Ogilvie syndrome

Overview

Ogilvie syndrome, also known as acute colonic pseudo-obstruction (ACPO), is a rare gastrointestinal condition characterized by massive dilation of the colon without any mechanical blockage. It mimics the symptoms of a true bowel obstruction, but upon investigation, no physical occlusion is found. Ogilvie syndrome most often affects the cecum and ascending colon and can result in life-threatening complications such as bowel ischemia or perforation if not promptly managed.

The syndrome was first described by Sir William Heneage Ogilvie in 1948. It typically occurs in hospitalized or postoperative patients and is associated with underlying systemic illness, trauma, or medications that impair the autonomic regulation of the colon. Prompt recognition and management are essential to prevent complications and reduce mortality.

Causes

The exact pathophysiology of Ogilvie syndrome involves a functional imbalance in autonomic nervous system control of the colon—specifically, reduced parasympathetic (excitatory) stimulation and/or increased sympathetic (inhibitory) tone. This leads to impaired motility and progressive colonic distention.

Common Triggers and Risk Factors

• Postoperative states: Particularly after orthopedic, gynecologic, urologic, or abdominal surgeries.

• Severe illness or trauma: Including myocardial infarction, stroke, sepsis, or spinal cord injury.

• Medications:

  • Opioids

  • Anticholinergics

  • Calcium channel blockers

  • Phenothiazines

• Electrolyte imbalances: Hypokalemia, hypomagnesemia, or hypocalcemia.

• Neurological conditions: Parkinson’s disease, multiple sclerosis, or Guillain–Barré syndrome.

• Prolonged bed rest or immobility

Symptoms

Symptoms of Ogilvie syndrome can resemble those of mechanical bowel obstruction, though there is no physical blockage.

Common Clinical Features

• Abdominal distension: The most prominent and often earliest symptom.

• Abdominal pain or discomfort: Usually mild to moderate, without signs of peritonitis unless complications develop.

• Nausea and vomiting: May be present in more advanced cases.

• Constipation or obstipation: Failure to pass stools or gas is common.

• Decreased bowel sounds: May be hypoactive or absent.

• Tympanic abdomen: On percussion, due to gaseous distention of the colon.

Signs of Complications

• Fever and leukocytosis: May indicate ischemia or perforation.

• Peritoneal signs: Guarding or rebound tenderness suggest a surgical emergency.

Diagnosis

Diagnosis is made by combining clinical suspicion with radiological imaging that confirms colonic distension in the absence of a mechanical cause.

Diagnostic Workup

• Abdominal X-ray: Shows massive colonic dilation, especially of the cecum and right colon. Cecal diameter >12 cm increases risk of perforation.

• CT scan of the abdomen: Most sensitive test. Helps exclude mechanical obstruction, volvulus, or ischemia.

• Water-soluble contrast enema (Gastrografin enema): May be used to rule out distal obstruction.

• Laboratory tests:

  • Electrolyte levels (to detect imbalances)

  • Complete blood count (leukocytosis may indicate infection)

  • Liver and renal function tests

Treatment

Management of Ogilvie syndrome depends on the severity of colonic dilation and presence or absence of complications like perforation or ischemia. The goal is to decompress the colon and prevent further distention.

Conservative Management

• Bowel rest: Nothing by mouth (NPO).

• Nasogastric tube: For decompression and relief of upper gastrointestinal symptoms.

• Rectal tube: May help decompress the distal colon.

• Correction of underlying causes: Such as electrolyte imbalances, infection, or medication side effects.

• Ambulation: Encouraging movement and repositioning in bed can help restore motility.

Pharmacologic Management

• Neostigmine: A cholinesterase inhibitor that stimulates colonic motility. Administered intravenously under monitoring due to risk of bradycardia. Often effective within 30 minutes.

• Antibiotics: If perforation or sepsis is suspected.

Procedural and Surgical Options

• Colonoscopic decompression: Therapeutic colonoscopy may be used if conservative measures fail. A decompression tube may be left in place.

• Surgical intervention: Required in cases of colonic perforation, ischemia, or unresponsive severe distention. May involve segmental resection or cecostomy.

Prognosis

The prognosis of Ogilvie syndrome depends on early recognition and effective management. When treated promptly, most cases resolve without the need for surgery. The overall mortality rate is low (<10%) when complications are avoided.

However, the risk of death rises significantly (up to 40%) if complications such as bowel ischemia or perforation occur. Recurrence is possible, especially if the underlying condition is not addressed.

With appropriate treatment including reversal of the underlying cause, supportive care, and monitoring, many patients recover fully. Long-term outcomes are excellent in uncomplicated cases, but continued vigilance is required in high-risk or hospitalized patients.