Postpartum Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome): A systematic review of case reports and case series

Gastrointestinal dysmotility in the ICU

PURPOSE OF REVIEW

This review aims to provide a comprehensive overview of gastrointestinal dysmotility, particularly in critically ill patients within the ICU. It highlights the pathophysiology, prevalence, and clinical implications of conditions, such as oesophageal dysmotility, gastroparesis, ileus, and Ogilvie's syndrome. By examining current diagnostic and treatment approaches, the review emphasizes the importance of recognizing and managing gastrointestinal dysmotility to improve patient outcomes.

RECENT FINDING

Recent literature indicates that up to 60% of ICU patients experience some form of gastrointestinal dysmotility, with those on mechanical ventilation being particularly at risk. The review identifies key contributors to gastrointestinal dysmotility, including inflammatory states, electrolyte imbalances, and the effects of certain medications. Nonpharmacological strategies, such as early enteral feeding, correcting electrolyte abnormalities, and mobilization are critical. Prokinetic agents have shown promise in alleviating feeding intolerance and improving gastric emptying, though their effects on overall mortality remain inconclusive.

SUMMARY

Gastrointestinal dysmotility presents a significant challenge in critically ill patients, leading to various complications that hinder recovery. Understanding the underlying pathophysiology, coupled with effective diagnostic and treatment strategies, is essential for enhancing patient care. This review underscores the need for continued research and clinical focus on gastrointestinal motility disorders in the ICU to improve health outcomes for this vulnerable population.

An Unusual Cause of Large Bowel Obstruction

A 38-year-old female developed acute onset abdominal pain and vomiting on post-operative day 2 following Cesarean section delivery. She was well until 12 h prior to consultation. She reported abdominal distention and noted no bowel movement or flatus over the last 24 h. She had received one dose of hydromorphone in the last 24 h. Prior gastrointestinal history was remarkable for gestational GERD only. At baseline she reported two formed bowel movements daily. Surgical history was remarkable for prior Cesarean section only.

Post Cesarean Section Peritonitis: A Case Report of Ogilvie's Syndrome

Acute colonic pseudo-obstruction (ACPO) is characterized by colon dilation without a mechanical obstruction. This report describes a 39-year-old pregnant woman who developed ACPO following a cesarean section. Right hemicolectomy, distal ileoctomy, and enterorraphy, with subsequent ileostomy and colostomy mucus fistula placement were done. Early consideration of the disease and its diagnosis is crucial for initiating treatment instantly to maximize the benefits of non-invasive medications and minimize the need for surgical procedures and potentially life-threatening complications following a cesarean section.

Ogilvie syndrome with caecal perforation following cesarean section: a rare case report from Jordan

Introduction

Ogilvie syndrome is a rare condition characterized by acute colonic dilation. In 1948, H. Ogilvie first described it in medical literature. Its incidence is estimated at 100 cases per 100 000 per year in the US. Both abdominal distention and pain are considered major symptoms.

Presentation of case

A 32-year-old woman, 36+1 weeks pregnant, experienced labour pain and was admitted to the hospital. Upon examination, she was in labour, but the foetus was in a breech position, necessitating a caesarean section. After 36 h later, she returned to the emergency department with severe, 1-day-old diffuse abdominal pain, accompanied by moderate bilious vomiting and significant abdominal distension. Abdominal CT with contrast revealed pneumoperitoneum, abdominal wall emphysema, and pneumatosis intestinalis involving the caecum and ascending colon, suggesting bowel necrosis. Emergency laparotomy revealed a caecal perforation, which was closed surgically without resection.

Clinical discussion

Ogilvie syndrome is more common in males but can occur in females for several reasons, including pregnancy, caesarean section, pelvic surgeries, and trauma. Several factors contribute to the occurrence of this syndrome, such as pelvic fractures and cardiac events. Surgery may be required if there is suspicion of bowel perforation or ischaemia.

Conclusion

OS is a rare condition in women, often seen after childbirth or pelvic surgery, with an unclear cause but believed to be related to autonomic nervous system imbalance. Patients with abdominal pain and distension, without evidence of obstruction, should be evaluated for pseudo-obstruction using abdominal pelvic CT, and treatment may involve conservative measures, medication, and colonoscopic decompression.

Acute colonic pseudo-obstruction in polytrauma patients

BACKGROUND

Acute colonic pseudo-obstruction (ACPO) is characterized by severe colonic distension without mechanical obstruction. It has an uncertain pathogenesis and poses diagnostic challenges. This study aimed to explore risk factors and clinical outcomes of ACPO in polytrauma patients and contribute information to the limited literature on this condition.

METHODS

This retrospective study, conducted at a Level 1 trauma center, analyzed data from trauma patients with ACPO admitted between July 2009 and June 2018. A control cohort of major trauma patients was used. Data review encompassed patient demographics, abdominal imaging, injury characteristics, analgesic usage, interventions, complications, and mortality. Statistical analyses, including logistic regression and correlation coefficients, were employed to identify risk factors.

RESULTS

There were 57 cases of ACPO, with an incidence of 1.7 per 1,000 patients, rising to 4.86 in major trauma. Predominantly affecting those older than 50 years (75%) and males (75%), with motor vehicle accidents (50.8%) and falls from height (36.8%) being the commonest mechanisms. Noteworthy associated injuries included retroperitoneal bleeds (RPBs) (37%), spinal fractures (37%), and pelvic fractures (37%). Analysis revealed significant associations between ACPO and shock index >0.9, Injury Severity Score >18, opioid use, RPBs, and pelvic fractures. A cecal diameter of ≥12 cm had a significant association with cecal ischemia or perforation.

CONCLUSION

This study underscores the significance of ACPO in polytrauma patients, demonstrating associations with risk factors and clinical outcomes. Clinicians should maintain a high index of suspicion, particularly in older patients with RPBs, pelvic fractures, and opioid use. Early supportive therapy, vigilant monitoring, and timely interventions are crucial for a favorable outcome. Further research and prospective trials are warranted to validate these findings and enhance understanding of ACPO in trauma patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Acute colonic pseudo-obstruction post-cesarean section is not a benign entity: A case series and review of the literature

Acute colonic pseudo-obstruction (ACPO) is an infrequent occurrence after cesarean section. Anecdotal evidence suggests that the clinical course of ACPO in the obstetric setting is different to that seen in non-pregnant adult patients with ACPO secondary to alternative causes, such as systemic illnesses, the use of certain medications, and after non-abdominal surgery. The risk of progression to ischemia and perforation, as well as the need for emergency surgery, appears to be higher after cesarean section. Here we describe the clinical course of ACPO in four patients after cesarean section from our institution, followed by a review of the literature and a discussion of the important issues surrounding this condition in the postpartum time period. The findings from our cohort of patients and the reports from the medical literature support a hands-on combined approach from a group of specialists including obstetricians, surgeons, radiologists, and enterostomal therapists. Immediate imaging followed by regular observation is mandatory for any patient being managed conservatively. Early use of endoscopic decompression should be considered for patients who are not resolving with a conservative approach. Clinical signs of peritonism or radiological signs of ischemia or perforation in patients with ACPO mandate immediate surgical intervention. Appropriate postoperative care is necessary to deal with the complex physiological and psychological consequences of emergency surgery and potential stoma formation so soon after cesarean section.

A case of acute colonic pseudo-obstruction, sigmoid volvulus, and massive pneumoperitoneum in a young female patient

INTRODUCTION AND IMPORTANCE

Acute colonic pseudo-obstruction (ACPO) is an uncommon phenomenon that is especially rare in young patients and can result in bowl ischemia and perforation if left untreated. Furthermore, pneumoperitoneum is almost always a concerning imaging finding and in the context of recent colonic resection may be a sign of anastomotic leakage.

CASE PRESENTATION

We describe a case of a young female patient with postpartum ACPO who subsequently underwent a hemicolectomy with colorectal anastomosis. The patient's hospital course was complicated by massive postoperative pneumoperitoneum that resulted in resection of the anastomosis and creation of an end colostomy. However, despite this measure, there was recurrent pneumoperitoneum on cross-sectional imaging 36 h later. This was treated non-operatively and the remainder of their hospital course was uneventful.

CLINICAL DISCUSSION

A potential etiology for ACPO during pregnancy may be due to compression of parasympathetic plexus nerves by the gravid uterus. Idiopathic pneumoperitoneum has been documented on a number of occasions, though this is generally in older patients. It can present with signs of peritonitis or can be asymptomatic. Simultaneous pneumothorax and pneumoperitoneum is rare and may be due to the transmission of air from the peritoneum to the mediastinum and thorax. The pneumoperitoneum itself may be due the air leakage through the significantly distended colon into the peritoneum.

CONCLUSION

The combination of ACPO following pregnancy and associated pneumothorax, pneumomediastinum, and recurrent pneumoperitoneum suggest a communicating defect between the thoracic, mediastinal, and peritoneal cavities. Furthermore, the possibility of underlying colonic dysmotility should be considered prior to the restoration of large bowel continuity.

Postpartum Ogilvie's Syndrome After a Vaginal Delivery

Ogilvie's syndrome is a colonic pseudo-obstruction that results in colonic dilation without a mechanical obstruction. We discuss a 33-year-old, 36-week pregnant, G1P0L0A0 female who presented with severe pre-eclampsia. Less than 24 hours after induction by vaginal delivery, she developed significant abdominal pain and distention. On a CT scan of the abdomen and pelvis, she was diagnosed with Ogilvie's syndrome due to a finding of large bowel dilation with an abrupt transition point at the splenic flexure without a noted mass. She was initially treated conservatively with nasogastric tube decompression and IV fluid resuscitation. When these conservative measures failed, neostigmine was administered with transient improvement in symptoms. Despite the appropriate administration of neostigmine and initial relief of symptoms with stool output, the patient ultimately required surgical intervention with the creation of a transverse loop colostomy. The development of Ogilvie's syndrome in the postpartum period is a very rare finding, particularly after a vaginal delivery.

Mortality Due to Complications Associated With Acute Ogilvie's Syndrome in an Older Adult Treated for Psychosis: A Case Report

Acute colonic pseudo-obstruction or Ogilvie's syndrome is a disorder causing massive colonic dilation with no evidence of mechanical obstruction. The actual incidence of acute colonic pseudo-obstruction is unclear; However, electrolyte imbalance, psychiatric disorders, the use of medications such as anticholinergics or antipsychotics, and recent abdominal surgery are the most common predisposing factors associated with this syndrome. Ogilvie's syndrome is most likely caused due to impairment of the gut's motor system and an imbalance of the autonomic nervous system including a reduction in the activity of stimulatory neurotransmitters. The predisposition to psychotic disorders could be, in some instances, due to neurodevelopmental abnormalities of the brain and the gut's autonomic nervous system. The symptoms of Ogilvie's syndrome are similar to mechanical obstruction of the colon but no physical cause of obstruction is usually present. Ogilvie's syndrome can be managed conservatively; however, if left untreated, Ogilvie's syndrome can lead to bowel perforation, which is associated with a high mortality risk. Antipsychotics have been considered the cornerstone treatment for psychiatric disorders including schizophrenia. Even though they are highly effective in treating psychiatric illnesses, their usage carries multiple risks. Overall, constipation is a common side effect of antipsychotic medications with some classes posing more risk than others. Constipation can be severe and may lead to serious complications such as paralytic ileus, bowel ischemia, and death. We present here a case of delusional disorder managed with risperidone and complicated by intestinal pseudo-obstruction. This case reiterates the need to consider all complications of antipsychotic medications, even rare ones, and include them in the discussion with patients and their caregivers before commencement.

Ogilvie Syndrome and Acute Kidney Injury: A Rare Complication of Cesarean Section and Preeclampsia

Ogilvie syndrome, or acute colonic pseudo-obstruction (ACPS) is a rare occurrence, usually following surgery. It consists of a massive dilatation of the cecum, whose diameter becomes greater than 10 cm; its severity is variable, but, if not promptly recognized, it may be life-threatening. Acute kidney injury (AKI) is reported in this context due to both septic complications and to effective hypovolemia. ACPS most commonly affects males and individuals older than 60. In women, the median age at diagnosis is lower due to a strong association with Caesarean sections. The differential diagnosis after delivery may be challenging, due to a potential overlap of symptoms with preeclampsia or hemolysis low platelet elevated liver enzymes (HELLP) syndrome, both associated with AKI. The case herein discussed, regarding a 35-year-old woman, who developed AKI and Ogilvie syndrome after a Caesarean section for preeclampsia, may exemplify these diagnostic and therapeutic challenges, and is intended to raise awareness on this unusual complication of Caesarean delivery.

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.

Risk factors for acute colonic pseudo-obstruction after caesarean section: A retrospective case-control study

BACKGROUND

Pregnancy and caesarean section are known to predispose to the development of acute colonic pseudo-obstruction (ACPO), a rare form of functional ileus of the distal large bowel. Pathogenesis of ACPO is likely influenced by pregnancy and childbirth and subsequent changes to hormonal, autonomic and metabolic physiology. Identifying pregnancy risk factors will assist with early identification, as the insidious onset postpartum often leads to delayed diagnosis and bowel ischaemia, perforation and sepsis.

AIMS

To establish pregnancy risk factors associated with the development of ACPO after caesarean section.

MATERIALS AND METHODS

A retrospective case-control study included 19 121 women undergoing caesarean between 1 January 2008 and 31 December 2016 at a tertiary referral hospital. Twenty-three cases of computerised tomography (CT)-diagnosed ACPO post-caesarean were identified from hospital medical records and imaging databases. Controls were matched for gestational and maternal age within one week of delivery with a ratio of 1:3.

RESULTS

The incidence of ACPO was one in 800 caesarean sections. ACPO was significantly more likely to occur in women who had been administered opioid analgesia in labour (odds ratio (OR) 4.67, P = 0.04), and a trend for increased estimated blood loss (OR 1.01, P = 0.01). There was no increased risk associated with emergency or elective caesarean classification, previous abdominal surgery, type of anaesthesia, duration of labour, oxytocin augmentation, intrapartum fever, hypertensive disorders, diabetes in pregnancy, antepartum haemorrhage, multiple gestation, fetal presentation or birthweight.

CONCLUSIONS

Risk factors for developing ACPO post-caesarean include opioid analgesia in labour and a trend for increased blood loss.

Ogilvie's Syndrome with Perforation Peritonitis after Caesarean Section

Acute colonic pseudo-obstruction in the immediate post-partum period, following Caesarean section is rare, and requires a high index of suspicion for diagnosis. Sometimes, rapidly progressive dilatation of the caecum can lead to perforation peritonitis. There are only a few case reports describing this important entity. Presented herein is a young primigravida, who developed Ogilvie's syndrome and peritonitis 5 days following an uneventful elective Caesarean section. Clinical details, management strategy adopted and a brief review of literature is presented to draw attention to this condition.

Management of acute colonic pseudo-obstruction in a neutropenic patient

Acute colonic pseudo-obstruction, also known as Ogilvie's syndrome, is a rare condition involving acute large bowel dilatation without mechanical obstruction. Management begins with conservative treatment and may include pharmacological therapy, colonoscopic decompression and surgery. Timely resolution is important due to the increased risk of bowel perforation and ischaemia associated with colonic dilatation. However, conditions such as neutropenia that place patients at an elevated risk of infection may limit treatment options. We report a case of acute colonic pseudo-obstruction in a neutropenic elderly man resistant to conservative measures and neostigmine and discuss the additional management considerations in an immunocompromised patient.

Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction (ACPO) is a functional disorder of the large intestine distinguished by colonic dysmotility resulting in colonic distension in the absence of mechanical obstruction. The underlying pathophysiology of ACPO remains unclear despite technological advances in understanding the physiology of colonic motility, such as spatio-temporal mapping and high-resolution manometry. In many ways, the management of ACPO has remained relatively unchanged for 40 years. Patients with perforation or suspected ischemia undergo operative intervention, while patients without undergo initial conservative management with bowel rest, correction of electrolyte disturbances, and mobilization. Patients who fail conservative management or have prominent cecal dilatation undergo decompression with either neostigmine or colonoscopy. A subset of patients with ACPO will have recurrent symptoms despite endoscopic and medical management. For these patients who are difficult to manage, an underlying colonic functional disorder, such as slow-transit dysmotility or chronic intestinal pseudo-obstruction may be considered. The following review of ACPO aims to provide a concise update of the causes, diagnosis, and management of this emergency surgical condition.

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

Ogilvie's syndrome, or acute colonic pseudo-obstruction, is a rare presentation occasionally observed postpartum, particularly following caesarean sections. Challenges in diagnosis often lead to delays in initiation of treatment, which significantly increases complications, including caecal ischaemia, perforation, sepsis and death. This case report describes the development of Ogilvie's syndrome within 24 h of an emergency caesarean section which was promptly recognised and confirmed by computed tomography, which demonstrated caecal dilatation of 9.7 cm without evidence of mechanical obstruction. An elevated level of C-reactive protein of 320 mg/L raised early clinical suspicion of caecal ischaemia, and this was managed endoscopically. Fortunately, the patient did not have any significant complications despite the high morbidity and mortality rate associated with Ogilvie's syndrome, highlighting the importance of clinician awareness and early initiation of management.

•

Ogilvie’s syndrome must be a differential considered for a postpartum woman with abdominal pain, particularly following a caesarean section.

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Early diagnosis and treatment significantly reduce morbidity and mortality from Ogilvie's syndrome.

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Increasing caesarean section rates globally is likely to result in increasing presentations of Ogilvie's syndrome.

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Management of Ogilvie's syndrome requires early multidisciplinary involvement.

Acute Colonic Pseudo-Obstruction in Severe Falciparum Malaria: A Case Report

Severe falciparum malaria is associated with multiple organ dysfunctions. The most manifestations of severe falciparum malaria are cerebral malaria, acute lung injury, and acute kidney injury. Acute colonic pseudo-obstruction is extremely rare. Early recognition and management are essential because a delay in diagnosis is associated with substantial morbidity and mortality. A 29-year-old peacekeeper in the Democratic Republic of Congo (DRC) was diagnosed as severe falciparum malaria with high-grade fever, jaundice, electrolyte disturbance, and thrombocytopenia. Although adequate antimalaria therapy with intramuscular artemether was given, the patient had persistent fever, shallow and fast breathing, and abdominal pain. Investigations suggested a diagnosis of acute colonic pseudo-obstruction. Antimalarial therapy was continued with intravenous artesunate. And rectal decompression and fasting were taken. Soon, symptoms of colonic obstruction mitigated. And the patient was cured and discharged. Acute colonic pseudo-obstruction should be considered for severe malaria patients with abdominal distention and pain. The early diagnosis and proper management of the patient with severe malaria complicated with acute colonic pseudo-obstruction are the keys to a good prognosis.

Iatrogenic caecal perforation two days after a caesarean section, a case report

INTRODUCTION

and importance: The caesarean section is a widely spread procedure and 29.7 million times performed every year inn 169 countries in the world. Overall, complications are seen in 6% for elective caesarean to 15% for emergency caesarean.

CASE PRESENTATION

We here report a case which was initially diagnosed as a postoperative paralytic ileus. After a complicated caesarean section caused by bleeding and problems with haemostasis, a healthy child was born with full mother recovery for the first 24 hours after surgery. Unfortunately, her condition deteriorated between 24 and 48 hours and she reported progressive nausea and painful bloating. Laboratory tests and CT imaging showed progressive signs of inflammation and distention of the caecum and colon. A second CT scan the next day revealed signs of perforation. An ileocecal resection was performed with a primary anastomosis. Full recovery occurred two weeks later.

CLINICAL DISCUSSION

With an estimated incidence of only 0,08%, bowel perforations due to caesarean section, are rare. Moreover, is the clinical presentation diverse and computed topography is essential during the diagnostic process. To avoid potential morbidity and mortality, the surgeon must consider performing a laparotomy in case of a deteriorating patient in non-invasive treatment fails.

CONCLUSION

Caecal perforation must be considered as complication after a caesarean section. An ileocecal resection is necessary in this situation. This case report shows that a primary anastomosis is a possible option in a healthy patient that is hemodynamically stable during the operation. In case of an unhealthy or hemodynamic unstable patient, the safest option is a temporary ileostomy.

Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome) After Primary Spinal Fusion: An Analysis of Outcomes and Risk Factors from 2005 to 2014

BACKGROUND

Ogilvie syndrome (OS) is a rare but serious condition seen in the postoperative period. This was an epidemiologic study using data from the National Inpatient Sample from 2005 to 2014 to look at incidence, risk factors, and outcomes associated with OS after primary spine fusion.

METHODS

International Classification of Diseases, Ninth Revision codes were used to identify patients who underwent spine fusion surgery. Patients were separated into 2 cohorts based on the diagnosis of OS. Outcome measures and risk factors for cohorts were analyzed using multivariate logistic regression and compared.

RESULTS

Over the 10-year study period, 3,884,395 patients underwent primary spine fusion surgery. Among these, 0.04% developed OS during the index hospitalization. The greatest incidence seen in primary fusion involved the thoracic spine (0.15%). OS was more common after spine fusion for spine deformity (P < 0.001). Patients with OS were more likely to be men (P < 0.001), older (P < 0.0001), and have more comorbidities (P < 0.0001). Patients with OS were more likely to require postoperative blood transfusions (odds ratio [OR], 3.39; 95% confidence interval [CI], 2.51-4.59; P < 0.001) and sustain any complication (OR, 4.20; 95% CI, 3.17-5.57; P < 0.001). Patients with OS had a longer length of stay (15.7 vs. 3.9 days; P < 0.001) and increased average hospitalization cost ($63,037.03 vs. $26,792.19; P < 0.001). The development of OS was associated with fluid electrolyte disorder (OR, 4.06; 95% CI, 2.99-5.51; P < 0.001).

CONCLUSIONS

OS is a rare but serious complication of primary spine fusion surgery. Identifying the specific risk factors, symptoms, and potential complications related to OS is critical to aid in decreasing the significant morbidity associated with its development.

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.

Acute colonic pseudo-obstruction with bowel rupture after caesarean section in HELLP syndrome: a case report

Background

Ogilvie syndrome, also known as acute colonic pseudo-obstruction (ACPO), can occur postpartum after caesarean section (C-section), often resulting in caecal dilatation. The incidence rate is approximately 100 cases in 100,000 patients per year (Ross et al., Am Surg 82:102-11, 2016). Without proper diagnosis and treatment, it may progress to intestinal perforation or other fatal complications.

Case presentation

A 39-year-old pregnant woman underwent emergency low-segment C-section due to complications of Haemolysis, Elevated Liver enzymes and Low Platelets syndrome (HELLP) syndrome. ACPO was suspected on the third day after C-section based on inability to pass flatus, evident abdominal distension, slight abdominal pain, and computed tomography (CT) scan revealing severe, diffuse colonic distention with caecal dilatation of approximately 9 cm. Based on these findings, conservative treatment was implemented. However, 6 days after C-section, her symptoms worsened, and CT showed possible intestinal perforation; thus, an emergency laparotomy was performed. Due to a 3-cm (diameter) laceration in the anterolateral wall of the ascending colon and a 5-cm tear in the ileocecal junction, in combination with mucosal eversion in the colon, resection of the ileocecum, distal closure of the ascending colon, and a terminal ileostomy were performed. The patient was discharged 2 weeks post-laparotomy and continued to undergo nursing care for the incision and stoma. Ileostomy was performed 4 months later.

Conclusion

Ogilvie syndrome after C-section is an extremely rare but severe condition, which warrants early recognition and treatment to prevent potentially fatal complications, especially in patients with poor health status.

Pseudoobstrucción colónica aguda (Sindrome de Ogilvie) posterior a una nefrectomía radical: Reporte de caso

El Sindrome de Ogilvie se caracteriza por una dilatación masiva del colon y una clínica sugestiva de obstrucción intestinal mecánica, sin causa orgánica. Presentamos un caso de dilatación aguda idiopática del colon secundaria a una cirugía abdominal.

El objetivo de este reporte fue la descripción de una patología urológica inusual que puede pasarse por alto o tratarse como un íleo adinámico y, la revisión de la literatura relacionada con la definición, factores de riesgos, etiología, fisiopatología y el tratamiento de la misma.

Paciente masculino de 61 años con antecedente de nefrectomía radical izquierda por tumor renal que, a las 48hs del alta hospitalaria, consultó por presentar distensión abdominal aguda. Se solicitó una radiografía abdominal y una tomografía computada que evidenciaba importante dilatación intestinal y un diámetro cecal mayor a 12cm.

Se practicó una laparotomía exploradora de urgencia constatándose dilatación colónica del colon transverso y ascendente con un cambio de diámetro a nivel del ángulo esplénico, sin causa osbtructiva. Finalmente, se realizó colostomía en asa.

A los 6 meses de seguimiento, la videocolonoscopía no mostró lesiones endoluminales concluyendo en un Sindrome de Ogilvie secundario a la nefrectomía. Finalmente, se efectuó reconstrucción del tránsito con buena evolución posterior.

En nuestro caso, el Sindrome de Ogilvie fue una complicación postoperatoria y como fallaron las terapias conservadoras iniciales instauradas, este reporte provee una modalidad de tratamiento alternativo. Si se reconoce temprano y se trata adecuadamente, la pseudoobstrucción se resolverá en la mayoría de los pacientes y la tasa de mortalidad posterior será menor.

Safety and Efficacy of Intermittent Bolus and Continuous Infusion Neostigmine for Acute Colonic Pseudo-Obstruction

PURPOSE

To compare clinical response of intermittent bolus versus continuous infusion neostigmine for acute colonic pseudo-obstruction (ACPO). Acute colonic pseudo-obstruction occurs due to reduced colonic parasympathetic activity. Neostigmine is an acetylcholinesterase inhibitor that increases frequency of smooth muscle contraction by increasing acetylcholine at autonomic nervous system synapses. Although these administration modalities have been studied separately, they have never been compared.

METHODS

This retrospective study compared bolus versus continuous infusion neostigmine for ACPO. The primary outcome was initial clinical response, defined as bowel movement (BM) within 4 hours of bolus dose or 24 hours of initiation of continuous infusion. Secondary outcomes included time to BM, bowel diameter reduction at 24 hours, incidence of bradycardia, additional neostigmine requirements, and need for colonic decompression or surgical intervention.

RESULTS

Seventy-five patients were included (bolus n = 37; infusion n = 38). Median total 24-hour neostigmine dose was 2.0 mg (interquartile range [IQR]: 2.0-2.6) with bolus and 9.6 mg (IQR: 6.3-9.6) with continuous infusion. Initial clinical response was similar (infusion 81.6% vs bolus 62.2%, P = .06), but continuous infusion was associated with greater bowel diameter reduction (73.7% vs 40.5%, P = .004). Bolus administration had shorter time to BM (1.4 vs 3.5 hours, P = .0478) and increased need for colonic decompression (67.6% vs 39.5%, P = .0148). Bolus dosing was associated with less bradycardia (13.5% vs 39.5%, P = 0.011), with no difference in atropine usage (10.8% vs 5.3%, P = .43).

CONCLUSION

Initial clinical response was similar between groups; however, continuous infusion neostigmine was associated with greater bowel diameter reduction at 24 hours. Bolus administration resulted in less bradycardia; however, given the lack of difference in atropine use, clinical significance is unknown. This study is the first to compare bolus versus continuous infusion neostigmine for ACPO. Further studies are needed to confirm findings.

Characterization of megapouch in patients with restorative proctocolectomy

BACKGROUND

Megapouch is a rare functional complication of restorative proctocolectomy with ileal pouch-anal anastomosis characterized by pouch ± small bowel dilatation with no evidence of obstruction on endoscopy and imaging. Little is known about clinical characteristics and outcomes of this entity.

METHODS

We included all patients diagnosed with megapouch at our institution, identified from a pouch database. Data on baseline characteristics, management, and outcomes were documented and analyzed from electronic medical records. Appropriate statistical measures were used. p < 0.05 was considered significant.

RESULTS

Twenty-three patients with megapouch were identified. The mean age was 40.7 years; 95.6% had underlying ulcerative colitis; most common indication for colectomy was medically refractory disease (56.5%). Abdominal pain (82.6%) and bloating (52.2%) were most common presenting symptoms. Most common finding on pouchoscopy was pouch dilatation (81.8%), while barium or gastrografin enemas and MRI/CT mostly revealed dilatation of pouch and/or small bowel. Fourteen (66.7%) patients required some forms of surgery-six patients required pouch excision and three required either pouch redo or revision. Rates of pouch failure and IBD-related 1-year hospitalization were higher among patients managed surgically versus those managed medically (p = 0.007 and 0.024, respectively), while need for escalation of IBD-therapy was comparable between the groups (p = 0.133). No deaths were reported and no patient had recurrence of megapouch. IPAA revision or redo did not lead to more IBD-related morbidity.

CONCLUSIONS

Majority of our patients with megapouch required surgery. In selected patients, redo pouch offered cure. Rates of pouch failure and IBD-related 1-year hospitalization were higher among patients managed surgically.

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.