From the Guidelines
Colonic pseudo-obstruction after cesarean section should be managed with a stepwise approach, prioritizing bowel rest, nasogastric tube decompression, correction of electrolyte abnormalities, and early ambulation, as recommended by recent guidelines 1. This approach is crucial in preventing serious complications like bowel perforation. The condition, also known as Ogilvie's syndrome, occurs due to autonomic imbalance with excessive sympathetic activity and parasympathetic suppression following abdominal surgery, exacerbated by hormonal changes of pregnancy, electrolyte disturbances, and medications. Initial management includes:
- Bowel rest
- Nasogastric tube decompression
- Correction of electrolyte abnormalities (particularly potassium, magnesium, and calcium)
- Discontinuation of medications that slow gut motility (such as opioids)
- Early ambulation If no improvement occurs within 24-48 hours, neostigmine should be administered at 2 mg IV over 3-5 minutes with cardiac monitoring, which can be repeated once if needed after 3 hours, as supported by recent reviews on bowel obstruction management 1. For patients who fail medical management or have cecal diameter >12 cm with risk of perforation, colonoscopic decompression should be considered. Surgery is reserved for cases with perforation, peritonitis, or failure of all other interventions. Most cases resolve with conservative management within 3-5 days, but prompt recognition and treatment are essential to prevent serious complications. The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a pathway for postoperative care, including elements that can help prevent colonic pseudo-obstruction, such as early mobilization and nutritional care 1. By following this stepwise approach and prioritizing patient care, morbidity, mortality, and quality of life can be improved.
From the Research
Colonic Pseudo-Obstruction after Cesarean
- Colonic pseudo-obstruction is a rare but potentially life-threatening condition that can occur after cesarean section, characterized by massive dilation of the colon without mechanical obstruction 2.
- The risk of progression to ischemia and perforation, as well as the need for emergency surgery, appears to be higher after cesarean section compared to other causes of colonic pseudo-obstruction 2.
- A hands-on combined approach from a group of specialists, including obstetricians, surgeons, radiologists, and enterostomal therapists, is recommended for managing colonic pseudo-obstruction after cesarean section 2.
Treatment Options
- Neostigmine has been shown to be an effective treatment for acute colonic pseudo-obstruction, with rapid decompression of the colon achieved in most patients 3, 4.
- Colonoscopic decompression is also a viable treatment option, particularly for patients who do not respond to neostigmine or have contraindications to its use 5, 6.
- A colonoscopy-first approach may be associated with fewer subsequent interventions compared to a neostigmine-first approach, but both strategies have similar outcomes 6.
Management Strategies
- Immediate imaging followed by regular observation is mandatory for any patient being managed conservatively for colonic pseudo-obstruction after cesarean section 2.
- Early use of endoscopic decompression should be considered for patients who are not resolving with a conservative approach 2.
- Clinical signs of peritonism or radiological signs of ischemia or perforation in patients with colonic pseudo-obstruction mandate immediate surgical intervention 2.