What is the recommended management of Ogilvie’s syndrome (pseudo‑colonic obstruction) in an 80‑year‑old woman?

Management of Ogilvie's Syndrome in an 80-Year-Old Woman

Begin immediate conservative management with IV crystalloid resuscitation, nasogastric tube decompression, bowel rest, and aggressive correction of electrolyte abnormalities—particularly potassium—while discontinuing all opioids and anticholinergic medications; this approach resolves the majority of cases and should continue for 24-72 hours before escalating to pharmacologic or endoscopic intervention. 1

Initial Conservative Management (First 24-72 Hours)

The cornerstone of Ogilvie's syndrome management is aggressive supportive care, which differs critically from mechanical obstruction because surgery worsens outcomes in this functional disorder.

Immediate Interventions

• Insert a nasogastric tube for gastric decompression to prevent aspiration pneumonia and reduce proximal distension. 1, 2

• Start IV crystalloid fluid resuscitation immediately to correct the near-universal dehydration and electrolyte abnormalities present in these patients. 1, 2

• Place a Foley catheter to monitor urine output and assess hydration status accurately. 1, 2

• Correct electrolyte abnormalities aggressively, with particular attention to hypokalemia, which directly worsens colonic dysmotility and is frequently present. 1, 2

• Discontinue all motility-impairing medications immediately, especially opioids and anticholinergics, which are major contributors to pseudo-obstruction. 1, 2

• Insert a rectal tube to achieve colonic decompression when the colon is dilated, serving as a key component of enteral decompression strategies. 1

• Maintain strict bowel rest (NPO status) throughout the conservative trial. 2

Critical Monitoring Parameters

Given the 80-year-old patient's age and likely comorbidities, vigilant monitoring is essential:

• Monitor vital signs every 4 hours, specifically watching for fever, tachycardia, or hypotension that might indicate perforation or ischemia. 1, 2

• Perform serial abdominal examinations to detect development of peritoneal signs, rebound tenderness, or worsening distension. 1, 2

• Obtain laboratory monitoring every 24-48 hours, including complete blood count, electrolytes, renal function, and inflammatory markers. 1, 2

• Measure cecal diameter on imaging; cecal dilatation >10-12 cm carries significant risk of perforation and warrants more aggressive intervention. 3, 4

Pharmacologic Intervention (If Conservative Measures Fail After 24-48 Hours)

• Administer neostigmine for established colonic ileus that does not respond to simple measures, particularly when associated with significant colonic dilatation. 1, 5

• Neostigmine is highly effective, with success rates of 88.6% at first attempt and 92.5% at second attempt in decompressing the colon. 3

• Contraindications to neostigmine include bradycardia, recent myocardial infarction, active bronchospasm, and mechanical obstruction (which must be excluded first). 6

Endoscopic Decompression (If Pharmacologic Treatment Fails or Is Contraindicated)

• Colonoscopic decompression with placement of a decompression tube is effective and safe for acute colonic pseudo-obstruction not responding to 24-hour conservative treatment. 3

• Endoscopic treatment achieves clinical success in 88.6% of cases at first attempt, with a complication rate of only 3.8%. 3

• Place a decompression tube during colonoscopy to maintain decompression and prevent recurrence. 3

Absolute Indications for Surgical Intervention

Surgery should be reserved only for specific complications, as surgical intervention in pseudo-obstruction carries high morbidity and mortality due to underlying dysmotility:

• Signs of peritonitis on examination (rebound tenderness, guarding, rigidity) are absolute indications for surgery. 1, 2

• Free perforation with pneumoperitoneum on imaging mandates immediate surgical intervention. 1

• Bowel ischemia or necrosis, evidenced by abnormal bowel wall enhancement, mesenteric edema, or pneumatosis on CT, requires urgent surgery. 1

• Cecal perforation, which carries a mortality rate as high as 40-50% if it occurs, necessitates emergency surgery. 6, 4

Special Considerations for the 80-Year-Old Patient

Older patients with Ogilvie's syndrome require additional vigilance and modifications to standard management:

• Higher comorbidity burden necessitates optimization of cardiac, pulmonary, and renal function before any interventional procedures. 1, 2

• Polypharmacy is nearly universal in this age group; involve a pharmacist to identify drug-drug interactions and motility-impairing agents beyond the obvious opioids and anticholinergics. 1, 2

• Functional status and frailty should guide the intensity of interventions, particularly when considering endoscopic or surgical options. 1, 2

• Multidisciplinary approach engaging gastroenterology, geriatrics, pharmacy, and potentially colorectal surgery is necessary to optimize outcomes. 1, 2

• Procedural risks must be carefully weighed against benefits, as tolerance for anesthesia and invasive procedures may be reduced. 1, 2

Critical Pitfalls to Avoid

• Do not proceed to surgery without attempting conservative management first, as pseudo-obstruction is a functional disorder and surgery worsens outcomes in patients with underlying dysmotility. 1, 2

• Do not delay intervention beyond 72 hours if conservative measures fail, as prolonged colonic distension increases perforation risk exponentially. 3, 6

• Do not miss mechanical obstruction; obtain CT imaging to definitively exclude a mechanical cause before diagnosing Ogilvie's syndrome. 7, 6

• Do not continue opioids or anticholinergics even at low doses, as these directly perpetuate the pseudo-obstruction. 1, 2

• Do not ignore cecal diameter >10-12 cm, as this threshold significantly increases perforation risk and warrants escalation to neostigmine or endoscopic decompression. 3, 4

Algorithmic Approach

1. Confirm diagnosis with CT scan showing colonic dilatation without mechanical obstruction. 7, 6
2. Initiate conservative management (IV fluids, NGT, rectal tube, electrolyte correction, stop offending drugs) for 24-48 hours. 1, 2
3. If no improvement or cecal diameter >10-12 cm: administer neostigmine (if no contraindications). 1, 3, 5
4. If neostigmine fails or is contraindicated: proceed to colonoscopic decompression with tube placement. 3, 6
5. If peritonitis, perforation, or ischemia develops at any point: proceed immediately to surgery. 1, 2