How should acute colonic pseudo‑obstruction (Ogilvie’s syndrome) be managed?

Management of Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome)

Conservative management should be the initial approach for Ogilvie's syndrome, as it yields similar or superior outcomes compared to interventional management, with significantly fewer complications. 1

Initial Assessment and Diagnosis

Establish the diagnosis through clinical history, physical examination, and plain abdominal radiography showing colonic dilatation (typically ≥9 cm cecal diameter) in the absence of mechanical obstruction. 2, 3, 1

Key diagnostic features include:

• Acute, progressive colonic distension in hospitalized patients with serious underlying medical or surgical conditions 2, 4
• Abdominal distension with tympany on percussion 5
• Variable bowel sounds (may be hyperactive early, then diminished or absent) 5, 6
• Plain abdominal X-ray demonstrating massive colonic dilatation without mechanical obstruction 3

Critical warning signs requiring urgent intervention:

• Cecal diameter >12 cm (high perforation risk) 3
• Peritoneal signs (guarding, rebound tenderness) suggesting perforation 5
• Fever, tachycardia, or leukocytosis indicating ischemia or perforation 5

Treatment Algorithm

Step 1: Conservative Management (First-Line for All Patients)

Begin with aggressive conservative measures, which successfully resolve most cases without intervention. 1

Conservative therapy includes:

• NPO status with nasogastric tube decompression 3, 6, 1
• Rectal tube placement for distal decompression 1
• Intravenous fluid resuscitation and correction of electrolyte abnormalities (particularly hypokalemia, hypomagnesemia, hypocalcemia) 6
• Discontinue all medications that inhibit intestinal motility (opioids, anticholinergics, calcium channel blockers) 6
• Treat underlying contributing conditions (sepsis, metabolic derangements) 6
• Mobilize the patient and encourage position changes (left lateral decubitus, knee-chest position) 3

Continue conservative management for 24-48 hours if cecal diameter remains <12 cm and no signs of ischemia or perforation develop. 2, 3

Step 2: Pharmacologic Decompression with Neostigmine

If conservative measures fail after 24-48 hours and cecal diameter is 9-12 cm without contraindications, administer neostigmine 2 mg IV over 3-5 minutes with continuous cardiac monitoring. 2, 6

Neostigmine administration details:

• Contraindications: bradycardia, hypotension, bronchospasm, mechanical obstruction, recent myocardial infarction, acidosis, renal failure 2
• Have atropine 0.6-1.2 mg at bedside for treatment of bradycardia or other cholinergic side effects 2
• Response typically occurs within 10-30 minutes if effective 2
• May repeat dose once if no response after 3 hours 2

Common pitfall: Neostigmine should not be used as first-line therapy before adequate conservative management, as this increases complication rates. 1

Step 3: Endoscopic Decompression

If neostigmine fails or is contraindicated, and cecal diameter is >12 cm or progressive dilatation continues, proceed to colonoscopic decompression. 2, 3, 6

Colonoscopic decompression considerations:

• Perform with minimal air insufflation (use CO2 if available) to avoid worsening distension 2
• Advance to the hepatic flexure or cecum if possible 2
• Place a decompression tube through the colonoscope to maintain decompression 2, 3
• Success rate is 60-95%, but recurrence occurs in 20-50% of cases 3

Step 4: Surgical Intervention

Surgery is reserved for patients with perforation, ischemia/necrosis, or failure of all other measures. 2, 3, 4

Surgical options include:

• Tube cecostomy for decompression in patients without perforation or ischemia 2, 3
• Segmental resection if localized ischemia or necrosis is present 2
• Subtotal colectomy with end ileostomy for perforation or diffuse ischemia 2, 3

Surgical mortality approaches 30% when perforation has occurred, compared to <5% with elective decompression. 3

Critical Prognostic Factors

Age, severity of underlying diseases, elapsed time before treatment, cecal diameter >12 cm, and presence of necrosis or perforation are the main determinants of outcome. 3

• Overall in-hospital mortality is approximately 30% when all cases are included 3
• Mortality is primarily related to underlying comorbidities rather than the pseudo-obstruction itself 1
• Recurrence rate after successful medical treatment is 20-50% 3

Evidence-Based Approach: Conservative vs. Interventional Management

A retrospective study of 37 patients demonstrated that conservative management resulted in significantly fewer Ogilvie's-syndrome-related complications (21%) compared to interventional management (61%, P<0.01), with no difference in length of stay or mortality. 1 This finding challenges the traditional aggressive approach and supports initial conservative management for most patients, reserving interventions for those who fail conservative therapy or develop complications.

The key to successful management is early recognition, prompt initiation of conservative measures, and close monitoring for signs of perforation or ischemia that mandate urgent intervention. 2, 4