Pseudo-obstruction of the large bowel

An Alternative Approach to the Terminal Management of Ogilvie Syndrome

Ogilvie syndrome is defined as colonic pseudo-obstruction due to nonmechanical causes. Mortality of nearly 50% is associated with perforation of the distended, pseudo-obstructed colon. While conservative medical therapy has proven to be beneficial in a majority of cases, >3% of patients have significant distention or perforation of the colon that warrants surgical resection. The case of a 48-year-old male with progressive abdominal discomfort and distention 12 days following knee replacement surgery is presented. He was subsequently diagnosed with colonic pseudo-obstruction and definitively treated with subtotal colectomy and colostomy. We propose that a more conservative approach to treatment of colonic pseudo-obstruction may prevent the need for colostomy, significantly improving quality of life.

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.

Colonic pseudoobstruction: CT findings

OBJECTIVE

The purpose of this review was to define the imaging features of colonic pseudoobstruction and to describe the pathologic findings.

CONCLUSION

Colonic pseudoobstruction can be diagnosed on the basis of CT findings that show extensive colonic dilatation without an obstructive lesion at the intermediate transitional zone or adjacent to the splenic flexure. Pathologic examination reveals that intramural ganglion damage has a high tendency to occur in cases of chronic colonic pseudoobstruction.

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.

Acute colonic pseudo-obstruction following major orthopaedic surgery

OBJECTIVE

Acute colonic pseudo-obstruction (ACPO) has been linked with multiple aetiologies including orthopaedic surgery. However, the actual incidence and natural progression are not well described in these patients. We aim to assess the incidence of ACPO in patients undergoing elective orthopaedic procedures, and to examine for potential exacerbating factors.

PATIENTS AND METHODS

All patients from the orthopaedic directorate that had abdominal imaging in the five years from August 1998 to August 2003 were identified from radiology archives. A manual search of the patients' notes was conducted with data recorded on the patients' history, operative details and their postoperative course including their haematological and biochemical results. Details regarding their ACPO were documented with respect to the onset of symptoms, how the diagnosis was achieved, what treatment was instigated and how the condition progressed. A control group of age and sex matched patients was included for comparison.

RESULTS

Thirty-five patients with ACPO were identified. The operations included 21 hip replacements, 10 knee replacements and 4 spinal operations. The incidence of ACPO was 1.3%, 0.65% and 1.19%, respectively. In comparison to control patients, patients with ACPO had a lower postoperative serum sodium (P = 0.001), a higher serum urea (P = 0.021) and remained in hospital longer (P < 0.001).

CONCLUSION

ACPO is uncommon in orthopaedic patients, however, its occurrence results in prolonged hospital stay. Attention to patients' postoperative fluid balance and biochemical status may reduce the incidence.

Pseudo-obstruction in the critically ill

Intestinal pseudo-obstruction is defined as a clinical syndrome characterized by impairment of intestinal propulsion, which may resemble intestinal obstruction, in the absence of a mechanical cause. It may involve the small and/or the large bowel, and may present in acute, subacute or chronic forms. We have performed a systematic review of acute pseudo-obstruction, also referred to as Ogilvie's syndrome in the literature, and focused on proposed mechanisms, manifestations and management of post-surgery and critically ill patients who suffer from one or more underlying clinical conditions. The hallmark of the syndrome is massive intestinal distension, which is detected on clinical inspection and plain abdominal radiography. The underlying pathophysiological mechanisms are not fully understood. Therefore, treatment focuses on preventing intestinal perforation, which is associated with an average 21% mortality rate.

Pseudo-obstruction in the critically ill

Intestinal pseudo-obstruction is defined as a clinical syndrome characterized by impairment of intestinal propulsion, which may resemble intestinal obstruction, in the absence of a mechanical cause. It may involve the small and/or the large bowel, and may present in acute, subacute or chronic forms. We have performed a systematic review of acute pseudo-obstruction, also referred to as Ogilvie's syndrome in the literature, and focused on proposed mechanisms, manifestations and management of post-surgery and critically ill patients who suffer from one or more underlying clinical conditions. The hallmark of the syndrome is massive intestinal distension, which is detected on clinical inspection and plain abdominal radiography. The underlying pathophysiological mechanisms are not fully understood. Therefore, treatment focuses on preventing intestinal perforation, which is associated with an average 21% mortality rate.

Manejo clínico de la seudoobstrucción aguda de colon en el enfermo hospitalizado: revisión sistemática de la bibliografía

Intestinal pseudoobstruction is a clinical syndrome characterized by impairment of intestinal propulsion, which may resemble intestinal obstruction, in the absence of a mechanical cause. It usually affects the colon but the small intestine may also be involved, and may present in acute, subacute or chronic forms. We have performed a systematic review of the acute form of pseudoobstruction, also referred to as Ogilvie's syndrome. We discuss proposed pathophysiological mechanisms, manifestations and management of this clinical condition in post-surgery and critically ill patients. The hallmark of the syndrome is massive intestinal distension, which is detected on clinical inspection and plain abdominal radiography. The underlying pathophysiological mechanisms are not fully understood. Therefore, treatment has focussed on preventing intestinal perforation, which is associated with a 21% mortality rate.

Management and causes of acute large-bowel obstruction

Acute LBO has many possible causes. In the United States, the most common cause is colorectal carcinoma. Mechanical obstruction should be differentiated from pseudo-obstruction by contrast enema or colonoscopy because the treatments differ. The high postoperative mortality and morbidity of LBO compared with elective resection are explained by the multiple associated pathophysiologic changes of obstruction. Management of this condition requires careful assessment, awareness, and expertise in the current modalities of treatment. Gangrene and perforation should be avoided because they limit treatment options and are associated with an increase in mortality. We prefer, in most instances, to perform a single-stage procedure, which has the advantages of reduced hospital stay (and cost) and avoidance of a stoma. However, the appropriate treatment needs to be tailored to the individual situation. Recent developments in nonoperative decompressing procedures may demonstrate advantages in the future.

The acute contrast enema in suspected large bowel obstruction: value and technique

In order to determine the value of the acute contrast enema (ACE) as compared to the plain abdominal film for the diagnosis of colonic obstruction and to determine the optimal technique for performing this examination, we reviewed 140 cases performed over a 4 year period. The study shows that when provided with the case history and the plain abdominal films of patients referred for an ACE the diagnosis of colonic obstruction can be made with a sensitivity of 84% and a specificity of 72%, whereas the ACE has a sensitivity of 96% and a specificity of 98%. The ACE resulted in two false negatives, one false positive and one technical failure, analysis of which has enabled an optimal technique for the performance of this examination to be recommended.

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.

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.

[Value of the gastrografin enema in the diagnosis of ileus]

From 1978-1984 421 patients were examined by colon enema with gastrografin. The indication in 246 cases was an acute abdomen, in 172 patients the procedure has been performed postoperatively, 3 patients suffered from gastrointestinal bleeding. 81 of 236 pathological findings showed an ileus. 58 of them underwent an operation. The cause of the ileus were tumors of the colon, extraluminal tumors as well as performations and inflammations. In 55 cases the findings of the gastrografin enema were confirmed by the operation, one was proved to be false negative, one uncertain and one false positive. Therefore the diagnostic accuracy of this procedure amounted to 96%.

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.

Constipation with colonic inertia. A manifestation of systemic disease?

Transit of radiopaque markers was delayed in the ascending colon of 51 females and 3 males treated for severe idiopathic constipation. Onset of symptoms was between age 10 and 20 in more than half of the patients. Eighteen percent had previously undergone unnecessary laparotomy for large bowel pseudoobstruction. Stool frequency ranged from 1 stool every three days to 1 every 2 months. Twenty-six percent suffered from fecal incontinence. In addition, 30% had orthostatic hypotension and 15% galactorrhea of idiopathic origin. Patients had a higher than normal anal pressure (P less than 0.001). They all had a rectoanal inhibitory reflex, but it was abnormal in 76%. In the upper esophageal sphincter, resting pressure was higher (P less than 0.02), and coordination poorer (P less than 0.05) than in normal control subjects. Incidence of spontaneous tertiary contractions in the body of the esophagus was greater than normal (P less than 0.03). In the lower esophageal sphincter, resting pressure was lower (P = 0.001) and gastroesophageal gradient weaker (P = 0.05). Closing pressure of the sphincter was lower (P less than 0.001) and coordination less adequate (P less than 0.02). After subcutaneous injection of 0.035 mg/kg bethanechol, urinary bladder intraluminal pressure increased by over 15 cm H2O in 31% of patients but never did in controls, and average maximal pressure was greater (P less than 0.025). Time taken to reach peak pressure was shorter (P less than 0.01). This study provides evidence that patients who suffer from constipation with colonic inertia also have abnormal function in other hollow viscera.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Phenothiazine effect on gastrointestinal tract function

Clinical evidence indicates that phenothiazines, specifically chlorpromazine (CPZ), used extensively in the treatment of patients with mental and/or neurologic disorders produce an ileus characterized by pseudoobstruction with an extended barium transit time of eight to ten days. Postoperatively, these patients have a protracted ileus, lasting from ten to fourteen days. In our present study we investigated the mechanism of action by which phenothiazines block gastrointestinal tract function as well as the possible reversal of this effect by pharmacologic agents. Guinea pigs were injected intraperitoneally with CPZ at a dose of 30 mg/kg/day for five to seventeen days. This caused deleterious effects in the gastrointestinal tract, such as cessation of peristalsis of small intestine and colon, and marked distension of the cecum. In vitro pharmacologic studies were performed on the electrically stimulated longitudinal muscle-myenteric plexus of the guinea pigs. We found that phenothiazines interfered with the neuromuscular mechanism of the intestine, as exemplified by a lack of response to electrical current stimulation. The effect was protracted, lasting at least 24 hours. These effects were reversed by the administration of the anticholinesterase, physostigmine (PGM), provided the block was less than 80 per cent. The paralytic ileus produced was similar to that found in man.

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.