The role of sigmoidoscopy and colonoscopy in the diagnosis and management of lower gastrointestinal disorders: endoscopic findings, therapy, and complications

Flexible sigmoidoscopy and colonoscopy have revolutionized the clinical management of colonic diseases. Colonoscopy is a highly sensitive and specific test. Colonic diseases often produce characteristic colonoscopic findings, as well as characteristic histologic findings, as identified in colonoscopic biopsy or polypectomy specimens. Colonoscopy is relatively safe, with a low incidence of serious complications, such as colonic perforation, hemorrhage, cardiopulmonary arrest, or sepsis. Colonoscopy is becoming more important clinically because of more widespread use of screening colonoscopy for colon cancer, application of therapeutic colonoscopy, and exciting new technical improvements.

Long-term outcome of congenital intestinal pseudoobstruction

We evaluated 85 children with congenital chronic intestinal pseudoobstruction (CIP) over the past 10 years. Twelve (14%) were born prematurely. One had a family history of CIP. Six had systemic diseases. Thirty-five (41%) had urinary bladder involvement. Manometric features were consistent with myopathy in 32, neuropathy in 48, and mixed disease in 5. Of 48 patients with neuropathy, 6 had urinary bladder involvement (12.5%) (P < 0.0001 vs myopathy), and 10 had malrotation (21%) (P = NS vs myopathy). Upon referral, 53 (62%) were dependent on partial or total parenteral nutrition (PN). At the time of chart review (median 25 months after evaluation), 22 patients had died, 14 of whom were on total PN, 13 of them died because of PN-related complications and 1 died of sepsis. Three others died of sepsis while on partial PN (P = 0.007 vs mortality in patients fed enterally) and five died after small bowel transplantation. In conclusion, in children with congenital CIP, the risk for prematurity is increased twofold, the majority of cases are sporadic, abnormal bladder function is more common in myopathic CIP, and complications related to parenteral nutrition are the main cause of death in children with CIP.

Colonic pseudo-obstruction due to herpes zoster

Visceral motor complications are uncommon manifestations of herpes zoster (varicella zoster). We report a 59-year-old man who developed acute colonic pseudo-obstruction, which followed the appearance of dermatomal herpes zoster.

Controlled transperitoneal percutaneous cecostomy as a therapeutic alternative to the endoscopic decompression for Ogilvie's syndrome

Acute colonic pseudo-obstruction, the so-called Ogilvie's syndrome, results in massive colonic dilation without mechanical obstruction. In most cases, a conservative treatment with or without endoscopic decompression is sufficient. In rare cases of relapses or failures, a cecostomy has to be performed. A surgical cecostomy is associated with high morbidity and mortality. However, a percutaneous cecostomy could be an interesting alternative treatment. We report the case of a 67-yr-old male with colonic pseudoobstruction for which both the conservative and the endoscopic treatments were unsuccessful. A percutaneous cecostomy was performed, and for the first time in this indication, a transperitoneal access was used with the help of nylon T-fasteners.

Update on acute colonic pseudo-obstruction

Acute colonic pseudo-obstruction is characterized by distention of the colon in the absence of mechanical obstruction. This presentation is typically related to recent surgery, severe illness, or medication. Nasogastric and rectal tube decompression and correction of electrolyte abnormalities are the standard of care. Colonoscopic decompression, performed in a number of these cases, was felt to be unwarranted in many situations and is associated with a high recurrence rate. Medical management beyond conservative measures has been limited. Medical therapy with pharmacologic agents such as erythromycin, metoclopromide, and cisapride was of limited use. Recent findings confirm that an older agent, neostigmine, provides excellent results, including colonic decompression and clinical improvement after administration. This suggests a new standard of care.

[Acute colonic pseudo-obstruction]

Colonic Pseudo-obstruction is a poorly understood syndrome. It was first described by Ogilvie in 1948 and is characterized by signs of large bowel obstruction with a non-mechanical etiology. The suggested cause of this pathophysiology is an imbalance in the autonomic nerve supply to the colon. The syndrome affects mainly old, bedridden patients, usually hospitalised for non-colonic causes. The actual incidence of this syndrome is unknown, mainly due to the fact that spontaneous recovery may occur. When massive abdominal distention is apparent, diagnosis and treatment are usually problematic and other causes of obstruction must be ruled out. It is usually managed by water soluble contrast administered orally or rectally, or by colonic decompression. In extreme cases surgical treatment is required with significant morbidity and mortality. Pharmacologic management with parasympathomimetic drugs has been suggested recently. We describe the successful treatment of a patient with neostigmine and review the current literature.

[Ogilvie syndrome]

Ogilvie's syndrome is a rare condition with progressive dilatation of the proximal colon without mechanical obstruction. Untreated it can lead to coecal perforation, peritonitis and death. It develops in patients with medical or surgical complications, but can be idiopathic. Caesarean section is the most common preceding surgical procedure. An imbalance between the parasympathetic and the sympathetic innervation of the intestine is thought to be the cause. Trauma to the retroperitoneum, infections, bleeding and electrolyte disturbances, hormonal changes and medicamina are predisposing factors. The syndrome can result in perforation of the coecum as early as the third or fourth day. Therefore a diagnostic abdominal X-ray should not be delayed by the intermittent presence of flatus and stool which is characteristic for this pseudo-obstructive condition. Medical treatment with neostigmine may be successful, coloscopic decompression of the colon is effective as is placing a tube in or close to coecum. If laparotomy is necessary, coecostomy has lower mortality than ileo-coecal resection.

[Colonic pseudo-obstruction (Ogilvie syndrome) following cesarean section]

Acute colonic pseudo-obstruction, or Ogilvie syndrome can be a major surgical complication. Ogilvie syndrome, unlike adynamic ileus, is usually not self-limiting and may cause ischemic necrosis and colonic perforation, with a mortality rate as high as 50 percent. Ogilvie syndrome represents a diagnostic and therapeutic challenge that deserves a multidisciplinary approach. We present a case report and a literature review of the syndrome.

Ogilvie's syndrome (colonic pseudo-obstruction) occurring in an 18-year-old Nigerian female

Ogilvie's syndrome which is colonic obstruction without an identifiable distal mechanical cause is reported in an 18 year old female Nigerian. A high index of awareness is required to diagnose this condition.

Nephrosplenic entrapment in the horse: a retrospective study of 174 cases

The clinical findings and outcome of 161 horses diagnosed with 174 episodes of nephrosplenic entrapment (NSE) were reviewed retrospectively. The median age at presentation was 5 years (9 months to 24 years), and duration of colic was 2-92 h. Nasogastric reflux was present in 49 of 113 horses (43.4%) and was significant (> or = 21) in 32 (28.3%) horses. The recurrence rate was 13/161 (8.1%). Thirteen horses (13/174, 7.5%) had other lesions including small intestinal obstruction (4), 360 degrees large colon torsion (5), gastric rupture (2), thromboembolic colic (1) and small colon infarction (1). Of 115 cases, in 107 horses treated by surgery alone, 2 horses required a large colon resection, and 8 (8/107, 7.5%) horses died or were subjected to euthanasia. Twenty-six of 35 horses (74%) were successfully corrected by rolling under general anesthesia and, of the 9 horses taken to surgery after rolling, 4 had other lesions and 2 were corrected at surgery. Phenylephrine was used in 20 of 35 horses that were rolled and 2 horses required surgery after rolling with phenylephrine. Five horses were jogged after phenylephrine administration and all were successfully corrected. Eleven horses presented with the left colon located between the spleen and the body wall were treated successfully by fasting and/or i.v. fluids. One horse had a gastric rupture after rolling. The overall success rate was 92.5%. In conclusion, NSE is a condition associated with a good prognosis for medical or surgical correction. A small number of horses may have additional gastrointestinal lesions, which may affect outcome.

Ogilvie syndrome as a postoperative complication

HYPOTHESIS

Ogilvie syndrome is a postoperative complication.

DESIGN

Case series.

SETTING

University-affiliated tertiary-care hospital.

PATIENTS AND METHODS

The medical records of patients diagnosed as having Ogilvie syndrome after trauma or operation between 1989 and 1998 were reviewed. Medical charts were examined for history, treatment, cecal diameter, and outcome.

MAIN OUTCOME MEASURES

Data were summarized in an attempt to identify patient populations at risk for Ogilvie syndrome.

RESULTS

Ogilvie syndrome was diagnosed in 36 patients, 24 of whom were men. Average age at diagnosis was 68.9 years. Abdominal radiographs were obtained at time of diagnosis (mean cecal diameter, 13.4 cm; range, 8-20 cm). Operations preceding Ogilvie syndrome were orthopedic or spinal (n= 14), cardiothoracic (n= 12), abdominal (n= 5), and vascular (n= 2). Nonoperative trauma accounted for 3 cases. Coronary artery bypass grafting was the single most frequent procedure leading to Ogilvie syndrome (n=9 [25%]). Conservative treatment was successful in 52.8% of cases (n = 19). Twenty colonoscopic decompressions were performed on 13 patients, with an overall success rate of 77% (n= 10). Of the 3 patients in whom colonoscopic decompression failed, 2 died and 1 required operation. Five of the 36 patients required surgical intervention, with a mortality rate of 60% (n= 3).

CONCLUSIONS

Previous studies have shown Ogilvie syndrome to occur most commonly after obstetrical/ gynecologic, abdominal/pelvic, and orthopedic procedures. Our data confirm that patients undergoing orthopedic and spinal procedures are at higher risk, but that the surgical procedure most commonly leading to Ogilvie syndrome was coronary artery bypass grafting. Cardiothoracic surgeons, orthopedic surgeons, and neurosurgeons should be cognizant of this complication in the patient whose abdomen becomes distended postoperatively. If recognized early and treated appropriately, pseudo-obstruction will resolve in most patients. If surgical intervention is required, the subsequent mortality rate is high.

Ogilvie's syndrome after cesarean delivery

Ogilvie's syndrome is a rare postsurgical complication that can be associated with cesarean delivery. It is characterized by massive dilation of the colon, much like that which occurs with an obstruction but in the absence of a mechanical obstruction. Early detection and intervention are necessary to avoid serious morbidity and/or mortality. Conservative treatment is effective in many cases, but surgical intervention may be required. Nursing assessment of the gastrointestinal system in the postsurgical patient is reviewed using a case report of a patient who developed Ogilvie's syndrome after a cesarean delivery.

Ogilvie's syndrome as a rare complication of lumbar disc surgery

BACKGROUND

In this study we report a rare complication after lumbar surgery, Ogilvie's syndrome, that presents as acute colonic dilatation in the absence of mechanical obstruction.

CASE

A 43-year-old obese woman underwent lumbar surgery for L4-L5 lumbar disc herniation. The patient complained of persistent abdominal distention and lack of bowel sounds. Plain radiography and ultrasonography revealed massive dilatation of the colon. Nasogastric aspiration was initiated and all analgesic drugs were withdrawn. Abdominal distention gradually disappeared within three days.

CONCLUSIONS

Only three cases of Ogilvie's syndrome following lumbar spinal surgery have been reported in the literature. In our case obesity, chronic constipation, and narcotic drugs were the most likely precipitating causes. Ogilvie's syndrome may resolve with conservative treatment, but if the cecal diameter continues to increase, colonoscopy or laparotomy may be needed to prevent perforation of colon.

[Rectal catheter decompression in colonic pseudoobstruction (Ogilvie syndrome). Report of a case and review of the literature]

The Ogilvie's Syndrome is a major surgical complication. It is defined as a severe dilatation of the colon, the cecum, ascendant and transverse, without the presence air at the distal colon following abdominal surgery. The causes are unknown. We described a clinical case of patient delivered by C-S who developed this syndrome and a review of the literature. We emphasized on the importance of the early diagnosis by the use of the traditional abdomen X-Rays and we described a relatively new approach for this patients through the decompression by colonoscopy using a Levin's catheter successfully. This is an alternative minimum-invasive treatment which could be of a great benefit for the patients with this disease.

Sigmoid stiffener for decompression tube placement in colonic pseudo-obstruction

BACKGROUND AND STUDY AIMS

Decompression tube placement improves outcome in colonic pseudo-obstruction (CP) which is refractory to conservative measures, especially if the decompression tube is placed proximal to the hepatic flexure. We evaluate the ability of a sigmoid stiffener to facilitate more proximal colonoscopy and decompression tube placement.

PATIENTS AND METHODS

A sigmoid stiffener is used in the standard fashion during colonoscopic decompression for pseudo-obstruction. After cecal wire placement, the colonoscope is withdrawn, leaving the stiffener and wire in place. By passing through the stiffener, an over-wire decompression tube can avoid sigmoid looping. We compared proximal extent of colonoscopy, tube position, endoscopy time, and patient outcomes using a sigmoid stiffener, with a control group of patients treated previously. Patients with colonic ischemia were excluded.

RESULTS

Using this technique, nine consecutive colonoscopies and decompression tube placements reached the right colon. Significantly, only three of seven control colonoscopies and two control decompression tubes did so. However, improvements in procedural time and patient outcome did not reach statistical significance. No complications occurred.

CONCLUSION

The use of a sigmoid stiffener during colonic decompression allows more proximal colonoscopy and decompression tube placement, with possible clinical benefit. We do not use this technique in the setting of left colon ischemia.

Conservative management of acute pseudo-obstruction in a major burn

We present a case of recurrent acute colonic pseudo-obstruction (ACPO) in a burn patient that responded to a postural change which has not been previously reported.

Changing diagnostic and therapeutic approaches to the 'Ogilvie syndrome'

The only thing that has remained unchanged about the genuinely described 'Ogilvie syndrome' is its name. Recently it was considered to be an acute colonic pseudoobstruction, a clinical entity mimicking the mechanic ileus of the distal large intestine, without organic obstruction. It is almost always secondary to other diseases. Not all details of the pathogenesis are known, but it has become clear that the direct factor leading to the disturbance of the motility is a vegetative imbalance. X-ray findings are highly characteristic and critical in the planning of treatment. The danger for the patients is the progression of the state or the long duration of the process. Conservative treatment is suitable only for early cases, without complications. In case of failure non-invasive endoscopic or endoscopically assisted minimally invasive procedures may be mandatory. These methods have seen rapid advance in recent years. Uncertain diagnoses or complications call for open surgery. Cecostomy is the solution of choice anyway. The mortality is high in this group of elderly polymorbid patients. Authors compare six of their cases with data collected from the literature.

[Idiopathic dilatation of the large intestine (Ogilvie syndrome--acute pseudo-obstruction)]

Acute colonic pseudo-obstruction (Ogilvie's syndrome) is characterized by abdominal distention and massive colonic dilatation without any mechanical cause of obstruction. We have reviewed the records of 57 patients, 36 men and 21 women (median age 65.4 y), from 1/1992 to 12/1996, with a colonic pseudo-obstruction, defined as dilatation of at least 10 cm on plain abdominal x-ray. 38 cases (66.5%) followed surgery or trauma and 19 (33.5%) developed symptoms during severe medical illness. 36 cases (63.2%) got i.v. narcotics prior to development of Ogilvie's syndrome. 4 patients underwent conservative treatment alone, 53 patients (93%) had endoscopic decompression with a decompression tube placed in 49 (86%). Due to 2 failures and 2 complications of endoscopic treatment (one ischemic lesion, one perforation; complication rate 3.8%) 4/53 patients had to be operated (7.5%). Clinical success of endoscopic treatment was 88.6% at first attempt and 92.5% at second attempt. General complications tended to be severe, according to the concomitant diseases (morbidity 35%); overall hospital mortality was 21% (12/57). In conclusion, we believe that endoscopic decompression and tube placement is effective and safe for acute colonic pseudo-obstruction not responding to 24 hour conservative treatment.

Ogilvie's syndrome in the surgical patient: a new therapeutic modality

Acute colonic pseudo-obstruction, Ogilvie's syndrome, most often appears as a complication of other clinical conditions. It is characterized by massive colonic dilation in the absence of a mechanical cause. Therapy for this condition has traditionally been colonoscopic decompression via a flexible colonoscope. We performed a retrospective study to assess the efficacy of Cystografin enema for colonic decompression in Ogilvie's syndrome. We present a series of 18 patients who developed Ogilvie's syndrome while hospitalized for trauma (n = 10), burn (n = 1), gastrointestinal surgery (n = 4), and hip replacement (n = 3). The mean pre-enema cecal size was 13 cm (range 10 to 15 cm). The mean postenema cecal size was 8.5 cm (range 6 to 15 cm). Fifteen of the 18 patients underwent Cystografin enema as the primary mode of decompression. Three had undergone prior colonoscopy, which had failed. One of the 18 patients required repeat enema for inadequate decompression after the first enema and one underwent colonoscopy for recurrence. Two patients underwent operative intervention after the enema. There were no complications related to the enema. In all patients we were able to rule out a mechanical cause of large bowel obstruction. We believe the safety, efficacy, and ease of this procedure make Cystografin enema optimal first-line treatment for acute colonic pseudo-obstruction.

Acute colonic pseudo-obstruction

BACKGROUND

Acute colonic pseudo-obstruction is an acute non-mechanical colonic obstruction. Twenty patients with this condition presenting between 1988 and 1996 were retrospectively reviewed to identify the incidence and potential aetiologic factors, and to establish a uniform therapeutic approach.

METHODS

Patients who fulfilled the criteria of acute pseudo-obstruction of the colon were reviewed retrospectively from a computerized database, and from a study of the hospital notes.

RESULTS

There were 12 men and eight women with a median age of 71 years. Seventeen patients (85%) had various coexisting medical conditions, and none of the cases had a recent surgical operation or trauma. Four patients had previous similar attacks. Patients had a median duration of symptoms and a hospital stay of 3 and 7 days, respectively. Diagnosis was based on the clinical features coupled with the findings on plain abdominal X-rays and contrast enema. Sixteen patients were successfully treated conservatively over a median time of 5 days. Three patients had a laparotomy: two patients had tube caecostomy (followed by complications), and one patient had no further treatment. One patient had colonoscopy with an unsatisfactory result. Two patients (10%) died and three (15%) developed complications.

CONCLUSIONS

Acute colonic pseudo-obstruction is an uncommon but serious condition. The majority of our patients (17/20) had associated significant medical problems. Most of the patients were successfully managed conservatively. This was the preferred initial line of treatment in this department during the study period.

[Value of intraluminal intestinal decompression by endoscopic placement of a Dennis tube in therapy of ileus. Retrospective clinical study of 174 patients]

For determination of the efficacy of intraluminal bowel decompression by an endoscopically placed Dennis tube, 174 patients with paralytic ileus or different kinds of partial small bowel obstruction were reviewed retrospectively. There were 66 cases (37.9%) of early postoperative ileus (A), 27 (15.5%) of late postoperative ileus (B), 38 (21.8%) of paralytic ileus (C), 31 (17.8%) with obstruction due to advanced intraabdominal tumors (D), and 12 (6.8%) of obstructive ileus caused by inflammatory stenosis of the small bowel in Crohn's disease (E). Successful endoscopic placement of the intestinal tube was achieved in 97.2% of patients. Placement of the tube was impossible in 5 cases. A total of 95 patients (54.6%) were successfully managed by long intestinal tube decompression. Success rates for the individual groups were 71.2% (A), 18.5% (B), 86.8% (C), 16.1% (D), and 41.7% (E). Some 75 patients (43.1%) had to be operated on because of insufficient conservative therapy. Four patients with advanced intraabdominal tumors died during the treatment with the intestinal tube; 13 patients died postoperatively. There was no tube-related mortality, but tube-related complications occurred in 6.9%. We conclude that intraluminal intestinal tube decompression after endoscopic placement provides a therapeutic tool with a concomitant low complication and high success rate in paralytic and early postoperative ileus.

Early resolution of Ogilvie's syndrome with intravenous neostigmine: a simple, effective treatment

PURPOSE

Our aim was to assess the value of a parasympathomimetic drug (neostigmine) in the early resolution of acute colonic pseudo-obstruction (Ogilvie's syndrome).

METHODS

A prospective study was undertaken in 18 consecutive patients (mean age, 76 (range, 31-87) years) with acute colonic pseudo-obstruction. After a varying period of conservative treatment in all cases, 16 patients with persistent, massive abdominal distention were given intravenous neostigmine.

RESULTS

A rapid and satisfactory clinical and radiologic decompression of the large bowel was obtained in 12 patients (75 percent) after a single dose of the drug; another patient had complete resolution after a second dose, and the other 3 patients had only partial resolution, in one of them after a second dose of the drug. No patient required surgical decompression of the bowel.

CONCLUSION

These results give support to the theory of excessive parasympathetic suppression in most cases of Ogilvie's syndrome. The treatment with intravenous neostigmine has proved very effective, preventing in many cases prolonged periods of uncomfortable and potentially hazardous conventional conservative management and avoiding surgical treatment in a consecutive series of patients.

Colonoscopy and acute colonic pseudo-obstruction

There is no well-defined standard of care for the use of colonoscopy in the treatment of acute colonic pseudo-obstruction (ACPO). Colonoscopy can be helpful for ACPO, but it can be accompanied by complications, is not completely effective, and can be followed by recurrence. These possibilities must be weighed against the overall risk of spontaneous perforation, which is low but real. The use of colonoscopy therefore should be selective, and it should be performed by experts and accompanied generally by tube placement.

Stellate ganglion block alleviates pseudo-obstruction symptoms followed by episodes of hypermetropia: case report

BACKGROUND AND OBJECTIVES

The chronic intestinal pseudo-obstruction due to visceral myopathy is a disorder resembling bowel obstruction but without mechanical occlusion. Frequently, parenteral nutrition becomes the final palliative treatment. A patient affected with this syndrome for 16 years was suffering causalgic pain provoked by intraveneous perfusion. Stellate ganglion block was requested in the hope of maintaining the perfusion.

METHODS

Stellate ganglion block not only stopped the pain but unexpectedly, it temporarily relieved the pseudo-obstruction symptoms. Two radiofrequency coagulations in the stellate ganglion prolonged the beneficial effects on gastrointestinal transit for more than 3 weeks, after which the symptoms returned. Multidisciplinary and multicenter advice was that further destructive treatments not be attempted.

RESULTS

Repetitive stellate ganglion blocks with 2 mL of bupivacaine 0.75% restored gastrointestinal function for more than 3 weeks. However, after performance of radiofrequency coagulation, infiltration with bupivacaine was followed by hypermetropia on the right eye of 2 weeks duration.

CONCLUSIONS

The relationship between stellate ganglion block and gastrointestinal function has not been described. This case report does not provide sufficient information to recommend this technique for pseudo-obstruction symptoms. Moreover, the result in this case is a fortuitous observation, lacking a clear scientific explanation. Further study may be warranted.

Acute pseudo-obstruction of the colon (Ogilvie's syndrome): advances in management

The management of the patients with acute pseudo-obstruction of the colon (APOC) still represents a matter of debate. To better evaluate and compare the effectiveness of various therapeutic approaches in the management of APOC 29 patients were considered. These were included according to three consecutive periods in: group A (1977-1982) concerning patients who underwent medical treatment alone (n = 8) or endoscopic (n = 4) and surgical (n = 1) decompression; group B (1983-1990) in which the management was based on simple endoscopic decompression (n = 10); group C (1991-1995) including patients in whom placement, under fluoroscopic control, of a tube in the cecum following endoscopic decompression was provided (n = 6). Mean time required for resolution of colonic distension was 2.3 (+/- 0.50 SD) days in patients who underwent endoscopic decompression and tube placement, as compared to 4.5 (+/- 2.47 SD) days in the group of patients treated either with conservative measures or simple endoscopic decompression (p = 0.04). No recurrence occurred after colonoscopic decompression and tube placement while colonic distension recurred in 4 of 14 patients managed by simple endoscopic decompression (0% vs. 28.6%, n.s.). Our experience showed that endoscopic decompression is an effective method, moreover if associated with the placement of an indwelling tube into the right colon. This method, for its easiness and safeness, besides its effectiveness in preventing the recurrence of colonic distension, may be surely considered an advance in the management of acute pseudo-obstruction of the colon.

[Ogilvie syndrome or acute colonic pseudo-obstruction. Current concepts in diagnosis and treatment]

Ogilvie's syndrome or acute colonic pseudo-obstruction is a motility disorder characterized by acute and progressive colonic distension. This syndrome occurs in hospitalized patients with several medical or surgical diseases with an unclear pathophysiology. Diagnosis is established by the clinical history, physical examination and radiological findings on plain abdominal X-ray. Treatment includes: 1. general measures to reduce colonic distension, 2. drugs that improve colon motility, 3. endoscopic colonic decompression and 4. surgery. Age, associated diseases, elapsed time and diameter of cecal dilatation, presence of necrosis and perforation are the main prognostic factors. Recurrence after medical treatment is 20-50 percent; intrahospital mortality is 30 percent. A practical algorithm for the management of these patients is proposed.

Intestinal pseudo-obstruction (Ogilvie's syndrome) in theophylline overdose

Intestinal pseudo-obstruction (Ogilvie's syndrome) has previously been reported in 2 patients with theophylline toxicity treated with activated charcoal (AC), mechanical ventilation and opioid induced sedation. We report a case of Ogilvie's syndrome in a theophylline toxic patient treated with AC. A 45-y-old male with severe chronic obstructive pulmonary disease presented with vomiting and multifocal atrial tachycardia after an intentional theophylline overdose. His initial potassium concentration was 2.7 mEq/L and his theophylline was 191 mg/L (1060 mumol/L). The patient was hemodialyzed and given a total of 1,000 g of AC without cathartics during the first hospital day. He also received iv potassium replacement. On the second hospital day he required mechanical ventilation for respiratory acidosis. Clindamycin was given for purulent sputum and fever. Haloperidol was given to treat agitation. No other anticholinergic agents or opioids were given. The patient's potassium rose to 6.5 mEq/L and he was given kayexalate. During the third hospital day the patient developed abdominal distention, tenderness and leukocytosis. Abdominal radiographs revealed a distended cecum. In the operating room the cecum was found dilated to 16 cm with no distal obstruction. A cecostomy tube drained AC and pill fragments. A 6 cm charcoal bezoar was found in the stomach. The patient recovered uneventfully.

Acute pseudo-obstruction of the colon: a clinical contribution and review of the literature

Acute idiopathic pseudo-obstruction of the colon, or Ogilvie's syndrome, is a rather unfrequent condition. Although it has been associated to a variety of pathological conditions, the etiology is still unknown. The authors refer upon a case of Ogilvie's syndrome observed by them and, confronting the data that emerged reviewing the literature with their experience, they retain that if the conservative therapy fails, and in absence of perforations or ischemic lesions, the treatment to prefer is the positioning of a cecostomy tube in local anesthesia. For elderly patients with unsufficiently good general conditions who present a recurrent acute pseudo-obstruction of the colon, it is advisable to confection a definitive cecostomy.

Pseudoobstruction of the colon: early recognition and therapy

A case of pseudoobstruction of the colon in a patient receiving oral nimodipine therapy is presented. Early recognition of this entity, diagnostic aids, and therapy are discussed. Successful colonoscopic decompression and close observation allowed completion of nimodipine course of therapy.

[Ogilvie syndrome. Diagnostic and therapeutic attitude]

Ogilvie's syndrome (OS) is a clinical condiction with the symptoms, signs and radiological appearances of acute bowell obstruction but without any apparent mechanical cause. Diagnosis and treatment are often delayed and many patients are still inappropriately managed which in turn results in an increase in morbidity and mortality. We have reviewed our experience in eleven patients with OS in order to establish a system for their diagnostic and therapeutic management.

Acute pseudo-obstruction in critically ill patients with burns

Acute pseudo-obstruction of the colon (Ogilvie's syndrome) is a rare but potentially morbid complication of burn injury. Two thousand seven hundred three consecutive critically ill patients with burns were reviewed for findings consistent with pseudo-obstruction. Eight (0.29%) patients were identified. Mean age was 63.5 years, and mean burn size was 24.6% total body surface area. All patients were undergoing mechanical ventilation at the time of diagnosis. Six had a previous cardiac condition or complication, and five were on digoxin. Diagnosis was suspected in seven patients before colonoscopy or surgery. Six patients were treated with colonoscopy alone with one treatment failure. Two deaths occurred during hospitalization. Two late deaths were due to underlying cardiac conditions. The preferred treatment of Ogilvie's syndrome is nasogastric suction, colonic decompression, and close observation with surgery reserved for treatment failures or when diagnosis is in doubt. The incidence of Ogilvie's syndrome in patients with burns appears to be related to nonburn medical conditions, especially cardiopulmonary complications and age, rather than to the burn itself.