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At a glance

Acute colonic pseudoobstruction (ACPO) characterized by clinical signs, symptoms, and radiographic appearance of an acute large-bowel obstruction with no evidence of distal colonic obstruction. The colon may become massively dilated. If not decompressed, the patient risks perforation, peritonitis, and death.

Synonyms

Acute Colonic Pseudoobstruction Syndrome; Nontoxic Megacolon; Adult Hirschsprung Disease.

History

First described in 1948 by Sir Heneage Ogilvie, a British physician, in two patients with signs and symptoms of colonic obstruction but no evidence of organic obstruction to intestinal flow. In 1958, Dudley et al used the term pseudoobstruction to describe the clinical appearance of a mechanical obstruction with no evidence of organic disease during laparotomy.

Incidence

Uncommon. No reliable data exist in the United States and internationally. Possible male predominance ratio of 1.5:1.

Genetic inheritance

None.

Pathophysiology

Acute large-bowel obstruction in the absence of an obvious mechanical cause. Colonic dysmotility probably results, in part, from an imbalance in the autonomic innervation of the colon. This syndrome most commonly follows pelvic surgery, trauma, normal pregnancy, or cesarean section, but it has also been described in association with many conditions, including myocardial or mesenteric ischemia, most types of surgery, intraabdominal sepsis, pneumonia, metabolic disturbances, drugs (eg, antidepressants), and multiple sclerosis. Marked dilatation of the colon may cause localized ischemia of the serosa, resulting in splitting of the serosa, herniation of the mucosa, and ultimately bowel perforation in 1 to 3% of patients carrying a mortality of greater than 50%.

Diagnosis

Acute colonic obstruction in the absence of a mechanical cause confirmed clinically and radiologically.

Clinical aspects

Ogilvie Syndrome almost invariably occurs in adults (males affected more than females) who are often ill as a result of any of the conditions mentioned in Pathophysiology. Patients are frequently hospitalized and complain of colicky abdominal pain and distension. Constipation, nausea, and vomiting are common, and fever may be present in patients with ischemic or perforated bowel. Examination reveals a markedly distended abdomen that may not be as tender as anticipated until ischemia occurs. Plain abdominal radiographs are suggestive of a distal colonic obstruction with proximal large-bowel dilatation. Free air is noted in the presence of perforation. The pseudoobstruction is usually self-limited (3-6 days) and is managed conservatively with nasogastric drainage, correction of fluid and electrolyte disturbances, and removal of pharmacologic agents that might be implicated (eg, opioids or anticholinergic drugs). Sympathetic blockade caused by an epidural anesthesia may be useful in the management of this acute problem. Colonoscopic decompression is a well-accepted form of therapy, and CT-guided needle decompression has been described. Surgical intervention is reserved for cases in which conservative therapy has failed or in the presence of impending or suspected bowel ...

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