From the Research
Management of Ogilvie's syndrome should start with conservative measures, as they have been shown to yield similar, if not superior, results to interventional management, with a lower risk of complications 1.
Initial Management
Initial management includes:
- Bowel rest
- Nasogastric tube decompression
- Correction of electrolyte abnormalities
- Discontinuation of medications that decrease bowel motility, such as opioids and anticholinergics
- Intravenous fluid resuscitation to correct any dehydration
Pharmacologic Therapy
If conservative management fails after 24-48 hours, pharmacologic therapy with neostigmine is recommended, as it has been shown to be effective in improving colonic motility 2. Neostigmine, a reversible acetylcholinesterase inhibitor, is administered at a dose of 2-2.5 mg intravenously over 3-5 minutes with cardiac monitoring due to potential bradycardia.
Endoscopic Decompression
If neostigmine is unsuccessful or contraindicated, endoscopic decompression should be considered, as it is effective in about 80% of cases, although it carries a recurrence risk of 10-40% 3.
Surgical Intervention
For patients with cecal diameter >12 cm, signs of peritonitis, or perforation, surgical intervention is necessary, which may include cecostomy, colostomy, or colectomy depending on the clinical situation, as it can be a life-threatening complication if left untreated 3.
The underlying pathophysiology involves autonomic imbalance with excessive sympathetic activity or parasympathetic suppression, leading to functional large bowel obstruction without mechanical blockage. Some medications, such as clozapine, can induce Ogilvie's syndrome by decreasing intestinal motility, and discontinuation of these medications should be considered as part of the management plan 4. A novel technique using Ryle's tube for colonic decompression has also been reported to be effective in some cases 5.