Suspected Ogilvie's Syndrome (ACPO)
Colonic dilation without mechanical obstruction
All Pathways
Colorectal SurgeryEmergency
Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome) Management (ASCRS 2016)
Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome) Management (ASCRS 2016): Suspected Ogilvie's Syndrome (ACPO) → Clinical Presentation → Diagnostic ...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Clinical Presentation
Typical features and risk factors
- Massive abdominal distension
- Absent or minimal pain (unless ischemia)
- Nausea, vomiting
- Obstipation (may still pass flatus)
- RISK FACTORS:
- - Post-operative (orthopedic, cardiac, spinal)
- - Critical illness, sepsis
- - Medications (opioids, anticholinergics)
- - Electrolyte abnormalities
- - Neurologic conditions
03Action Diagnostic Workup
Exclude mechanical obstruction
- CT abdomen/pelvis WITH contrast
- Must rule out mechanical obstruction
- Assess for: Transition point, mass, volvulus
- Measure cecal diameter (critical)
- Labs: Electrolytes (K, Mg, Ca), CBC
- Water-soluble contrast enema if CT unclear
04Decision Signs of Perforation/Ischemia?
Emergency surgery if present
- Peritonitis
- Free air
- Cecal pneumatosis
- Severe localized pain
05Warning EMERGENCY SURGERY
Perforation or ischemia
- Exploratory laparotomy
- Right hemicolectomy if ischemic cecum
- Subtotal colectomy if extensive
- Primary anastomosis vs ileostomy
- Mortality 30-50% with perforation
06Action Post-Treatment Care
Prevent recurrence
- Advance diet slowly
- Continue bowel regimen
- Mobilize patient
- Monitor for recurrence (10-30%)
- Address underlying cause
- Repeat neostigmine if recurs
07Outcome Outcomes
Prognosis
- Overall mortality: 15-30%
- With perforation: 30-50%
- Recurrence: 10-30%
- Most respond to conservative + neostigmine
08Decision Cecal Diameter Assessment
Determines urgency of intervention
- HIGH RISK: >12cm or >9cm for >3 days
- Perforation risk increases significantly
09Action Conservative Management
For cecum <12cm, <3 days duration
- NPO, NG tube if vomiting
- IV fluids, correct electrolytes
- Discontinue opioids/anticholinergics
- Mobilize patient if possible
- Rectal tube (limited benefit)
- Knee-chest position intermittently
- Daily abdominal X-rays
- Trial for 24-48 hours
10Decision Response to Conservative Rx?
Reassess at 24-48 hours
- Path rejoins step 06Shared downstream outcome
11Action Neostigmine Administration
Pharmacologic decompression
- DOSE: 2mg IV over 3-5 minutes
- MONITORING: Continuous cardiac (bradycardia risk)
- Atropine at bedside
- CONTRAINDICATIONS:
- - Recent MI
- - Bradycardia <60
- - Active bronchospasm
- - Mechanical obstruction not excluded
- Response expected within 30 min
- Can repeat once if partial response
12Decision Response to Neostigmine?
Assess clinical/radiographic improvement
- Success: 80-90%
- Decompression within 30 min
- May repeat once if partial response
- Path rejoins step 06Shared downstream outcome
13Action Colonoscopic Decompression
If neostigmine fails or contraindicated
- Minimal insufflation
- Decompress to hepatic flexure
- Place decompression tube
- Suction as advancing
- Success rate: 70-80%
- Recurrence: 10-30%
- Risk: Perforation 1-3%
14Decision Decompression Successful?
Assess need for surgery
- Path rejoins step 06Shared downstream outcome
15Action Surgical Intervention
For refractory cases
- CECOSTOMY: Percutaneous or surgical
- Decompresses without resection
- For poor surgical candidates
- RESECTION: If ischemia/perforation
- Ileostomy vs anastomosis based on status
- Path rejoins step 06Shared downstream outcome
- Path rejoins step 11Shared downstream outcome
Guideline Source
ASCRS Clinical Practice Guidelines for Acute Colonic Pseudo-Obstruction
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Neostigmine contraindicated with cardiac conditions
- Requires cardiac monitoring
- Multiple etiologies may coexist
- Recurrence common
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome) Management (ASCRS 2016)?
The Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome) Management (ASCRS 2016) is a emergency clinical algorithm for Colorectal Surgery. It provides a structured decision tree to guide clinical decision-making, based on ASCRS Clinical Practice Guidelines for Acute Colonic Pseudo-Obstruction.
What guideline is the Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome) Management (ASCRS 2016) based on?
This algorithm is based on ASCRS Clinical Practice Guidelines for Acute Colonic Pseudo-Obstruction (DOI: 10.1097/DCR.0000000000000489).
What are the limitations of the Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome) Management (ASCRS 2016)?
Known limitations include: Neostigmine contraindicated with cardiac conditions; Requires cardiac monitoring; Multiple etiologies may coexist; Recurrence common. Individual patient factors may require deviation from these recommendations.
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