Syndrome of Intestinal Pseudo-obstruction

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.

Chronic intestinal pseudo-obstruction: clinical features, diagnosis, and therapy

CIPO is the very “tip of the iceberg” of functional gastrointestinal disorders, being a rare and frequently misdiagnosed condition characterized by an overall poor outcome. Diagnosis should be based on clinical features, natural history and radiologic findings. There is no cure for CIPO and management strategies include a wide array of nutritional, pharmacologic, and surgical options which are directed to minimize malnutrition, promote gut motility and reduce complications of stasis (ie, bacterial overgrowth). Pain may become so severe to necessitate major analgesic drugs. Underlying causes of secondary CIPO should be thoroughly investigated and, if detected, treated accordingly. Surgery should be indicated only in a highly selected, well characterized subset of patients, while isolated intestinal or multivisceral transplantation is a rescue therapy only in those patients with intestinal failure unsuitable for or unable to continue with TPN/HPN. Future perspectives in CIPO will be directed toward an accurate genomic/proteomic phenotying of these rare, challenging patients. Unveiling causative mechanisms of neuro-ICC-muscular abnormalities will pave the way for targeted therapeutic options for patients with CIPO.

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.

Endoscopic decompression for acute colonic pseudo-obstruction

BACKGROUND

Acute colonic pseudo-obstruction is often treated by colonoscopic decompression. Efficacy, safety, and outcome of endoscopic decompression was assessed.

METHODS

Colonoscopic decompressions from 1988 to 1994 were reviewed. Resolution without further endoscopic intervention was defined as clinical success.

RESULTS

Acute colonic pseudo-obstruction was diagnosed in 50 patients. Thirty-three cases followed surgery or trauma and 17 developed during severe medical illness. Orthopedic joint surgery was most common. Nineteen of 50 patients (38%) had severe underlying medical disease. Forty-one patients (82%) had one colonoscopic decompression with clinical success in 39 (95%). Nine patients (18%) required multiple (2 to 4) colonoscopic decompressions with clinical success in 5 (56%). A decompression tube positioned in the right colon (57%) and in the transverse colon (33%) had similar clinical success. In 8 procedures a decompression tube was not placed, with poor clinical success (25%). The overall clinical success of colonoscopic decompression was 88% (44 of 50). An endoscopic perforation occurred in 1 patient (2%). Overall hospital mortality was 30%.

CONCLUSIONS

Colonoscopic decompression is effective and safe for acute colonic pseudo-obstruction that does not respond to conservative therapy. Most patients will respond to one colonoscopic decompression with decompression tube placement. Complete colonoscopy and cecal tube placement is unnecessary.

Aerobilia and hypomotility of the sphincter of Oddi in a patient with chronic intestinal pseudo-obstruction

A 50-year-old woman with a typical history of chronic idiopathic intestinal pseudo-obstruction was admitted to hospital because of an acute episode of abdominal cramps, nausea, and vomiting. The diagnosis of chronic idiopathic intestinal pseudo-obstruction had been established in this patient who had malnutrition and extreme weight loss as a result of severe malabsorption syndrome. The abdominal roentgenogram showed a typical hypotonic intestine with an enlarged stomach and distended intestinal loops with the radiological signs of an ileus. In addition to former episodes, there was also a transient aerobilia. The patient had not undergone biliary surgery or endoscopic sphincterotomy. To investigate the cause of the findings, endoscopic retrograde cholangiopancreatography and endoscopic manometry of the sphincter of Oddi were performed. The endoscopy showed the stomach and duodenum with a wide and dilated lumen and no spontaneous motility. Endoscopic manometry of the biliary tract and the sphincter of Oddi showed several abnormalities compared with a group of normal volunteers or patients who were examined via biliary manometry for other reasons. There was a low basal pressure (3.5 mm Hg) in the sphincter of Oddi together with low-amplitude phasic contractions (25-30 mm Hg), but the contraction frequency was in the normal range. Further investigations of the motility of the gastrointestinal tract in this patient showed diffuse esophageal spasms and a markedly delayed gastric emptying. The findings of biliary manometry in this patient suggest involvement of the sphincter of Oddi and the biliary system in chronic idiopathic pseudo-obstruction.

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.

Neuroleptic malignant syndrome: another medical cause of acute abdomen

We present a patient with neuroleptic malignant syndrome and intestinal pseudo-obstruction misdiagnosed as being secondary to septicaemia. The management of the patient is discussed with emphasis on the role of creatine kinase and liver function tests.

Acute large-bowel pseudo-obstruction

The clinical and radiological features of acute large-bowel pseudo-obstruction occurring in 13 patients over a 7-year period are reviewed. Clinical features included atypical signs and symptoms of large-bowel obstruction and serious concomitant illness, including trauma in 10. The predominant radiological features were gross colonic dilatation, scant fluid levels, a gradual transition to collapsed bowel and a normal gas and faecal pattern in the rectum. Correct diagnosis was established by plain film and/or barium enema examination in the majority of cases (nine out of the 13). In the remaining four cases the diagnosis was made at laparotomy, although review of the radiographs suggested that the correct diagnosis could have been made pre-operatively in three. Instant barium enema is recommended in doubtful cases to rule out distal obstruction. Prompt recognition of the condition, with daily monitoring and conservative management, should eliminate unnecessary surgery and minimise the risk of caecal perforation.

Acute pseudo-obstruction of the colon

Nineteen patients presenting with pseudo-obstruction of the colon are described. Thirteen were female and the mean age was 65.7 years (48-82). Five cases appeared idiopathic but the remainder were associated with either intercurrent disease, surgery or trauma. Six patients underwent laparotomy, 3 for gross caecal distension and 1 subsequently died with bronchopneumonia. Thirteen patients were treated conservatively with flatus tube decompression or colonoscopy, but 3 died, 1 from a perforated caecum, 1 from a recurrent subarachnoid haemorrhage and 1 from bronchopneumonia. The high mortality of caecal perforation in this condition is stressed, and gross radiological caecal distension with overlying tenderness is an indication for urgent decompression.

Colonoscopic decompression of the colon in patients with Ogilvie's syndrome

Pseudoobstruction of the large bowel occurs as acute distention of the colon, usually in a high risk and seriously ill patient without any mechanical obstruction. Massive distention of the colon results in perforation of the cecum and fecal peritonitis and is associated with a very high mortality rate. Laparotomy with cecostomy is the recommended surgical therapy for this problem which carries a mortality rate of over 20 percent. We have used the colonoscope to decompress the distended colon, and especially the cecum, in 10 patients with Ogilvie's syndrome, with a 90 percent success rate and no deaths or complications. The surgeon should follow the several technical guidelines mentioned herein for successful and safe performance of the procedure. These guidelines include a tap water enema of about 1,000 ml before the procedure, avoidance of the liberal use of air insufflation during the procedure, and blind insertion of the colonoscope. This procedure is not indicated in any patient with signs of peritonitis and perforation.

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.

Pseudoobstruction of the colon

Pseudoobstruction of the colon is a specific variety of adynamic ileus. Its characteristic clinical presentation is severe cramping lower abdominal pain, a massively distended abdomen, and a characteristic x-ray picture. Thirty-five patients with this disease complex have been reviewed, and their surgical and medical therapy is discussed. Guidelines for continued medical versus surgical intervention are suggested. Two patients underwent decompression with the colonoscope. Its use and a possible hazard of the procedure are discussed. For those patients who develop pseudoobstruction after trauma or surgery, a pathophysiologic explanation is offered. The possible role of prostaglandin abnormality in the genesis of pseudoobstruction is also discussed.

Colonic ileus

Nine cases of colonic ileus, characterized by selective or disproportionate distention of the large intestine without organic obstruction, are detailed. Massive cecal dilatation often dominates the radiographic presentation and may portend perforation. While management is generally conservative, cecostomy may be necessary to prevent peritonitis.

Chronic idiopathic intestinal pseudo-obstruction syndrome in children--clinical characteristics and prognosis

Eleven children with the diagnosis of chronic idiopathic intestinal pseudo-obstruction are presented. Four children, all siblings of a symptomatic patient, were asymptomatic and were diagnosed radiographically. The clinical course was characterized by intermittent episodes of abdominal distention, vomiting, abdominal pain, diarrhea, constipation, and malnutrition. Radiographic studies were most helpful in making the diagnosis. Findings on upper gastrointestinal series included abnormal esophageal motility, delayed gastric emptying, dilated loops of small bowel, and disorganized transit of barium. Half of the patients had abnormal evacuation patterns on barium enema. Manometric studies of esophageal motility were abnormal in seven of ten children. In those patients studied, small bowel and rectal biopsies contained ganglion cells. Treatment was directed at relieving symptoms, which in four patients became persistent and required total parenteral nutrition. CIIPS carries a poor long-term prognosis in children.

Pseudo-obstruction of the bowel. Therapeutic trial of metoclopramide

A patient with chronic idiopathic pseudo-obstruction is reported and the results of a double blind therapeutic trial of metoclopramide are described. Within the limits of this trial metoclopramide was ineffective by all clinical criteria.

Gangrene and spontaneous perforation of the cecum as a complication of pseudo-obstruction of the colon: report of three cases and speculation as to etiology

"Pseudo-obstruction of the colon" refers to a condition in which physical and radiologic findings identical to those associated with mechanical obstruction of the large bowel are found, but in which no organic cause of colonic distention can be identified. These cases may involve progressive proximal large-intestinal dilation to the point of cecal perforation or necrosis. Two cases of spontaneous perforation of the cecum and one case of gangrene of the cecum secondary to proximal distention of the right colon that followed pseudo-obstruction of the colon are presented. Various etiologic factors reported in the medical literature are discussed and analyzed, and an anatomicophysiologic explanation of a possible mechanism, based on sympathetic-parasympathetic neurostimulatory imbalance, is offered.

Pseudo-obstruction of the large bowel

Twelve episodes of large bowel pseudo-obstruction occurring in 11 patients are described. The clinical and radiological features are discussed from a diagnostic aspect. The aetiology and treatment of the condition are considered.

Intestinal pseudo-obstruction in systemic amyloidosis

The occurrence of clinical manifestations of mechanical intestinal obstruction in eight cases of systemic amyloidosis is reported. Seven similar cases have been recorded in the literature and are briefly reviewed. Correct diagnosis is important in these cases if useless surgical treatment or prolonged diagnostic investigations are to be avoided. Gastrointestinal involvement by systemic amyloidosis should be considered in a patient presenting with clinical manifestations of mechanical obstruction but paralytic ileus seen on plain films. In these cases an attempt should be made, by means of a barium enema, to exclude an obstructing lesion of the colon or distal small bowel. Once amyloidosis is considered, it can be confirmed easily and safely by biopsy of the rectal or small-intestinal mucosa.

Spinal ileus

Spinal ileus is a functional intestinal obstruction complicating a lesion in the spine. In 8 cases reported here the primary pathology was a spinal fracture in 2 cases, a prolapsed intervertebral disk in 3 cases, and 1 case each of fractured pelvis, infarcted spinal cord, and plaster-cast treatment for a tuberculous cervical spine. The intestinal disturbance was a pseudo-obstruction in 5 cases and an adynamic ileus in 3, and involved small or large bowel.

That an intestinal obstruction is of functional origin is suggested by the presence of a plausible remote cause—in these cases a spinal lesion, which was often painful. Colicky abdominal pain and loud bowel-sounds do not exclude the diagnosis; indeed they are the rule in pseudo-obstruction. A predominantly gaseous bowel distension seen on plain radiographs, together with the release of flatus by sigmoidoscopy if there is dilatation of the distal colon, further support the diagnosis, which may then be accepted provisionally provided there is no marked abdominal tenderness. Subsequently the absence of a mechanical obstruction may be proved by contrast radiography.

Treatment generally follows accepted conservative lines with nasogastric and rectal intubation, and intravenous fluid replacement as necessary. However, operative treatment is indicated in a minority of patients if there develops serious doubt as to the diagnosis, or if gross distension threatens caecal rupture or respiratory failure.

Intestinal obstruction

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