Ogilvie's syndrome: management and outcomes

Abstract

Ogilvie's syndrome, also known as acute colonic pseudo-obstruction, refers to pathologic dilation of the colon without underlying mechanical obstruction, occurring primarily in patients with serious comorbidities. Diagnosis of Ogilvie's syndrome is based on clinical and radiologic grounds, and can be treated conservatively or with interventions such as acetylcholinesterase inhibitors (such as neostigmine), decompressive procedures including colonoscopy, and even surgery. Based on our clinical experience we hypothesized that conservative management yields similar, if not superior, results to interventional management. Therefore, we retrospectively examined all patients over the age of 18 with Ogilvie's syndrome who presented to the Medical University of South Carolina (MUSC). The diagnosis of Ogilvie's syndrome was confirmed by clinical criteria, including imaging evidence of colonic dilation ≥9 cm. Patients were divided and analyzed in 2 groups based on management: conservative (observation, rectal tube, nasogastric tube, fluid resuscitation, and correction of electrolytes) and interventional (neostigmine, colonoscopy, and surgery). Use of narcotics in relation to maximal bowel size was also analyzed. Over the 11-year study period (2005-2015), 37 patients with Ogilvie's syndrome were identified. The average age was 67 years and the average maximal bowel diameter was 12.5 cm. Overall, 19 patients (51%) were managed conservatively and 18 (49%) underwent interventional management. There was no significant difference in bowel dilation (12.0 cm vs 13.0 cm; P = .21), comorbidities (based on the Charlson Comorbidity Index (CCI), 3.2 vs 3.4; P = .74), or narcotic use (P = .79) between the conservative and interventional management groups, respectively. Of the 18 patients undergoing interventional management, 11 (61%) had Ogilvie's-syndrome-related complications compared to 4 (21%) of the 19 patients in the conservative management group (P < .01). There was no difference in overall length of stay in the 2 groups. Two patients, one in each group, died from complications unrelated to their Ogilvie's syndrome. We conclude that Ogilvie's syndrome, although uncommon, and typically associated with severe underlying disease, is currently associated with a low inpatient mortality. While interventional management is often alluded to in the literature, we found no evidence that aggressive measures lead to improved outcomes.

Figure 1

Potential patients from 2005 to 2015 at the Medical University of South Carolina were screened using the ICD-9 code: 560.82. Forty-eight patients with Ogilvie's syndrome were identified. Ten patients were excluded because they had a maximal bowel diameter <9 cm and 1 patient was excluded due to incidental discovery of colonic obstruction during unrelated laparotomy.

Figure 2

Maximal bowel diameter (cm) and serum electrolytes. Correlation analyses were used to investigate the relationship between maximal bowel diameter (cm) and serum electrolytes at onset (defined as the date of radiologic diagnosis of Ogilvie's syndrome). The correlation between the 2 variables was determined using Spearman correlation coefficient for non-normal data. A correlation was found only between serum calcium levels and bowel size (r² = 0.2347).

Figure 3

Relationship between narcotics and colon bowel diameter. Spearman correlation coefficient was determined for the 20 patients who received narcotics before and during the onset of Ogilvie's syndrome to assess a relationship between 48-hour dose of narcotics and maximal bowel size (cm). All narcotics doses were standardized to equianalgesic doses of oxycodone (mg), as described in Methods.

Figure 4

Outcome of patients with Ogilvie's syndrome. Resolution of bowel dilation was defined as decrease in bowel diameter to <9 cm radiologically or clinical resolution of abdominal distension. (A) A comparison of the 19 patients treated conservatively and those who were treated with interventional methods (neostigmine, colonoscopy, surgery). (B) The response to the different interventional methods including neostigmine, colonoscopy, and surgery.