Endoscopic Management of Acute Colonic Pseudo-Obstruction

Objectives

Acute colonic pseudo-obstruction (ACPO), also referred to as Ogilvie’s syndrome, is a clinical condition that presents with the symptoms, signs, and radiographic appearance of acute large-bowel obstruction without a mechanical cause (Figure [1]). ACPO is an important cause of morbidity and mortality. Early detection and prompt, appropriate management are critical to minimize morbidity and mortality. The decision to intervene with active therapy is dictated by the patient’s clinical status. The risk of spontaneous colonic perforation in ACPO is estimated to be approximately 3 %. The mortality rate in ACPO is approximately 40 % when ischemia or perforation is present, compared with 15 % in patients with intact and viable bowel [1].

Figure 1 An abdominal radiograph demonstrating the characteristic findings of acute colonic pseudo-obstruction (ACPO), that is, marked colonic dilation of all segments, particularly the right colon. There is also gaseous distension of the small bowel.

According to Laplace’s law, the risk of mucosal ischemia dramatically increases with luminal distension, due to increasing intramural tension that retards orthograde intramural blood flow. The risk of colonic perforation, likewise, dramatically increases with luminal distension because the bowel wall becomes thinner and weaker when stretched, while the intramural tension increases with increasing luminal diameter. The analogous mechanical effect occurs when a balloon bursts (“perforates”) as the balloon wall becomes progressively thinner and intramural tension increases during balloon overinflation. Decompression is performed, therefore, to prevent both bowel ischemia and perforation.

References

• 1 Vanek V W, Al-Salti M. Acute pseudo-obstruction of the colon (Ogilivie’s syndrome). An analysis of 400 cases.  Dis Colon Rectum. 1986;  29 203-210
• 2 Eisen G M, Baron T H, Dominitiz J A. et al . Acute colonic pseudo-obstruction.  Gastrointest Endosc. 2002;  56 789-792
• 3 Rex D K. Colonoscopy and acute colonic pseudo-obstruction.  Gastrointest Endosc Clin N Am. 1997;  7 499-508
• 4 Geller A, Petersen B T, Gostout C J. Endoscopic decompression for acute colonic pseudo-obstruction.  Gastrointest Endosc. 1996;  44 144-150