Perforated Colon Caused by Neostigmine Refractory Ogilvie Syndrome

Abstract

Background Ogilvie syndrome, also known as acute colonic pseudo-obstruction (ACPO), is a rare form of idiopathic colonic dilation without mechanical obstruction. It typically occurs in elderly patients who have recently been hospitalized or undergone surgery with an incidence rate of about 100 cases per 100,000 hospitalizations every year. Despite neostigmine being the treatment of choice, we highlight the importance of early management and diagnosis. Case Presentation A 76-year-old male with a history of class III obesity, diabetes mellitus, systolic heart failure, and ulcerative colitis well-controlled with sulfasalazine was admitted due to acute lower back pain with radiculopathy to lower extremities after lifting heavy boxes. The hospital course was complicated by developing acute kidney injury. In addition, a gradually enlarging but painless abdominal distension was noted, along with severe constipation. Serum measurements reflected persistent hypokalemia, leukocytosis, and elevated creatinine. Abdominal imaging revealed a markedly dilated colon with a cecal diameter of 12.8 cm but without signs of inflammation or perforation. Although neostigmine, correction of electrolytes, and rectal tube placement initially alleviated his condition, the abdominal distention continued to worsen. On day 16 of his stay, a repeat abdominal computed tomography showed pneumoperitoneum and the patient required emergent surgery. A 4cm perforation was appreciated in the transverse colon resulting in a total colectomy with end ileostomy. The patient recovered without complications after the surgery. Discussion Although the etiology remains unclear, our patient’s advanced age and renal and cardiac comorbidities potentially precipitated the onset of Ogilvie syndrome, causing a perforated colon. The risk of perforation is increased when the cecal diameter is larger than 12cm, and the colonic distension lasts greater than 6 days, both of which were observed in our patient. Management of Ogilvie syndrome is primarily focused on urgent bowel decompression and correction of electrolyte abnormalities. Although neostigmine has been shown to rapidly alleviate Ogilvie syndrome, our patient did not respond accordingly. The mortality rate in Ogilvie syndrome increases with surgical management, regardless of the presence of perforation, and can reach up to 40% following a perforated colon. Therefore, early diagnosis and conservative management of Ogilvie syndrome are important to prevent serious complications.