What is the treatment for Ogilvie's syndrome (acute colonic pseudo-obstruction)?

Treatment of Ogilvie's Syndrome (Acute Colonic Pseudo-obstruction)

Conservative management should be the first-line approach for Ogilvie's syndrome, as it yields similar or superior outcomes compared to interventional management with fewer complications.

Diagnostic Confirmation

• Diagnosis based on clinical presentation and radiological findings showing colonic dilation ≥9 cm without mechanical obstruction
• CT abdomen and pelvis with IV contrast is the investigation of choice (93-96% sensitivity, 93-100% specificity) 1
• Typical presentation includes abdominal distention, nausea, vomiting, and either absent or high-pitched bowel sounds

Treatment Algorithm

Step 1: Initial Conservative Management (24-48 hours)

• Nothing by mouth (NPO)
• Nasogastric tube decompression
• Intravenous fluid resuscitation with 0.9% saline
• Correction of electrolyte abnormalities (particularly sodium, potassium, magnesium)
• Discontinue medications that decrease gut motility (opioids, anticholinergics)
• Rectal tube placement for decompression
• Early mobilization when possible

Step 2: If No Improvement After 48-72 Hours

• Pharmacologic intervention with neostigmine:
  • Dose: 2-2.5 mg IV over 3-5 minutes 2, 3
  • Monitor in ICU setting with continuous cardiac monitoring
  • Contraindications: bradycardia, recent myocardial infarction, asthma, mechanical obstruction
  • Have atropine (0.5-1 mg) readily available to reverse cholinergic crisis

Step 3: If Neostigmine Fails or Contraindicated

• Colonoscopic decompression
• Consider placement of decompression tube during colonoscopy

Step 4: Surgical Intervention (Reserved for Complications)

• Indications: perforation, peritonitis, ischemia, or failure of all conservative measures
• Options include cecostomy, colostomy, or partial colectomy depending on findings

Monitoring and Follow-up

• Serial abdominal examinations
• Daily abdominal radiographs to assess colonic diameter
• Monitor for signs of perforation or ischemia:
  • Worsening abdominal pain
  • Fever
  • Leukocytosis
  • Peritoneal signs
  • Lactic acidosis

Evidence for Conservative Management

Research shows that conservative management (observation, rectal tube, nasogastric tube, fluid resuscitation, and correction of electrolytes) results in significantly fewer complications (21%) compared to interventional management (61%) with no difference in length of stay 4. This supports prioritizing conservative approaches before escalating to interventional therapies.

Special Considerations

• Cecal diameter >12 cm increases risk of perforation and may warrant more aggressive management
• Underlying causes should be identified and treated (immobility, medications, electrolyte disorders, recent surgery)
• Patients with comorbidities (especially elderly and immobile patients) are at higher risk for developing Ogilvie's syndrome 5

Pitfalls to Avoid

• Delaying diagnosis and treatment when cecal diameter exceeds 12 cm
• Administering neostigmine without cardiac monitoring
• Overlooking potential underlying causes
• Prolonged conservative management in patients with signs of ischemia or perforation
• Administering opioids or anticholinergics, which can worsen the condition

The evidence strongly supports starting with conservative management for 48-72 hours before considering pharmacological intervention with neostigmine, which has been shown to provide rapid correction in the emergency department setting 2. Surgical intervention should be reserved only for cases with complications or failure of all other measures.