Treatment of Colon Volvo and Acute Colon Pseudo-Obstruction (Ogilvie’s Syndrome)

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Colon obstructions can be mechanical or non-mechanical and constitute about 25% of all intestinal obstructions. Among the mechanical causes, the most common are:

1. obstructive tumor in the colon or rectum (60%);
2. cicatricial stenosis from previous diverticulitis (10%);
3. colon volvulus (15 to 20%).

The colon volvulus is the twisting of a redundant segment of the colon in its mesentery that can lead to luminal occlusion of the twisted segment and ischemia by rotation of the mesocolon and, consequently, to perforation.

Although the colon volvulus can occur in any redundant segment, it most commonly involves the sigmoid (60%–75% of all cases) and cecum (25%–40% of all cases).

The sigmoid volvulus mainly occurs during the 6th to 8th decades of life, being more common in men, institutionalized patients, patients with chronic constipation, neuropsychological impairment or decompensated comorbidities. On the other hand, the cecal volvulus usually presents in younger patients and has a female predominance.

The acute pseudo-obstruction of the colon, or Ogilvie’s syndrome, is a non-mechanical functional cause of obstruction believed to be a consequence of the deregulation of the autonomic impulses of the colon’s innervation. There is great distension of the colon without an obstructive factor, but which can also evolve into ischemia and perforation. Clinical presentations vary according to the degree of distension, whether the ileocecal valve is competent or not, and the patient’s clinical condition. More commonly, Ogilvie’s syndrome affects elderly patients or patients hospitalized for unrelated reasons, including elective surgery, trauma, or treatment of an acute medical condition.

Here we present some recommendations from the guidelines of the American Society of Colorectal Surgery for the management of these cases.

Colon Volvulus

• Initial evaluation with history, physical examination, and basic laboratory tests. Symptoms may include cramps, nausea, vomiting, abdominal discomfort. The sigmoid volvulus usually has a more indolent presentation, while the cecal volvulus tends to have a more acute presentation. On physical examination, there is generally abdominal distension with varying degrees of pain on palpation, up to peritonitis. The rectal touch reveals an empty rectal ampulla. Presentation in the emergency room with peritonitis and signs of shock occurs in 25 to 35% of cases.

• In hemodynamically stable patients, an abdominal radiograph aids in the initial evaluation (finding of “coffee bean” and, in patients with incompetent ileocecal valve, distension of the small intestine). Tomography is used to confirm the diagnosis.

Sigmoid Volvulus

• Hemodynamically stable patients, without signs of peritonitis or evidence of perforation should undergo rectosigmoidoscopy to assess the viability of the sigmoid, undo the torsion and decompress the colon, effective therapy in 60 to 95% of cases. It is possible to maintain a probe for decompression after the rectosigmoidoscopy. The recurrence rate is 43 to 75% in cases that are not submitted to subsequent surgical intervention.

• Emergency sigmoidectomy is indicated when endoscopic distortion is not successful and in cases of colon suffering or perforation, as well as in patients with signs of peritonitis or septic shock. After resection of the twisted segment, the decision to perform a primary anastomosis, terminal colostomy or anastomosis with derivation should be individualized considering the patient’s clinical context at the time of surgery, the conditions of the remaining colon and comorbidities.

• Patients submitted to successful endoscopic distortion are candidates for segmental colectomy during the same hospital stay to avoid recurrent volvulus and its complications. Operations without resection, including only distortion, sigmoidopexy and mesosigmoidoplasty, are inferior to colectomy for the prevention of recurrent volvulus.

• Endoscopic fixation of the sigmoid can be considered in selected patients in whom surgical intervention has a prohibitive risk.

Cecal Volvulus

• Attempts at endoscopic reduction of cecal volvulus are not recommended.

• Segmental resection is the treatment of choice for patients with cecal volvulus. Unviable or ischemic cecum is present in 18% to 44% of patients with cecal volvulus and is associated with a significant mortality rate.

• In the case of cecal volvulus with viable intestine, the use of surgical procedures without resection should be limited to patients without clinical conditions for resection.

Acute Pseudo-Obstruction of the Colon (Ogilvie’s Syndrome)

• The initial evaluation should include history and physical examination, laboratory tests, and imaging diagnosis.
  In the absence of fever, leukocytosis, peritonitis, pneumoperitoneum or cecal diameter > 12?cm, the initial therapy consists of correcting hydroelectrolytic disorders, volume replacement, avoiding or minimizing the use of opioids, avoiding anticholinergic drugs and identifying and treating concomitant infections. Ambulation, fasting, positioning maneuvers (knee-chest or prone) to promote intestinal motility and decompression with nasogastric and rectal tubes are also recommended. Oral osmotic laxatives should be avoided as they can worsen colon dilation. Abdominal radiographs are part of the daily evaluation, accompanied by physical examination.

• The initial treatment is clinical support and includes the exclusion or correction of conditions that predispose patients to the condition or prolong its course.

• Pharmacological treatment with neostigmine is indicated when the condition does not resolve with supportive therapy.

• Endoscopic decompression of the colon should be considered in patients with Ogilvie in whom neostigmine therapy is contraindicated or ineffective.

• Surgical treatment is recommended in cases complicated by ischemia or perforation of the colon or refractory to pharmacological and endoscopic therapies.

Reading suggestion: also check out the American Guidelines for better postoperative recovery (ERAS)

How to cite this article

Camargo MGM., Treatment of Colon Volvulus and Acute Pseudo-Obstruction of the Colon (Ogilvie’s Syndrome). Gastropedia, 2022. Available at: https://gastropedia.com.br/cirurgia/colorretal/tratamento-do-volvo-de-colon-e-da-pseudo-obstrucao-aguda-do-colon-sindrome-de-ogilvie/

References:

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