Ogilvie’s Syndrome Flashcards
definition
Gradual or sudden onset associated with an acute dilation of the colon with no evidence of mechanical obstruction.
Pathogenesis
impairment of the autonomic nervous system leading to an atonic distal colon and functional obstruction.
At what day Risk of Ischemia +- perforation increase
particularly if the duration of distention exceeds 6 days.
Rf
hospitalized or institutionalized patients
severe comorbid illness
infection
cardiac disease
inoperative trauma
orthopedic procedures including hip and spine surgery
after pelvic surgery.
CT of the abdomen and pelvis
- proximal colon dilation with an intermediate transition zone near the splenic flexure
- Occasional dilation may extend to the rectum.
- This will exclude a mechanical obstruction.
Something You Shouldnt Do, increase risk for Perf
Contrast enemas can be hazardous and may increase the risk of perforation.
Initial Tx
- NPO
- decompression with nasogastric and rectal tube suction,
avoiding medications such as
opioids, anticholinergics, antipsychotics, cytotoxic drugs, calcium channel blockers, and clonidine - Fluid and electrolyte corrected.
- Serial labs , lactate, rule out C.Diff
- Mobilizing the patient
- Position (prone position with hips elevated)
- considered for 24 to 48 hours as long as the patient is undergoing frequent physical examinations and abdominal films at 12-hour intervals.
Algorithmic approach to stepwise therapy in acute colonic pseudo-obstruction.
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What is Conservative Tx not effective
- Neostigmine, an anticholinesterase parasympathomimetic agent
- Indicated in patients with a cecal diameter of 12 cm who have failed conservative management.
- (2 mg) is given intravenously over a 5-minute period
- monitoring of vital signs and electrocardiography.
- Patients should be supine
- response will generally occur within 30 minutes.
- Glycopyrrolate should be available to treat bradycardia.
- A second dose can be given no sooner than 8 hours but up to 24 hours later
Neostigmine Therapy
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Risk factors for neostigmine failure
male gender
younger age
electrolyte imbalance
postsurgical status.
What may increase the effectiveness of neostigmine
- regular administration of polyethylene glycol via nasogastric tube
Role of infusion
Continuous infusion of neostigmine was associated with greater bowel diameter reduction in 24 hours, and adverse events may also be diminished by continuous infusion.
SE of the Drug
Bradyarrhythmias
bronchoconstriction
hypotension
agitation
abdominal cramps
nausea and vomiting
salivation
diaphoresis.
How to Tx SE
Glycopyrrolate 0.4 mg
Absolute Contraindications
Mechanical intestinal obstruction
urinary tract obstruction
peritonitis
Other Drugs/Alternatives
- Oral pyridostigmine, a long-acting acetylcholinesterase inhibitor, has been successful in treating some patients refractory to neostigmine
Endoscopic Decompression
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what to do after Endoscopic Decompression
- Repeat colonoscopy is often required due to a recurrence rate of 40%.
-The use of polyethylene glycol after endoscopic decompression is recommended.
IF conservative, Pharmacologic and endoscopic fail
percutaneous cecostomy (PECcecum) may be considered for colon decompression
placed endoscopically or through interventional radiology techniques
percutaneous cecostomy Complications
wound infection, bleeding, perforation, granuloma, and buried bumper necrosis.
Last , Surgery
Surgery may include the placement of a cecostomy tube or
subtotal colectomy and stoma formation.
High mortality rates are associated with those patients with ischemic disease or perforation.
