In June 2023, we commenced a project to review and update the Maternity and Neonatal eHandbook guidelines, with a view to targeting completion in 2024. Please be aware that pending this review, some of the current guidelines may be out of date. In the meantime, we recommend that you also refer to more contemporaneous evidence.
Background
- Ogilviclinie’s syndrome2 (acute colonic pseudo-obstruction/ACPO) is defined as an acute dilatation of the colon usually involving the caecum and right hemicolon, without any existing mechanical obstruction.
- The incidence and pathophysiology of Ogilvie’s Syndrome are not fully understood, but if untreated the distension can result in rupture or ischaemic perforation of the bowel.
- Ogilvie’s syndrome most commonly presents following caesarean section. However it can occur in women following a vaginal birth, instrumental birth or during pregnancy.
- Factors that contribute to mortality rates include acuteness of onset of the condition; baseline state and co-morbidities; mode of treatment; delay in bowel decompression; complications of surgery and cardiac arrhythmias secondary to electrolyte imbalance.
The Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) in Victoria has reviewed several cases of Ogilvie’s syndrome since 2018. It found:
- there were no specific risk factors for acute colonic obstruction, but cases were seen in association with significant narcotic analgesia particularly following caesarean section
- Ogilvie’s syndrome developed in healthy women, as well as those with co-morbidities
- some untreated cases led to bowel perforation and faecal peritonitis, with consequent increased morbidity and mortality.
Signs and symptoms
Signs and symptoms of Ogilvie’s syndrome in the postpartum period mimic those of mechanical large bowel obstruction.
- 80% of women have abdominal pain3
- progressive abdominal distension is the most typical finding – most frequently 2 to 12 days after caesarean section
- bowel movements cease or only a small amount of faecal fluid is passed
- Nausea can be present but vomiting is usually a late symptom
- Bowel sounds noted in 90% of patients – may be reported as hyperactive, high pitched or absent
- 40-50% of women continue to pass flatus (in contrast with obstructive symptoms)4
- Tachycardia
- A raised white cell count in the absence of sepsis or signs of peritonism
- Temperature is usually normal but pyrexia indicates sepsis, bowel necrosis and/or perforation.
The woman becomes acutely ill with dehydration, oliguria and features of electrolyte imbalance.
If not diagnosed, the bowel may perforate requiring a laparotomy, bowel resection and formation of a stoma.
Localised tenderness in the right iliac fossa over the caecum can indicate impending rupture.
Signs of progressive disease or peritoneal irritation:
- Fever, chills, rigor
- Persistent tenderness and increased distension, including Blumberg’s sign (rebound tenderness in the abdomen)
- Nausea and vomiting
- Diarrhoea, constipation, failure to pass flatus
- Minimum urine output
- Loss of appetite
Women with significant bowel distension or signs of peritoneal irritation need URGENT senior obstetric and general surgical review for diagnosis and management.
Management
A postpartum woman with abdominal distension and pain should have appropriate imaging to rule out colonic dilatation and perforation.5
A plain abdominal X-ray is the most useful diagnostic test. In Ogilvie’s syndrome it will show a typical picture of a gaseous distension in the colon, especially the caecum. Perforation may occur with a caecal diameter less than 9cm but is more likely if the diameter exceeds 9cm. Perforation becomes increasingly likely as the dilation approaches 12cm.5
If plain radiography fails to confirm the diagnosis a water soluble (preferably) contrast enema should be performed to rule out mechanical obstruction.4 However, its role in specific cases of Ogilvie’s syndrome is unknown.
Women should be reviewed by a medical officer at least every 24 hours following caesarean section.
Refer concerns regarding abdominal distension to a medical officer and follow the management outlined in the flowchart.
Treatment
- An early diagnosis and timely intervention is essential to avoid caecal rupture and its associated high maternal mortality rate.
- Treatment should include an initial trial of conservative/supportive care measures (24-48 hours unless clinical deterioration warrants earlier intervention) with the woman being kept nil by mouth, nasogastric decompression, bowel rest, and correction of fluid and electrolyte imbalance.6,4
- Cessation of medications with the potential to exacerbate the condition, such as opioids, is recommended.
- Avoid aperients, anti-flatulents, antispasmodics.
- Monitoring of the woman’s haemodynamic status is essential.
- Commence a fluid balance chart and measure all urine output.
- Encourage mobilisation/ambulation. Continue or commence prophylaxis against venous thromboembolism as per local guidelines.
- There is emerging evidence to suggest that chewing gum is associated with early recovery of bowel motility, return of bowel function and shorter length of stay for women after caesarean section7
- Full Blood Count (FBC), C-reactive protein, electrolytes and other laboratory studies are indicated.
- Blood Culture if sepsis is suspected.
In the presence of peritoneal signs of perforation, surgery is the appropriate first intervention.4
Pharmacologic Treatment
- If conservative therapy elicits no improvement additional therapeutic options should be considered.
- The best evidence available for medical intervention is to administer neostigmine an acetylcholinesterase inhibitor that can be used to treat motility disorders.3,4
- Mechanical obstruction must be excluded prior to neostigmine therapy.
- CAUTION: Adverse effects of cholinesterase inhibitors include salivation, nausea, vomiting, abdominal pain, bradycardia, hypotension and bronchospasm. Contraindications to neostigmine therapy include signs of perforation, baseline heart rate lower than 60 beats per minute, systolic blood pressure lower than 90mm Hg or active bronchospasm necessitating medication3.
- Intravenous injection of 2 - 2.5mg of neostigmine over a period of 3-5 minutes.1,4
- Women should undergo cardiorespiratory monitoring during neostigmine therapy.
- Atropine should be readily available to counteract severe cholinergic reactions if they occur during administration of neostigmine. The atropine dose for symptomatic bradycardia is 0.5 to 1 mg administered by rapid intravenous injection.8-11 The dose may be repeated every 3 to 5 minutes if needed, until desired heart rate is achieved or a total of 3 mg has been given.8
Bowel decompression via colonoscopy
- Colonic decompression can be performed when bowel perforation is NOT suspected, caecal diameter is greater than 9cm or supportive and medical therapy is unsuccessful.12
- This is a useful method for removing air from the colon and thereby it is hoped reducing the risk of subsequent colonic perforation
- May be difficult to perform because of inability to complete a thorough bowel preparation.
Transfer is recommended if the health service capability does not allow for timely endoscopic surgical management.
Surgical Intervention
Surgery (laparotomy) is indicated when conservative medical management and colonoscopic decompression fail or when clinical signs of ischemia, abdominal sepsis, or perforation are present.
See Management flow chart*
*Note that not all recommendations are based on high-quality evidence but represents the best evidence available and should be used in conjunction with clinical assessment and advice from the surgical team.
Follow up and documentation
Women who develop Ogilvie’s syndrome can by psychologically traumatised by this unexpected complication after childbirth.
They require adequate debriefing, emotional support, explanation of the condition and appropriate follow up.
More information
Audit and performance improvement
All maternity services should have processes in place for:
- auditing clinical practice and outcomes
- providing feedback to clinicians on audit results
- addressing risks, if identified
- implementing change, if indicated.
Potential auditable standards include:
- adherence to standards of care
- LUSC
References
1. Kakarla K, Posnett H, Jain A, George M, Ash A. Review Acute colonic pseudo-obstruction after caesarean section. The Obstetrician & Gynaecologist. 2006;8:207-213. https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1576/toag.8.4.207.27269
2. Wells CI, O’Grady G, Bissett IP. Acute colonic pseudo-obstruction: A systematic review of aetiology and mechanisms. World Journal of Gastroenterology. 2017;23(30):5634-5644. https://www.wjgnet.com/1007-9327/full/v23/i30/5634.htm
3. Cagir B. Intestinal Pseudo-obstruction. Medscape [Internet]. Updated 2018 [cited 2019 Sep 30]. Available from: https://emedicine.medscape.com/article/2162306-overview
4. Maloney N, Vargas D. Acute Intestinal Pseudo-Obstruction (Ogilvie’s syndrome). Clinics in Colon and Rectal Surgery. 2005;18(2):96-101. https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-2005-870890
5. Jayaram P, Mohan M, Lindow S, Konje J. Postpartum Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome): A systematic review of case reports and case series. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2017;214:145–149.
https://www.ejog.org/article/S0301-2115(17)30187-2/fulltext
6. Haj M, Haj M, Rockey D. Ogilvie’s syndrome: management and outcomes. Medicine (Baltimore) [Internet]. 2018 [cited Sep 2019];97(27):e11187.Available here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6076157/
7. Zhu YP, Wang WJ, Zhang SL, Dai B, Ye DW. Effect of gum chewing on postoperative bowel motility after caesarean section : a meta analysis of randomised controlled trials BJOG. 2014;121:787-92. https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/1471-0528.12662
8. Australian Medicines Handbook 2019 (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2019 July. Available from: https://amhonline.amh.net.au/ [subscription required to view].[Internet : Cited : Oct 2019].
9. Trevisani GT, Hyman NH, Church JM. Neostigmine: safe and effective treatment for acute colonic pseudo-obstruction. Dis Colon Rectum. 2000;43:599-603.
10. İlban Ö, Çiçekçi F, Çelik JB, Baş MA, Duman A. Neostigmine treatment protocols applied in acute colonic pseudo-obstruction disease: A retrospective comparative study. Turk J Gastroenterol. 2019;30(3):228-33.
11. The Society of Hospital Pharmacists of Australia, 2019. Australian Injectable Drugs Handbook, 7th Edition. [Internet cited Oct 2019]. Available here: https://aidh.hcn.com.au/browse/about_aidh.
12. Hughes A, Smart N, Daniels I. Acute colonic pseudo-obstruction after caesarean section – a review and recommended management algorithm. The Obstetrician and Gynaecologist 2019;21:283-90. https://doi.org/10.1111/tog.12602
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Version history
First published: Nov 2020
Due for review: Oct 2022