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Ogilvie’s syndrome: management and outcomes
Magda Haj, BSc
a
, Mona Haj, MD
b
, Don C. Rockey, MD
b,∗
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.
Abbreviations: CCI =Charlson comorbidity index, LOS =length of stay, MUSC =Medical University of South Carolina, NG =
nasogastric.
Keywords: anti-cholinesterase, colonic pseudo-obstruction, colonoscopy, decompression, mortality, nasogastric tube,
neostigmine, prognosis, rectal tube
1. Introduction
Acute colonic pseudo-obstruction, also known as Ogilvie’s
syndrome, was first described in 1948 and refers to massive
dilation of the colon without underlying mechanical obstruction
or other organic cause.
[1]
The pathophysiologic basis of Ogilvie’s
syndrome remains unclear but is believed to be due to a
functional disturbance in the enteric nervous, leading to an
“adynamic colon,”massive dilation, and perforation.
[2]
Ogilvie’s
syndrome is typically found in hospitalized patients, who most
often have severe comorbid conditions, such as severe musculo-
skeletal abnormalities, trauma, surgery, or sepsis, and is
associated with increased morbidity and mortality.
[1,3]
Other
conditions that appear to increase the risk of Ogilvie’s syndrome
include electrolyte imbalances, medications (ie, narcotics,
anticholinergics), and debilitation.
[4,5]
Clinical manifestations of Ogilvie’s syndrome vary, and
include abdominal distention and pain (80%), nausea with
vomiting (60%), and obstipation (60%).
[3]
The diagnosis
depends on exclusion of structural and known causes of colonic
dilation, as well as clinical and radiologic evidence.
[6–9]
Ogilvie’s
syndrome usually involves the cecum and right colon, but
can involve any part or all of the colon.
[10]
Typically, diameters
>14 cm are believed to be associated with a high risk of
perforation.
[4,5]
Perforation and intestinal ischemia are the most
serious complications and are the major reason that intervention
is often attempted.
[2]
Many different approaches have been used to manage Ogilvie’s
syndrome. It may be managed by addressing underlying
conditions (ie, discontinuation of narcotics, correction of
electrolyte abnormalities
[3]
) and/or decompressing the gastroin-
testinal tract via nasogastric (NG) tube and/or rectal tube
insertion. Additionally, neostigmine has gained popularity due to
a small randomized study suggesting its benefit.
[11]
Decom-
pressive colonoscopy, although not established in randomized
clinical trials, is also often used, as it can provide immediate
colonic decompression.
[12,13]
Editor: Bülent Kantarçeken.
The authors have no funding and conflicts of interest to disclose.
a
American University of Beirut Medical Center, Beirut, Lebanon,
b
Department of
Internal Medicine and the Division of Gastroenterology and Hepatology, Medical
University of South Carolina, Charleston, SC.
∗
Correspondence: Don C. Rockey, Department of Internal Medicine, Medical
University of South Carolina, 96 Jonathon Lucas Street, Suite 803, MSC 623,
Charleston, SC 29425 (e-mail: rockey@musc.edu).
Copyright ©2018 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-
ND), where it is permissible to download and share the work provided it is
properly cited. The work cannot be changed in any way or used commercially
without permission from the journal.
Medicine (2018) 97:27(e11187)
Received: 15 December 2017 / Accepted: 25 May 2018
http://dx.doi.org/10.1097/MD.0000000000011187
Observational Study Medicine®
OPEN
1
Despite having been first described nearly 70 years ago,
literature focused on the management of Ogilvie’s syndrome
remains sparse and consists primarily of single case reports and
expert opinion. In this study, we have hypothesized that
conservative management, with treatment of underlying con-
ditions, discontinuation of drugs that alter bowel motility, and
correction of underlying electrolyte abnormalities is highly
effective and is rarely associated with progression to bowel
perforation. Therefore, we have investigated the prevalence,
etiology, management, and outcomes of Ogilvie’s syndrome
among patients at our institution.
2. Methods
2.1. Study population
All patients over the age of 18 with Ogilvie’s syndrome (pseudo-
obstruction of the colon ICD-9: 560.82) between January 2005 and
December 2015 at the Medical University of South Carolina
(MUSC), a tertiary care and academic medical center in Charleston,
SC, were included in this retrospective cohort. A diagnosis of
Ogilvie’s syndrome required radiographic evidence of colonic
dilatation >9 cm, the historically accepted diameter at which
treatment to avoid complications was warranted.
[4]
The data
collected included demographics, medical and surgical history,
reason for admission, admitting service, interventions or procedures
during the admission, and discharge status. Patients missing
historical, clinical, laboratory, or treatment data, or with Ogilvie’s
syndrome discovered incidentally during surgery were excluded
(Fig. 1).
Patients were divided into 2 groups: those receiving conserva-
tive management and those receiving interventional manage-
ment. Conservative management was defined as placement of a
NG tube and/or rectal tube to aid in gastrointestinal tract
decompression, correction of serum electrolytes, withdrawal of
narcotics or other predisposing medications, and administration
of bowel prep. Interventional management included administra-
tion of neostigmine, decompressive colonoscopy and/or sigmoid-
oscopy, placement of a gastrostomy tube with wall suction, and
surgical interventions such as colostomy or colectomy.
2.2. Data and statistical analysis
Primary endpoints were inpatient mortality and time to
resolution of obstruction. Secondary endpoints included clinical
complications associated with management of Ogilvie’s syn-
drome, defined as ischemia or perforation of the colonic wall,
primary failure of treatment or recurrence of Ogilvie’s syndrome
during the same inpatient admission, or severe bradycardia
leading to clinical symptoms. Resolution was defined as normal
imaging (by abdominal radiographic series or computed
tomography) or relief of abdominal distention on physical
examination with return of bowel movements. The Charlson
comorbidity index (CCI) was used to assess the severity of
underlying comorbidities, as previously reported.
[14]
Statistical analyses were performed using Statistical Analysis
System (SAS) versions 9.4 (SAS Institute, Cary, NC) and
GraphPad Prism version 6.04 for Mac (GraphPad software,
La Jolla, CA). Student’sttest was used for continuous variables
and was reported as means with corresponding standard
deviations. Fisher exact test was used for categorical variables
and was reported as percentages. The correlation between
narcotic use and dose over 48 hours, and maximal bowel
diameter was assessed using Spearman analysis. All narcotics
were calculated to the equianalgesic dose of oral oxycodone using
the Johns Hopkins Opioid Conversion Program Calculator.
[15,16]
Results are reported as percentages, odds ratios with correspond-
ing 95% confidence intervals (CIs), and mean with standard
deviations, where appropriate. Statistical significance was set at
P<.05 and all reported P-values were 2-tailed.
2.3. Study approval and data use agreement
The Institutional Review Board at the Medical University of South
Carolina (MUSC) approved the research protocol prior to initiation
of this research. A data use agreement was in place with the Clinical
Data Warehouse at MUSC for the identification and use of inpatient
data. The study met all guidelines for good clinical practice.
[17]
3. Results
From January 2005 to December 2015, 48 patients diagnosed as
having Ogilvie’s syndrome were identified as outlined in Section 2
(Fig. 1), with 38 patients having colonic dilatation >9 cm. One
patient was excluded after colonic dilatation was discovered
during an unrelated laparotomy for complicated pancreatitis,
leaving a cohort of 37 patients with symptomatic Ogilvie’s
syndrome. Women represented 27% of the cohort, the average
age was 67 years, and the average maximal bowel diameter was
12.5cm (Table 1). Nineteen patients (51%) were managed
conservatively and 18 (49%) had some form of interventional
management (Table 1). Age, race, and clinical features were
similar among the 2 groups. Women were more likely to receive
conservative management compared to males (P=.008).
The average maximal bowel dilation size was 12.0 cm in the
conservative management group and 13.0 cm in the interven-
tional management group (P=.21)). Of note, comorbidities were
similar in both groups of patients as evidenced by similar CCI
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.
Haj et al. Medicine (2018) 97:27 Medicine
2
scores (Table 1). The majority of patients in both groups were
admitted with their first episode of Ogilvie’s syndrome, although
several patients had recurrent disease (17% vs 11%; 95% CI;
P=.66) (Table 1). While more patients in the conservative
management group were admitted through a surgical service
(68% vs 44%), this was not significantly different among the
groups (95% CI; P=.191).
Overall, the most common location of dilation was the cecum
and/or right hemicolon (76%) (Table 1). A greater number of
patients in the interventional management group had a left-sided
or total colonic dilatation, compared to the conservative
management group (Table 1). All left-sided and total colonic
dilatations occurred in males. As expected, primary neurologic
and orthopedic disorders were common in patients in the cohort
(Table 2). Stroke, primary and metastatic brain tumors, and
subdural hemorrhages were responsible for the neurologic
disorders, while hip replacements, spinal surgeries, and fractures
after motor vehicle accidents characterized orthopedic disorders
in the cohort (Table 2).
Electrolyte levels at onset of Ogilvie’s syndrome were similar in
the conservative and intervention management groups (Table 1).
Hypocalcemia (serum Ca
2+
<8.4 mg/dL) was present in 62% of
Table 1
Patient cohort characteristics.
Full cohort (n =37) Conservative management (n=19) Interventional management (n=18) P-value
Female, % 27 47 6 .008
Age, mean ±SD 67 ±15 65 ±19 69 ±11 .75
BMI 29 ±628±729±6 .83
Race, % .15
White 59 74 44
Black 38 26 50
Other 3 0 6
Admission source, % .19
Medicine 43 32 56
Surgery 56 68 44
Comorbidities (CCI) 6.0 ±3.5 5.8 ±4.0 6.3±3.0 .79
History of Ogilvie’s syndrome, % .66
First episode 86 89 83
Recurrence 14 11 17
Side of distension .27
Right 76 86 63
Left 16 9 25
Total 8 5 12
Bowel diameter, cm 12.5 ±2.2 12.0 ±2.0 13.0 ±2.3 0.21
Lab values
Hemoglobin, g/dL 10.3 ±2.4 10.3 ±2.5 10.2 ±2.3 .86
Hematocrit, % 30 ±7.1 30 ±7.1 30 ±7.3 .70
Sodium, mmol/L 137 ±5.0 137 ±4.2 137 ±5.6 .97
Potassium, mmol/L 3.7 ±0.9 3.6 ±1.0 3.8±0.7 .39
Magnesium, mg/dL 2.1±0.6 2.2 ±0.7 2.0 ±0.4 .88
Calcium, mg/dL 8.4 ±0.7 8.2 ±0.6 8.6±0.8 .24
Phosphorous, mg/dL 3.5 ±1.5 3.5 ±1.3 3.5±1.7 .67
Bicarbonate, mmol/L 25 ±3.7 25 ±4.5 25 ±2.6 .88
Chloride, mmol/L 104 ±4.5 104±4.5 103 ±4.5 .44
Blood urea nitrogen, mg/dL 29 ±32 30 ±29 27 ±35 .31
Creatinine, mg/dL 1.6 ±1.6 1.7 ±1.6 1.6±1.6 .93
Total serum protein, g/dL 6.2 ±1.2 6.0 ±1.0 6.5±1.4 .60
Albumin, g/dL 3.0 ±0.6 2.8 ±0.7 2.9±0.6 .38
Narcotic
∗
use, % 73 79 67 .47
BMI =body mass index, CCI =Charlson comorbidity index, SD =standard deviation.
∗
Standardized to equianalgesic doses of oxycodone (mg).
Italic indicates statistically significant.
Table 2
Underlying clinical conditions among inpatients developing Ogilvie
syndrome (n =37).
Clinical condition n (%)
Neurologic 10 (27)
Orthopedic surgery 9 (24)
Gastrointestinal 8 (22)
Cardiopulmonary 4 (11)
Trauma 3 (8)
Others
∗
3 (8)
∗
Urologic surgery, oncology, and hematology each provided 1 case.
Table 3
Electrolyte abnormalities at onset of Ogilvie’s syndrome (n =37).
Electrolyte abnormality
∗
n (%)
Hypocalcemia 23 (62)
Hypokalemia 13 (35)
Hypophosphatemia 13 (35)
Hypomagnesemia 10 (27)
Hyponatremia 11 (30)
Hypermagnesemia 4 (11)
∗
Normal reference ranges: calcium (8.4–10.3 mg/dL); potassium (3.5–5.1 mmol/L); phosphorous
(2.3–4.7 mg/dL); magnesium (1.6–2.6 mg/dL); sodium (135–145 mmol/L).
Haj et al. Medicine (2018) 97:27 www.md-journal.com
3
patients at onset of Ogilvie’s syndrome, with hypokalemia (serum
K
+
<3.5mg/dL) and hypophosphatemia (serum PO
43-
<2.4mg/
dL) present in 35% (Table 3). Serum calcium levels at onset were
found to correlate with maximal bowel diameter (P=.01, R
2
=
0.17) (Fig. 2), though no correlation was identified with the other
electrolytes. We also investigated the influence of narcotics as a
predisposing factor in this cohort of patients. Narcotic doses were
converted to equianalgesic doses of oral oxycodone (mg) as in
Section 2 (Methods); a trend between maximal bowel size and the
48-hour narcotic dose immediately preceding the index diagnosis
of Ogilvie’s syndrome was noted (Fig. 3).
The overall time to resolution, defined as radiographic evidence
of decreased bowel diameter or clinical evidence of decreased
abdominal distension and/or resolution of pain or obstipation, was
5 days, with no difference in either group (Table 4). Overall
inpatient length of stay(LOS) was often prolonged, consistent with
substantial underlying disease inthe entire cohort ofpatients. One
patient in each group died (inpatient mortality 5.4% and 5.6% in
the conservative and interventional management groups, respec-
tively) from complications unrelated to their Ogilvie’s syndrome.
The rate of resolution also did not differ between the 2 groups
(Fig. 4A). Additionally, the rate of resolution did not differ with the
different interventional management options including neostig-
mine, colonoscopy, and surgery (Fig. 4B).
Overall, 15 patients (41%) experienced an Ogilvie-syndrome-
related complication, as defined, with recurrence of Ogilvie’s
syndrome being the most common (24%) (Table 4). Patients in the
interventional management group were more likely to experience
complications (61% vs 21% in the conservatively managed group;
P=.01); bradycardia after administration of neostigmine was the
most common complication experienced in this group (17%) and 1
patient (6%) developed colonic ischemia after an initial colonos-
copy, requiring urgent colectomy (Table 4). We used multiple
regression analysis to identify independent risk factors for
developing an Ogilvie’s-syndrome-related complication, as defined
earlier. Age, CCI, gender, narcotic use, maximal bowel diameter,
and management approach were assessed. The risk of a
complication (as defined) was reduced when conservative
management was used (OR: 0.03, 95% CI 0.002–0.512; P=.02).
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 (r
2
=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.
Haj et al. Medicine (2018) 97:27 Medicine
4
4. Discussion
Here, we have identified a large cohort of patients with Ogilvie’s
syndrome and have demonstrated that conservative treatment
appears to be safe and effective. Interventional treatments for
Ogilvie’s syndrome such as acetylcholinesterase inhibitors (ie,
neostigmine) and decompressive colonoscopy have been recom-
mended by experts and become popular.
[18,19]
In this study, we
report that although these more traditional interventional
treatments are commonly used, they do not appear to be any
more effective than conservative maneuvers.
Patients with Ogilvie’s syndrome typically have serious
underlying comorbid conditions, as was the case in our study.
Over half of our patients had serious underlying neurologic or
orthopedic disease; this is critically important to recognize, as
these illnesses are associated with decreased mobility, which in
turn appears to be a major predisposing factor in the
development of Ogilvie’s syndrome. Additionally, many patients
had electrolyte abnormalities, notably hypocalcemia (62%),
which may alter gut motility, predisposing to pseudo-obstruc-
tion.
[4,12,20]
In combination with decreased ambulation and
movement associated with chronic illness, such metabolic
disturbances are critical to identify and correct, and their
correction likely contributed to the success of conservative
treatment in this study.
While the exact pathogenesis of Ogilvie’s syndrome is not
understood, the fact that it is present in the setting of chronic
illness, electrolyte abnormalities, and often narcotic use implies
that management of these underlying contributory metabolic or
pharmacologic factors is critical. The results of our study suggest
that the correction of such inciting factors should be the
foundation of management. Although we cannot exclude
potential bias (ie, that “sicker”patients received interventional
management), we doubt this to be the case since at baseline there
was no difference in age, CCI, admission source, or baseline
electrolytes between the 2 groups. Additionally, there was no
difference in overall LOS, time to resolution, or rate of recovery in
the different treatment groups.
We found that patients who had conservative management
were less likely to experience an Ogilvie-syndrome-related
complication than those having interventional management.
Complications included bradycardia secondary to neostigmine,
recurrence of Ogilvie’s syndrome, progression of distension, and
colonic ischemia requiring surgery. While neostigmine was used
in 67% of patients in the interventional management group, its
use did not appear to lead to superior results to conservative
management. Indeed, although neostigmine has been found in
small randomized clinical trials to be effective for treatment of
Ogilvie’s syndrome, those same trials reported numerous adverse
effects ranging from increased abdominal pain, severe cholinergic
symptoms, as well as severe bradycardia, and syncope.
[21]
Furthermore, patients with Ogilvie’s syndrome receiving neo-
stigmine require monitoring on cardiac telemetry and immediate
bedside access to atropine, a setting often difficult to achieve
outside of an intensive care unit
[18,21]
); increasing the hospital
costs incurred to the patient. Conservative management,
however, is practical, safe, and efficacious.
We recognize strengths and limitations of this study. Perhaps
the greatest strength is that this is a large cohort of patients with
an uncommon disease. Additionally, we were able to obtain
Table 4
Outcomes.
Full cohort, n =37 Conservative management, n =19 Interventional management, n=18 P-value
Time to resolution, days 5 ±35±25±3 .55
Complications, % 41 21 61 .01
Recurrence of Ogilvie’s syndrome 24 16 33
Others
∗
14 5 22
Colonic ischemia 3 –6
LOS ±SD (d) 22 ±18 22 ±21 22 ±15 .41
Inpatient mortality, % 5.4 5.3 5.6 >.99
LOS =length of stay, SD =standard deviation.
∗
Bradycardia after administration of neostigmine, increased abdominal pain, lethargy.
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.
Haj et al. Medicine (2018) 97:27 www.md-journal.com
5
detailed clinical, laboratory, and outcome data on all patients.
We recognized the retrospective nature of the study, which could
lead to potential cases having been missed due to coding errors.
Further, given the retrospective nature of the study, it is possible
that there was bias as to which patients had conservative or
interventional management (ie, sicker patients with more
advanced disease had more aggressive interventional manage-
ment). While this is certainly possible, we think that it is highly
unlikely since the patients were evenly matched for comorbidity
and bowel diameter. Additionally, this was a single center study,
and thus our experience may not be generalizable to other
settings. For example, our practitioners may have pursed
interventional management early, which could have biased our
results toward either a more favorable outcome for interventional
therapy or less favorable interpretation of outcomes for the
conservative group. We tend to discount the latter possibility,
however, as the outcomes in the conservative group were similar
to those in the interventional group.
In summary, despite the fact that Ogilvie’s syndrome is a
relatively uncommon condition, it is important to recognize early
and manage appropriately, particularly in already chronically ill
patients. We report here that many patients will respond to
conservative management. In fact, from a quality and safety
standpoint, the data suggest that at least for certain patients,
conservative management may be preferable. Given our findings,
clinicians should be highly motivated to implement basic acts of
supportive care when managing Ogilvie’s syndrome, including
correcting electrolyte abnormalities, weaning narcotics, provid-
ing a NG or rectal tube for decompression, and encouraging
ambulation when possible.
Author contributions
Magda Haj: study concept and design; acquisition of data;
analysis and interpretation of data; drafting of the manuscript;
critical revision of the manuscript for important intellectual
content
Mona Haj: analysis and interpretation of data; statistical
analyses; critical revision of the manuscript for important
intellectual content
Don C. Rockey: study concept and design; analysis and
interpretation of data; drafting of the manuscript; critical
revision of the manuscript for important intellectual content;
supervisory activities
Conceptualization: Maggie Haj, Mona Haj, Don Rockey.
Data curation: Maggie Haj, Mona Haj.
Formal analysis: Maggie Haj, Mona Haj.
Funding acquisition: Don Rockey.
Investigation: Maggie Haj.
Methodology: Maggie Haj, Mona Haj.
Project administration: Mona Haj, Don Rockey.
Resources: Don Rockey.
Supervision: Mona Haj, Don Rockey.
Writing –original draft: Maggie Haj, Mona Haj, Don Rockey.
Writing –review & editing: Maggie Haj, Mona Haj, Don
Rockey.
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