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Essential Features

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  • • Massive colonic distention in the absence of mechanical obstruction

    • Severe form of ileus

    • May result from autonomic imbalance

    • Aerophagia and impairment of colonic motility by drugs are contributing factors

    • Diagnosis of exclusion

    • –Must rule out mechanical obstruction

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Epidemiology

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  • • Most common in bedridden, elderly patients; following orthopedic injuries; in patients taking psychotropic medications or narcotics

    • Associated with metabolic disorders:

    • –Hypothyroidism

      –Diabetes

      –Renal failure

    • Associated with collagen vascular diseases:

    • –Lupus

      –Amyloidosis

      –Scleroderma

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Clinical Findings

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Symptoms and Signs

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  • • Abdominal distention without pain or tenderness initially

    • Later symptoms may mimic obstruction: abdominal pain, tenderness

    • Tympanitic abdomen

    • Peritoneal signs indicate bowel compromise and/or perforation

    • Bowel sounds often diminished or absent

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Laboratory Findings

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  • • May reveal electrolyte abnormalities (especially magnesium and potassium)

    • WBC count usually normal, but an elevation may indicate bowel compromise

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Imaging Findings

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  • Abdominal x-ray: Marked gaseous distention of colon, especially right colon

    Contrast enema: Absence of mechanical obstruction

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Diagnostic Considerations

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  • • Mechanical obstruction

    • –Carcinoma

      –Hernia

      –Stricture

      –Adhesions

      –Diverticulitis

      –Volvulus

      –Intussusception

    • Hirschsprung disease

    • Toxic megacolon

    • Fecal impaction

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Rule Out

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  • • Mechanical obstruction

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Work-up

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  • • Rule out mechanical obstruction

    • Review medication history

    • Obtain abdominal x-ray

    • Contrast enema to determine presence of mechanical obstruction

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When to Admit

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  • • Must rule out other etiologies for bowel obstruction and perform serial exams

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Treatment and Management

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  • • NG decompression and aggressive enema regimen: Resolution in 86% of patients

    • Bowel rest

    • Rectal tube placement

    • Correct metabolic abnormalities

    • Discontinue medications that decrease motility

    • Colonoscopic decompression if cecum dilated > 9–10 cm

    • If performing colonoscopy, use minimal to no air insufflation

    • May place long decompression tube at colonoscopy (Miller or Cantor tube)

    • Ensure adequate volume status

    • Remove or drain septic collections/abscesses

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Surgery

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Indications
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  • • Failure to reduce dilation following conservative measures and endoscopic intervention

    • Laparotomy should be performed in patients with peritonitis, nonviable bowel

    • Perforated cecum may require ileocecectomy, end ileostomy, and mucus fistula

    • Nonperforated cecum may be managed with tube cecostomy

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Contraindications
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  • • Ogilvie syndrome occurs most frequently in patients with severe medical comorbidities; early recognition is essential to decrease the need for surgical therapy for complications (perforation/peritonitis)

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Medications

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  • • Neostigmine (anticholinesterase) may be efficacious in decompressing colon (must be used in monitored setting)

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Treatment Monitoring

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  • • Serial abdominal exam

    • Serial abdominal x-rays following colonoscopic decompression

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Complications

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