Colonic pseudo-obstruction in surgical patients

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 (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.

Incidence and Risk Factors for the Development of Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome) in Total Joint Arthroplasty Patients

BACKGROUND

Acute colonic pseudo-obstruction (Ogilvie syndrome [OS]) is a rare but devastating condition that can develop in orthopaedic patients postoperatively. The objective of this study was to identify the risk factors for developing OS after total hip arthroplasty (THA) or total knee arthroplasty (TKA) and to compare the outcomes between patients who did and did not develop OS postoperatively.

METHODS

This was a retrospective review using the National Inpatient Sample, a national database incorporating inpatient hospitalization information. ICD-9 codes were used to identify patients who underwent primary and revision THA or TKA. Patients were separated based on the diagnosis of OS. Primary outcomes assessed included patient mortality, postoperative complications, length of stay, and cost during index hospitalization.

RESULTS

From 2001 to 2014, a total of 12,541,169 patients underwent primary and revision THA or TKA. Of those, 3,182 patients (0.03%) developed OS postoperatively. There was an increased incidence of OS in revision THA and TKA compared with primary THA and TKA. Fluid and electrolyte disorders were associated with the largest increased adjusted risk of OS. Patients with OS had an increased adjusted risk of overall postoperative complications and being discharged to skilled nursing facility. Patients with OS had an increased average length of stay and hospitalization cost compared with patients without OS.

DISCUSSION

Given our findings, the risk factors for the development of OS, including revision surgery, should be identified and minimized during the perioperative period to prevent the development of this morbid and potentially life-threatening complication.

LEVEL OF EVIDENCE

III (Retrospective cohort study).

Paediatric Intestinal Pseudo-obstruction: Evidence and Consensus-based Recommendations From an ESPGHAN-Led Expert Group

OBJECTIVES

Chronic intestinal pseudo-obstructive (CIPO) conditions are considered the most severe disorders of gut motility. They continue to present significant challenges in clinical care despite considerable recent progress in our understanding of pathophysiology, resulting in unacceptable levels of morbidity and mortality. Major contributors to the disappointing lack of progress in paediatric CIPO include a dearth of clarity and uniformity across all aspects of clinical care from definition and diagnosis to management. In order to assist medical care providers in identifying, evaluating, and managing children with CIPO, experts in this condition within the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition as well as selected external experts, were charged with the task of developing a uniform document of evidence- and consensus-based recommendations.

METHODS

Ten clinically relevant questions addressing terminology, diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to June 2017 using a number of established electronic databases as well as repositories. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to evaluate outcome measures for the research questions. Levels of evidence and quality of evidence were assessed using the classification system of the Oxford Centre for Evidence-Based Medicine (diagnosis) and the GRADE system (treatment). Each of the recommendations were discussed, finalized, and voted upon using the nominal voting technique to obtain consensus.

RESULTS

This evidence- and consensus-based position paper provides recommendations specifically for chronic intestinal pseudo-obstruction in infants and children. It proposes these be termed paediatric intestinal pseudo-obstructive (PIPO) disorders to distinguish them from adult onset CIPO. The manuscript provides guidance on the diagnosis, evaluation, and treatment of children with PIPO in an effort to standardise the quality of clinical care and improve short- and long-term outcomes. Key recommendations include the development of specific diagnostic criteria for PIPO, red flags to alert clinicians to the diagnosis and guidance on the use of available investigative modalities. The group advocates early collaboration with expert centres where structured diagnosis and management is guided by a multi-disciplinary team, and include targeted nutritional, medical, and surgical interventions as well as transition to adult services.

CONCLUSIONS

This document is intended to be used in daily practice from the time of first presentation and definitive diagnosis PIPO through to the complex management and treatment interventions such as intestinal transplantation. Significant challenges remain to be addressed through collaborative clinical and research interactions.

Ogilvie's syndrome after pediatric spinal deformity surgery: successful treatment with neostigmine

Ogilvie's syndrome is a rare and potentially fatal disease that can easily be mistaken for postoperative ileus. Also known as acute colonic pseudo-obstruction, early recognition and diagnosis of the syndrome allows for treatment prior to bowel perforation and requisite abdominal surgery. The authors report a case of Ogilvie's syndrome following spinal deformity correction and tethered cord release in an adolescent who presented with acute abdominal distension, nausea, and vomiting on postoperative Day 0. The patient was initially diagnosed with adynamic ileus and treated conservatively with bowel rest, reduction in narcotic dosage, and a regimen of stool softeners, laxatives, and enemas. Despite this treatment, her clinical course failed to improve, and she demonstrated significant colonic distension radiographically. Intravenous neostigmine was administered as a bolus with a rapid and dramatic response. This case is the first reported instance of neostigmine use for Ogilvie's syndrome treatment following a pediatric neurosurgical operation.

Pathogenesis and clinical and economic consequences of postoperative ileus

Postoperative ileus is a preventable disease with surprising economic consequences. Understanding the triad of dysmotility in conjunction with an enhanced recovery program improves patient outcome, decreases length of stay in hospital, and lowers the cost. Alvimopan and other investigational promotility medications can help attain these goals. Surgeons should avoid labeling all postoperative abdominal distention as ileus, which not only prevents timely diagnosis and treatment of early postoperative small bowel obstruction or acute colonic pseudo-obstruction but also increases patient 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.

Acute colonic pseudo-obstruction: rapid correction with neostigmine in the emergency department

Ogilvie's syndrome, now known as acute colonic pseudo-obstruction, is characterized by massive dilatation of large bowel in the absence of mechanical obstruction. It is found in a variety of patients, although elderly and immobile patients make up a large portion of the afflicted population. This article discusses the case of a 64-year-old bedridden, paraplegic, male nursing home resident who presented to the Emergency Department with a chronic history of abdominal distention that acutely worsened on the day of his arrival. A diagnosis of acute colonic pseudo-obstruction was made and 2 mg of intravenous neostigmine was administered, with resolution of the patient's condition allowing for subsequent Emergency Department discharge. This report discusses the utilization of neostigmine, an acetylcholinesterase inhibitor, for patients with colonic pseudo-obstruction. We also briefly review the literature on this condition and other therapeutic options.

[Nonocclusive ischemia of the right colon]

BACKGROUND

Nonocclusive disease (NOD) is known to be a common cause of ischemic colitis, which is frequently underestimated.

MATERIAL AND METHODS

A computer-assisted search of radiological reports at our institute over a period of 18 months, describing ischemic colitis of the ascending colon with an unimpaired perfusion of the superior mesenteric artery, was performed.

RESULTS

A retrospective analysis of the clinical and radiological data of 14 patients was performed. In ten cases colonic ischemia was confirmed clinically or intraoperatively. Most of our patients needed intravenous catecholamines due to severe hypotension. However, no significant radiographic predictors could be identified.

CONCLUSION

Awareness of NOD seems to be crucial. Especially in cases of acute abdominal pain associated with severe hypotension, renal insufficiency, or pancreatitis, one should include NOD as a differential diagnosis at an early stage.

Bowel obstruction and pseudo-obstruction

The gastroenterologist is frequently involved in the care of patients with bowel obstruction and pseudo-obstruction. In the case of obstruction, the central problem is determining which patients should be managed surgically. In both SBO and LBO, evidence of vascular compromise to the gut mandates surgical intervention. Most patients with pseudo-obstruction respond to conservative therapy or neostigmine. Endoscopic decompression is indicated in recalcitrant cases, with surgery reserved as a last resort.

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.

Obstructive colitis: an analysis of 50 cases and a review of the literature

Obstructive colitis is an ulcero-inflammatory and necrotizing condition that occurs in the colon proximal to benign or malignant stenosing lesions. it is the result of ischemia due to impairment of blood supply secondary to elevation of the endoluminal pressure, distension of the colonic wall and other factors which impair adequate perfusion. The incidence among patients with colonic obstruction is reported at between 1 and 7%. Of 50 patients with this condition in this series, 30 female and 20 male, 2/3rds were well over 70 yrs of age. Obstruction was most common in the rectosigmoid. In half the patients this was due to adenocarcinoma, 24 were due to benign obstruction and 15 were caused by diverticular disease. Type, extent and depth of ischemic lesions were highly variable and comprised early mucosal hemorrhage and edema, ulcero-hemorrhagic lesions and transmural necrosis. There was always an abrupt transition between affected and normal bowel. A segment of preserved mucosa was usually present on the proximal side of the stenosis. In 16 patients massive dilatation with stretching and thinning of the bowel wall, associated with a blow-out type of perforation or with transmural necrosis, was observed and was considered to have resulted from a rapid rise of endoluminal pressure to high levels. The microscopic and macroscopic features are described in detail and histological factors discussed in relation to the pathological lesions encountered. Emphasis is placed upon the range of appearances and similarities are shared with other inflammatory colonic diseases, particularly idiopathic inflammatory bowel disease. The importance of recognition of this disease entity, not only by pathologists but by surgeons dealing with the disease at operation, is stressed.

Acute colonic pseudo-obstruction in a burn patient

Acute colonic pseudo-obstruction as a syndrome was first described by Ogilvie in 1948 (Br. Med J. 2, 671). It is characterized by colonic dilatation with no mechanical cause which affects critically ill patients. As a result of this complication the prognosis worsens. Initially there are few clinical symptoms, but subsequently colonic obstruction develops which, if not treated, can cause perforation of the caecum resulting in a high mortality rate. The treatment includes decompression via rectal and nasogastric probes, colonoscopy and caecostomy.

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.

Diagnostic laparoscopy and laparoscopic cecostomy for colonic pseudo-obstruction

Marked cecal dilatation due to colonic psuedo-obstruction (Ogilvie's syndrome) is most often treated by colonoscopic decompression. When this fails, cecostomy is usually indicated if the bowel is not infarcted. We describe a new technique of laparoscopy-guided percutaneous cecostomy using T-fasteners to retract and anchor the cecum to the anterior abdominal wall and using a Foley catheter as a cecostomy tube. We performed this procedure successfully in a patient with colonic pseudo-obstruction who had marked cecal dilatation that could not be decompressed by colonoscopy. Laparoscopic inspection showed that the cecum was viable, and a laparoscopic cecostomy was placed. This procedure can be performed easily and safely and with much less morbidity than laparotomy and open cecostomy.

Diagnosis and treatment of Ogilvie's syndrome after lumbar spinal surgery. Report of three cases

Three patients who developed Ogilvie's syndrome following lumbar spinal surgery are described. Ogilvie's syndrome, also known as pseudo-obstruction of the colon, is characterized by massive cecal distention without mechanical obstruction. If this condition is not recognized and not promptly treated, it may be complicated by cecal perforation, a life-threatening hazard. The etiology, diagnosis, management, and potential relationship between lumbar spinal surgery and Ogilvie's syndrome are discussed.

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.

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.

Acute abdominal disease in the aged

The elderly patient with acute abdominal disease may present with a classical clinical picture. However, the presentation often is atypical and perplexes the physician. The factors involved include altered anatomical features, fear of being placed in an institution, difficulty in communicating with the physician and family members, diminished response to infection, and multiple coexisting diseases. Awareness of the atypical clinical presentations and the judicious use of special investigations will enable the clinician to make earlier and more accurate diagnoses and, thus, reduce morbidity and mortality.

Obstruction of the large and small intestine

This article provides an overview of mechanical small and large bowel obstruction with emphasis on newer diagnostic and therapeutic surgical techniques. Small and large intestinal pseudo-obstruction is discussed with reference to its diagnosis and appropriate treatment.

Treatment of acute nontoxic megacolon during colonoscopy: tube placement versus simple decompression

The study compares the efficacy of colonoscopic decompression versus decompression and tube placement in the treatment of Ogilvie's syndrome. Nine patients were treated with a single colonoscopic decompression which resulted in four recurrences. In contrast, there were no recurrences observed in 11 patients who underwent decompression and subsequent tube placement (p less than 0.05). There was no morbidity observed from either decompression or tube placement. Tube placement added less than 10 min of additional procedure time to the colonoscopy. The tube utilized in this study was an enteroclysis tube with sideholes cut in the distal 20 cm. The tube was easily inserted over a Teflon-coated flexible guide wire inserted through the colonoscope into the cecum following decompression. This study demonstrates that colonoscopic decompression followed by tube placement is the preferred treatment modality for acute nontoxic megacolon.

Medical care of the surgical patient with gastrointestinal disease

Common perioperative gastrointestinal disorders of surgical patients are presented. Recommendations for appropriate medical evaluation and management are described.

Acute colonic pseudo-obstruction (Ogilvie's syndrome). Presentation of 14 of our own cases and analysis of 1027 cases reported in the literature

In addition to the presentation of 14 of our own patients, this study analyzes 1027 cases with acute colonic pseudo-obstruction reported in the literature from 1948 to 1987. Principal associated diseases are cardiopulmonary insufficiencies, postoperative conditions, and systemic disorders. The syndrome is related to a disturbance of colonic autonomic innervation resulting in gross dilatation of the cecum and the right hemicolon. Therapeutic measures include conservative management, colonoscopic decompression, and surgical procedures. The latter have been associated with high morbidity and mortality. Our data support a nonoperative approach to this condition, including conservative measures and colonoscopic decompression as the initial therapy of choice with few complications and high efficacy.

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.