Ogilvie's syndrome following cesarean delivery: The Dubai's case.

We present a case of acute colonic pseudo obstruction (Ogilvie's Syndrome) post Cesarean Section in a 35 years old Arabic patient with co-existing systemic lupus erythematosus. Due to developed complications-perforations of the colon and peritonitis, the patient required laparotomy and right hemicolectomy. To our knowledge, this is the first case of Ogilvie's syndrome, reported from the Middle East. The possible etiologic factors, pathophysiology, clinical presentation, diagnostic work up and treatment are discussed. The need for awareness about the syndrome and early diagnosis is emphasized.

INTRODUCTION

Ogilvie's syndrome (acute colonic pseudo-obstruction) is a rare entity, occurring in many of the reported cases in postsurgical procedures. It is characterized by abdominal distention and massive dilatation of the colon, without mechanical obstruction. Conditions that have been associated with the syndrome include surgery, infection, electrolyte disturbances, connective tissue and cardiac diseases and medications-corticosteroids, Syntocinon, opioids, etc. We describe a case of Ogilvie's syndrome in a parturient with systemic lupus erythematosus (SLE) following cesarean delivery at term under general anesthesia.

CASE REPORT

A 35-year-old, gravida 4, para 3, American Society of Anesthesiologist (ASA) 2, Arabic female was admitted for elective cesarean section at 37 weeks of gestation. As the ultrasound report was inconclusive, an MRI was done which revealed anterior low-lying placenta. The obstetric history consisted of previous 3 cesarean sections under general anesthesia which have been uneventful. The medical history was significant for SLE discovered 10 years ago. The patient was on corticosteroids (Prednisolon 10 mg daily), vitamins, aspirin, and low molecular weight heparin (Enoxaparin 40 mg o.d.), which was discontinued the day before the operation.

Preoperatively, the patient received aspiration prophylaxis consisting of an H2 blocker, the night before and on the morning of surgery, and 30 ml Sodium Citrate prior to sending her to the operating theatre. Gastro kinetic agent and corticosteroid cover were given. As the patient refused regional anesthesia, the cesarean section was done under general anesthesia with invasive monitoring of blood pressure. The neonate was delivered with Appgar scores 9/9 at 1 and 5 minutes. A bolus of 2.5 units of Oxytocin and an infusion were started following delivery. Prostaglandin F2 (Carbaprost) and Methergine were needed in order to maintain the contraction of the uterus. Fentanyl, antibiotic prophylaxis, and antiemetic were given after delivery. The estimated blood loss was less than 1 000 ml, replaced with crystalloids and colloids. No adhesions were found during the surgery. The mother has remained stable throughout the operation and after initiating patient-controlled analgesia with Morphine in the recovery room, she was sent to the ward.

Postoperatively, initially the patient was stable, asymptomatic, with blood pressure, 120/70; pulse rate, 80; and SpO2, 98% on room air and respiratory rate 12/min. Abdomen was soft, bowel sounds present, uterus contracted, and urine output good. Approximately 34 hours postoperatively, the patient vomited several times greenish material and complained from abdominal pain. The abdomen was distended, with sluggish bowel sounds. The temperature was normal and the laboratory results were unremarkable, apart from the low potassium (3.1 mmol/l). The obstetricians transferred the patient to the intensive care unit and summoned help from a general surgeon who found no signs of peritonitis. A nasogastric and rectal tubes were inserted and the potassium replacement therapy, which had already been started, was continued.

As the patient's condition did not improve—the abdomen remained distended and the vomiting continued—a plain abdominal film was taken and abdominal ultrasound done. The findings were described as massive gaseous distention of the bowels without fluid levels [Figure 1]. A diagnosis of paralytic ileus was made by the surgeons and conservative treatment with intravenous fluids and potassium replacement was advised.

Figure 1

Colonic distention — Ogilvie's syndrome

On the third postoperative day, the patient's condition further deteriorated. Despite the aggressive fluid management and electrolyte replacement, the urine output has dropped to 20 ml/h and potassium remained low (3.4 mmol/l). The abdominal girth had increased with large nasogastric aspirates (500 ml for six hours). The repeated plain abdominal film showed air under the diaphragm [Figure 2]. The anesthesia team insisted for an operation.

Figure 2

Perforation of the colon-gas under the diaphragm

The surgeons decided to do laparoscopy, which revealed perforations on the ascending colon and severe peritonitis. The laparoscopy was abandoned and during the laparotomy which followed, right hemicolectomy was done with ileostomy.

Postoperatively, the patient was brought back to the intensive care unit. She was managed with fluids, antibiotics, nutritional support, etc., along the standard guidelines for management of peritonitis.

The patient recovered and she was discharged after 5 days of intensive care unit (ICU) management to the ward.

Hospital discharge was done 12 days after the cesarean section with instructions for follow-up.

DISCUSSION

Ogilvie's syndrome (acute colonic pseudo-obstruction) is a rare postsurgical complication, which can be associated with cesarean section. Clinically, it presents with abdominal distention and massive dilatation of the colon, without mechanical obstruction.[1] Since its description by Ogilvie in 1948, a number of reports have been published. A Medline search revealed 127 publications so far (at the time of writing this report). None of them has come from the Middle East, which may give the impression that the genotype of the Arabic population protects them from the above disease entity.

Multiple factors have been implicated in the development of the syndrome, but the disease is seen mainly in patients who have other causative distress.[2] Obstetric and gynecologic surgery,[34] co-existing medical problems and immobility,[5] opioids,[6] tocolytics,[7] Syntocinon[8] and other drugs,[9] electrolyte disturbance, etc., have all been reported.

The suggested pathophysiology is imbalance in the autonomic nerve supply to the colon.[10] The parasympathetic nervous system promotes gut motility through the vagus and sacral parasympathetic nerves (S2-S5), while sympathetic stimuli inhibit bowel peristalsis. An imbalance in the sympathetic and parasympathetic tone leads to reduced colonic motility and functional bowel obstruction. Although the cecum is the usual site of dilatation, all parts of the colon can be affected.

In Dubai's patient, the etiology appears to be multifactorial. The cesarean section, corticosteroids, opioids, and oxytocin could have contributed to the development of the Ogilvie syndrome. The effect of prostaglandin F2 on the smooth muscles and vasoconstrictor effect of Methergine need further consideration. Vasculitis from the SLE might have played a role. The low potassium in our patient should be considered as a causative factor, although it could have been a result from the vomiting and gastric stasis.

Although the exact cause of the patient's condition initially remained uncertain, attempts to address some of the possible causes and elicit the diagnosis were made. Aggressive fluid therapy and electrolyte replacement, nasogastric and flatus tubes, etc., were commenced.

The presenting symptoms in our case—nausea and vomiting, abdominal pain and distention, hypoactive bowel sounds—should have alerted the team about the possibility of Ogilvie syndrome. The plain X-ray abdominal film [Figure 1], taken in our patient, confirms the diagnosis, showing cecum and colon dilatation, without air-fluid levels and absent cause of mechanical obstruction.

Although less than 9 to 10 cm dilatation of the cecum and colon is considered an indication for nonsurgical treatment,[11] in our case, only corrections of the fluid and electrolyte balance and nasogastric and flatus tubes were done. Colonoscopic decompression, with or without placement of an indwelling tube, should have been employed as part of the management[1213] and is effective in 70 to 85% of the cases, but carries its own small risk of perforation and is difficult to perform. Pharmacologic management with parasympathomimetic drugs enhancing gut motility has been described in the treatment of Ogilvie's syndrome, including neostigmine, erythromycin, etc., and might have been attempted in the above case.[10] Enema with laxative or contrast could have been another therapeutic approach.[14]

The suddenly arisen abdominal distention with its progressive course in Dubai's patient could have led the clinicians toward including the Ogilvie's syndrome in the differential diagnosis, as it is considered to be the most relevant clinical finding.[15]

The apparent failure of the conservative treatment in the above case should have prompted a surgical approach, consisting of either open[16] or percutaneous cecostomy.[17]

The progressive increase of colonic dilatation in the above patient has led to increased intraluminal pressure, ischemia with splitting of the serosa, herniation of the mucosa, perforation, and peritonitis [Figure 2]. Ascending colon perforations in our patient was the spontaneous outcome, due to the vicious circle, perpetuating functional obstruction.[18] The poor tissue quality in a patient with SLE and steroid treatment added to the above.

Although perforations of the colon in Ogilvie's syndrome after failure of the conservative treatment and right hemicolectomy is described in the literature,[1920] mortality is high in these cases and can reach up to 50%.[21] In our case, the patient survived, but lessons have to be learned.

In conclusion, we have presented the first case of acute colonic pseudo obstruction in Arabic patient with SLE post-cesarean section. Although genetic predisposition to the Syndrome is an unanswered question, Arabic population is not immune to it. We were able to identify only 3 reports in the literature in which laparoscopy have been used as part of the diagnosis and/or management.[22-24] The author debates this approach, as due to the distended bowels the possibility of iatrogenic visceral injury is high. The insufflation of the abdomen with gas during laparoscopy will further deteriorate patient's condition, considering the negative effects of high intra-abdominal and intrathoracic pressures. Although a rare condition, Ogilvie's syndrome should not be forgotten. The possibility of its occurrence has to be considered in a patient with abdominal distention, nausea, vomiting, and dilated bowels on an X-ray film postoperatively. Early diagnosis is important, as the condition can progress quickly to bowel ischemia, perforation, and peritonitis. Endoscopic decompression and, when needed, early surgical intervention can decrease the mortality and morbidity associated with the disease.

Interestingly, it was the anesthesiologist who reached/put the diagnosis in the above case and prompted the surgical team. It emphasizes the notion that the anesthesiologists should always look at the patient from a broader perspective, have the knowledge and skills, and act as perioperative physicians.