
- Volvulus, which can affect the cecum or sigmoid part of the intestine
- Mesenteric ischemia, a condition causing poor blood flow to the intestines
- Toxic megacolon, a life-threatening complication affecting the colon
- Incarcerated hernia, a type of hernia that can’t be pushed back into the abdomen
- Intussusception, which is when one part of the intestine slides into another part
- Stricture, a narrowing of the intestine
- Malignancy, or cancer
- Adynamic ileus, a condition where the intestines stop working
- Constipation or stool impaction, when hard stool is stuck in the colon or rectum
The doctor will rule out these other conditions before making a diagnosis of ACPO. They might perform different tests or ask about your symptoms to do this.
What to expect with Ogilvie Syndrome
The outlook of a condition called ‘acute colonic pseudo-obstruction’ (ACPO) can vary, generally due to the number and severity of other health issues the patient might have, as well as the underlying condition that caused ACPO to develop. This means that patients with multiple health issues already might have a tougher time dealing with ACPO.
Typically, the mortality rate, or death rate, for people diagnosed with uncomplicated ACPO is around 15%. When complications occur, which might happen in roughly 3% to 15% of patients, the mortality rate increases noticeably, ranging between 30% and 40%.
There are certain factors linked to the development of complications in ACPO, like the diameter of the cecum (a part of the large intestine), and how long the patient has been sick. One study found that none of the patients with a cecum diameter less than 12 cm experienced complications. However, complications occurred in 23% of patients whose cecum measured 14 cm in diameter.
The duration of the dilation of the large intestine is another important factor. The onset of complications becomes a concern after 5 days and the mortality rate reportedly increases fivefold when the disease is not resolved after 7 days.
In terms of treatment, surgeries have the highest mortality rate. This is likely because surgeries are usually reserved for patients with complications or a prolonged disease course. Even without complications like bowel ischemia (lack of blood flow to the intestines), the postoperative mortality rate, or the death rate after surgery, is around 26%.
Thus, the outlook and survival rate for patients really depend on how soon ACPO is recognized and diagnosed, and how quickly the build-up of gases in the colon is relieved, usually via a procedure called colonic decompression.
