Case data
Female patient, 60 Aged, with a history of developmental delay and epilepsy, was admitted to the emergency department from the nursing home for evaluation of changes in mental status and hypoxemia. Examination revealed: body temperature 98.2 °F; heart rate 78/min; blood pressure 171/88 mmHg; respiratory rate 20/min; oxygen saturation 97% with 3 L of oxygen.
The patient is lethargic and only responds to painful stimuli. The abdomen was significantly distended but there was no tenderness, and bowel sounds were diminished. Laboratory evaluations were unremarkable. Abdominal and pelvic CT scans are shown below (Figures 1, 2, and 3).
Figure 1 >
Figure 2 p>
Figure 3
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What is the most likely diagnosis?
A. Toxic Hirschsprung
B. Hirschsprung p>
C. Ogilvie syndrome
D. paralytic ileus
Analytical diagnosis
The correct answer is Ogilvie syndrome.
CT scan showed marked distention of the stomach, massive fecal load throughout the colon, gas distention in the sigmoid colon, and in addition No mechanical obstruction was observed. All four of the above options can cause large bowel distention, but different diseases have their own unique characteristics.
Toxic megacolon from infection or inflammatory bowel disease is often accompanied by signs of systemic toxicity (fever , tachycardia, leukocytosis, dehydration, altered mental status, and hypotension).
Hirschsprung’s disease is usually diagnosed in childhood and rarely persists into adulthood. Hirschsprung’s disease may be suspected in men with a history of constipation since childhood and no fecal incontinence.
In paralytic ileus, imaging usually shows dilation of the small and large bowel and multiple air-fluid levels throughout the gastrointestinal tract.
Therefore, based on clinical and imaging features, the diagnosis of Ogilvie syndrome or acute colonic pseudocolon obstruction.
Knowledge Class: Ogilvie Syndrome
Ogilvie The syndrome, also known as acute colonic pseudo-obstruction, is characterized by acute massive expansion of the colon in the absence of mechanical obstruction. Predisposing factors include recent surgery, critical illness, electrolyte disturbances, and trauma. Sustained and severe colonic dilatation can lead to ischemia or perforation, so early diagnosis and urgent intervention are necessary to prevent rapid deterioration.
The diagnosis of Ogilvie syndrome is mainly based on medical history, clinical manifestations, imaging data and colonoscopy. The disease mainly manifested by abdominal distension. Except for intestinal ischemia or perforation, most patients are not accompanied by abdominal pain and abdominal muscle tension. , bowel sounds weakened or disappeared. abdominalX-ray plain film features: dilated colon with well-spaced, deep colonic pouch, smooth bowel wall, lumen There is not much liquid, and the gas-liquid level is not common. abdominalCT can detect organic lesions before colonoscopy, such as tumors, volvulus, extraintestinal pressure mass, etc. .
Mainly after early diagnosis Conservative medical treatment, such as fasting, continuous gastrointestinal decompression, correction of water, electrolyte and acid-base balance caused by intestinal obstruction, and infection control. Patients who fail conservative treatment can be treated with drug therapy, and most patients respond to single or multiple doses of neostigmine therapy. The use of osmotic laxatives (eg, polyethylene glycol, lactulose, and magnesium hydroxide) is discouraged because these drugs can exacerbate colon distention by increasing gas formation. Endoscopic decompression should be considered in patients who are refractory to conservative and medical therapy and have no evidence of ischemia or perforation. If the patient is a refractory case or has peritonitis, ischemia, perforation, or the diameter of the cecum >12 cm, surgical treatment should be timely.
References:
< p>[1] Siddiqui WT. A Very Large Bowel. Gastroenterology. 2021 Aug 28:S0016-5085(21)03464-8.
[2] Xi Chunhua , Sha Du, Sun Yueming. Advances in the diagnosis and treatment of acute colonic pseudo-obstruction[J]. Chinese Journal of Colorectal Diseases, 2015, 4(06):648-652.
[3] Yu Lirong, Guo Lvyun, Zhan Yazhen, et al. Clinical analysis of 26 cases of acute colonic pseudo-obstruction[J]. China Rural Medicine, 2016, 23(01):8+18.