49: Acute Colonic Pseudo-Obstruction (ACPO): Ogilvie’s Syndrome

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Acute Colonic Pseudo-Obstruction (ACPO): Ogilvie’s Syndrome

AnatheaC.Powell andDavidA.Etzioni

Refer toAlgorithm inFig. 49.1

A. Overview

Acute colonic pseudo-obstruction (ACPO) was rst described by Sir Heneage Ogilvie in a 1948 report of two patients who presented with signs and symptoms of colonic obstruction without evidence of any organic disease. As both patients were found to have malignant masses invading the celiac plexus, he hypothesized that the tumors had disrupted the sympathetic innervation to the intestine. Since this initial description, many series of the phenomenon have been published, and ACPO is now a well-recognized clinical entity. Currently, ACPO is dened as massive colonic dilatation in the absence of mechanical obstruction.

The etiology of ACPO is incompletely characterized but is still thought to be due to autonomic dysregulation of the colon causing unopposed parasympathetic stimulation. Although ACPO is idiopathic in some patients, the vast majority of patients have

A. C. Powell Department ofSurgery, Brigham andWomen’s Hospital, Boston, MA, USA

D. A. Etzioni (*) Section of Colon and Rectal Surgery, Dignity Health Cancer Center/St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA e-mail: etzioni.david@mayo.edu

underlying conditions that predispose them to ACPO.These conditions include trauma, surgery, infection, malignancy, cardiopulmonary conditions, and others. Electrolyte disturbances and medications can be instigating factors; familiar precipitators are opioids and calcium channel blockers. A 2011 study using the National Inpatient Sample (NIS) found the incidence of ACPO to be 105 cases per 100,000 hospitalizations.

ACPO affects both men and women, but there is a small preponderance in men. Patients present typically in the fth or sixth decade of life. As described, these patients usually have a predisposing condition, and for surgical patients, present on average between post-operative days 4 and 5. Signs and symptoms can include nausea and vomiting, abdominal pain, constipation, diarrhea, fever, abdominal pain and distention. Abdominal pain and distention are usually the chief ndings. Ischemia and perforation are the feared complications of ACPO, and avoidance of these drives management. Fever and leukocytosis are worrisome for ischemia or perforation. Reports of perforation vary from 3–15%.

B. Evaluation and Diagnosis

The diagnosis of ACPO is made on the basis of clinical and radiographic ndings. The evaluation should consist of a complete history and physical examination. All medica-

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A. C. Powell and D. A. Etzioni

Fig. 49.1 Algorithm for evaluation and management of ACPO

tions, including non-prescription medications, should be reviewed. Every attempt should be made to immediately discontinue all narcotics. Laboratory investigation is obtained to evaluate for leukocytosis, acidosis, renal insufciency, and electrolyte disturbances such as hypokalemia or hypocalcemia. Leukocytosis and/or acidosis indicate possible perforation and/or ischemia and should prompt intervention.

Plain radiographs of patients with ACPO will show gaseous distention of the colon, either throughout the colon, or sometimes with a cutoff at the splenic exure with proximal dilatation. It is essential to distinguish between mechanical obstruction and ACPO;

ACPO should be a diagnosis of exclusion. This goal can be accomplished with either abdominal computed tomography (CT) or water soluble contrast enema. CT is benecial as it provides additional extra-colonic information. The exam can be performed without contrast, but enteral contrast is helpful to delineate the bowel lumen; retrograde is the preference of the authors. Once mechanical obstruction is excluded and the diagnosis of ACPO made, plain radiographs and serial examination can be used to follow patients.

The cecum is most susceptible to perforation based on LaPlace’s law of wall tension. Risk factors for perforation can be judged

49 Acute Colonic Pseudo-Obstruction (ACPO): Ogilvie’s Syndrome

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based on the diameter of the cecum and duration of dilation. In one of the largest reported series, the rate of perforation was zero when the cecum was less than 12cm, but rose to 7% at 12 cm, and almost 25% at 14 cm or greater. Duration of dilation is also a risk factor for perforation; in this same study, the mortality based on delay in decompression from time of diagnosis for <4days, 4–7days and >7days was 15%, 27%, and 73% respectively. Another study showed higher perforation rates when dilation had been present for more than 2days. Therefore, in the absence of physiologic or laboratory concern for ischemia or perforation, intervention should typically be undertaken when cecal diameter is 12 cm or greater, and/or dilation has been present for more than 2–3days.

C. Optimization/Non-operative Management

Once the diagnosis of ACPO has been established, the management is well established. The vast majority of patients with ACPO (over 75%) will improve with conservative measures alone directed at decompression and restoration of colonic motility (Table 49.1). These steps consist rst of bowel rest and decompression. A large bore urinary catheter (20 French) with holes cut in the side in the manner of a chest tube should be inserted into the rectum and connected to straight drainage. Nasogastric tube decom-

Table 49.1 Non-operative measures for ACPO

Non-operative measures

• Nothing per mouth

• Nasogastric decompression (minimize swallowed air reaching colon)

• Rectal decompression with rectal tube (large urinary catheter with holes cut in side)

• Aggressively correct electrolyte imbalances

• Limit or stop offending medications

– Review medications with pharmacist – For surgical patients, use non-opioid pain

medication as much as possible

• Mobilize patient out of bed

– Ambulate – Out of bed to chair if unable to walk – If unable to be out of bed, turn frequently and use

knee-chest position if possible

• Treat underlying conditions

pression is useful to eliminate swallowed air as best as possible.

The patient’s medications should be carefully reviewed and medications that alter bowel motility, such as opioids or calcium channel blockers, should be stopped or their doses minimized. Enlisting the help of a pharmacist can be very useful in these cases. Opioid pain relievers are common precipitating factors in surgical patients. Again, every effort should be used to achieve pain control with non-opioid medication. Options include acetaminophen (especially now that an intravenous preparation is available), ketorolac if renal function will permit, regional anesthetics, or transdermal patches.

Electrolytes should be aggressively supplemented to achieve normal levels. Patients should be mobilized out of bed; ideally to walking. If walking is not possible, patients should sit in a chair; failing this, patients should be turned frequently and the kneechest position may be attempted. Underlying conditions, such as infection, should be treated.

While treating patients with ACPO with conservative measures, daily abdominal radiographs should be obtained to evaluate the diameter of the cecum. Additionally, the duration of distention should be tracked. If these measures fail to provide clinical and radiographic improvement within 2–3 days, or the cecal diameter approaches 12cm, more aggressive measures should be undertaken.

D. Pharmacologic Stimulation (Neostigmine)

Neostigmine is an acetylcholinesterase inhibitor administered intravenously as a stimulatory agent. Neostigmine was shown to be effective in a small randomized clinical trial published in 1999. Ten of eleven patients receiving neostigmine experienced immediate improvement in symptoms and distention within minutes. Two of the responders recurred and required further intervention. None of the ten patients who received placebo had an immediate clinical response. Other non-randomized studies have been performed with similar results. The side

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Table 49.2 Neostigmine for ACPO

Neostigmine administration

• Ensure no contraindication – Bronchospasm, arrhythmias major

contraindications

• Move patient to monitored setting with telemetry and frequent vital sign measurement

• Atropine at bedside to treat symptomatic bradycardia

• Give 2mg of neostigmine as infusion over 5min

• If no response within 30min, give second infusion of 2mg

• The patient should remain monitored for at least 30min after infusion(s)

effects of neostigmine include bradycardia, excessive salivation, abdominal pain and vomiting.

Neostigmine should be administered in a monitored setting with telemetry and frequent vital sign measurement (Table49.2). An infusion of 2 mg of neostigmine is given over 5min and the patient monitored by the physician for improvement. If there is no response within 30min, a second dose of 2mg of neostigmine may be given. As bradycardia can be clinically signicant, atropine must be available at the bedside for symptomatic bradycardia. If the patient shows no response after two doses, endoscopic decompression should be initiated.

E. Endoscopic Decompression

Endoscopic decompression for ACPO was rst introduced in 1977. Prior to this, patients for whom other measures had failed had been managed operatively. Endoscopic decompression has been reported in many studies to be safe, although it is technically challenging in these patients. This technique is the established next line of management if an experienced endoscopist is available. Decompression can be achieved with colonoscopy alone or with colonoscopy and placement of decompression tube (Table 49.3). Perforation, the major complication of decompressive colonoscopy, is low in reported series (as low as 2%).

Benzodiazepines alone should be used for sedation to avoid opioid exacerbation of colonic inertia. A bowel prep is unnecessary as the colonic dilatation facilitates colonoscopic advancement over feces without difculty in

Table 49.3 Endoscopic decompression in ACPO

Tips Tools

• Should be performed by experienced endoscopist

• Use benzodiazepines alone for sedation

• No prep is needed

• Minimize insufation

• Liberal use of suction

• Advance colonoscope beyond splenic exure

• Leave long rectal decompression tube

• Stop and proceed to operation if mucosal ischemia seen

• Best colonoscopic options

– Large therapeutic

channel

– Dual channel

• Decompression tubes

– Vary in diameter and

length based on commercial kit used

almost all cases. The colonoscope should be advanced using as little insufation as possible and liberal suction should be used for both stool and air. Little is known regarding the benet of carbon dioxide insufation versus air. Decompression is achieved by advancing the colonoscope past the splenic exure, but it is not necessary to advance all the way to the cecum.

In several series, successful decompression with immediate clinical and radiographic improvement has been reported in approximately 60–85% of cases. However, recurrence can be as high as 45% and varies in time to recurrence. In one study, the mean time to recurrence was 3.7 days (range 1–8 days). Placement of a long rectal tube during decompressive colonoscopy has been shown to signicantly decrease recurrence rate versus colonoscopy alone. If recurrence does occur and the patient remains non-toxic, colonoscopy may be attempted again. There is debate regarding what to do if mucosal ischemia is seen and there are few data to guide decision making. The authors recommend starting antibiotics and proceeding to surgery if the patients develop recurrent symptoms after two colonoscopies or ischemia is seen.

F. Denitive Decompression Denitive decompression is required in a small

percentage of patients for whom neostigmine was either contraindicated or failed and endoscopic decompression failed.

For non-toxic patients without evidence for

ischemia or perforation, either percutaneous

49 Acute Colonic Pseudo-Obstruction (ACPO): Ogilvie’s Syndrome

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or open cecostomy may be considered. These procedures have been reported to be successful in small series of patients. However, cecostomy is an infrequently performed procedure and may become a legacy technique.

If laparotomy is planned, factors dictating management include the length and section of involved bowel, presence of perforation or ischemia, and surgeon experience. Mortality for patients requiring surgery ranged from 12% to 15% in the 2011 NIS study, but has been reported previously to be as high as 35–60%. In the case of suspected perforation or ischemia, bowel resection and proximal diversion is the standard. The distal bowel can either be managed with a long Hartmann’s pouch or as part of a Prasad ileostomy; the Prasad ileostomy technique will assist with reversal in the future. In the absence of perforation or ischemia, options for management vary and include partial colectomy, almost always including the right colon, with or without diversion, total colectomy and ileostomy, and ileostomy. Given the high mortality rates associated with laparotomy, diversion is safest. The ileostomy may be an end, Prasad, or loop, although little has been written about loop ileostomy in this setting.

Colonic Conditions: Irritable Bowel Syndrome (IBS)

CrystalP.Koerner andPatrickS.Sullivan

Introduction

Irritable bowel syndrome (IBS) is a chronic functional disorder characterized by abdominal pain and altered bowel habits in the absence of an organic cause to explain these symptoms. IBS may be divided into subtypes, including IBS with diarrhea, IBS with constipation, IBS with mixed bowel habits, alternating IBS, post infectious IBS, and unspecied IBS (refer to Table50.1). Various factors are thought to contribute to the pathology of IBS and include changes to the gut microbiome, intestinal permeability, gut immune function, motility, visceral sensation, brain-gut interactions, and psychosocial state. There appears to be a genetic component, as genetic polymorphisms have recently been associated with the development of IBS.Alterations in the innate immune system have been demonstrated in patients with IBS and are hypothesized to contribute to the development of IBS. IBS is one of the most commonly encountered medical conditions, with a worldwide prevalence of 10–15%. It is also one of the costliest medical conditions with an estimated cost of $21 billion to the United States yearly. Younger patients and women are more likely to be diagnosed with IBS, with a female to male ratio of 2:1. The most common age at diagnosis is between 30

C. P. Koerner · P. S. Sullivan (*) Division of Colon and Rectal Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA e-mail: Patrick.s.sullivan@emory.edu

Table 50.1 Classication of IBS subtypes

• IBS with constipation: hard stools ≥25%, loose stools <25%

• IBS with diarrhea: loose stools ≥25%, hard stools <25%

• IBS with mixed symptoms: hard stools ≥25%, loose stools ≥25%

• Undened IBS: absence of sufcient abnormality in stool consistency

• IBS with alternating symptoms: symptom uctuance over time

and 50years of age. The prevalence of IBS is equal among Caucasians and African Americans and may be lower in Hispanics. Other functional bowel disorders such as functional dyspepsia, pain disorders including bromyalgia, chronic pain, interstitial cystitis and psychological conditions inclusive of anxiety, somatization are often seen in patients with IBS and are more prevalent than in the general population.

Refer toAlgorithm inFig. 50.1

A. Abdominal discomfort or pain with an alter-

ation in bowel habits are the classic symptoms described in patients with IBS. The abdominal pain is often diffuse, intermittent and crampy in nature. The alterations in bowel habits may include diarrhea, constipation or both. Other symptoms that many patients experience include bloating, urgency, and relief of pain after defecation.

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Fig. 50.1 Algorithm diagnostic workup and treatment of irritable bowel syndrome

It has been demonstrated that patients with IBS are more likely to have additional comorbid conditions, as high as 50%. In particular, functional dyspepsia and GERD have a high prevalence among patients with

.−

IBS

associated extra-intestinal complaints

may include fatigue, headache, musculo-

skeletal pain, pelvic pain and impaired sleep. Alarm symptoms are symptoms that should alert the clinician that an organic cause for symptoms should be sought out. These include weight loss, blood in the stool, fever, pain that awakens one from sleep, and age greater than 50.

50 Colonic Conditions: Irritable Bowel Syndrome (IBS)

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B. The diagnosis of IBS can be challenging and

frustrating for the clinician. Patients with IBS usually present to a physician with a host of nonspecic complaints. Performing a thorough history, physical exam and utilizing selected tests to exclude various organic causes are essential to the diagnosis of IBS. Clinicians should consider the diagnosis of IBS if a patient reports abdominal pain or discomfort, bloating and a change in bowel habits for greater than 6months. Targeted questions regarding alarm symptoms should be asked and an alternative diagnosis should be sought out if present. Any of the following physical signs should alert the clinician to a possible alternative diagnosis, anemia, blood on rectal exam, palpable abdominal or rectal masses.

C. Many factors are thought to increase the risk

of developing IBS, the most well documented is post-infectious IBS.Post-infectious IBS is a subtype that occurs after development of gastroenteritis, most commonly with salmonella, campylobacter, shigella or giardia. The risk of developing IBS with exposure to acute gastroenteritis has been estimated at 5–32%. IBS has been shown to cluster in families, with an increased risk of two- to threefold if a relative is diagnosed with IBS.Other risk factors include recent antibiotic use, history of childhood abuse, and having a low birth weight.

D. The Rome III criteria can be utilized to help

diagnose patients with IBS (Table50.2).

E. The differential diagnosis for irritable bowel

syndrome is broad and varies according to the subtype. In patients with diarrheapredominant, these include microscopic colitis, infectious colitis, malabsorption, bacterial

Table 50.2 Rome III diagnostic criteria for irritable bowel syndrome (IBS)

• At least 3months, with onset at least 6months previously of recurrent abdominal pain or discomfort associated with two or more of the following:

– Relieved with defecation and/or – Onset associated with a change in frequency of

stool and/or

– Onset associated with a change in appearance of

stool

overgrowth, lactose intolerance, ulcerative colitis, Crohn’s disease, and Celiac disease. The differential for constipation and mixed type include medication induced, malignancy and endocrinopathies.

F. The role of diagnostic testing in patients with

IBS should be targeted and begin with a careful history and physical examination. Patients with alarm symptoms, signs or strong family histories of colorectal cancer, inammatory bowel disease, or celiac disease should prompt the clinician to investigate causes other than IBS.Basic lab work including CBC, ESR, and CRP can help exclude inammatory bowel disease. In patients with diarrhea-predominant IBS, stool studies and fecal fat testing can help to rule out infectious and malabsorptive etiologies. Tissue Transglutaminase IgA can be obtained if celiac disease is a concern. The role of imaging studies is limited in patients with IBS and should be considered if organic pathology is in the differential. In patients that are anemic or older than 50 years of age, a colonoscopy should be performed to exclude malignancy. In addition, endoscopy may be used in IBS diarrhea predominant patients to exclude microscopic colitis as a cause of the diarrhea with a mucosal biopsy.

G. It has long been recognized that a signicant

proportion of patients with IBS have associated psychiatric illness and personality pathology. Multiple standard psychometric instruments have been utilized to evaluate anxiety and depression as well as personality characteristics in patients with IBS, including Hamilton anxiety scale, Beck depression scale, State-Trait Anxiety Inventory (STAI), Minnesota Multiphasic Personality Inventory (MMPI), and Eysenck Personality Inventory. Recent studies have demonstrated a signicant difference in scores between patients with IBS compared to healthy controls. In addition, it has been shown in various randomized clinical trials that dietary, lifestyle, medical, and behavioral modications are effective in the treatment of irritable bowel syndrome. It is clear that a strong patientphysician relationship is an important com-

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ponent in the care of patients with IBS and decreases health care visits.

H. Dietary and lifestyle modications have been

shown to be effective in patients with IBS.In particular, a high ber diet has been shown to improve symptoms. Recently, there has been a growing interest in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) as they relate to IBS symptoms. FODMAPs are poorly absorbed short chain fatty acids such as fructose and lactose. Evidence suggests that intake of FODMAPs increase GI symptoms in patients with IBS, and studies have shown signicant symptom reduction with a low FODMAP diet. Physical activity has also been shown to reduce symptoms and symptom severity in patients with IBS.

I. In many patients with IBS the goal of therapy

is symptom reduction. Antispasmodic agents have been shown to reduce symptom severity when compared to placebo. Antidepressants such as Tricyclic antidepressants (TCAs) and SSRIs, have been shown in some series to improve symptoms. Although, other studies have shown no benet between TCAs and SSRIs when compared to placebo. The benet of antidepressants remains to be elucidated. Other therapies such as probiotics and neuropathic agents are often used to treat IBS. Gabapentin was shown to reduce symptom thresholds in patients with IBS and studies have shown that probiotics improve abdominal pain and atulence when compared to placebo.

J. Specic agents have shown efcacy in the sub-

types of IBS and include antidepressants and serotonin antagonists. Amitiza

(Lubiprostone) a chloride channel activator and Linzess® (Linaclotide), a Guanylate cyclase agonist, have been FDA approved for treatment in patients with IBS-C subtype. In a recent metaanalysis, Amitiza® was found to decrease the severity of constipation, improve the consistency of stool, decrease degree of straining and degree of abdominal bloating compared to placebo in patients with IBS- C.Linzess® has been shown to decrease abdominal pain, discomfort,

bloating and fullness when compared to placebo in patients with IBS-C. In patients with IBS-D subtypes, Rifaximin, Loperamide, and Alosetron have been shown to improve symptoms. In particular, Alosetron was shown to improve quality of life scores and bowel function, in patients with diarrhea predominant IBS. Rifaximin improved abdominal pain, bloating and loose stools when compared to placebo in a double-blind randomized control trial.

K. Alternative therapies have been utilized for the

treatment of IBS including acupuncture, biofeedback and psychotherapy. Acupuncture has been shown to be associated with greater symptom improvement than standard pharmacologic treatment in multiple RCTs. Psychotherapy has been shown to have an impact in the treatment of IBS.In one study, psychotherapy was delivered in ten sessions and focused on coping mechanisms and resolving emotional problems. Psychotherapy was found to relieve abdominal pain and bowel dysfunction more than medical therapy alone. Biofeedback has recently been shown to improve abdominal pain and bloating in patients with IBS-C, when delivered consistently.

L. As a functional disease, surgery has had

a limited role in the management of IBS patients, yet a high surgical rate exists in these patients. Patients with IBS have a higher rate of cholecystectomy, appendectomy, hysterectomy, colon resection, and back surgery than those without IBS.Newer minimally invasive procedures such as sacral nerve stimulation (SNS) may be of use in highly selected patients with IBS refractory to conservative management. However, IBS is not an FDA labeled indication for SNS.In one small randomized, crossover control trial, sacral nerve stimulation was shown to improve pain, bloating, diarrhea, constipation, and satiety. In addition, SNS improved quality of life endpoints including, sleep, emotional distress, eating habits, fatigue and impaired daily activity. The mechanism of symptom improvement with SNS has yet to be fully explained, but it has been shown that SNS relaxes the rectal wall, making the rectal

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wall more sensitive to stretch and less sensitive to cold. Decreased rectal wall stiffness has been associated with symptomatic relief. Additional studies are needed to further elucidate the efcacy and safety of sacral nerve stimulation as a therapy for patients with IBS.

M. IBS is a chronic relapsing disorder that can

greatly affect the quality of life of patients, but studies have shown no increase in mortality when compared to patients without IBS. In addition, when followed over the long term, very few patients are found to have an organic cause of their symptoms. Patients with IBS have been shown to have lower quality of life scores when compared to healthy subjects, with scores similar to other chronic disorders such as GERD and diabetes. However, quality of life scores have been shown to increase when proper therapeutic treatments were initiated.

Acute Colonic Pseudo-Obstruction (ACPO): Ogilvie’s Syndrome

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Colonic Conditions: Irritable Bowel Syndrome (IBS)

Introduction

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