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.

Epidemiology

It is a relatively rare condition. Males are more commonly affected than females. It is more common in the elderly and in 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 bedrest - as may be 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 disease.
• Conditions affecting muscle, e.g. dermatomyositis, muscular dystrophy.
• Pregnancy.^5,6
• It has been reported in association with herpes zoster.^7,8

Presentation

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 examination.⁹

Differential diagnosis

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

Investigations

• 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.¹⁰
• Abdominal X-ray often shows massive dilation of the colon (megacolon) with caecal diameters measuring 10-14 cm.

Associated diseases

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

Management

General measures

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

Pharmacological

• Antiemetic prokinetics, e.g. metoclopramide.
• Intravenous (IV) fluids.
• IV neostigmine has been used to give clinical decompression of the colon.¹¹

Surgical

• Decompression with flexible colonoscope.
• Alternatively, gastrografin enema has been found to give good results. No complications needing surgery were found.¹²
• Surgery, i.e. caecostomy or colostomy, is only indicated if conservative treatment fails and the risk of perforation is high.¹³ There is a high (57%) mortality rate associated with surgery in Ogilvie's syndrome.¹⁴ This is most likely to be due to the elderly, frail nature of the majority of the patients.

Complications

Perforation of the bowel wall is the main complication. This is associated with a 21% mortality rate.¹⁵

Prognosis

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

Prevention

• Avoidance of bedrest.
• Adequate hydration.
• Avoidance of drugs which inhibit parasympathetic gastrointestinal muscle action.

Document references

1. Ogilvie, H. Original description of syndrome. British Medical Journal, 1948;ii: 671-3
2. Caves PK, Crockard HA; Pseudo-obstruction of the large bowel. Br Med J. 1970 Jun 6;2(5709):583-6.
3. Sloyer AF, Panella VS, Demas BE, et al; Ogilvie's syndrome. Successful management without colonoscopy. Dig Dis Sci. 1988 Nov;33(11):1391-6. [abstract]
4. Catena F, Caira A, Ansaloni L, et al; Ogilvie's syndrome treatment. Acta Biomed Ateneo Parmense. 2003;74 Suppl 2:26-9. [abstract]
5. Mander R, Smith GD; A systematic review of medical diagnosis of Ogilvie's syndrome in childbearing. Midwifery. 2010 Dec;26(6):573-8. Epub 2008 Nov 18. [abstract]
6. Rawlings C; Management of postcaesarian Ogilvie's syndrome and their subsequent outcomes. Aust N Z J Obstet Gynaecol. 2010 Dec;50(6):573-4. doi:
7. Dedemadi G, Georgoulis G; Clinical challenges and images in GI. Colonic pseudo-obstruction as a rare complication of herpes zoster. Gastroenterology. 2008 Aug;135(2):362, 715. Epub 2008 Jul 9.
8. Edelman DA, Antaki F, Basson MD, et al; Ogilvie syndrome and herpes zoster: case report and review of the literature. J Emerg Med. 2010 Nov;39(5):696-700. Epub 2009 Mar 27. [abstract]
9. Vijay Naraynsingh; Ogilvie's Syndrome: The Rectal Balloon Sign, The Internet Journal of Surgery (2003)
10. Tamhane U, Allen S, Maddens M; Pseudo-obstruction due to foreign body: importance of good physical examination. J Am Geriatr Soc. 2008 May;56(5):952-3.
11. Stephenson BM, Morgan AR, Salaman JR, et al; Ogilvie's syndrome: a new approach to an old problem. Dis Colon Rectum. 1995 Apr;38(4):424-7. [abstract]
12. C.R. Schermer, J.J. Hanosh et al; Ogilvie's syndrome in the surgical patient: A new therapeutic modality, The Society for Surgery of the Alimentary Tract (1998)
13. Georgescu EF, Vasile I, Georgescu AC; Intestinal pseudo-obstruction--a rare condition with heterogeneous etiology and unpredictable outcome. A case report. J Gastrointestin Liver Dis. 2008 Mar;17(1):77-80. [abstract]
14. Tenofsky PL, Beamer L, Smith RS; Ogilvie syndrome as a postoperative complication. Arch Surg. 2000 Jun;135(6):682-6; discussion 686-7. [abstract]
15. Delgado-Aros S, Camilleri M; Pseudo-obstruction in the critically ill. Best Pract Res Clin Gastroenterol. 2003 Jun;17(3):427-44. [abstract]

Internet and further reading

• Remy P et al; Ogilvie Syndrome, Medscape, Dec 2009

Acknowledgements