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Ogilvie Syndrome following Caesarean Section

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    This blog highlights the importance of prompt diagnosis of Ogilvie’s Syndrome, and looks at the potential complications if the condition is misdiagnosed following caesarean section.

    By Naomi Todd

Ogilvie or Ogilvie’s Syndrome is the acute obstruction of the colon, without a mechanical cause. It is rare and usually associated with complications following surgery, including caesarean sections. If the condition is left untreated, it can lead to bowel perforation or ischaemia.

It is reported by the Archive of Gynaecology and Obstetrics that mortality rates from Ogilvie’s syndrome can be as high as 36–50% when bowel perforation or ischemia develops.  This clearly highlights the importance of early recognition of this condition, and early diagnosis is essential to prevent serious morbidity and mortality.

What are the Risk factors?

Pregnancy is one of the main risk factors of Ogilvie’s Syndrome. Associated with this are risk factors such as prolonged bed rest, and the use of drugs such as morphine, diazepam and antidepressants.

What are the Symptoms?

Symptoms can include:

• Abdominal pain, usually cramping or colicky.
• Bloated feeling.
• Nausea and vomiting.
• Intermittent constipation.

In addition, patients may experience abdominal distension, reduced or obstructed bowel sounds, and an empty or air-filled rectum on digital rectal examination.

Following caesarean section, symptoms typically occur in the first 72 hours after the operation, and the majority of caecal perforations typically occur by the fifth post-operative day.

What investigations should be carried out?

If Ogilvie’s Syndrome is suspected, the treating clinician should carry out a full history, including ascertaining symptoms, drug history, previous surgery, past medical history and family history, and should thereafter conduct a full examination, including a digital rectal examination, to identify other conditions.

In addition, an abdominal x-ray should be carried out, as this would show any dilation of the colon. A CT scan should also be performed, and a surgical opinion requested.

How should Ogilvie’s Syndrome be managed?

Depending on when Ogilvie’s Syndrome is diagnosed, initial treatment includes no oral intake, a nasogastric tube to decompress the stomach and relieve vomiting, reduction or discontinuation of any drugs that inhibit gastrointestinal motility, and the treatment of any infection. If caecal dilatation is significant, decompression of the colon to avoid ischaemic perforation can be achieved by means of colonoscopy.

If there is a prompt diagnosis, colonoscopic decompression of the colon will usually prevent perforation and therefore avoid the subsequent need for any surgical intervention.
However, if there is a significant delay in diagnosis and conservative treatment fails, then surgery, i.e. a caecostomy or colostomy, will be necessary.

Complications following misdiagnosis.

The main concern of this condition is that if left untreated the bowel will perforate. Perforation occurs because of gaseous distension of the colon, which renders it ischaemic.

Perforation is associated with a mortality rate of 50% to 71%. Therefore the need to diagnose the condition as soon as possible is vital in order to avoid this complication.  Diagnosis of the condition is usually made by an X-ray of the abdomen.

Prevention

To prevent complications and surgery, the key is early diagnosis and prompt management. The success rate of conservative management is reported the Indian Journal of Critical Care Medicine at 85%, which shows that on the balance of probabilities, if Ogilvie’s Syndrome is appropriately acted upon in time and medically managed, surgery will not be necessary.

Conclusion

Given the severity of symptoms and treatment if Ogilvie’s Syndrome is not promptly diagnosed, early recognition is evidently essential to avoid significant complications including bowel perforation.

Early detection by clinicians can result in successful management of the condition and an excellent outcome.  I am acting for a number of patients who have suffered injury due to late diagnosis of Ogilvie’s Syndrome and the evidence obtained is that my clients would have avoided injury and achieved a better outcome had their symptoms been acted on promptly.

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