Ogilvie Syndrome

Diffuse abdominal pain with nausea, vomiting, and constipation developed in a 69-year-old man with poorly differentiated mesothelioma several days after he was hospitalized for left-sided intractable pleuritic chest pain that warranted opiates.

Vital signs were normal. The abdomen was distended, mildly tender, and hypertympanic with positive bowel sounds. There were no signs of ascites or organomegaly. Abdominal radiographs revealed marked distention of colonic loops (A and B). Electrolyte levels were normal. Stool culture results were negative. White blood cell count was normal. Results of a recent abdominal CT scan excluded intestinal obstruction. Acute colonic pseudo-obstruction (Ogilvie syndrome) was diagnosed.

Ogilvie syndrome is characterized by gross dilatation of the cecum and right hemicolon that may extend to the rectum in the absence of intestinal obstruction.¹ The exact mechanism is unknown; however, an impairment of the autonomic nervous system has been suspected. Associated conditions include malignancy, trauma, infection, cardiac disease, major surgeries, severe illness, electrolyte imbalance (especially hypokalemia, hypocalcemia, or hypomagnesemia), and use of certain medications (eg, narcotics, phenothiazines, calcium channel blockers, α₂-adrenergic agonists, epidural analgesics).^1-3

Clinical manifestations include nausea, vomiting, abdominal pain, and constipation. Abdominal distention is usually present and can cause labored breathing.^1-3 There are no pathognomonic physical or laboratory findings. Plain abdominal radiographs show the colonic dilatation. CT findings support the diagnosis and exclude intestinal obstruction and toxic megacolon.

Treatment includes supportive care, removal of an underlying cause, gentle enema, and decompression procedures. ⁴ Rapid colonic decompression may be achieved with neostigmine,⁵ erythromycin,⁶ or cisapride.⁷ Cautious administration of neostigmine is advised because of associated major adverse effects.⁵

Surgery is reserved for patients in whom medical and endoscopic management fails and for those who have signs of peritonitis or perforation.⁸

This patient did well with nasogastric and rectal tube suction and gentle enemas.