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4. It occurs in the absence of an anatomic lesion that obstructs the flow of intestinal contents
Acute colonic pseudo-obstruction (Ogilvie's syndrome) is a disorder characterized by gross dilatation of the cecum and right hemicolon (although occasionally extending to the rectum). The approximate risk of spontaneous perforation is 3 percent, with an attendant mortality rate of 50 percent (1).
In a review of 400 cases, the most common associations were: trauma (nonoperative) 11%, infection (pneumonia, sepsis most common) 10%, cardiac (myocardial infarction, heart failure) 10%, obstetric or gynecologic disease 10%, abdominal/pelvic surgery 9%, neurological (Parkinson disease, spinal cord injury, multiple sclerosis, Alzheimer disease) 9%, orthopedic surgery 7%, miscellaneous medical conditions (metabolic, cancer, respiratory failure, renal failure) 32%, and miscellaneous surgical conditions (urologic, thoracic, neurosurgery) 12% (2).
In the literature, Cesarean section (even in the absence of bowel injury), normal vaginal delivery and spinal anesthesia are associated with acute colonic pseudo-obstruction. It also occurs as a rare complication during the post-operative period of cardiac surgery, occurring in 0.06% of patients in one series (3). An increasingly recognized association of acute colonic pseudo-obstruction is chemotherapy. Vincristine, all transretinoic acid and methotrexate are most commonly associated (4,5).
The pathogenesis of acute colonic pseudo-obstruction is unknown. There is no proposed mechanism to explain colonic dilation in those patients without obvious involvement of the parasympathetic nerves.
Case continued:
Gastroenterology was consulted for urgent decompression. However, he was deemed a high risk for perforation given the severity of colonic dilatation. A rectal tube was placed and a large amount of air and loose stool was evacuated.
What is the role of pharmacologic therapy in patients with acute colonic pseudo-obstruction? (Click on the correct answer to proceed to the next panel)