The acute colonic pseudoobstruction (ACPO), nonobstructive colonic dilatation, or Ogilvie’s syndrome is a rare entity that is characterized by acute dilatation of the colon, usually involving caecum and right hemicolon in the absence of any mechanical obstruction (80–90%), abdominal pain (80%), abdominal tenderness (62%), nausea and/or vomiting (60%), constipation (40%), and fever (37%). It is usually associated with an underlying illness, infection, or surgery and rarely occurs spontaneously. Identification of this condition is important due to the increased risk of subsequent bowel ischemia and perforation, particularly with caecal diameter >9 cm, with high mortality rate up to 50%. Here, we report a case of right colon necrosis and perforation after cesarean section that leads to urgent laparotomy and highlights early and appropriate diagnosis from an obstetric point of view.
A 40-year-old female, G7P4+2, was admitted for elective cesarean section at 38 weeks. Her medical history included gestational diabetes mellitus (GDM) during her current pregnancy that was controlled on metformin (500 mg, three times daily), four previous cesarean sections, two early pregnancy losses at six-week gestation, hypothyroidism, and previous eye surgery at childhood for eye squint. Her family history was positive for diabetes and hypertension.
The patient had an elective cesarean section under spinal anesthesia and gave birth to a living female. It was noticed that she has been omental to the anterior abdominal wall adhesions and omental to the anterior uterine wall adhesions. There were no intraoperative complications and estimated blood loss was about 500 cc.
On the first postoperative day [POD1], the patient looked well with stable vital signs. System review was within normal, and physical examination showed soft and lax abdomen with audible bowel sounds. The patient was started on the liquid diet. The patient passed flatus and was started on the soft diet. The same day at night, she developed mild abdominal distension, bowel sounds still audible with stable vital signs, and the patient was advised to mobilize. The patient mentioned she used to have more abdominal distension after each caesarian delivery.
On POD2, the patient started to have more abdominal distension despite passing stool, and bowel sounds become sluggish then nonaudible. Patient was kept NPO; serum electrolytes were requested and showed mild hypokalemia 3.29 mmol/L. Patient was encouraged to mobilize and was started on potassium chloride infusion and NGT was inserted. She initially was diagnosed to have paralytic ileus, but her general condition eventually deteriorated dramatically, and she developed tachycardia and shortness of breath.
The patient was transferred to the Intensive Care Unit (ICU), reviewed by ICU and surgical team. Abdominal X-ray was performed and showed distended abdomen with pneumoperitoneum (see Figures
Exploration laparotomy performed through longitudinal abdominal incision. There was gangrenous changes of the caecum and right colon with its anterior wall showing multiple ischemic areas and necrosis; some of them are perforated with gross picture of ischemic changes, others thinned out and were about to perforate in subhepatic area; right hemicolectomy and iliostomy were performed till the area of normal color of the colon was reached (see Figures
The patient was transferred back to ICU. The patient received broad-spectrum antimicrobial agents; she was under close monitoring, multidisciplinary team management and discharged to regular room 6 days postoperatively. The postoperative course passed otherwise uneventful. The multidisciplinary team shared in plan of care were surgeons, pulmonologists, ICU intensivists, obstetricians, and cardiologist. Thrombophilia screening was suggested and hyperhomocysteinemia was found; homocysteine level was 14.26 Umol/L. She was discharged in a good general condition 12 days postoperatively.
Ogilvie’s syndrome or ACPO was first reported by Sir Ogilvie in 1948 [
It has been reported after pregnancy or cesarean section [
The exact pathophysiology of the disease is still unclear but it was hypothesized that either the increase in the sympathetic tone or the decrease in the sacral parasympathetic innervations to the colon results in decreased colon motility with subsequent proximal colon dilation which will eventually increase the intraluminal pressure in the proximal colon and cecum, obstructing the caecal capillary circulation and causing subsequent ischemia, gangrene, and perforation [
As the ACPOs have serious complications, timely diagnosis and treatment are critical. Clinical and radiological findings are both needed to confirm the diagnosis of the syndrome [
Compares between Ogilvie’s syndrome and paralytic ileus.
Ogilvie’s syndrome | Paralytic ileus | |
---|---|---|
Impaired area | Limited to colon | Throughout the gut |
Bowel sounds | Hyperactive/high-pitched/absent | Always absent |
Nausea & vomiting | Mild and inconstantly present | More common |
Passing flatus | Present | Always ceased |
Passing stool | Present/diarrhea/obstipation | Always ceased |
Plain abdominal X-ray is the most useful diagnostic modality that reveals gaseous distention in colon, mostly involving the caecum and ascending colon, with or without fluid levels seen in small bowel [
In ACPO, laboratory findings are nondiagnostic. Some electrolyte imbalances like hyponatremia, hypomagnesemia, and hypokalemia can be seen in ACPO, but they represent a consequence of the pathological condition rather than its etiologic factor. Similarly, leukocytosis can be present, especially with perforation or bowel ischemia. Hypokalemia and leukocytosis were present in our case.
Management for uncomplicated patients is initially conservative with limiting oral intake, active mobilization, cessation of opioids, and correction of electrolytes, and underlying comorbidities should be treated [
The most effective pharmacological agent is neostigmine, given intravenously at a dose of 2
If conservative and medical management, including the second dose of neostigmine, failed, colonoscopic decompression is recommended. It is successful in 68–95% of cases and prevents any ischemia and bowel perforation, yet recurrence is common. Colonoscopic decompression is contraindicated if perforation or peritonitis exists [
Surgery is recommended if colonoscopic decompression failed, or progressive clinical deterioration or signs of ischemia and perforation are present, or if caecal diameter is >12 cm. Surgical treatment can be either caecostomy or, in case of ischemic bowel, hemicolectomy with or without primary anastomosis or total abdominal colectomy. The surgical treatment has mortality rate ranging from 30% to 60%.
For pregnant woman with severe constipation and undergoing C-section, certain measures can be done preop and intra-op to prevent or reduce the occurrence of adynamic ileus (see Table
Pre- and intraoperative measures taken in pregnant women to avoid adynamic ileus.
Preoperative measure | Intraoperative measure |
---|---|
Correct poor bowel habits during pregnancy |
Reduce blood loss |
After review of cases, we suggest the management algorithm (see Figure
Stepwise approach to Ogilvie’s syndrome.
To conclude, Ogilvie’s syndrome is rare yet very important to obstetricians, midwifery staff, and general surgeons to diagnose and manage it as early as possible in patients who underwent C-section to avoid any subsequent fatal complications. The authors recommend precise assessment and close monitoring with conservative management in any suspected case. Reassessment is important to assess whether the disease progresses or regresses. With progression, medical, interventional, and surgical management can be considered as described in the context.
The authors declare that there are no conflicts of interest regarding the publication of this article.