Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 15-28: Intestinal Motility Disorders + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Severe abdominal distention Massive dilation of cecum or right colon Arises in postoperative state or with severe medical illness May be precipitated by electrolyte imbalances, medications Absent to mild abdominal pain; minimal tenderness +++ General Considerations ++ Spontaneous massive dilation of the cecum and proximal colon in hospitalized patients Progressive cecal dilation may lead to ischemia and spontaneous perforation Etiology unknown Associated conditions Trauma Respiratory failure Malignancy Myocardial infarction or heart failure Pancreatitis Stroke or subarachnoid hemorrhage Ischemic colitis Use of drugs, eg, opioids, anticholinergics +++ Demographics ++ Occurs mainly in hospitalized patients with recent trauma, surgery (especially cardiothoracic), or severe medical illness May be precipitated by electrolyte imbalance or opioids + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Sometimes asymptomatic Constant but mild abdominal pain Nausea and vomiting Abdominal distention Bowel movements may be absent; however, up to 40% of patients continue to pass flatus or stool Abdominal tenderness with some degree of guarding or rebound tenderness; however, signs of peritonitis absent unless perforation has occurred Bowel sounds may be normal or decreased Fever suggests colonic perforation +++ Differential Diagnosis ++ Mechanical colonic obstruction, eg, malignancy, diverticulitis, volvulus, fecal impaction Toxic megacolon due to inflammatory bowel disease or Clostridioides difficile colitis, cytomegalovirus + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ Obtain complete blood count, serum sodium, potassium, magnesium, phosphorus, and calcium Leukocytosis suggests colonic ischemia or perforation +++ Imaging Studies ++ Plain radiographs demonstrate colonic dilation, usually cecum and proximal colon Varying amounts of small intestinal dilation and air-fluid levels Cecal diameter > 10–12 cm associated with increased risk of colonic perforation A CT scan should generally be obtained to exclude a distal colonic mechanical obstruction due to malignancy, volvulus, or fecal impaction + Treatment Download Section PDF Listen +++ +++ Medications ++ Discontinue opioids, anticholinergics, and calcium channel blockers, if possible Correct electrolyte abnormalities Oral laxatives are not helpful and may cause perforation Neostigmine 2 mg intravenously as a single dose results in rapid (within 30 minutes) colonic decompression in 75–90% and should be considered for following patients: No improvement or clinical deterioration after 24–48 hours of conservative treatment Cecal dilation > 12 cm Cecal dilation > 10 cm for prolonged period (3–4 days) +++ Therapeutic Procedures ++ Treat underlying illness Conservative treatment is recommended if no or minimal abdominal tenderness, no fever, no leukocytosis, and a cecal diameter < 12 cm Place a nasogastric tube and a rectal tube Ambulate patients, or roll periodically from side to side and to knee-chest position Judicious administration of enemas if large amounts of stool on radiography Conservative treatment successful in > 80% Colonoscopic decompression in selected patients who do not respond to neostigmine, successful in up to 70%; dilation recurs in up to 50% +++ Surgery ++ In patients in whom colonoscopy is unsuccessful, a tube cecostomy placed through a small laparotomy or percutaneously with radiologic guidance can decompress the colon + Outcome Download Section PDF Listen +++ +++ Follow-Up ++ Watch for signs of worsening distention or abdominal tenderness Assess cecal size by abdominal radiographs every 12 hours Cardiac monitoring after neostigmine for possible bradycardia that may require atropine administration +++ Complications ++ Colonic perforation or ischemia +++ Prognosis ++ Prognosis related to the underlying illness With aggressive therapy, perforation unusual +++ When to Refer ++ Failure to improve within 24–48 hours of conservative therapy Cecal size > 12 cm Signs of perforation +++ When to Admit ++ Usually occurs in hospitalized patients + References Download Section PDF Listen +++ + +Haj M et al. Ogilvie's syndrome: management and outcomes. Medicine (Baltimore). 2018 Jul;97(27):e11187. [PubMed: 29979381] + +Jayaram P et al. Postpartum acute colonic pseudo-obstruction (Ogilvie's syndrome): a systematic review of case reports and case series. Eur J Obstet Gynecol Reprod Biol. 2017 Jul;214:145–9. [PubMed: 28531835] + +Jeong SJ et al. Endoscopic management of benign colonic obstruction and pseudo-obstruction. Clin Endosc. 2020 Jan;53(1):18–28. [PubMed: 31645090] + +Naveed M et al. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus. Gastrointest Endosc. 2020 Feb;91(2):228–35. [PubMed: 31791596] + +Wells CI et al. Acute colonic pseudo-obstruction: a systematic review of aetiology and mechanisms. World J Gastroenterol. 2017 Aug 14;23(30):5634–44. [PubMed: 28852322]