(P04) Living to Tell the Tale About Ogilvie's Syndrome

Introduction: Colonic pseudo-obstruction or Ogilvie's syndrome is characterized by bowel dilation in the absence of a mechanical obstruction that results from autonomic dysregulation and impaired peristalsis. Estimated incidence is about 0.5 to 1.3% following major orthopedic, spinal and cardiothoracic surgery. A higher incidence is suspected in the post-acute and long-term care (PALTC) setting. This is a unique case of successful neostigmine infusion in a 97-year-old with Ogilvie's syndrome following obturator hernia repair.

Case Description : A 97-year-old female undergoing rehabilitation in a skilled nursing facility was brought to the Emergency Department for an incarcerated right obturator hernia that required urgent surgical repair. Worsening abdominal distension was noted on hospital day 9. Abdominal X-ray revealed colonic distention with no evidence of obstruction, consistent with Ogilvie's syndrome. Perforation, peritonitis, or ischemia were ruled out. Testing for clostridium difficile was negative. Nasogastric tube was placed for decompression. Despite supportive care, cecum diameter increased from 8 to 11cm in 24 hours. Due to rapid worsening a 12-hour, 5 mg neostigmine infusion was ordered. Treatment was well-tolerated; cecum diameter decreased to 7cm with return of bowel function.

Discussion: Ogilvie's syndrome is a rare post-surgical complication following open hernia repair. Awareness of this condition is crucial for PALTC clinicians since it typically presents around 5 days post-operatively and could be encountered after transitioning out of the hospital. Associated risk factors include heart failure, diabetes, neurocognitive disorders, immobilization and electrolyte abnormalities. Careful medication reconciliation should be implemented as opioids, anticholinergics and antipsychotics increase risk.

Suspicion for Ogilvie's syndrome warrants rapid referral to the hospital as intestinal rupture carries a >50% mortality rate. Clostridium difficile colitis, ulcerative colitis, volvulus, and mechanical obstruction should be ruled out. Nasogastric decompression, bowel rest, correction of electrolyte abnormalities, early mobilization, and discontinuation of potentially contributing medications is effective in 70-90% of cases with a cecum diameter less than 12 cm. Neostigmine is effective in 85-94% of cases and should be considered after 48 to 72 hours of supportive treatment, severe abdominal pain, or cecal diameter > 12 cm.

Continuous infusion has been associated with greater bowel diameter reduction and decreased risk for procedural colonic decompression when compared to bolus dosing. Despite a high-risk side effect profile, it is still a preferred option to avoid more invasive treatments.

Ogilvie's syndrome should be suspected in any older adult residing in post-acute and long-term care who presents with a distended abdomen in the early postoperative period. Rapid diagnosis can be lifesaving, and treatment is usually well tolerated.