Ogilvie syndrome

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Ogilvie syndrome
Other namesAcute colonic pseudo-obstruction
Ogilvie ct coronal.jpg
CT-Scan showing a coronal section of the abdomen of an elderly woman with Ogilvie syndrome
Specialty Gastroenterology   OOjs UI icon edit-ltr-progressive.svg

Ogilvie syndrome, or acute colonic pseudo-obstruction is the acute dilatation of the colon in the absence of any mechanical obstruction in severely ill patients. [1]

Contents

Acute colonic pseudo-obstruction is characterized by massive dilatation of the cecum (diameter > 10 cm) and right colon on abdominal X-ray. [2] [3] It is a type of megacolon, sometimes referred to as "acute megacolon," to distinguish it from toxic megacolon.

The condition carries the name of the British surgeon Sir William Heneage Ogilvie (1887–1971), who first reported it in 1948. [4] [5] [6]

Ogilvie syndrome is an acute illness, which means it occurs suddenly and temporarily, and it only affects your colon. "Intestinal pseudo-obstruction" is a broad term that refers to any paralysis of the intestines that is not caused by a mechanical obstruction. Some individuals develop chronic intestinal pseudo-obstruction as a result of a chronic disease or a congenital condition. [7]

Signs and symptoms

Usually the patient has abdominal distention, pain and altered bowel movements. [2] [8] There may also be nausea and vomiting. [9]

Cause

Ogilvie syndrome may occur after surgery, especially following coronary artery bypass surgery and total joint replacement. [10] Drugs that disturb colonic motility (such as anticholinergics or opioid analgesics) contribute to the development of this condition. [2] [8]

Pathophysiology

The exact mechanism is not known. The probable explanation is imbalance in the regulation of colonic motor activity by the autonomic nervous system. [1] It has been postulated that reactivation of varicella zoster virus (which causes chickenpox and shingles) in the enteric ganglia may be a cause of Ogilvie syndrome. [11]

Acute megacolon develops because of abnormal intestinal motility. Normal colonic motility requires integration of myogenic, neural, and hormonal influences. The enteric nervous system is independent but is connected to the central nervous system by sympathetic and parasympathetic nerves. The targets of the enteric neurons are muscle cells, secretory cells, endocrine cells, microvasculature, and inflammatory cells. The neurons in the enteric plexuses are stimulated by a food bolus, which both distends the gut and stimulates the mucosal surface, leading to the release of factors that stimulate interneurons. The stimulated interneurons transmit excitatory signals proximally, which cause contraction and inhibitory signals distally, and these in turn cause relaxation. These signals are transmitted by the neurotransmitters acetylcholine and serotonin, among others. [12]

Acute megacolon can also lead to ischemic necrosis in massively dilated intestinal segments. This is explained by Pascal's law and Laplaces's law. Pascal's principle states that a change in pressure at any point in an enclosed fluid at rest is transmitted undiminished to all points in the fluid; the pressure across all parts of the lumen is equal. Laplace's law states that:

where T is wall tension, P is pressure, r is the radius, and t is wall thickness. Since the wall tension is proportionate to the radius, a dilated intestinal segment has a greater wall tension than a nondilated segment; if the dilatation and tension are sufficiently great, blood flow may be obstructed and ischemia of the bowel will occur. [12] Ogilivie syndrome may precipitate volvulus.[ citation needed ]

Diagnosis

Diagnosis starts with physical exam, observation, and interview of the patient. Imaging to diagnose dilation of the colon involves one view abdominal xray or obstruction series (PA chest, erect abdomen, and supine abdomen images). If further imaging is needed CT may be ordered. [13]

Treatment

It usually resolves with conservative therapy stopping oral ingestions and employing a nasogastric tube, [2] but resolution may require colonoscopic decompression which is successful in 70% of the cases. A study published in the New England Journal of Medicine showed that neostigmine is a potent pharmacological way of decompressing the colon. [1] According to the American Society for Gastrointestinal Endoscopy (ASGE), it should be considered prior to colonoscopic decompression. The use of neostigmine is not without risk since it can induce bradyarrhythmia and bronchospasms. [8] Therefore, atropine should be within immediate reach when this therapy is used. [1] [2] [3]

Prognosis

Ogilvie syndrome is a serious medical disorder. Its mortality rate can be as high as 30%. [8] The high rate is likely a measure that this syndrome is seen in critically ill patients, rather than this syndrome being in itself lethal, although it can also present in otherwise healthy individuals (especially if the disorder was induced by pharmacologic agents). Drug-induced megacolon (such as from clozapine) has been associated with mortality as high as 27.5%. [12]

Related Research Articles

<span class="mw-page-title-main">Defecation</span> Expulsion of feces from the digestive tract

Defecation follows digestion, and is a necessary process by which organisms eliminate a solid, semisolid, or liquid waste material known as feces from the digestive tract via the anus or cloaca. The act has a variety of names ranging from the common, like pooping or crapping, to the technical, e.g. bowel movement, to the obscene (shitting), to the euphemistic, to the juvenile. The topic, usually avoided in polite company, can become the basis for some potty humor.

<span class="mw-page-title-main">Hirschsprung's disease</span> Medical condition

Hirschsprung's disease is a birth defect in which nerves are missing from parts of the intestine. The most prominent symptom is constipation. Other symptoms may include vomiting, abdominal pain, diarrhea and slow growth. Most children develop signs and symptoms shortly after birth. However, others may be diagnosed later in infancy or early childhood. About half of all children with Hirschsprung's disease are diagnosed in the first year of life. Complications may include enterocolitis, megacolon, bowel obstruction and intestinal perforation.

<span class="mw-page-title-main">Bowel obstruction</span> Medical condition

Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas. Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital.

<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important.

<span class="mw-page-title-main">Neostigmine</span> Anti-full body paralysis drug treatment

Neostigmine, sold under the brand name Bloxiverz, among others, is a medication used to treat myasthenia gravis, Ogilvie syndrome, and urinary retention without the presence of a blockage. It is also used in anaesthesia to end the effects of non-depolarising neuromuscular blocking medication. It is given by injection either into a vein, muscle, or under the skin. After injection effects are generally greatest within 30 minutes and last up to 4 hours.

<span class="mw-page-title-main">Ileus</span> Medical condition

Ileus is a disruption of the normal propulsive ability of the intestine. It can be caused by lack of peristalsis or by mechanical obstruction. The word 'ileus' is from Ancient Greek eileós. The term 'subileus' refers to a partial obstruction.

<span class="mw-page-title-main">Toxic megacolon</span> Potentially lethal large intestine emergency

Toxic megacolon is an acute form of colonic distension. It is characterized by a very dilated colon (megacolon), accompanied by abdominal distension (bloating), and sometimes fever, abdominal pain, or shock.

Colic in horses is defined as abdominal pain, but it is a clinical symptom rather than a diagnosis. The term colic can encompass all forms of gastrointestinal conditions which cause pain as well as other causes of abdominal pain not involving the gastrointestinal tract. What makes it tricky is that different causes can manifest with similar signs of distress in the animal. Recognizing and understanding these signs is pivotal, as timely action can spell the difference between a brief moment of discomfort and a life-threatening situation. The most common forms of colic are gastrointestinal in nature and are most often related to colonic disturbance. There are a variety of different causes of colic, some of which can prove fatal without surgical intervention. Colic surgery is usually an expensive procedure as it is major abdominal surgery, often with intensive aftercare. Among domesticated horses, colic is the leading cause of premature death. The incidence of colic in the general horse population has been estimated between 4 and 10 percent over the course of the average lifespan. Clinical signs of colic generally require treatment by a veterinarian. The conditions that cause colic can become life-threatening in a short period of time.

<span class="mw-page-title-main">Volvulus</span> Twisting of part of the intestine, causing a bowel obstruction

A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be fever or significant pain when the abdomen is touched.

<span class="mw-page-title-main">Fecal impaction</span> Medical condition

A fecal impaction or an impacted bowel is a solid, immobile bulk of feces that can develop in the rectum as a result of chronic constipation. Fecal impaction is a common result of neurogenic bowel dysfunction and causes immense discomfort and pain. Its treatment includes laxatives, enemas, and pulsed irrigation evacuation (PIE) as well as digital removal. It is not a condition that resolves without direct treatment.

Intestinal malrotation is a congenital anomaly of rotation of the midgut. It occurs during the first trimester as the fetal gut undergoes a complex series of growth and development. Malrotation can lead to a dangerous complication called volvulus, in which cases emergency surgery is indicated. Malrotation can refer to a spectrum of abnormal intestinal positioning, often including:

<span class="mw-page-title-main">Megacolon</span> Medical condition

Megacolon is an abnormal dilation of the colon. This leads to hypertrophy of the colon. The dilation is often accompanied by a paralysis of the peristaltic movements of the bowel. In more extreme cases, the feces consolidate into hard masses inside the colon, called fecalomas, which can require surgery to be removed.

<span class="mw-page-title-main">Intestinal pseudo-obstruction</span> Medical condition

Intestinal pseudo-obstruction (IPO) is a clinical syndrome caused by severe impairment in the ability of the intestines to push food through. It is characterized by the signs and symptoms of intestinal obstruction without any lesion in the intestinal lumen. Clinical features mimic those seen with mechanical intestinal obstructions and can include abdominal pain, nausea, abdominal distension, vomiting, dysphagia and constipation depending upon the part of the gastrointestinal tract involved.

<span class="mw-page-title-main">Ischemic colitis</span> Medical condition

Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply. Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Causes of the reduced blood flow can include changes in the systemic circulation or local factors such as constriction of blood vessels or a blood clot. In most cases, no specific cause can be identified.

<span class="mw-page-title-main">Distal intestinal obstruction syndrome</span> Medical condition

Distal intestinal obstruction syndrome (DIOS) involves obstruction of the distal part of the small intestines by thickened intestinal content and occurs in about 20% of mainly adult individuals with cystic fibrosis. DIOS was previously known as meconium ileus equivalent, a name which highlights its similarity to the intestinal obstruction seen in newborn infants with cystic fibrosis. DIOS tends to occur in older individuals with pancreatic insufficiency. Individuals with DIOS may be predisposed to bowel obstruction, though it is a separate entity than true constipation.

<span class="mw-page-title-main">Chronic intestinal pseudo-obstruction</span> Medical condition

Chronic intestinal pseudo-obstruction (CIPO) is an uncommon syndrome with chronic and recurrent symptoms that suggest intestinal obstruction in the absence of any mechanical blockage of the lumen. The most common symptoms of CIPO include abdominal pain, constipation, nausea, vomiting, dysphagia, and abdominal distention. CIPO can lead to malnutrition.

Stercoral ulcer is an ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation due to a large bowel obstruction, damage to the autonomic nervous system, or stercoral colitis. It is most commonly located in the sigmoid colon and rectum. Prolonged constipation leads to production of fecaliths, leading to possible progression into a fecaloma. These hard lumps irritate the rectum and lead to the formation of these ulcers. It results in fresh bleeding per rectum. These ulcers may be seen on imaging, such as a CT scan but are more commonly identified using endoscopy, usually a colonoscopy. Treatment modalities can include both surgical and non-surgical techniques.

<span class="mw-page-title-main">Intestinal ischemia</span> Restriction of blood flow to the small intestine resulting in injury

Intestinal ischemia is a medical condition in which injury to the large or small intestine occurs due to not enough blood supply. It can come on suddenly, known as acute intestinal ischemia, or gradually, known as chronic intestinal ischemia. The acute form of the disease often presents with sudden severe abdominal pain and is associated with a high risk of death. The chronic form typically presents more gradually with abdominal pain after eating, unintentional weight loss, vomiting, and fear of eating.

<span class="mw-page-title-main">Prucalopride</span> Drug used to treat chronic constipation

Prucalopride, sold under brand names Resolor and Motegrity among others, is a medication acting as a selective, high affinity 5-HT4 receptor agonist which targets the impaired motility associated with chronic constipation, thus normalizing bowel movements. Prucalopride was approved for medical use in the European Union in 2009, in Canada in 2011, in Israel in 2014, and in the United States in December 2018. The drug has also been tested for the treatment of chronic intestinal pseudo-obstruction.

Megaduodenum is a congenital or acquired dilation and elongation of the duodenum with hypertrophy of all layers that presents as a feeling of gastric fullness, abdominal pain, belching, heartburn, and nausea with vomiting sometimes of food eaten 24 hours prior.

References

  1. 1 2 3 4 Ponec RJ, Saunders MD, Kimmey MB (1999). "Neostigmine for the treatment of acute colonic pseudo-obstruction". N. Engl. J. Med. 341 (3): 137–41. doi: 10.1056/NEJM199907153410301 . PMID   10403850.
  2. 1 2 3 4 5 Feldman, Mark; Friedman, Lawrence S.; Sleisenger, Marvin H. (July 2002). Sleisenger & Fordtran's Gastrointestinal and Liver Disease (7th ed.). Elsevier. ISBN   978-0-7216-8973-9.
  3. 1 2 Pratt DS, Epstein SK (2000). "Recent advances in critical care gastroenterology". Am. J. Respir. Crit. Care Med. 161 (5): 1417–20. doi:10.1164/ajrccm.161.5.16159. PMID   10806132.
  4. ↑ Ogilvie H (1948). "Large-intestine Colic due to Sympathetic Deprivation". Br Med J. 2 (4579): 671–673. doi:10.1136/bmj.2.4579.671. PMC   2091708 . PMID   18886657. Reproduced in: Ogilvie WH (December 1987). "William Heneage Ogilvie 1887-1971. Large-intestine colic due to sympathetic deprivation. A new clinical syndrome". Dis. Colon Rectum. 30 (12): 984–7. doi:10.1007/BF02554291. PMID   3319452. S2CID   68079923.
  5. ↑ Sir William Heneage Ogilvie at Who Named It?
  6. ↑ Haubrich WS (2008). "Ogilvie of the Ogilvie Syndrome". Gastroenterology. 135 (2): 337. doi: 10.1053/j.gastro.2008.06.071 .
  7. ↑ Cleveland Clinic medical professional (2023-03-08). "What Is Ogilvie Syndrome (Acute Colonic Pseudo-Obstruction)?". Cleveland Clinic. Retrieved 2024-04-15.
  8. 1 2 3 4 Irwin, Richard S.; Rippe, James M. (January 2003). Intensive Care Medicine. Lippincott Williams & Wilkins, Philadelphia & London. ISBN   0-7817-3548-3. Archived from the original on 2005-11-07.{{cite book}}: |website= ignored (help)
  9. ↑ Skeik N, Jabr FI (2009). "Ogilvie Syndrome". Consultant. 49 (2).
  10. ↑ Tenofsky PL, Beamer L, Smith RS (2000). "Ogilvie syndrome as a postoperative complication". Arch Surg. 135 (6): 682–6, discussion 686–7. doi:10.1001/archsurg.135.6.682. PMID   10843364.
  11. ↑ Gershon, A. A. (2013). "Varicella zoster vaccines and their implications for development of HSV vaccines". Virology. 435 (1): 29–36. doi:10.1016/j.virol.2012.10.006. PMC   3595154 . PMID   23217613.
  12. 1 2 3 Alam HB, Fricchione GL, Guimaraes AS, Zukerberg LR (October 2009). "Case records of the Massachusetts General Hospital. Case 31-2009. A 26-year-old man with abdominal distention and shock". N. Engl. J. Med. 361 (15): 1487–96. doi:10.1056/NEJMcpc0900643. PMID   19812406.
  13. ↑ Conner S, Nassereddin A, Mitchell C (2 July 2021). Ogilvie Syndrome. Treasure Island (FL): StatPearls Publishing [Internet]. PMID   30252358.
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