Acute colonic pseudo-obstruction post-cesarean section is not a benign entity: A case series and review of the literature

Acute colonic pseudo-obstruction (ACPO) is an infrequent occurrence after cesarean section. Anecdotal evidence suggests that the clinical course of ACPO in the obstetric setting is different to that seen in non-pregnant adult patients with ACPO secondary to alternative causes, such as systemic illnesses, the use of certain medications, and after non-abdominal surgery. The risk of progression to ischemia and perforation, as well as the need for emergency surgery, appears to be higher after cesarean section. Here we describe the clinical course of ACPO in four patients after cesarean section from our institution, followed by a review of the literature and a discussion of the important issues surrounding this condition in the postpartum time period. The findings from our cohort of patients and the reports from the medical literature support a hands-on combined approach from a group of specialists including obstetricians, surgeons, radiologists, and enterostomal therapists. Immediate imaging followed by regular observation is mandatory for any patient being managed conservatively. Early use of endoscopic decompression should be considered for patients who are not resolving with a conservative approach. Clinical signs of peritonism or radiological signs of ischemia or perforation in patients with ACPO mandate immediate surgical intervention. Appropriate postoperative care is necessary to deal with the complex physiological and psychological consequences of emergency surgery and potential stoma formation so soon after cesarean section.

Pheochromocytoma leading to Takotsubo and Ogilvie syndrome, a pathophysiological triad

Takotsubo syndrome (TTS) is a transient left ventricle dysfunction usually caused by a stressful trigger (emotional or physical). We report the case of a 77 year-old female patient who presented with TTS caused by a pheochromocytoma, a catecholamine-producing neuroendocrine tumour. Diagnosis was facilitated by acute kidney injury prompting renal ultrasound, recurrence of TTS and symptoms of episodic palpitations, profuse sweating and labile blood pressure. Furthermore, during her hospitalisation the patient also developed an Ogilvie syndrome, an acute colonic pseudo-obstruction, due to the catecholamine-excess. Treatment consisted of betablocker and angiotensin-converting enzyme inhibitor for TTS, neostigmine for Ogilvie syndrome, in combination with alpha-blocker and surgical removal of the tumour after recuperation of left ventricular function and colonic pseudo-obstruction. To our knowledge, this is the first case report of the pathophysiological triad of pheochromocytoma leading to Takotsubo and Ogilvie syndrome in a single patient.

Ogilvie's Syndrome in a Young Female With Chronic Constipation

Ogilvie's syndrome, also known as acute colonic pseudo-obstruction, is often encountered in post-surgical patients or those with serious comorbidities requiring intensive care. For this reason, it has rarely been reported in patients younger than 50 years without any predisposing risk factors. Our case report highlights a unique case of Ogilvie's syndrome in a young female with no recent trauma or surgical history. To that extent, we discuss risk factors that predisposed her to this condition, including her history of chronic constipation. We also emphasize the need for outpatient workups for such patients to prevent the worsening of their symptoms.

A Novel Technique Using Ryle's Tube for Colonic Decompression in Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction, also known as Ogilvie's syndrome, involves colon dilation without mechanical obstruction. It is conventionally treated with conservative measures such as fasting, nasogastric and rectal tube placement, correction of fluids and electrolytes, and, if necessary, use of neostigmine and colonic decompression through colonoscopy. Surgical intervention may be considered in severe cases. In this report, we present a case of acute colonic pseudo-obstruction where initial conservative management failed. The patient was successfully treated using a novel rectal tube insertion technique.

Dilated gut conditions: diagnosis and management

Dilatation of the gut occurs in response to either mechanical obstruction or aperistalsis. The hallmark features are symptoms of bowel obstruction with vomiting, constipation, abdominal pain and distension. This review will primarily deal with the non-mechanical causes of gut dilatation, both intestinal and colonic, and differentiate between acute and chronic presentations.

Acute colonic pseudo-obstruction following spinal fixation for trauma

PURPOSE

Acute colonic pseudo-obstruction (ACPO) is a potentially highly morbid surgical complication. The incidence of ACPO following spinal trauma is unknown, but is likely higher than after elective spinal fusion. The purpose of this study was to establish the incidence of ACPO in patients with major trauma undergoing spinal fusion for unstable thoracic and lumbar fracture. Secondly, to characterise the nature of ACPO in this group, including treatment and complications.

METHODOLOGY

A metropolitan hospital prospective trauma database was utilised to identify all patients from November 2015 to December 2021 meeting major trauma criteria and undergoing thoracic or lumbar spinal fusion for fracture. Individual records were then evaluated for occurrence of ACPO. ACPO was defined as radiological evidence of colonic dilation without mechanical obstruction in symptomatic patients undergoing dedicated abdominal imaging.

RESULTS

After exclusions, 456 patients with major trauma undergoing thoracic or lumbar spinal fusion were identified. ACPO occurred in 34; an incidence rate of 7.5%. There was no evidence of difference in terms of the spinal fracture type, level, surgical approach or number of segments fused. There were no perforations; only two patients required colonoscopic decompression and none required surgical resection.

CONCLUSION

ACPO occurred at a high frequency in this group of patients, although it required relatively simple treatment. High vigilance for ACPO should be maintained in trauma patients requiring thoracic or lumbar fixation, with a view to early intervention. The aetiology driving the high rates of ACPO in this cohort is not understood and would benefit from further investigation.

Acute Colonic Pseudo-Obstruction Secondary to Renal Calculus: A Case Report and Review of Pathophysiology

Acute colonic pseudo-obstruction (ACPO) is obstruction of the large bowel without a mechanical cause. The exact mechanism remains incompletely understood but is thought to result from disruption to the autonomic regulation of the colon, typically in the context of hospitalized patients with medical illness, precipitating medications, or recent surgical intervention. This paper presents an unusual case of ACPO in an ambulatory patient with a recently passed renal calculus, explores the anatomy and physiology underlying the autonomic dysfunction theory of ACPO pathogenesis in the context of the case, and provides a 3D reconstruction of the patient's CT to illustrate the abrupt caliber change at the splenic flexure characteristic of ACPO.

Risk factors for acute colonic pseudo-obstruction after caesarean section: A retrospective case-control study

BACKGROUND

Pregnancy and caesarean section are known to predispose to the development of acute colonic pseudo-obstruction (ACPO), a rare form of functional ileus of the distal large bowel. Pathogenesis of ACPO is likely influenced by pregnancy and childbirth and subsequent changes to hormonal, autonomic and metabolic physiology. Identifying pregnancy risk factors will assist with early identification, as the insidious onset postpartum often leads to delayed diagnosis and bowel ischaemia, perforation and sepsis.

AIMS

To establish pregnancy risk factors associated with the development of ACPO after caesarean section.

MATERIALS AND METHODS

A retrospective case-control study included 19 121 women undergoing caesarean between 1 January 2008 and 31 December 2016 at a tertiary referral hospital. Twenty-three cases of computerised tomography (CT)-diagnosed ACPO post-caesarean were identified from hospital medical records and imaging databases. Controls were matched for gestational and maternal age within one week of delivery with a ratio of 1:3.

RESULTS

The incidence of ACPO was one in 800 caesarean sections. ACPO was significantly more likely to occur in women who had been administered opioid analgesia in labour (odds ratio (OR) 4.67, P = 0.04), and a trend for increased estimated blood loss (OR 1.01, P = 0.01). There was no increased risk associated with emergency or elective caesarean classification, previous abdominal surgery, type of anaesthesia, duration of labour, oxytocin augmentation, intrapartum fever, hypertensive disorders, diabetes in pregnancy, antepartum haemorrhage, multiple gestation, fetal presentation or birthweight.

CONCLUSIONS

Risk factors for developing ACPO post-caesarean include opioid analgesia in labour and a trend for increased blood loss.

Persistent Hypokalemia in a Patient With Ogilvie's Syndrome

Ogilvie's syndrome, also known as acute colonic pseudo-obstruction (ACPO), is a rare disease characterized by acute dilatation of the colon in the absence of anatomic intestinal obstruction. It is of clinical importance because of its preponderance in elderly males in the seventh decade of life who may present with constipation or diarrhea. We present an 80-year-old male who presented with diarrhea, with laboratory investigations showing hypokalemia and a CT abdomen revealing colonic distension. The patient was wasting potassium both from colon and renal losses, despite low aldosterone levels. The patient was treated with Neostigmine, which helped relieve abdominal distention. Subsequently, potassium was corrected with aggressive replacement. This case sheds light on newer modalities of treatment such as neostigmine, as in this case.

Delayed Recurrence of Acute Colonic Pseudo-Obstruction in the Setting of Acute Hypoxic Respiratory Failure

Acute colonic pseudo-obstruction (ACPO) is a rare cause of massive colonic dilation without mechanical obstruction. We report on a 58-year-old gentleman who developed two separate episodes of ACPO following different surgical and medical stressors. The initial episode occurred shortly after lumbar laminectomy and was successfully managed with medical therapy. His second episode occurred several months later in the setting of acute hypoxic respiratory failure secondary to bacterial pneumonia and was refractory to conservative, medical, and endoscopic therapy. Recurrence and the refractory nature of symptoms are presumably multifactorial in etiology, likely due to his episode of acute hypoxic respiratory failure in the setting of chronic immobility following recent spine surgery. The patient was discharged in stable condition to a subacute rehabilitation facility with the expectation that physical therapy would improve his abdominal symptoms.

Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction (ACPO) is a functional disorder of the large intestine distinguished by colonic dysmotility resulting in colonic distension in the absence of mechanical obstruction. The underlying pathophysiology of ACPO remains unclear despite technological advances in understanding the physiology of colonic motility, such as spatio-temporal mapping and high-resolution manometry. In many ways, the management of ACPO has remained relatively unchanged for 40 years. Patients with perforation or suspected ischemia undergo operative intervention, while patients without undergo initial conservative management with bowel rest, correction of electrolyte disturbances, and mobilization. Patients who fail conservative management or have prominent cecal dilatation undergo decompression with either neostigmine or colonoscopy. A subset of patients with ACPO will have recurrent symptoms despite endoscopic and medical management. For these patients who are difficult to manage, an underlying colonic functional disorder, such as slow-transit dysmotility or chronic intestinal pseudo-obstruction may be considered. The following review of ACPO aims to provide a concise update of the causes, diagnosis, and management of this emergency surgical condition.

Acute Colonic Pseudo-Obstruction Following the Use of Dexmedetomidine

Dexmedetomidine is a preferred agent for light sedation with minimal adverse effects. We report a case of acute colonic pseudo-obstruction following dexmedetomidine use in a patient with alcohol withdrawal. He was treated with benzodiazepines first to control the withdrawal symptoms, then escalated to dexmedetomidine once delirium tremens ensued. Later on, the patient developed abdominal distension and vomiting. Imaging showed dilated bowel loops and absence of peristalsis on ultrasound. Decompression with the nasogastric (NG) tube was done, with high output from the NG tube. Dexmedetomidine infusion was used twice, and once it was stopped, the NG tube output was reduced, with the resumption of gastrointestinal motility and improvement of the abdominal distension. Recent similar reports of functional intestinal obstruction following alpha-2 (α2) agonist use necessitate further studies of intestinal motility following dexmedetomidine use and awareness of the possible side effect of dexmedetomidine on intestinal motility.

Acute colonic pseudo-obstruction (Ogilvie syndrome) leading to respiratory compromise and death

Here, we present an unusual case of acute colonic pseudo-obstruction (ACPO), also known as Ogilvie syndrome, which resulted in respiratory failure and sudden death. The patient was a 19-year-old man with a history of cerebral palsy (CP) and severe autism who experienced marked abdominal distension that progressed over several days in his skilled nursing facility. He developed shortness of breath and episodic diarrhea, before having an unwitnessed cardiac arrest and subsequently expiring after prehospital and emergency department care. Autopsy revealed developmental deformities consistent with CP, rectal prolapse, and significant abdominal distension. Postmortem radiography showed diffuse bowel distension with bilateral upward displacement of the diaphragm and consequent lung compression. Thorough examination of the gastrointestinal tract failed to reveal any perforation or obstruction. The cause of death was determined to be respiratory compromise secondary to diaphragmatic compression as a result of ACPO, a condition defined as colonic distension without a mechanical explanation for obstruction. This case highlights the challenges that ACPO can pose to a forensic pathologist at autopsy, and serves as a teaching point to clinicians on the warning signs and treatment measures for ACPO.

A novel mechanism for acute colonic pseudo-obstruction revealed by high-resolution manometry: A case report

BACKGROUND

Acute colonic pseudo-obstruction (ACPO) is a severe form of colonic dysmotility and is associated with considerable morbidity. The pathophysiology of ACPO is considered to be multifactorial but has not been clarified. Although colonic motility is commonly assumed to be hypoactive, there is little direct pathophysiological evidence to support this claim.

METHODS

A 56-year-old woman who developed ACPO following spinal surgery underwent 24 h of continuous high-resolution colonic manometry (1 cm resolution over 36 cm) following endoscopic decompression. Manometry data were analyzed and correlated with a three-dimensional colonic model developed from computed tomography (CT) imaging.

RESULTS

The distal colon was found to be profoundly hyperactive, showing near-continuous non-propagating motor activity. Dominant frequencies at 2-6 and 8-12 cycles per minute were observed. The activity was often dissociated and out-of-phase across adjacent regions. The mean amplitude of motor activity was higher than that reported from pre- and post-prandial healthy controls. Correlation with CT imaging suggested that these disordered hyperactive motility sequences might act as a functional pseudo-obstruction in the distal colon resulting in secondary proximal dilatation.

CONCLUSIONS

This is the first detailed description of motility patterns in ACPO and suggests a novel underlying disease mechanism, warranting further investigation and identification of potential therapeutic targets.

Stretched to the Max: The Successful Medical Management of Ogilvie Syndrome in a Pediatric Patient

Ogilvie syndrome, or acute colonic pseudo-obstruction, is a rare disease in adults, and it is seldom seen in pediatric patients. It was first described in 1948 by Dr. William Ogilvie. Unless promptly recognized and treated, it carries the risk of colonic ischemia and perforation. In this report, we present the case of a 10-year-old patient who developed Ogilvie syndrome and was successfully treated with conservative medical management including bowel rest, rectal decompression, along with the addition of erythromycin. The patient responded well to the treatment and was able to be discharged home without event.

A case series of 3 patients with acute colonic pseudo-obstruction after vincristine administration

Acute colonic pseudo-obstruction (ACPO) or Ogilvie's syndrome is characterized by acute colonic dilatation in the absence of mechanical obstruction. It usually occurs in hospitalized patients with acute illness or following surgical procedures, but several medications such as cytotoxic chemotherapy can also induce ACPO. We report three cases of patients with Ogilvie's syndrome after induction therapy with vincristine-containing chemotherapy. Conservative management failed in all three cases. Awareness for this syndrome is necessary when administrating vincristine, because delay in diagnosis may lead to colonic ischaemia and perforation.

Safety and Efficacy of Intermittent Bolus and Continuous Infusion Neostigmine for Acute Colonic Pseudo-Obstruction

PURPOSE

To compare clinical response of intermittent bolus versus continuous infusion neostigmine for acute colonic pseudo-obstruction (ACPO). Acute colonic pseudo-obstruction occurs due to reduced colonic parasympathetic activity. Neostigmine is an acetylcholinesterase inhibitor that increases frequency of smooth muscle contraction by increasing acetylcholine at autonomic nervous system synapses. Although these administration modalities have been studied separately, they have never been compared.

METHODS

This retrospective study compared bolus versus continuous infusion neostigmine for ACPO. The primary outcome was initial clinical response, defined as bowel movement (BM) within 4 hours of bolus dose or 24 hours of initiation of continuous infusion. Secondary outcomes included time to BM, bowel diameter reduction at 24 hours, incidence of bradycardia, additional neostigmine requirements, and need for colonic decompression or surgical intervention.

RESULTS

Seventy-five patients were included (bolus n = 37; infusion n = 38). Median total 24-hour neostigmine dose was 2.0 mg (interquartile range [IQR]: 2.0-2.6) with bolus and 9.6 mg (IQR: 6.3-9.6) with continuous infusion. Initial clinical response was similar (infusion 81.6% vs bolus 62.2%, P = .06), but continuous infusion was associated with greater bowel diameter reduction (73.7% vs 40.5%, P = .004). Bolus administration had shorter time to BM (1.4 vs 3.5 hours, P = .0478) and increased need for colonic decompression (67.6% vs 39.5%, P = .0148). Bolus dosing was associated with less bradycardia (13.5% vs 39.5%, P = 0.011), with no difference in atropine usage (10.8% vs 5.3%, P = .43).

CONCLUSION

Initial clinical response was similar between groups; however, continuous infusion neostigmine was associated with greater bowel diameter reduction at 24 hours. Bolus administration resulted in less bradycardia; however, given the lack of difference in atropine use, clinical significance is unknown. This study is the first to compare bolus versus continuous infusion neostigmine for ACPO. Further studies are needed to confirm findings.

Post-Pneumonectomy ARDS and Ogilvie Syndrome - A Case Report

Introduction

The Acute Respiratory Distress Syndrome (ARDS) is a severe hypoxemic acute lung injury that may complicate lung resections. Reported mortality is very high, up to 50%. This report covers an ARDS case occurring post left pneumonectomy, with a favorable outcome, despite association with an acute colonic pseudo-obstruction syndrome (Ogilvie syndrome) that required abdominal surgery for decompression.

Case Report

A 60-year old Caucasian male, diagnosed with a stage IIIA left lung tumor underwent a left pneumonectomy. On the second postoperative day, the patient developed ARDS, requiring ventilatory support. Two days later, as the multiple organ dysfunction worsened, a bowel obstruction occurred. With an acute colonic pseudo-obstruction diagnosis, the decision was to perform laparotomy and a temporary cecostomy. A subsequent improvement in the respiratory parameters and vital functions resulted in weaning from ventilator 8 days after the onset of the ARDS and transfer to the surgery ward 14 days after pneumonectomy.

An unusual manifestation of diabetic ketoacidosis and acute colonic pseudo-obstruction

Patients presenting with diabetic ketoacidosis and acute colonic pseudo-obstruction should undergo a focused evaluation to identify underlying precipitants.

Advances and challenges in the management of acute colonic pseudo-obstruction (ogilvie syndrome)

Although acute colonic pseudo-obstruction (ACPO), also known as Ogilvie syndrome, is a well-known clinical entity, in many respects it remains poorly understood and continues to challenge physicians and surgeons alike. Our understanding of ACPO continues to evolve and its epidemiology has changed as new conditions have been identified predisposing to ACPO with critical illness providing the common thread among them. A physician must keep ACPO high in the list of differential diagnoses when dealing with the patient experiencing abdominal distention, and one must be prepared to employ and interpret imaging studies to exclude mechanical obstruction. Rapid diagnosis is the key, and institution of conservative measures often will lead to resolution. Fortunately, when this fails pharmacologic intervention with neostigmine often proves effective. However, it is not a panacea: consensus on dosing does not exist, administration techniques vary and may impact efficacy, contraindications limit its use, and persistence and or recurrence of ACPO mandate continued search for additional medical therapies. When medical therapy fails or is contraindicated, endoscopy offers effective intervention with advanced techniques such as decompression tubes or percutaneous endoscopic cecostomy providing effective results. Operative intervention remains the treatment of last resort; surgical outcomes are associated with significant morbidity and mortality. Therefore, a surgeon should be aware of all options for decompression-conservative, pharmacologic, and endoscopic-and use them in best combination to the advantage of patients who often suffer from significant concurrent illnesses making them poor operative candidates.