A 79-year-old nursing home resident is admitted to the hospital for nausea, vomiting, and abdominal distension. He has had little oral intake over the last 48 hours. This morning, workers at his facility noticed that his abdomen was distended. The patient's medical history is remarkable for advanced dementia, coronary artery disease, hypertension, cerebrovascular accident, atrial fibrillation with rapid ventricular response, chronic low back pain, and gastroesophageal reflux disease. Medications include aspirin, furosemide, hydrocodone with acetaminophen, metoprolol, calcium, vitamin D, simvastatin, and omeprazole. He was hospitalized for a myocardial infarction 3 months ago.
The patient's temperature is 36.7 C (98 F) , blood pressure is 131/78 mm Hg, pulse is 98/min, and respirations are 18/min. Pulse oximetry shows an oxygen saturation of 98% on room air. BMI is 22 kg/m². Lungs are clear to auscultation. The abdomen is distended and nontender. Bowel sounds are present with increased tympany to percussion throughout.
Laboratory results are as follows:
Abdominal radiograph reveals marked dilation of the cecum, right hemicolon, and transverse colon with a maximal colonic diameter of 11.3 cm. Abdominal CT scan confirms colonic dilation with no evidence of mechanical obstruction or bowel wall thickening.
Intravenous fluids are administered along with potassium and magnesium supplementation.
Which of the following is the best initial management for this patient?

Question

A 79-year-old nursing home resident is admitted to the hospital for nausea, vomiting, and abdominal distension. He has had little oral intake over the last 48 hours. This morning, workers at his facility noticed that his abdomen was distended. The patient's medical history is remarkable for advanced dementia, coronary artery disease, hypertension, cerebrovascular accident, atrial fibrillation with rapid ventricular response, chronic low back pain, and gastroesophageal reflux disease. Medications include aspirin, furosemide, hydrocodone with acetaminophen, metoprolol, calcium, vitamin D, simvastatin, and omeprazole. He was hospitalized for a myocardial infarction 3 months ago.
The patient's temperature is 36.7 C (98 F) , blood pressure is 131/78 mm Hg, pulse is 98/min, and respirations are 18/min. Pulse oximetry shows an oxygen saturation of 98% on room air. BMI is 22 kg/m². Lungs are clear to auscultation. The abdomen is distended and nontender. Bowel sounds are present with increased tympany to percussion throughout.
Laboratory results are as follows:

Abdominal radiograph reveals marked dilation of the cecum, right hemicolon, and transverse colon with a maximal colonic diameter of 11.3 cm. Abdominal CT scan confirms colonic dilation with no evidence of mechanical obstruction or bowel wall thickening.
Intravenous fluids are administered along with potassium and magnesium supplementation.
Which of the following is the best initial management for this patient?

Quizplus · Accepted Answer

11ec193a_96cb_0d9d_853d_47771d8132a3_MD0002_00 This institutionalized man's presentation of nausea, vomiting, a distended abdomen, and CT findings of a dilated colon without mechanical obstruction likely indicates an acute colonic pseudo-obstruction (Ogilvie syndrome). Ogilvie syndrome is most common in hospitalized or institutionalized men age >60. Although its etiology is unclear, it is suspected to be related to autonomic nervous system dysfunction in the setting of prior insults (eg, trauma, surgery, infection, neurologic disorders), particularly in combination with metabolic abnormalities (eg, hypokalemia, hypomagnesemia) or inciting medication (eg, narcotics). Patients typically have abdominal distension, pain, nausea/vomiting, constipation, or diarrhea. Examination commonly reveals a distended abdomen with increased tympany, mild tenderness, and active bowel sounds; peritoneal signs are suggestive of perforation. CT scan is diagnostic and can differentiate Ogilvie syndrome from mechanical obstruction (presence of transition point) and toxic megacolon (thickened colonic wall with thumbprinting). Treatment is initially supportive. Serial abdominal examinations and x-rays should be performed to evaluate for perforation. In addition, management includes nasogastric tube decompression, treatment of possible underlying causes (eg, electrolyte imbalances, narcotic cessation), and early ambulation. Neostigmine is indicated in patients who fail 24-48 hours of conservative therapy and in those with a cecal diameter >12 cm. It can lead to bradycardia, bronchospasm, and hypotension and is contraindicated in those with certain cardiovascular risk factors (recent myocardial infarction, bradycardia, beta blocker therapy), active bronchospasm, or peptic ulcer disease (Choice B). Patients who fail neostigmine or have contraindications may require colonoscopic or surgical decompression, including a percutaneous tube cecostomy (Choice C). (Choice A) Prokinetic agents (including metoclopramide and erythromycin) may have some uses in intestinal pseudo-obstruction. However, there is only limited anecdotal experience, and these drugs are not first-line therapy. (Choice E) Methylnaltrexone is a peripherally acting opioid antagonist that reverses the constipating effects of narcotics on the bowels. There are reports of methylnaltrexone being used prior to decompression in patients with Ogilvie syndrome refractory to neostigmine and associated with narcotic use; however, it is not first-line therapy and may be associated with increased risk of perforation. Further studies are needed to define its role in this condition. Educational objective: Ogilvie syndrome presents with marked colonic dilation without evidence of obstruction and frequently occurs in elderly males. Therapy is usually supportive with treatment of possible underlying causes; neostigmine is indicated in patients who fail conservative therapy. Those who fail neostigmine or have contraindications may require colonoscopic or surgical decompression. __________ References: Ogilvie's syndrome: colonoscopic decompression and analysis of predisposing factors. (http://www.ncbi.nlm.nih.gov/pubmed/1473414) Acute colonic pseudo-obstruction. (http://www.ncbi.nlm.nih.gov/pubmed/19224517)

A 79-Year-Old Nursing Home Resident Is Admitted to the Hospital