OGILVIE’S SYNDROME
Abstract
Ogilvie’s Syndrome characterizes the occurrence of acute colonic pseudo-obstruction with
progressive dilatation of the colon without an evident mechanical cause.1,2
Of rare incidence, it has been reported in patients post caesarean section with
complications of bowel perforation and ischaemia.2 Various medical and surgical conditions
are associated with Ogilvie’s Syndrome. Over half of known cases are preceded by trauma
or surgical procedure, most often caesarean section.1
Little is known about this condition, which poses diagnostic as well as therapeutic
challenges in patients following Caesarean section. Therefore I describe a case of Ogilvie’s
Syndrome following an elective repeat caesarean section necessitating emergency
hemicolectomy to avoid colonic perforation, review cases of similar presentations in the
literature, and discuss features of Ogilvie’s syndrome and its management.
Introduction
Ogilvie’s Syndrome describes acute massive colonic dilatation in the absence of any distinct
cause of organic obstruction of the distal colon.1,2 Despite accurate descriptions since then,
this Syndrome with mortality rates as high as 36-50% when complicated by bowel
perforation remains hard to diagnose.3
Case Report
A healthy non-smoker thirty year old para 2, with a past surgical history of two previous
caesarean sections was admitted for an elective third repeat caesarean section.
Her previous obstetric history included one emergency caesarean section for no progress at
8cm, followed by an elective caesarean section 3 years later. Her antenatal care in the third
pregnancy was uneventful with no placental abnormalities demonstrated.
The procedure was completed under spinal anaesthesia with findings of fibrotic rectus
sheath with moderate adhesions between the sheath and anterior abdominal wall upon
entry. There were no other features of concern. Neonate was delivered with good apgar
scores. Her immediate post operative recovery was reasonable.
Four days post operatively surgery she developed generalised abdominal pain associated
with mild nausea and vomiting, becoming pyrexial at 38.1 degrees. Her abdomen was
grossly distended with sluggish bowel sounds. The inflammatory markers were elevated.
Plain abdominal X-ray showed generalised dilated loops of large bowel, followed by a CT
scan demonstrating significant gaseous distension of transverse and ascending colon as well
as caecum. Radiologically caecal dilatation was as high as 12 cm and had been commented
on at being at risk of perforation whereby urgent laparotomy was undertaken by general
surgeons. Right colon had ischaemic appearances and distension of caecum extended upto
transverse colon. This was decompressed and a right hemicolectomy and primary end to
end anastomosis was carried out. The patient made good post operative recovery
subsequently.
Histopathological investigation of resected bowel specimen showed thin atrophic necrotic
caecal wall with patchy areas of ischaemia, mucosal ulceration and necrosis.
Discussion
Ogilvie’s syndrome, or acute colonic pseudo-obstruction, is a functional disorder
characterised by massive dilatation of the colon in the absence of any mechanical
obstruction,1 first described by Sir Heneage Ogilvie in 1948.2 Though exact data on
prevalence is unknown,3 Ogilvie’s syndrome is relatively rare. It has also been reported as
isolated case reports and small case series.2,3
The exact pathophysiology of Ogilvie’s syndrome is not completely understood, but it is
believed to be due to an imbalance between sympathetic and parasympathetic colonic
innervation, leading to massive dilatation of the colon.4 The causes for this imbalance are
likely multifactorial, but can occur as a consequence of caesarean section (the most
common cause), pregnancy (including following preterm labour, vaginal delivery and preeclampsia), sepsis, spinal trauma, and spinal, pelvic, cardiothoracic and abdominal surgery.
In the case of Ogilvie’s syndrome following an obstetric or gynaecological event (such as
caesarean section), it is thought that damage to the nerves of S2-4 lying close to the cervix,
vagina and broad ligaments during the procedure may play a role, where the normal
parasympathetic outflow from sacral segments S2-4 suffer disruption causing this functional
obstruction where proximal and distal nerve supplies to the colon overlap.1 It has a clinical
and radiological picture of acute large bowel obstruction without an obvious mechanical
cause.2 Without appropriate treatment, it may lead to progressive colonic dilatation
resulting in necrosis and perforation typically of the caecum with high mortality rates of 35%
to 72%.1
Through searching the literature, 24 cases of Ogilvie’s syndrome following Caesarean
section were identified, the characteristics of which are details in Table 1. Patient’s ages
ranged from 21-47 years (mean= 33.1 years), with 6 patients having a multiple pregnancy (5
patients pregnant with twins, 1 with triplets). 5 patients experienced operative
complications.
Table 1: Characteristics of patients found on literature search
Patient
Patient
Age
Single/multiple
Pregnancy
Weeks Gestation
at C/S
Indication for C/S
A
32
Single
37
Placenta previa + 2 previous C/Ss
B
30
Single
39
Failure to progress
C
28
Single
32
D
29
Single
37
Antepartum massive
haemorrhage
Breech, previous myomectomy
E
40
Single
39
Severe pre-eclampsia + high
multiparity
F
40
Single
39
G
29
Multiple (twins)
N/A
Severe pre-eclampsia, previous
C/S
Breech presentation of first twin
H
22
Multiple (triplets)
32
Pre-eclampsia, multiple pregnancy
I
38
Single
At term
J
47
Multiple (twins)
29 (+6) weeks
K
28
Single
39/40
L
35
Single
33
2 weeks past expected date of
delivery
Abruptio placentae
M
26
Single
Not recorded
Elective C/S for narrow pelvis
N
21
Single
Not recorded
Abruptio placentae
O
41
Single
Term
P
42
Single
Term
Q
31
Multiple (twins)
25 (+6) weeks
R
33
Single
40
Failure to progress
S
28
Multiple (twins)
36
Atypical pre-eclampsia
T
32
Single
41
Elective, for previous C/S
U
39
Single
35
Obstructed labour
V
29
Single
28
Breech presentation, low fetal size
W
44
Multiple (twins)
35
Failure to progress (pregnancy
induced due to pre-eclampsia)
Suspected fetal distress
Pre-eclampsia
Emergency C/S for prolonged 2nd
stage of pregnancy
Elective C/S for narrow pelvis
Fetal bradycardia in twin 2
Among the cases we reviewed, abdominal pain was the most common presenting symptom
(83.3%, n=20) often being described as colicky and initially poorly localised, and distension
(83.3%, n=20). Vomiting and constipation were frequently experienced. Nausea and
tachypnoea have also been reported. Bowel sounds were frequently absent or sluggish,
though occasionally hyperactive or high-pitched (“tinkling”), corresponding to what is stated
in the literature.5 Pyrexia and peritonitic or shoulder-tip pain may indicated perforation, and
patients may become acutely ill with dehydration and oliguria.5
While differential diagnoses include mechanical bowel obstruction, volvulus, 5 bowel
perforation and peritonitis, the most difficult step is often distinguishing Ogilvie’s syndrome
from paralytic ileus, a relatively frequent complication of abdominal surgery. There are,
however, a number of key differences exist between the two:




paralytic ileus often involves generalised impairment of the whole gut, while
Ogilvie’s syndrome is specific to the colon
Ogilvie’s syndrome often presents with hyperactive or high-pitched bowel sounds,
while bowel sounds are usually absent in paralytic ileus
patients with Ogilvie’s syndrome often continue to pass flatus and loose stool
nausea and vomiting are more common in paralytic ileus
The most important considerations when investigating possible Ogilvie’s syndrome are
exclusion of mechanical obstruction and assessing for possible ischaemia or perforation.
Abdominal x-ray is the most important diagnostic test and, in the case of Ogilvie’s
syndrome, will reveal either pancolonic dilatation or segmented colonic dilatation. 1 Indeed
colonic dilatation was observed on abdominal x-ray in 100% of patients found in the
literatures. A caecal diameter greater than 9-12cm indicates a high risk of impending
perforation. Air seen under the diaphragm suggests perforation. Water-soluble contrast
enema can be used to rule out mechanical obstruction.
Early detection is important, as it allows more conservative management and improves
prognosis.
Management is individualised depending on degree of bowel dilatation and risk of
ischaemia and perforation. Of the patients identified in the literature, 8 (33.3%) were
managed conservatively (including 1 patient requiring decompression via flexible
sigmoidoscopy) while 16 (66.6%) required surgical intervention, ranging from tube
caecostomy to right hemi-colectomy.
Initial conservative management of Ogilvie’s syndrome may involve measures such as
correcting any fluid or electrolyte imbalance, nasogastric suction, and avoiding any drugs
which might impair colonic motility.5 Maintaining mobility, and avoiding keeping the patient
in a supine where possible, can help. Pharmacological management often includes the use
of the parasympathomimetic drugs increasing gastro-intestinal motility, neostigmine and
cisapride.1
Surgical intervention is necessary when conservative methods fail, symptoms worsen,
and/or caecal diameter exceeds 12 cm (which indicates impending perforation). Colonic
decompression is often the first step in invasive treatment, though symptoms often recur
and serial decompression may be necessary.5 Caecostomy may be the next procedure of
choice, but failing these options, laparotomy will be mandatory, usually bowel resection
with primary anastomosis or temporary diversion and 2nd stage closure.5 However, surgery
is associated with a high mortality.1 This syndrome is serious because it is possible for the
caecum to burst causing faecal peritonitis which carries a heavy mortality.
OS is an established post-operative complication, but since it occurs rarely it may be
overlooked or treated as an adynamic ileus because of the similarity in symptoms. The
diagnosis is particularly difficult in puerperium since mild pyrexia, leucocytosis and some
lower abdominal tenderness is generally present following CS. The hallmark symptom is
development of marked abdominal distension over a short period of time and therefore a
diagnostic abdominal X- ray should not be delayed even if the bowel sounds are normal.1
CONCLUSION
This case highlights the need for a greater awareness, amongst obstetric practitioners, of
this potentially lethal syndrome, since it may be successfully treated if identified early. 1 If a
postoperative patient presents with features consistent with a bowel obstruction, prompt
imaging should be performed in order to aid timely diagnosis.4
Reference
1) De M, Mandal A & Cooper JC; “A case of Ogilvie’s syndrome after caesarean section”; J
Obstet Gynaecol (2002); 22:686-687
2) Ogilvie H; “Large intestine colic due to sympathetic deprivation. A new clinical syndrome”;
BMJ (1948); 2:671-673
3) Srivastava G, Pilkington A, Nalla D, Polson Dw & Holt E; “Ogilvie’s syndrome: a case report”;
Arch Gynecol Obstet (2007); 276:555-557
4) Rawlings C; “Management of postcaesarean Ogilvie’s syndrome and their subsequent
outcomes; Aus and New Zeal J of Obstet and Gynaecol (2010); 50:573-581
5) Kakarla A, Posnett H, Jain A, George M & Ash A; “Acute colonic pseudo-obstruction after
caesarean section”; The Obst and Gynecol (2006); 8:207-213