Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome)

Acute colonic pseudo-obstruction: A systematic review of aetiology and mechanisms

AIM

To critically review the literature addressing the definition, epidemiology, aetiology and pathophysiology of acute colonic pseudo-obstruction (ACPO).

METHODS

A systematic search was performed to identify articles investigating the aetiology and pathophysiology of ACPO. A narrative synthesis of the evidence was undertaken.

RESULTS

No consistent approach to the definition or reporting of ACPO has been developed, which has led to overlapping investigation with other conditions. A vast array of risk factors has been identified, supporting a multifactorial aetiology. The pathophysiological mechanisms remain unclear, but are likely related to altered autonomic regulation of colonic motility, in the setting of other predisposing factors.

CONCLUSION

Future research should aim to establish a clear and consistent definition of ACPO, and elucidate the pathophysiological mechanisms leading to altered colonic function. An improved understanding of the aetiology of ACPO may facilitate the development of targeted strategies for its prevention and treatment.

Colonoscopic decompression should be used before neostigmine in the treatment of Ogilvie's syndrome

BACKGROUND

Performance of urgent colonoscopy for the purposes of diagnosis and treatment of Ogilvie's syndrome remains controversial. However, no trials have directly compared neostigmine with endoscopic therapy. This study aimed to compare the effect of neostigmine and colonoscopic decompression in the treatment of Ogilvie's syndrome.

METHODS

This study was designed as a retrospective, non-randomized clinical study of sequential patients. Patients who were diagnosed as having acute colonic pseudo-obstruction were separated into two groups after conservative treatment. Group 1 comprised patients who underwent colonoscopic decompression, because they had a poor first response to neostigmine treatment. Group 2 constituted patients who had a poor first response to colonoscopic decompression, and neostigmine was added to the treatment regimen. Groups 1 and 2 were compared for the success of disease management.

RESULTS

In groups 1 and 2, the average age of the patients was 63.19 years (±14.71 years) and 59.45 years (±15.31 years) (p = 0.312), respectively. No significant difference was determined between the groups in terms of distribution of sex, hospital stay, etiologies, and initial cecal sizes in imaging (p > 0.05). Response to first intervention was statistically significant (p < 0.01). Also, the total response was determined statistically significant for hospital stay if colonoscopic decompression was performed (p < 0.01). No recurrence was determined during the 1-month follow-up in both groups. Although there was no etiologic factor for neostigmine response according to univariate analysis results, colonoscopic success was decreased due to age, sex, and the presence of a cardiac disease.

CONCLUSIONS

Although the success rate of neostigmine treatment was significantly lower in our homogeneous groups, no significant decrease was determined in terms of hospital stay, intensive care unit stay, and requirement of colostomy compared with colonoscopic decompression. By comparison, colonoscopic decompression, which was performed by experienced endoscopists as a first-line treatment option, was more effective as an initial therapy and was more effective at avoiding a second treatment modality.

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.

Nutrition risk assessment in the ICU

PURPOSE OF REVIEW

Nutrition risk assessment is of great importance to identify patients who may benefit from nutritional intervention to prevent ICU starvation and avoid side-effects of nutrition care. The full spectrum of nutrition risk assessment in ICU has not been defined in guidelines.

RECENT FINDINGS

Many patients are admitted to ICUs with nutritional deficits related to acute and chronic disease. The vast majority of patients who cannot resume sufficient oral feeding within a few days will lose body cell mass due to the severe and prolonged inflammatory process and insufficient nutrient intake. All patients staying longer than 1-2 days in the ICU need nutrition support, close monitoring and risk assessment. Risk assessment has to be constantly maintained throughout the ICU stay to manage properly risks associated with critical illness and nutrition care. Many patients are at risk to develop a refeeding syndrome, to experience serious motility disorders and finally dysphagia after extubation. The dramatic consequences of intra-abdominal hypertension may be decreased by early detection and treatment. There is a close interaction between evolution of critical illness, the associated inflammatory reaction, ICU treatments and nutrition care.

SUMMARY

Safe and efficient nutrition care may only be obtained when gastrointestinal function and metabolic tolerance of nutrients are regularly assessed.

Gastrointestinal motility in acute illness

Critical illness affects gastrointestinal motility - not only as a primary problem, which brings the patient to the intensive care unit (ICU), but also as a complication consecutive to the ICU stay. Motility disturbances may result from impaired function of gastrointestinal muscle, pacemaker cell function and nerve activity. The most important neural control system is the enteric nervous system that contains the largest collection of neurons (10(8) cells) outside the central nervous system. Through its organization it can operate independently of the brain and generate motility patterns according to need: a postprandial motility pattern starting after food intake, and an interdigestive motility pattern starting several hours after a meal. Undisturbed intestinal motility depends critically on a balanced interaction between inhibition and excitation, and a disturbance in this balance leads to severe derangements of intestinal motility. These motility disturbances differ in clinical appearance and location but can affect all parts of the gastrointestinal tract. This review focuses on select motility disturbances such as gastroparesis, postoperative ileus, and Ogilvie's syndrome. Generally effective methods to treat these conditions are given. Finally, we focus on special management options to prevent such motility disturbances or to reduce their severity.

Ogilvie's syndrome: a case report

OBJECTIVE

Ogilvies syndrome (OS) is a rare condition in obstetrics but occurs most commonly after caesarean section. Mortality rates from OS can be as high as 36-50% when bowel perforation or ischemia develops which highlights the early recognition of this condition. Early diagnosis is therefore essential to prevent serious morbidity and mortality.

CONCLUSION

We, therefore report a case of OS after caesarean section in which early detection by senior clinicians resulted in successful management of the condition and an excellent outcome.