The phantom Block: Ogilvie’s

Thanmayi. K. A Roy

MEM 1st year resident, Kauvery Hospital, Bangalore

Case Presentation

An 85-year-aged female, presented to the ED with progressive abdominal distension since two days, associated with abdominal pain and obstipation.

Primary survey

AirwayPatent
BreathingNVBS, SpO2-94% ON RA, RR-16/MIN
CirculationBP: 110/70 mmHg, HR: 86/min, peripheral pulses felt
DisabilityGCS-15/15(E4V5M6), Pupils - BERL
ExposureAbdomen is grossly distended, hysterectomy scar seen, no dilated veins

History of present illness

An 85-year-aged female, k/c/o schizophrenia, on antipsychotics (Tab. Quetiapine) since two years, presented with progressive abdominal distension associated with abdominal pain since two days and also with obstipation.

  • H/o Hysterectomy 5yrs back (uterine prolapse).
  • H/o fall from bed 3yrs back and sustained T12 # with no neurological deficits, treated conservatively.
  • No H/o fever/vomiting/loose stools.

Allergies: Not known

Medications: Tab. Quetiapine, Tab. Ecosprin 75 mg

Last meal: 9.00 AM

Events – As described above.

Primary adjuncts

  • ECG – RBBB with flattened T-waves.
  • ABG – Lactate: 3.3, Sodium: 119, Potassium: 3.1
  • Temp: 98.6°F
  • 2D-ECHO: EF-55-60%, Concentric LVH, No RWMA
  • USG (Bedside): Dilated bowel loops, reduced peristalsis.

Systemic examination

P/A- Inspection: Abdomen is distended, no dilated veins, no discolouration.

Palpation: Soft, non-tender, no guarding/rigidity, no shifting dullness.

Percussion: Tympanic note heard over epigastrium, Umblical, Hypogastric, Rt. Hypochondriac, Rt. Iliac, Rt. Paraumblical regions, no fluid thrill.

Auscultation: Bowel sounds absent

CVS-S1, S2 Heard

RS –B/L NVBS heard, No added sounds

CNS-NO focal neurological deficits

Investigations (Lab Values)

CBC-Hb-10.8, TLC-9700/mm3, PLT-1,50,000

  1. Lactate-3.3

RFT: S. Urea-36

  1. Creat-0.9
  2. Sodium-129
  3. Potassium-3.1

RBS-146mg/dl

LFT/Sr. Calcium/Thyroid profile were WNL

Differential Diagnosis

CT-abdomen

Grossly dilated caecum measuring approximately 11 cm. Grossly dilated ascending and transverse colon with transition zone at splenic flexure (Griffith’s point). No features suggestive of a mechanical obstruction.

Diagnosis

  • H/o Obstipation, abdominal pain and distension since two days
  • Regular use of quetiapine
  • Chronic use of opiods
  • Cardiac disease
  • Electrolyte abnormality like hypokalemia seen
  • X- Ray showing Rt large intestinal distension
  • CT-Abdomen-showing grossly dilated ascending and transverse colon with a transition zone at splenic flexure
  • No features of mechanical obstruction

Based on above findings we can come to conclusion that patient is having “Ogilvie’s Syndrome”

Course in the hospital

  • NG tube inserted.
  • Electrolyte abnormality corrected.
  • Antipsychotics were titrated.
  • Patient improved signoificantly on 2nd day of admission.
  • Abdominal distension decreased, bowel habits returned to normal in a week.

Nerve supply of large intestine

OGILVIE’S syndrome

Commonly called as Acute Colonic Pseudo Obstruction. It is a diagnosis of exclusion. It is a functional rather than mechanical obstruction of large intestine involving cecum, asc. colon, transverse colon upto splenic flexure

Age :Generally involves elderly population (64-84yrs). Generally seen in patients with multiple chronic conditions

  • A/W-Surgical procedures
  • SLE
  • Haematological cancers
  • Cardio-pulmonary diseases

Pathogenesis

Mostly Idiopathic. Unopposed parasympathetic activity where there is decrease in activity of stimulatory neurotransmitters relative to inhibitory neurotransmitters (stimulatory NT ACH, Neurokinin-A, Substance P, Inhibitory NT-VIP, NO). Dilatation is proximal to splenic flexure.

Risk factors

  • Previous surgeries.
  • Electrolyte imbalance.
  • DM, Renal failure, cardiac and other renal conditions.

Why do we need to know about OGILVIE as an ER physician?

  • Unnecessary surgical intervention can be prevented.
  • Studies show that conservative management yields similar if not superior results than surgical intervention in Ogilvie’s syndrome.

References

  • Burt Cagir et al., Intestinal Pseudo Obstruction medscape/article/2162306
  • CHOI JS, Lim JS, Kim H et al. Colonic pseudoobstruction: CT findings. AJR AM J Roentgenol. 2008:190(6):1521-6.
  • Sleisenger, Fordtran. Gastrointestinal and Liver Diseases; Saunders Elsevier, Ninth edition.
  • J. Gouma. Update Gastroenterology 2004:New Developments in the Management of Benign Gastrointestinal Disorders.

Journals

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