INTRODUCTION:

Acute colonic pseudo-obstruction (ACPO) a rare disorder, otherwise called Ogilvie's syndrome (OS) or non-obstructive colonic dilatation, is attributed to acute dilation of the lower bowel, typically involving the caecum, ascending colon and hepatic flexure in the absence of mechanical blockage (80–90%)¹

The condition often occurs in individuals in their geriatric age with several comorbidities and surgical treatments, and men are more frequently impacted than women²

Sir W. Heneage Ogilvie first reported this syndrome in the year 1948 in two individuals in whom a neoplasm may have obstructed the sympathetic innervation to the colon, hence permitting unbroken parasympathetic activation³. Recent theories implicate either an overactive sympathetic nervous system or a decreased parasympathetic nervous system, but the sympathetic nervous system plays a significant role⁴. The pathogenesis of ACPO is unclear, but it is believed to be due to a malfunction of the autonomic neural system with decreased activity of agnostic neurotransmitters like acetylcholine and increased activity of antagonistic neurotransmitters like vasoactive intestinal peptide⁵.

ACPO typically develops in hospitalized individuals with severe sickness or trauma or after general, neurosurgical, orthopaedic, or other surgical operations, with an approximate frequency of 100 per 100,000 admitted cases and a fatality rate of 8%^6,8. Bowel perforation may transpire if the colon is dilated by 9 cm to 12cm, and the fatality rate can reach 46%^6,8. In a set of clinical cases, the prevalence of ACPO was 1.19 % for spine procedures, 0.65% for knee replacements, and 1.31% for hip replacements, with longer median hospital stays than the control group⁹. In a study involving surgery on the thoracic, cervical, and lumbar spine, radiographic POI occurred 32.9% of the time and symptomatic POI 13.4% of the time⁹_.

ACPO is uncommon but serious obstetric complication that can arise after a C-section. According to^10,11, the occurrence of postpartum ACPO is 1:1460 deliveries, with 0.4% of C-section deliveries affected. Spontaneous colon perforation, which can occur in cases of ACPO, has a reported probability ranging between 3 and 25% and a fatality rate of up to 50%^6,12. Therefore, early detection and therapy are essential for improving prognosis^13,14.

AIM:

The objective of this investigation regarding ACPO is to scrutinize its clinical manifestation, etiology, predisposing factors, diagnostic approaches, therapeutic interventions, and clinical outcomes. The study endeavours to furnish a holistic comprehension of ACPO, discern efficacious diagnostic and therapeutic modalities that could enhance patient prognosis, and address any deficiencies in the existing knowledge and comprehension of ACPO that necessitate further exploration. Ultimately, the objective of this study is to ameliorate the management of ACPO and mitigate the consequent morbidity and mortality.

DIAGNOSIS:

The accurate diagnosis of colonic pseudo-obstruction, ischemia, perforation, or mechanical obstruction necessitates a comprehensive clinical evaluation and the utilization of advanced imaging techniques. Abdominal X-ray examination can provide insight into colonic pseudo-obstruction through the observation of extensive bowel. Computed tomography (CT) imaging, which boasts a sensitivity of 96% and a specificity of 93%, is more precise than conventional radiography for ruling out mechanical obstruction and often depicts enlargement of the proximal colon and the splenic flexure transition zone.^12,15,16

Barium enema is capable of diagnosing mechanical obstruction, but is not advised when perforation is suspected and is used less often due to the high diagnostic yield of CT^12,16,17. Ogilvie's syndrome (OS) and colonic perforation, which present with similar symptoms, require radiographic imaging to differentiate. CT scan and abdominal X-ray can reveal peritonitis symptoms and pneumoperitoneum when perforation complicates the condition.^7,18 In gynecologic patients who have undergone C-sections, ACPO symptoms typically arise within 48 hours post-surgery, and at the most, within 12 days. Gastrografin enema can serve as both a diagnostic and therapeutic option for colonic pseudo-obstruction, as it induces a fluid shift in the colon and enhances intestinal motility. In some instances, however, exploratory laparotomy remains the sole definitive diagnostic option.^19,20,21,22

Colon visualization is achieved by employing a colonoscope, an elongated instrument comprising a camera, light, and ports akin to an endoscope. This cutting-edge device is inserted through the rectum, facilitating limited visualization of the small intestine. Its utility lies in the diagnosis of conditions such as colon polyps, obstructions, and colon cancer, as it enables the retrieval of biopsies for subsequent investigation. The procedure's duration may range from 15 to 60 minutes. To ensure optimal clarity of the colon's lining, patients must be advised to evacuate their bowels employing laxatives while discontinuing the use of over-the-counter medications and blood thinners.²³

Patients assume a supine or left lateral decubitus position, as the colonoscope is cautiously inserted and advanced towards the terminal ileum. Subsequently, it is meticulously retracted while meticulously scrutinizing the colon lining. In instances where complete visualization of the colon is unfeasible, the physician may opt for a subsequent colonoscopy with varied bowel preparation or order an X-ray or CT scan. Potential complications include perforation, infection, bleeding, anesthesia-related side effects, chest pain, hematochezia, dysphagia, dyspepsia, and heartburn.²³

SIGNS AND SYMPTOMS:

OS is a pathological condition that is attributed to a constellation of symptoms, including bowel obstruction, severe constipation, dilated colon from cecum to splenic flexure without blockage, abdominal distension, tenderness on palpation, and diminished bowel sounds on auscultation.²⁴ In addition, patients may experience abdominal discomfort (80%), nausea and/or vomiting (60%), and abdominal distension. In about 40% of cases, passing flatus or stool is reported. Although fever is more frequently observed in individuals with ischemia or perforation, there are no significant differentiation in symptoms among those with these complications and those without. Physical examination may reveal a tympanitic abdomen and audible bowel noises. Leukocytosis, significant abdominal discomfort, and fever may also occur in patients who have not developed ischemia or perforation⁶.

AFFECTED POPULATION:

The incidence and epidemiology of ACPO have been well-documented in several studies. Although the prevalence of OS in overall population remains unknown, a retrospective longitudinal study estimated an annual incidence rate of approximately 100:100,000 hospitalized patients. The condition typically afflicts individuals around the age of 60, with a slightly higher prevalence in males than females. The mortality rate varies based on the severity of the case, with a fatality rate of 15% and 44% in simple and complex cases respectively.

Vanek (1986) conducted a comprehensive review of 400 cases of OS from scholarly literature and reported that men exhibited a higher incidence than women, with an average age of 59.9 years for men and 56.5 years for women. In most cases, patients had an underlying medical or surgical issue, with caesarean section being a significant factor in female patients who presented at a relatively younger age. Other studies have found links between OS and orthopaedic surgery, infection, heart disease, postoperative status, renal failure, electrolyte abnormalities, and narcotic abuse.

In children, OS has been observed with oncological disorders, spinal surgery, sickle cell and Kawasaki disease, and after kidney transplant. ACPO is also an infrequent condition, occurring in approximately 100 cases per 100,000 hospitalisations. Recent studies indicate that mortality rates associated with ACPO have decreased from 9.4% in 1998 to 6.6% in 2011 in the United States, although the possibility of over-diagnosis exists, there has been a decline. Historically, fatality rates were as high as 30%, with 10-20% of patients experiencing perforation and ischemia of the colon, leading to death rates of up to 45%.

OS disproportionately affects geriatric and comorbid individuals, frequently those with chronic neurological, cardiac, or respiratory ailment and an acute illness. The condition is also observed after various surgical procedures, including general, orthopaedic, neurosurgery, gynaecological and cardiothoracic procedures. Incidence rates have been documented for spinal or orthopaedic surgery (1% to 2%), burn injuries (0.3%), and cardiac bypass (up to 5%). Overall, these findings suggest that OS and ACPO are serious medical conditions that require prompt diagnosis and appropriate management to prevent potentially fatal outcomes.

COMPLICATIONS:

Timely identification and prompt treatment are of paramount importance in preventing fatal complications in patients diagnosed with ACPO¹ Delayed diagnosis, typically after six days from the onset of symptoms, and colonic dilation exceeding 9-12 cm in diameter are recognized risk factors for the progress of complications⁶.

Among the possible complications, ischemia and perforation are considered the most ominous⁶. Perforation is relatively rare, affecting 1-3% of cases, but is associated with a mortality rate of 50-71%, significantly higher than the non-perforated group which has an 8% mortality rate⁶.

In gynecologic oncology patients, OS is an infrequent surgical complication, with only a few documented cases in the literature¹². As such, gynecologic and obstetric surgeons must be knowledgeable about this unusual complication¹⁸. Notably, ischemic colonic complications have been reported after 7-10 days of treatment¹², highlighting the importance of early detection and intervention.

Cecal perforation is the most dreaded consequence of OS. Although historically, radiographic measurements of cecal distension exceeding 9cm were associated with a greater risk of rupture, recent studies indicate that perforation is uncommon when the cecal diameter is less than 12cm²⁵. However, when the diameter exceeds 14 cm, the frequency of complications rises to 23%⁶.

In pregnant women, emergency exploratory laparotomy may be necessary to mitigate the risk of serious maternal-fetal complications, especially colonic perforation²⁶. While endoscopy for decompression therapy has no contraindications, it carries a greater risk of morbidity in gestational women compared to the entire population (6-7% vs. 1%, respectively)²⁶.

RISK FACTORS:

Numerous factors have been identified as potential hazards that may lead to severe complications or infections in senior inpatients and outpatients. These include metabolic imbalance, critical illness, recent hand surgery, and non-surgical reasons^12,27,28. In addition, elements of danger such as severe infection, neurologic events, cardiac events, metabolic imbalance, and significant surgery have also been reported to pose a significant risk^4,6,29.

Pelvic organ prolapse in women has been found to be primarily caused by C-sections and gestation, followed by trauma and pelvic surgery^30,31,32 found that C-section was a more frequent cause, followed by urological surgery. Obstetric patients with elevated levels of prostaglandin, glucagon, and progesterone during gestation are also at risk for acute colonic pseudo-obstruction (ACPO)³³. In addition, age over 60 years, caecal diameter greater than 14 centimeters, and duration of colonic dilatation greater than four days were identified as potential risk factors for death from ACPO⁶.

PATHOPHYSIOLOGY:

ACPO represents a rare but potentially life-threatening condition attributed to a functional blockade of the large intestine. The pathogenesis of this disorder is considered as complex and likely involves an instability in autonomic colon signalling. Although Sir W. Ogilvie initially described the illness in 1948 and proposed that it resulted from "sympathetic deprivation" of the distal colon, recent hypotheses implicate either an overactive sympathetic or a decreased parasympathetic response⁴.

ACPO leads to a decrease in the movement of the proximal colon while conserving the distal colonic regulation by the parasympathetic nervous system, which is dependent on the sacral spinal segments, thereby blocking the distal colon. This can result in a major dilation of the proximal colon and caecum, which carries a considerable risk of colonic ischemia and perforation if rapid decompression is not executed⁷.

A malfunction of the autonomic nervous system with diminished activity of agonistic neurotransmitters, like acetylcholine, and increased activity of antagonist neurotransmitters, such as vasoactive intestinal peptide, has been hypothesized to be the root cause of ACPO¹⁸. The celiac and mesenteric ganglia provide sympathetic input to the colon, while the parasympathetic neural system enhances contractility, and the sympathetic nervous system decreases motility)³⁴.

Numerous conditions produce an abnormality in autonomic innervation, leading to an imbalance between parasympathetic and sympathetic activity. As the colonic innervation terminates at the splenic flexure, and the left colon receives parasympathetic input from the sacral plexus, it has been postulated that transient dysfunction of the parasympathetic fibres at the sacral plexus may lead to atony of the distal colon and functional obstruction³¹.

Alternatively, overactivity of suppressive neurons to the lower bowel, caused by an increase in adrenergic drive, may play a significant role in the pathogenesis of ACPO³⁴. When triggered by distention, mechanoreceptors in the wall of the lower bowel activate a neuroreflex pathway whose end impact, via efflux sympathetic neurons addressing smooth muscle layers or the myenteric plexus, is the suppression of Colo-colonic reflex³⁴_.

Despite a greater understanding of the patho-physiology of colonic motility, the specific mechanisms that underly ACPO continue to be poorly understood.

TREATMENT:

The prognosis for patients with ACPO in gynecologic and obstetric settings appears favourable, although morbidity and mortality rates remain high due to the need for major operative treatment in most cases. The initial management of ACPO involves the administration of antibiotics, electrolyte correction, intravenous fluids, analgesics, and nasogastric tube insertion. Additionally, intravenous neostigmine and colonoscopic-assisted colon decompression have been used to manage ACPO, and the ASGE has developed a guideline for its treatment based on scientific evidence³⁵.

Treatment options for ACPO include conservative therapy with close monitoring, medical management, colonoscopic decompression, and surgery.

The sole controlled therapeutic interventional trial for ACPO investigated the use of intra-venous neostigmine²⁵. Neostigmine's proposed mechanism of action is based on the autonomic regulation imbalance in colonic function in ACPO. Neely and Catchpole first employed neostigmine more than three decades ago to modulate the autonomic innervation of the gastrointestinal tract in patients with small bowel paralytic ileus³⁶. Neostigmine has a rapid onset of action (1–20 minutes) and a short duration of effect (1–2 hours)³⁷. In patients with renal failure, the elimination half-life is prolonged.

Polyethylene glycol (PEG) electrolyte solution has been found to decline in the recurrence rate of colonic dilatation in patients with ACPO after initial resolution³⁸. Although there are few non-randomized reports on the use of additional prokinetic agents with ACPO, some case reports suggest the effectiveness of erythromycin, a motilin receptor agonist, in the treatment of ACPO³⁹ reported two individuals with ACPO achieving decompression following ten days of oral erythromycin (500mg QID), while another patient received three days of intra-venous erythromycin therapy. In a recent trial, the administration of intravenous erythromycin over a period of three days resulted in the resolution of ACPO in a patient. However, the efficacy of newly discovered motilin receptor agonists in improving colonic motility remains uncertain^39,40_.

Cisapride, a 5-HT4 receptor partial simulator, has been used to treat patients suffering from ACPO with moderate success⁴¹. However, this medication is no longer available in Canada and US due to its classification as a class III antiarrhythmic agent. Second-generation partial 5-HT4 receptor simulators like tegaserod is perhaps more effective in enhancing gut motility than cisapride⁴². Polyethylene glycol (PEG) administered orally, transrectally, and through a Faucher tube.

One study examined the efficacy of administering polyethylene glycol (PEG) orally, transrectally, and through a Faucher tube in preventing recurrence of OS after successful therapy with colonoscopic exsufflation or neostigmine³⁸.

Gastrografin® enema:

In another retrospective investigation involving 18 participants, Gastrografin® enema, a hyperosmotic, hydrophilic contrast agent, was found effective in 78% of cases when injected through the rectum under fluoroscopic supervision, resulting in an average reduction in cecal diameter of 4.6cm without colonic perforation⁴³. However, the lack of evidence precludes the recommendation of gastrografin® at present.

Stimulants of intestinal motility:

Erythromycin, a motility stimulant and GI-irritant, has been reported to have a success rate of 40% but also a high recurrence rate of 50%, and is therefore not recommended in contemporary clinical practice⁴⁴.

Anesthesia epidural:

Regarding anesthesia epidural, the nerve roots T11 and L2 that provide sympathetic innervation of colon play a role in the onset and duration of megacolon. Sympathetic hypertonia is a contributing factor to ACPO. An obstruction of the sympathetic neural system causes splanchnic vasodilation and impairs the neural flow of inhibitory colo-colic reflex. A study conducted in 1988 demonstrated the effectiveness of epidural anesthesia with bupivacaine or lidocaine for splanchnic blockage in reducing abdominal distension and cecal diameter, and facilitating the passage of flatus and stool^16,45. The onset of these effects was often rapid, nearly simultaneous with the epidural injection.

Endoscopic decompression:

Normativeaspects:

Mechanical decompression is a potential treatment option for ACPO, which can be accomplished via non-surgical interventions such as the radiographic installation of decompression tubes or colonoscopy with or without implantation^46,47,48. Neostigmine, an acetylcholinesterase inhibitor, is also recommended as a treatment protocol for ACPO, with the intravenous delivery of 2mg of neostigmine over 3-5 minutes, and continuous electrocardiogram and vital sign monitoring for 30 minutes to ensure safety⁴⁹.

Surgical treatment:

Surgical intervention is typically performed in patients with colonic ischemia or perforation or those who do not respond to non-surgical therapies. However, surgery carries significant morbidity and mortality risks, with reported rates of 6% and 30%, respectively⁶. The type of operative procedure depends on the condition of the digestive tract, with cecostomy recommended in the absence of a ruptured or ischemic intestine due to its high success rate and low morbidity⁶. For perforated or ischemic bowel segmental or primary anastomosis or subtotal resection with exteriorization is advised.

Colonoscopic exsufflation:

In 1977, Kukora and Denison⁵⁰ pioneered the technique of colonoscopic exsufflation. In cases where conventional medical interventions have proved ineffective and there is no suspicion of perforation, exsufflation remains the preferred course of action. However, caution must be exercised during the insufflation required for colonoscope implantation, as the presence of stercoral matter and water-soluble contrast can increase the risk of perforation within the intestinal lumen. Additionally, colonoscopy serves as a diagnostic tool for colonic ischemia that may require surgical intervention. The SAGES guidelines currently codify this approach in great detail. . The rate of colonoscopic rupture is 2%, and the expected mortality rate is 1%^27,51.

POTENTIAL IMPLICATIONS:

The study of acute colonic pseudo-obstruction has significant implications for clinical practice and medical research. A better understanding of this condition could lead to improved diagnosis, treatment, and management strategies for patients with colonic blockade. The development of more effective and targeted pharmacological therapies. The identification of specific biochemical pathways involved in the pathogenesis of colonic pseudo-obstruction may enable the design of more precise pharmacological interventions that target these pathways, resulting in better outcomes for patients.

The refinement of surgical techniques for colonic decompression. A deeper understanding of the mechanisms that underly colonic pseudo-obstruction may inform the development of minimally invasive surgical procedures that are less invasive and have fewer complications than traditional surgical approaches. Overall, the study of ACPO is critical to advancing the understanding and management of this challenging condition, and probably to significant improvements in patient outcomes and quality of life.

CONCLUSION:

In conclusion, ACPO is a rare but potentially perilous condition that can occur in Inpatients, particularly those undergoing surgery or with significant comorbidities. The pathogenesis of ACPO remains unknown, but malfunction of the autonomic neural system perhaps is known to play a significant role. Diagnosis is typically based on non-mechanical abdominal distension seen on imaging studies, but in resource-limited settings, clinical suspicion based on symptoms is crucial. Treatment options include supportive care, pharmacological interventions, colonoscopy, and surgery, depending on the intensity of the condition. The incidence of ACPO is highest in men and in the elderly population. Although the fatality rate associated with ACPO is low, bowel perforation can occur, leading to a significant increase in morbidity and fatality. Early detection and prompt intervention are critical for improving the diagnosis of affected individuals. Further research is necessary to better comprehend the pathogenesis of ACPO and to identify effective preventive and therapeutic strategies.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

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Received on 21.06.2023 Modified on 11.08.2023

Res. J. Pharmacology and Pharmacodynamics.2023;15(4):198-204.

DOI: 10.52711/2321-5836.2023.00035