Cause, risk factors and symptoms
Diagnosis and treatment
Ogilvie syndrome and COVID-19
Ogilvie's syndrome, also referred to as acute colonic pseudo-obstruction or ACPO, is a distinct type of colonic dilatation.
The progression of Ogilvie's syndrome is unpredictable, and there are no known causes. It is most frequent in geriatric patients with multiple underlying comorbidities; however, it can also occur in seemingly healthy patients after a traumatic event or surgery.
Patients with this illness gradually develop abdominal distension along with some abdominal discomfort. Ogilvie's syndrome is diagnosed based on clinical and radiological data.
In 1948, Sir William Heneage Ogilvie documented two patients with colonic pseudo-obstruction. Dudley first used the term "pseudo-obstruction" to describe functional obstruction of the colon. Nanni et al. published a review in 1982 that used the phrase "acute colonic pseudo-obstruction." In his 1997 article, Rex used the abbreviation "ACPO."
Cause, risk factors and symptoms
The development of Ogilvie's syndrome is unpredictable, and there are no specific causes; nonetheless, various clinical factors can place a patient at increased risk. Comorbidities related to electrolyte imbalance or polypharmacy, low underlying functional status, or immobility, are significantly associated.
Older persons who have been hospitalized, even for non-surgical care, are more vulnerable. For unknown reasons, there appears to be a link to cesarean operations.
Elderly persons who report to the emergency department or other acute care settings from long-term care facilities or nursing homes, those with an underlying degenerative neurological condition, or those who have just undergone abdominal surgery are also at risk.
The specific pathophysiology of Ogilvie's syndrome is uncertain. The initial mechanism proposed by Ogilvie was an imbalance in autonomic nervous system activity with parasympathetic overactivity resulting in colon dilatation.
It is hypothesized that the activity of stimulatory neurotransmitters, particularly acetylcholine, is lower than that of inhibitory neurotransmitters such as nitrous oxide and vasoactive intestinal peptides. Independent enteric nervous system malfunction, as well as intrinsic enteric reflex arcs and pacemaker activity, all play a role, but to what extent is unknown.
Pathologic distension of the colon in Oglivie's syndrome usually ends at or around the splenic flexure, which is also where autonomic parasympathetic efferent innervation switches from the Vagus nerve to the sacral, S2-S4, nerve roots.
Although symptoms and signs of major bowel obstruction are prevalent, it can manifest in many ways. Acute major abdominal distention and discomfort are common symptoms.
Systemic poisoning symptoms do not manifest until severe problems have occurred. Ogilvie’s syndrome manifests clinically as abdominal distention and pain (80%), nausea with vomiting (60%), and constipation (60%). The diagnosis is based on the exclusion of structural and recognized causes of colonic dilatation, as well as clinical and radiologic evidence.
Ogilvie's syndrome most commonly affects the cecum and right colon, however, it can affect any section or all of the colon. Diameters greater than 14 cm are thought to be associated with a high risk of perforation. The most significant complications are perforation and intestinal ischemia, which necessitate frequent intervention.
The annual incidence of this disease is generally given as 100 cases per 100,000 hospital admissions, however, some underreporting is suspected. Males appear to have a slightly higher prevalence. The typical age at presentation is around 60 years old. Almost all patients have several co-morbidities.
A 2017 study presents the case of a 48-year-old man with a history of diabetes, hypertension, hypercholesterolemia, and intellectual impairment. He was discharged from a nursing home with abdominal distention 12 days after undergoing right total knee arthroplasty.
He described gradual distention without pain that had occurred following the procedure. During this time, he reported experiencing everyday bowel movements. The patient denied experiencing any nausea, vomiting, fever, or chills.
In the emergency room, a CT scan of the abdomen revealed a significantly swollen colon with fluid and gas extending to the rectum. The patients' distention significantly improved, albeit for a limited duration. Eventually, the distention returned in full force, leading to the diagnosis of Ogilvie syndrome.
Six days later, he was given a 2 mg neostigmine trial. He had two bowel motions after the neostigmine infusion, but the colonic distention continued to persist. The next day, the second dose of neostigmine was given, but with similar results, and following the failure of conservative therapy, a subtotal colectomy with colostomy was performed.
The cecum was 8 cm in diameter and the rectum was 15 cm in diameter when they were measured intraoperatively the next day. The total length of the removed colon was 160 cm.
His stay in the hospital following surgery was uncomplicated. Diet was successfully progressed on postoperative day 3, and bowel function was restored on postoperative day 4. On future office visits, he had no further difficulties.
Diagnosis and treatment
Before a diagnosis of ACPO can be made, a complete examination, including contrast imaging, is required. The preferred diagnostic modality is a CT scan with oral and intravenous (IV) contrast. Laboratory tests and appropriate imaging are essential to the thorough diagnosis and management.
Ogilvie's condition can be treated by addressing the underlying cause and/or decompressing the gastrointestinal system with a nasogastric (NG) tube and/or a rectal tube. Furthermore, neostigmine has gained popularity as a result of a tiny randomized trial that demonstrated its efficacy.
Perforation of the distended, pseudo-obstructed colon is associated with a roughly 50% mortality rate. While conservative medical therapy is effective in the majority of instances, >3% of patients have substantial distention or perforation of the colon, necessitating surgical resection.
Although not proven in randomized clinical trials, decompressive colonoscopy is frequently employed since it can provide rapid intestinal decompression.
Ogilvie Syndrome and COVID-19
Up to 26% of COVID-19 patients have gastrointestinal (GI) problems. Diarrhea, nausea, vomiting, and abdominal discomfort are the most prevalent GI symptoms. Anorexia, anosmia, and dysgeusia are some of the other symptoms.
Notably, GI symptoms in COVID-19 individuals emerge early and may increase with time. GI symptoms may potentially be the only manifestation in some cases.
Critically ill patients may develop extrapulmonary complications. This can include transaminitis, severe ileus, GI hemorrhage, pancreatitis, intestinal ischemia, and Ogilvie syndrome. There have been very few reports of Ogilvie syndrome in COVID-19 patients.
Rapid identification of Ogilvie syndrome as a potential consequence of COVID-19 infection, quick treatment with conservative treatments, and prevention of possible fecal-oral virus transmission are critical stages.
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- Wang J, Marusca G, Tariq T, et al. (2021). Ogilvie Syndrome and COVID-19 Infection. Journal of Medical Cases, 12(8), 328–331. doi:10.14740/jmc3728. https://www.journalmc.org/index.php/JMC/article/view/3728
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Last Updated: Sep 5, 2023