Ogilvie's Syndrome

This is a syndrome of acute intestinal pseudo-obstruction associated with massive dilation, usually of the colon, but also of the small intestine. Mechanical obstruction is absent and there is parasympathetic nerve dysfunction. It was first described by Sir William Ogilvie in 1948,¹ an English surgeon who was also an examiner for Oxbridge and wrote papers on fractures and hernias.

It is a relatively rare condition. Males are more commonly affected than females. It is more common in the elderly and those with other illnesses - most commonly renal failure and myocardial infarction.^2,3

Risk factors

As above, presence of other medical conditions. In one series 64% of cases were associated with comorbidity, 36% with trauma or surgery.⁴ The most common operative procedure associated with Ogilvie's syndrome is coronary artery bypass grafting.

• Prolonged bed rest - as maybe found in nursing homes or on psychiatric units
• Ventilated patients
• Use of drugs e.g. morphine, diazepam, antidepressants
• Conditions affecting the nerves e.g. cerebrovascular event, Parkinson's
• Conditions affecting muscle e.g. dermatomyositis, muscular dystrophy
• It has been reported in association with herpes zoster.⁵

Symptoms

• Abdominal pain, usually cramping or colicky
• Bloated feeling
• Nausea and vomiting
• Intermittent constipation

Signs

• Massive abdominal distension
• Normal, reduced or obstructed bowel sounds
• Minimal tenderness
• Empty, air-filled rectum on digital rectal examination⁶

• Mechanical obstruction
• Colonic adenocarcinoma
• Scarring, adhesions
• Inflammatory conditions - peptic ulcer, appendicitis, pancreatitis
• Irritable bowel syndrome
• Hirschsprung's disease
• Parasitic infection e.g. Chagas' disease

• Full history - symptoms, drug history, previous surgery, past medical history and family history, psychiatric history, habits and normal diet.
• Full examination - to identify other conditions and including digital rectal examination.⁷
• Abdominal x-ray often shows massive dilation of the colon (megacolon) with caecal diameters measuring 10-14 cm.

• Any chronic medical condition- see previously.
• Surgery and trauma producing prolonged bed rest.

General measures

• If possible, treat the cause.
• Enable patient to be mobile and, if possible, exercise.
• Advise adequate fluid intake.
• Naso-gastric tube to decompress stomach and relieve vomiting.

Pharmacological

• Anti-emetic pro-kinetics e.g. metoclopramide
• Intravenous fluids
• Intravenous neostigmine has been used to give clinical decompression of the colon.⁸

Surgical

• Decompression with flexible colonoscope.
• Alternatively cystografin enema has been found to give good results. No complications needing surgery were found.⁹
• Surgery i.e.caecostomy or colostomy is only indicated if conservative treatment fails and the risk of perforation is high.¹⁰ There is a high (57%) mortality rate associated with surgery in Ogilvie's syndrome.¹¹ This is most likely to be due to the elderly, frail nature of the majority of the patients.

Perforation of the bowel wall is the main complication. This is associated with a 21% mortality rate.¹²

Patients avoiding surgery and perforation make good recovery generally, although recurrence is common.

• Avoidance of bed rest
• Adequate hydration
• Avoid drugs which inhibit parasympathetic GI muscle action