Man with abdominal distension.

CASE

A 63-year-old man presented with abdominal distension and shortness of breath for two days. He reported flatus and denied chest pain, anorexia, vomiting, or abdominal pain. Surgical history was notable for left hepatectomy, cholecystectomy and choledochojejunostomy with a Roux-en-Y. He was afebrile with a pulse in the 100s, blood pressure of 130/60, respiratory rate of 34, and oxygen saturation of 92% on room air. Breath sounds were decreased in the lower lung fields and bowel sounds were noted in the chest. Abdominal exam was notable for distension, tympany and normoactive bowel sounds, but no tenderness, rigidity or fluid wave.

Complete cell count, chemistry panel and lipase were normal. Bedside echocardiography was obscured by air. A computed tomography (CT) was obtained. What is the diagnosis?

DIAGNOSIS

Acute intestinal pseudo-obstruction (AIPO)

Also known as Ogilvie’s Syndrome, AIPO is a rare diagnosis seen in patients with history of trauma, recent surgery, neurologic disorder, infection or electrolyte abnormalities.1 Patients present with painless abdominal distension and have normal bowel sounds.2 Plain films show distended bowel without fluid levels. Abdominal CT is typically obtained to exclude mechanical obstruction, perforation or toxic megacolon.1 Most patients improve with fluids, bowel rest and nasogastric decompression. Neostigmine is also a safe and effective treatment.3–5 Surgery is only indicated if conservative therapy fails.1 If cardiac compression or tamponade is present, emergent decompression with percutaneous transabdominal catheterization can be performed.6 Mortality from AIPO is as high as 50%, and is mainly due to ischemic necrosis, perforation and other complications.1

Our patient’s vital signs normalized and his distension improved with fluid resuscitation and nasogastric decompression.