Diagnosis

Ogilvie syndrome

Etiology

Cause [cqv][gfw][czu]

• Triggers:

  • Critical ill patients:

    Trauma, infection, Pancreatitis, Cholecystitis, Meningitis, Pneumonia, CMV infection, Sepsis, Lyme disease, Kawasaki disease

  • Cardiac disease (myocardial infarction, heart failure)

  • Recent surgery

  • Neuropathy: Spinal cord injury, neurologic disorders, stroke, Parkinson disease, Alzheimer dementia, Multiple sclerosis, Guillain-Barre syndrome, Meningioma, Diabetic peripheral neuropathy, Neurofibromatosis, Familial visceral neuropathy, Hirschsprung disease, Ehlers-Danlos syndrome, Fabry disease, and Chagas disease

  • Electrolyte: hyponatremia, hypokalemia, hypocalcemia, hypercalcemia, hypomagnesemia

  • Other: Hypothyroidism, respiratory disorders, renal failure, cancer (leukemia)

  • Drug side effects from neuroleptic/opiate --> paralytic ileus

    • Opioids and narcotics

    • Calcium channel blockers

    • Antidepressants

    • Phenothiazines

    • Antiparkinsonian medications

    • Clonidine

    • Theophylline

    • Baclofen

    • Chemotherapy

    • Corticosteroids

    • H2 blockers

    • Epidural analgesics

    • Voglibose

    • Chemotherapy

Pathophysiology [cqv]

1. Inhibition of parasympathetic autonomic nervous system

   • Dysregulation of stretch receptors

   • Decreased ganglion cells in the colonic smooth muscle

2. Imbalance/dysregulation in the autonomic nervous system

3. Colonic atonia --> reduced colonic motility --> paralytic ileus

4. Cecal dilatation: diameter, duration and acceleration of the distension

   • 10 cm --> Risk for ischemia and perforation

   • 12 cm --> Impending perforation

Complications [cqv]

• Bowel ischemia

• Perforation

• Peritonitis

• Sepsis

Epidemiology

Incidence per 100.000 [cqv][bdk][bor][z2r][igq]

Approach

A diagnosis of exclusion and more common causes of functional or mechanical bowel dilatation must be investigated:

• Blood test: complete blood count, electrolytes, thyroid hormone

• Feces: Clostridium difficile toxin

• Blood gas

• Abdominal x-ray + Contrast enema

• CT abdomen

• Coloscopy + biopsy

Diagnostic criteria: [bdk]

1. Must include all of the following 4 points:

   1. Onset of 1 or more symptoms of bowel obstruction at least 6 months before a diagnosis

   2. One or both of the following for the previous 12 weeks

      • a) Abdominal bloating

      • b) Abdominal pain

   3. Dilatation and/or air-fluid level of the intestine on abdominal X-ray, echo, and/or computed tomography imaging

   4. No evidence of structural disease (on upper and lower gastrointestinal endoscopy, computed tomography, barium enema, and small-bowel follow-through) that could explain the dilatation and/or air-fluid level of the intestine

2. Important considerations:

   1. Congenital disease and onset before age 15 years must be excluded; only adult onset is included

   2. Surgical history, except surgery for CIPO, within the 6 months before the diagnosis must be excluded to rule out Ogilvie syndrome

   3. CIPO is defined as primary or secondary. Primary CIPO consists of 3 types: myogenic, neurogenic, and idiopathic. Secondary CIPO comprises 2 types: SSc and unclassified

   4. Family occurrence may be present

   5. Neuropathy, such as problems with urination, may be present

   6. Some psychosocial disorder may be present

Treatment

1. Rule out mechanical obstruction

2. Supportive care with close observation if uncomplicated [bor][qan]

   • Bowel rest --> Nothing by mouth

   • Nasogastric decompression

   • IV fluid resuscitation

   • Correct electrolyte abnormalities

   • Lie prone or in a knee-to-chest position

   • Frequent turns to promote passage of flatus

3. Pharmacologic intervention:

   • Discontinue opiates, anticholinergics, laxative

   • Neostigmine (acetylcholinesterase inhibitor) 2mg IV over 4 minutes (cardiac monitoring, bradycardia)

4. Invasive procedures: bowel decompression

   • Colonoscopy

   • Surgery (refractory disease, cecal diameter > 12cm, ischemia or perforation)

Differential diagnoses

Acute mesenteric ischemia, Adhesion, Alcoholism, Amyloidosis, Chronic mesenteric ischemia, Colorectal cancer, Constipation, Diverticulitis, Drug side effects, Femoral hernia, Gastrointestinal obstruction, Gastrointestinal perforation, Guillain-Barre syndrome, Hirschsprung's Disease, Incisional hernia, Inguinal hernia, Intestinal hypoperistalsis syndrome, Intussusception, Multiple myeloma, Peritonitis, Pseudomembranous colitis, Toxic megacolon, Umbillical hernia, Volvulus