Pseudo-obstruction of the large bowel

Colonic transendoscopic enteral tubing is revolutionizing intestinal therapeutics, diagnosis, and microbiome research

The intestine, as a crucial organ of the human body, has remained enigmatic despite the remarkable advancements in modern medical technology. Over the past decades, the invention of endoscopic technology has made the noninvasive intervention of the intestine a reality, expanding diagnostic and therapeutic options for diseases. However, due to the single-treatment feature of endoscopic procedures, continuous or repeated medication administration, sampling, and decompression drainage within the intestine have yet to be fulfilled. These limitations persisted until the invention of colonic transendoscopic enteral tubing (TET) in 2014, which realized repeated fecal microbiota transplantation, medication administration, and decompression drainage for the treatment of colon perforation and intestinal obstruction, as well as in situ dynamic sampling. These breakthroughs have not gone unnoticed, gaining global attention and recommendations from guidelines and consensuses. TET has emerged as a novel microbial research tool that offers new paradigms for human microbiome research. This review aims to update the research progress based on TET.

Ogilvie Syndrome in Patients With Traumatic Pelvic and/or Acetabular Fractures: A Retrospective Cohort Study

OBJECTIVES

To assess the incidence, risk factors, and clinical outcomes of Ogilvie syndrome (OS) in patients with pelvic and/or acetabular fractures.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS

One thousand sixty patients with pelvic and/or acetabular fractures treated at Rigshospitalet, Copenhagen, between 2009 and 2020.

INTERVENTION

Interventions comprised the treatment of pelvic and/or acetabular fractures with emergency external and/or internal fixation.

MAIN OUTCOME MEASUREMENTS

Outcomes included diagnosis of OS, perioperative complications, ICU stay and length, length of admission, and mortality.

RESULTS

We identified 1060 patients with pelvic and/or acetabular fractures. Of these, 25 patients were diagnosed with OS perioperatively, corresponding to incidences of 1.6%, 2.7%, and 2.6% for acetabular, pelvic, and combined fractures, respectively. Risk factors included congestive heart failure, diabetes, concomitant traumatic lesions, head trauma, fractures of the cranial vault and/or basal skull, retroperitoneal hematomas and spinal cord injuries, and emergency internal fixation and extraperitoneal packing. Six (24%) patients underwent laparotomy, and all patients had ischemia or perforation of the cecum for which right hemicolectomy was performed. Ogilvie syndrome was associated with a significant increase in nosocomial infections, sepsis, pulmonary embolism, ICU stay, and prolonged hospital admission.

CONCLUSION

Ogilvie syndrome in patients with pelvic and/or acetabular fractures is associated with increased risk of perioperative complications and prolonged hospital and ICU stays, resulting in an increased risk of morbidity and mortality.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Rare Case of a Failed AngioVac Procedure Used to Debride Tricuspid Vegetation Complicated by Ogilvie Syndrome

Ogilvie syndrome is a rare disorder characterized by dilatation of part or all of the colon and rectum without intrinsic or extrinsic mechanical obstruction. Its etiology is likely multifactorial with high mortality if left untreated. Here, we report for the first time a case of Ogilvie syndrome secondary to the AngioVac procedure. Because our patient had a high operative risk, we used the AngioVac system to debulk tricuspid valve vegetations to reduce bacterial load. Although AngioVac is considered safe overall, publications describing its side effects, safety, and efficacy are limited. Providers should be aware of this rare but potentially fatal complication and the importance of close clinical monitoring and serial abdominal examinations following AngioVac procedures.

The rare Ogilvie's Syndrome in pregnancy. How to manage? A case report and literature review

Acute colonic pseudo-obstruction, or Ogilvie's syndrome (OS), is a complication in gynaecology and obstetrics. Its occurrence during pregnancy is rare, redefining the therapeutic decision-making and treatment options. In this review we describe the case of a 37-year-old pregnant patient who developed OS at the 30th week of gestation. A laparotomy with colonic decompression was performed. Foetal condition, regularly monitored throughout the hospital stay, remained normal. The patient experienced an uncomplicated, natural delivery at 40 weeks. A comprehensive literature search, describing the occurrence of OS during pregnancy, was conducted. We identified six cases of OS arising during pregnancy. Demographic, clinical, diagnostic and therapeutic features were analysed. Non-surgical management is generally the first-line option, with intravenous drug administration, rectal and nasogastric tube positioning and colonoscopic decompression the treatments of choice. Surgical decompression in usually performed in cases of failure of the first-line treatments. Including our own experience, in all cases, neither maternal nor foetal mortality was reported. A conservative approach is mandatory as first-line treatment, but when prompt resolution is not achieved, a multidisciplinary team, involving the gynaecologist/obstetrician, the surgeon, the radiologist and the intensivist is mandatory to avoid diagnostic delays, thereby reducing morbidity and mortality rates.

Pseudo-Obstruction of the Large Bowel

Thirty patients with acute pseudo-obstruction of the large bowel are presented, and the aetiology and diagnosis of this recognized clinical entity are described. Emergency barium enema examination is recommended in patients with symptoms and signs of large bowel obstruction. When no mechanical blockage is found a diagnosis of pseudo-obstruction can be made. The management of pseudo-obstruction is conservative, with nasogastic suction, intravenous fluids and the treatment of any associated condition such as cardiac failure and inflammatory conditions. The indications for surgery in pseudo-obstruction are discussed.

Acute colonic pseudo-obstruction: A systematic review of aetiology and mechanisms

AIM

To critically review the literature addressing the definition, epidemiology, aetiology and pathophysiology of acute colonic pseudo-obstruction (ACPO).

METHODS

A systematic search was performed to identify articles investigating the aetiology and pathophysiology of ACPO. A narrative synthesis of the evidence was undertaken.

RESULTS

No consistent approach to the definition or reporting of ACPO has been developed, which has led to overlapping investigation with other conditions. A vast array of risk factors has been identified, supporting a multifactorial aetiology. The pathophysiological mechanisms remain unclear, but are likely related to altered autonomic regulation of colonic motility, in the setting of other predisposing factors.

CONCLUSION

Future research should aim to establish a clear and consistent definition of ACPO, and elucidate the pathophysiological mechanisms leading to altered colonic function. An improved understanding of the aetiology of ACPO may facilitate the development of targeted strategies for its prevention and treatment.

Ogilvie's syndrome-acute colonic pseudo-obstruction

Ogilvie's syndrome describes an acute colonic pseudo-obstruction (ACPO) consisting of dilatation of part or all of the colon and rectum without intrinsic or extrinsic mechanical obstruction. It often occurs in debilitated patients. Its pathophysiology is still poorly understood. Since computed tomography (CT) often reveals a sharp transition or "cut-off" between dilated and non-dilated bowel, the possibility of organic colonic obstruction must be excluded. If there are no criteria of gravity, initial treatment should be conservative or pharmacologic using neostigmine; decompression of colonic gas is also a favored treatment in the decision tree, especially when cecal dilatation reaches dimensions that are considered at high risk for perforation. Recurrence is prevented by the use of a multiperforated Faucher rectal tube and oral or colonic administration of polyethylene glycol (PEG) laxative. Alternative therapeutic methods include: epidural anesthesia, needle decompression guided either radiologically or colonoscopically, or percutaneous cecostomy. Surgery should be considered only as a final option if medical treatments fail or if colonic perforation is suspected; surgery may consist of cecostomy or manually-guided transanal pan-colorectal tube decompression at open laparotomy. Surgery is associated with high rates of morbidity and mortality.

Acute colonic pseudo-obstruction

Background

Acute colonic pseudo-obstruction is characterized by clinical and radiological evidence of acute large bowel obstruction in the absence of a mechanical cause. The condition usually affects elderly people with underlying co-morbidities, and early recognition and appropriate management are essential to reduce the occurrence of life-threatening complications.

Methods

A part-systematic review was conducted. This was based on key publications focusing on advances in management.

Results and conclusions

Although acute colonic dilatation has been suggested to result from a functional imbalance in autonomic nerve supply, there is little direct evidence for this. Other aetiologies derived from the evolving field of neurogastroenterology remain underexplored. The rationale of treatment is to achieve prompt and effective colonic decompression. Initial management includes supportive interventions that may be followed by pharmacological therapy. Controlled clinical trials have shown that the acetylcholinesterase inhibitor neostigmine is an effective treatment with initial response rates of 60–90 per cent; other drugs for use in this area are in evolution. Colonoscopic decompression is successful in approximately 80 per cent of patients, with other minimally invasive strategies continuing to be developed. Surgery has thus become largely limited to those in whom complications occur. A contemporary management algorithm is provided on this basis.

Factors predicting successful outcome following neostigmine therapy in acute colonic pseudo-obstruction: a prospective study

AIM

To evaluate predictors of neostigmine response in patients with acute colonic pseudo-obstruction.

METHODS

Twenty-seven patients with acute colonic pseudo-obstruction were enrolled in the study. All patients had received initial conservative management such as nil orally, nasogastric suction, rectal tube placement and correction of electrolyte imbalance for the first 24 h. Those who did not resolve with conservative management received 2 mg neostigmine intravenously. The same dose was repeated after 24 h in patients who did not response to the first dose (initial non-responders), or in those patients who relapsed after an initial response (initial responders). All non-responders to neostigmine underwent colonoscopic decompression followed by 2 mg neostigmine infusion for 30 min. A sustained response was defined as the resolution of symptoms and colonic dilatation on a plain radiograph.

RESULTS

The study enrolled 27 patients; 18 were male (67%), and the median age was 60 years (range 18-78 years). Eight (30%) patients had spontaneous resolution. Initial response with neostigmine was observed in 16 (84%) patients, of which 10 (63%) had a sustained response. Nine patients (three initial non-responders and six initial responders) had received a second dose of neostigmine. A sustained response was seen only in five initial responders. Four patients who did not respond to neostigmine underwent colonoscopic decompression followed by neostigmine infusion and had a sustained response. Neostigmine responders were more likely to be postoperative patients (11 of 15 (73%) vs one of four (25%), P = 0.07), less likely to have electrolyte imbalance and to be on antimotility agents (three of 15 (20%) vs four of four (100%), P = 0.009 and two of 15 (13%) vs four of four (100%), P = 0.003).

CONCLUSIONS

Electrolyte imbalance and usage of anti-motility agents are factors associated with a poor response, while postoperative patients showing good response to neostigmine therapy.

Does a water soluble contrast enema assist in the management of acute large bowel obstruction: A prospective study of 117 cases

We have performed a prospective study on 117 patients in order to assess the value of a single contrast water soluble enema in acute large bowel obstruction. In 99 cases where the plain films suggested a diagnosis of mechanical obstruction, the Diodone enema confirmed its presence in 52, and relocated its site in 11. There was free flow of contrast to the caecum in the remaining 35, 11 of whom were shown to have idiopathic pseudoobstruction. The plain films suggested a diagnosis of pseudo-obstruction in 18 patients. The Diodone enema confirmed this diagnosis in 15, but revealed an unsuspected mechanical obstruction in two. The examination failed in two cases. We conclude that the water soluble single contrast enema is of value in the management of large bowel obstruction. It will confirm the diagnosis of mechanical obstruction and prevent unnecessary surgery in patients with pseudo-obstruction.

Assessment of predictors of response to neostigmine for acute colonic pseudo-obstruction

OBJECTIVE

Acute colonic pseudoobstruction (ACPO) most commonly develops after surgery, with narcotic administration, or in association with severe illness. Most cases resolve with conservative management. Colonoscopic decompression may be required in patients failing to respond to conservative treatment. Neostigmine has been proposed as an effective treatment for ACPO as an alternative to colonoscopic decompression. We sought to identify factors associated with spontaneous resolution of ACPO and to identify variables associated with a response to i.v. administration of neostigmine for the treatment of ACPO.

METHODS

Retrospective analysis of Mayo Clinic's diagnostic index revealed all patients who developed ACPO between July, 1999 and September, 2001 at the Mayo Clinic Medical Center. We separately analyzed those patients who did not resolve ACPO with conservative management and to whom i.v. neostigmine was administered. Patient records were abstracted for demographic data, etiology of ACPO, management, and response to treatment.

RESULTS

A total of 151 patients were identified with ACPO between July, 1999 and September, 2001; 117 patients (77%) had spontaneous resolution of symptoms. Of the 34 "nonresolvers," 18 patients received neostigmine, whereas 16 did not receive neostigmine. Of those 16 patients, 11 required colonoscopic decompression, two underwent surgery, and three died of underlying illness. "Spontaneous resolvers" were less likely to be taking narcotics (59% vs 74%, p = 0.08). Of the 16 nonresolvers who did not receive neostigmine, only one had a contraindication to neostigmine use. Of the 18 patients that who received neostigmine, 16 patients (89%) had prompt evacuation (<30 min) of flatus or stool. Sustained clinical response to neostigmine was noted in 11 of 18 (61%); the remaining seven patients (39%) required colonoscopic decompression or surgery for recurrent or persistent colonic dilation. Neostigmine-responders were more likely to be older (mean age, 76 yr vs 54 yr, p = 0.03), than nonresponders. Preneostigmine cecal diameter did not differ significantly between responders (median, 12 cm) and nonresponders (median, 13 cm), p = 0.9. Median time to resolution of ACPO in spontaneous resolvers was 4 days compared to 2 days in patients responding to neostigmine; p = 0.038.

CONCLUSIONS

Most patients with ACPO respond to conservative treatment. Female gender and older age are associated with a response to neostigmine in those patients who do not respond to conservative management. Neostigmine appears to be under-used in patients with ACPO who do not have a true contraindication to its use.

Review article: the pharmacological treatment of acute colonic pseudo-obstruction

Acute colonic pseudo-obstruction (Ogilvie's syndrome) can be defined as a clinical condition with symptoms, signs and radiological appearance of acute large bowel obstruction unrelated to any mechanical cause. Recent reports of the efficacy of cholinesterase inhibitors in relieving acute colonic pseudo-obstruction have fuelled interest in the pharmacological treatment of this condition. The aim of the present review is to outline current perspectives in the pharmacological treatment of patients with acute colonic pseudo-obstruction. The best documented pharmacological treatment of Ogilvie's syndrome is intravenous neostigmine (2-2.5 mg), which leads to quick decompression in a significant proportion of patients after a single infusion. However, the search for new colokinetic agents for the treatment of lower gut motor disorders has made available a number of drugs that may also be therapeutic options for Ogilvie's syndrome. Among these agents, the potential of 5-hydroxytryptamine-4 receptor agonists and motilin receptor agonists is discussed.

Retrospective Study of Neostigmine for the Treatment of Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction (ACPO) typically develops postoperatively or after severe illness. Studies suggest that pharmacologic manipulation with intravenous (IV) neostigmine (NSM) may be an effective and less invasive treatment modality for ACPO with minimal side effects. The purpose of this study was to retrospectively assess the efficacy and incidence of complications of an IV NSM bolus in patients with ACPO. Eight patients with ten episodes of ACPO were treated with a bolus dose of NSM. Rapid and effective decompression of the colon was achieved in six episodes after a single dose of NSM at a mean of 22.8 ± 13.5 minutes. In three episodes decompression occurred after a second dose of NSM at a mean of 44.7 ± 37.7 minutes. One patient failed NSM treatment but responded to a Cystografin enema. One patient experienced significant bradycardia. NSM is a simple, safe, and effective treatment for ACPO and based on result comparison of this study and previous studies both bolus and slow infusion dosing practices of NSM are effective. The NSM bolus dosing side effect profile has been shown to include significant bradycardia, whereas when NSM was infused over one hour significant bradycardic episodes requiring treatment have not been encountered. We propose that a prospective study evaluating NSM dosing as an IV bolus versus an IV infusion would be useful in determining whether NSM infusion can be proven safer than bolus dosing for the treatment of ACPO.

Conservative management of acute pseudo-obstruction in a major burn

We present a case of recurrent acute colonic pseudo-obstruction (ACPO) in a burn patient that responded to a postural change which has not been previously reported.

Acute colonic pseudo-obstruction (Ogilvie's syndrome) after renal transplantation

BACKGROUND

Acute colonic pseudo-obstruction (Ogilvie's syndrome) in the immunosuppressed patient is associated with increased morbidity and mortality. Renal transplant recipients possess several comorbidities that increase the risk of acute pseudo-obstruction of the colon. The aims of this study were to present our experience with this syndrome and to evaluate the potentiating factors in these patients. A review of the literature for pseudo-obstruction following renal transplantation is presented.

METHODS

Seven patients who developed Ogilvie's syndrome were identified in a retrospective review of 550 kidney-only transplants. Pretransplant data, potential risk factors, presentation, management, and outcome details were retrieved. The medical literature was reviewed using Medline.

RESULTS

Seventy-eight patients with Ogilvie's syndrome in the early posttransplant period have been reported. The associated morbidity and mortality was heightened in this immunocompromised population. Obese transplant recipients (body mass index >30 kg/m2) were at significantly increased risk for developing this syndrome.

CONCLUSION

A broad armamentarium of treatment options is available, but the key to successful resolution lies in early recognition.

Colonic pseudo-obstruction in burns patients

Acute pseudo-obstruction is a rare complication in burns patients. An awareness of the factors implicated in its pathogenesis such as prolonged bed rest, narcotic medications, hypokalaemia, sepsis and surgery (all commonly associated with burns patients) is essential if this condition is to be avoided. Early diagnosis, prokinetic and cathartic agents, and aggressive endoscopic intervention are essential to halt the progression of caecal dilatation. Excisional surgery and stoma formation are necessary for salvage of complicated colonic pseudo-obstruction.

Long-term gastrointestinal problems in burns patients

Paralytic ileus occurs commonly in patients with over 20 per cent TBSA burns in the first few days after the burn. In the absence of sepsis, it is unusual for abdominal problems to develop later. We present an example of acute abdominal pseudo-obstruction occurring 5 weeks after a burn and review the management of this condition.

Acute colonic pseudo-obstruction

The syndrome of acute colonic pseudo-obstruction is well delineated but its aetiology remains poorly understood and patients are still treated inappropriately. This article reviews the pathogenesis and surgical management of this condition. Early diagnosis is stressed as a pivotal factor in reducing morbidity and mortality.

Colonoscopically guided tube decompression in Ogilvie's syndrome

Ogilvie's syndrome (pseudo-obstruction of the colon) may result in gangrene and perforation of the colon if not effectively treated. Colonoscopic decompression and endoscopically guided rectal tube placement were employed to treat five patients with this syndrome who had failed medical therapy. All patients tolerated the procedure well and required no further treatment.

Drug-induced colonic pseudo-obstruction. Report of a case

Colonic pseudo-obstruction may have many possible causes. Some of these are well described and pose no diagnostic problems. Drug-related colonic pseudo-obstruction remains underreported, but is of importance in modern society where drugs are endemically abused. This case highlights the importance of drugs in altering colonic motility and emphasizes the nonsurgical management of this condition.

Motor abnormalities of digestive and urinary tracts in patients on ventilator for acute exacerbation of chronic obstructive pulmonary disease

The frequency of digestive motor abnormalities was evaluated in 30 consecutive patients ventilated for acute exacerbation of chronic obstructive pulmonary disease. Total and segmental colonic transit times were investigated by radiopaque marker transit time in all patients. Eleven patients also had rectoanal and esophageal manometries, combined with urodynamic study in eight cases. The results show that total radiopaque marker transit time was increased, 201 +/- 14 hr (mean +/- SE), with two main regions of decreased transit rates: the right colon (42% of global transit time) and the rectosigmoid (36%). Delayed transit of radiopaque markers in nine of 11 cases was combined with esophageal motor dysfunction and absence of rectoanal inhibitory reflex. In three of eight cases there was disinhibition of urinary bladder contraction, and micturition was impossible in two of eight cases. We conclude that patients on ventilator for exacerbation of chronic obstructive pulmonary disease always have a delayed colonic transit time with diffuse digestive and bladder motor dysfunction.

Changes in colorectal function in patients with chronic colonic pseudoobstruction

Motility studies of the lower bowel, radiology to exclude other gastrointestinal involvement, and rectal biopsies were carried out in 11 patients, age 21-60 years, with isolated chronic colonic pseudoobstruction. Repeated plain abdominal x-rays during symptomatic periods revealed massive gaseous colonic distension in all. Seven patients had the primary form while four patients had an underlying disease which could have been responsible for the chronic colonic pseudoobstruction. Lower bowel motility was decreased in patients with the primary form. Rectal wall elasticity was increased in both the primary and secondary form. Some of the abnormalities measured may suggest myogenic abnormalities of the sigmoid or rectal wall. No specific neural or muscular morphologic defect was identified in colonic transmural sections in eight patients except in the patient with Hirschsprung's disease. Five of seven patients with primary colonic pseudoobstruction achieved symptomatic relief only after subtotal colectomy and ileoproctostomy.

Acute pseudo-obstruction of the colon (Ogilvie's syndrome). An analysis of 400 cases

This study analyzes 400 cases of acute pseudo-obstruction of the colon (Ogilvie's syndrome). Seven cases were reported at St. Elizabeth Hospital Medical Center between October 1982 and February 1985; 393 cases were reported in the literature from 1970-1985. Ogilvie's syndrome is most commonly reported in patients in the sixth decade, and is more predominant in men. It is caused by an unknown disturbance to the autonomic innervation of the distal colon, and is associated with different conditions. Plain abdominal roentgenogram is the most useful diagnostic test. If the cecal diameter is 12 cm or greater, or conservative management is unsuccessful, colonoscopic or operative decompression is needed. The mode of treatment, age, cecal diameter, delay in decompression, and status of the bowel significantly influence the mortality rate, which is approximately 15 percent with early appropriate management, compared with 36 to 44 percent in perforated or ischemic bowel.

Pseudo-obstruction of the colon following cesarean section. A review

Pseudo-obstruction of the colon is characterized by an adynamic unobstructed colon which rapidly progresses to marked dilatation of the cecum and transverse colon. Disagreements exist regarding the etiology or pathogenesis of this syndrome; it has been associated with metabolic, traumatic, postoperative, and idiopathic causes. In reviewing the literature we have concluded that in pseudo-obstruction of the colon after cesarean section, the mean age of occurrence is 35 years. The symptoms occur in the first 72 hours after operation. Straight x-ray examination of the abdomen is the most useful diagnostic measure. All cecal perforations occurred by the fifth postoperative day. For this reason, we recommend early diagnosis and prompt surgical intervention before that time. In cases when the cecal distention is 12 cm or more, decompression is urgent.

Ogilvie's syndrome (acute colonic pseudo-obstruction): review of the literature (October 1948 to March 1980) and report of four additional cases

Four additional cases of Ogilvie's syndrome (acute colonic pseudo-obstruction), representing the first cases described in Italy, are reported. The medical literature concerning the subject is also thoroughly reviewed. Ogilvie's syndrome is an acute massive dilatation of the large bowel without organic obstruction of the distal colon. Three hundred and fifty-one cases have been described in the literature to date. Eighty-eight per cent of the cases were associated with various extracolonic affections (metabolic and organ dysfunctions, postoperative and posttraumatic states, etc.). Twelve per cent of cases were not associated with known disorders and were defined as idiopathic. The pathophysiology of the syndrome is still unknown. Ogilvie, who first described the syndrome in 1948, suggested an imbalance between the sympathetic and parasympathetic innervation of the colon: this neurogenic hypothesis has been shared by other authors, although explanations may differ slightly. The clinical and radiologic picture closely resembles mechanical obstruction of the large bowel. The most marked dilatation usually takes place in the right colon and cecum: if the distended cecum reaches a diameter larger than 9 to 12 cm, perforation is likely to occur; if perforation occurs, the mortality rate increases from 25 to 31 per cent to about 43 to 46 per cent. If conservative management fails to control the dilatation and cecal rupture is impending or suspected emergency surgery is indicated, the surgical procedure of choice is dictated by the general conditions of the patient as well as by the intestinal findings: operation may consist of cecostomy, colostomy, or right hemicolectomy or simply emptying the bowel.

Pseudo-obstruction of the colon during pelvic radiotherapy

Pseudo-obstruction of the colon, or Ogilvie's syndrome, is characterized by an adynamic, dilated, unobstructed colon, the exact cause of which remains obscure. Although several precipitating factors have been described in the literature, we have observed three patients whose pseudo-obstruction of the colon occurred during interstitial and intracavitary pelvic irradiation. Such a cause has not been noted previously. Pseudo-obstruction of the colon can have serious consequences if it is not recognized early and treated vigorously.

Pseudo-obstruction due to clonidine

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