From the Guidelines
Ogilvie's syndrome after cesarean delivery should be managed promptly with conservative measures, including bowel rest, nasogastric tube decompression, and correction of electrolyte abnormalities, as recommended by recent guidelines for postoperative care in cesarean delivery 1. The management of Ogilvie's syndrome, or acute colonic pseudo-obstruction, after cesarean delivery involves a step-wise approach to prevent complications such as perforation, which carries high mortality.
- Key components of initial management include:
- Bowel rest to reduce the workload on the colon
- Nasogastric tube decompression to alleviate abdominal distention
- Correction of electrolyte abnormalities, particularly potassium, to support muscle function
- Discontinuation of medications that slow gut motility, which can exacerbate the condition
- Pharmacological treatment with neostigmine, a cholinesterase inhibitor, is considered first-line for patients who do not respond to conservative measures, administered intravenously at a dose of 2-2.5 mg over 3-5 minutes with cardiac monitoring due to the risk of bradycardia.
- For cases resistant to neostigmine, colonoscopic decompression may be necessary to relieve obstruction and prevent perforation.
- Surgery is typically reserved for cases with perforation or when other treatments fail, highlighting the importance of early recognition and intervention. The pathophysiology of Ogilvie's syndrome involves an imbalance between parasympathetic and sympathetic innervation of the colon, often triggered by the physiological and hormonal changes of pregnancy, abdominal surgery, and medications used during cesarean delivery, as discussed in guidelines for enhanced recovery after surgery in cesarean delivery 1.
- Patients typically present with abdominal distention, reduced or absent bowel sounds, and minimal passage of flatus or stool within days after cesarean delivery, necessitating a high index of suspicion for early diagnosis and treatment.
- Monitoring for signs of perforation, such as increasing abdominal pain, fever, or a cecal diameter exceeding 12 cm on imaging, is crucial for preventing mortality associated with this condition.
From the Research
Definition and Diagnosis of Ogilvie's Syndrome
- Ogilvie's syndrome, also known as acute colonic pseudo-obstruction, is a clinical picture of acute obstruction of the large bowel without an associated pathological lesion 2.
- Diagnosis is made by x-raying the patient's abdomen without any pre-x-ray preparation, and can be confirmed by an enema of gastroffin to show no organic cause for the obstruction 2.
- Clinical criteria, including imaging evidence of colonic dilation ≥9 cm, can also be used to confirm the diagnosis 3.
Ogilvie's Syndrome after Cesarean Section
- Caesarean section seems to be the most common operative procedure associated with Ogilvie's syndrome, with 41 cases described in the literature as of 1993 2.
- Ogilvie's syndrome after cesarean section is a rare but serious postsurgical complication, with a high mortality rate if left untreated or if complications arise 4, 5.
- Early diagnosis and intervention are necessary to avoid serious morbidity and/or mortality 5.
Treatment and Management
- Conservative treatment is usually effective and surgery should be reserved for complicated cases or refractory to conservative treatment 2, 4.
- Conservative management may yield similar, if not superior, results to interventional management, with no significant difference in bowel dilation, comorbidities, or narcotic use between the two groups 3.
- Interventional management, including neostigmine, colonoscopy, and surgery, may be necessary in some cases, but is often associated with a higher rate of complications 3.
- Decompressive procedures, including colonoscopy, can be used to rapidly decompress the colon, and may be performed with or without epidural anaesthesia 2.