Acta Neurochir (2014) 156:787–788 DOI 10.1007/s00701-014-2014-z
LETTER TO THE EDITOR - ABSTRACT
Ogilvie’s syndrome following ventriculoperitoneal shunt surgery for normal pressure hydrocephalus Miki Katzir & Sergey Abeshaus & Moshe Attia & Menashe Zaaroor
Received: 16 November 2013 / Accepted: 22 January 2014 / Published online: 9 February 2014 # Springer-Verlag Wien 2014
Dear Editor, We would like to present a patient that has developed acute colonic pseudo-obstruction (ACPO) following ventriculoperitoneal shunt (VP shunt) surgery. Sir William Ogilvie first described ACPO in 1948. He reported two patients with chronic colonic dilatation associated with malignant infiltration of the celiac plexus. Ogilvie related the condition to the lack of sympathetic tone. A 73-year-old male was admitted to our emergency department after a tonic clonic seizure. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a clinoid meningioma, cerebellopontine angle tumour and a communicating hydrocephalus. Several months before admission, the patient developed the Hakim and Adams triad of normal pressure hydrocephalus (NPH)-magnetic gait, urinary incontinence and slight mental decline. The patient’s symptoms were related mainly to the hydrocephalus and the presenting seizure to the meningioma. The patient underwent a VP shunt surgery; abdominal incision length was 2 cm. Immediate postoperative hours were unremarkable. In the morning of the first postoperative day, the patient developed marked abdominal distension, first without and later with generalized crampy abdominal pain, tympanic abdomen and no bowel sounds or movements. Blood tests showed slight leukocytosis and elevated lactic acid (2.9 mmol/L); the remaining parameters, electrolytes, kidney M. Katzir (*) : S. Abeshaus : M. Attia : M. Zaaroor Department of Neurosurgery, Rambam Health Care Campus, Haaliya Hasnia 8, Haifa, Israel 31096 e-mail: [email protected]
and liver function tests, were within normal limits. He was managed conservatively by maintaining fluid and electrolyte balance and placing a nasogastric tube. Abdominal X-ray and a CT scan of the abdomen did not demonstrate evidence of mechanical obstruction or caecal/sigmoid volvulus, but demonstrated mainly caecum, ascending colon and also some small bowel dilatation (Fig. 1a and b). At later blood tests in the next several days, the lactic acid value and leukocyte count returned to normal. On the fourth postoperative day, the abdominal tenderness and guarding started to resolve, and the patient passed some feces and flatulence. Sixty-seven percent of the patients diagnosed with Ogilvie are male with a mean age of 68.9 years [3]. Common abdominal VP shunt complications include subcutaneous collection of cerebrospinal fluid (CSF), peritoneal pseudocyst, bowel perforation, intestinal volvulus and migration of the distal catheter to different sites [1]. Ogilvie’s syndrome has not previously been in the differential diagnosis for abdominal distension and pain following VP shunt surgery. Our patient had a short period of gradually increasing painless abdominal distension without vomiting, which was not accompanied by any mechanical obstruction to the small or large bowel. Medical and surgical aetiologies associated with this syndrome include infections (pneumonia/sepsis), nonoperative trauma and cardiac diseases (heart failure/myocardial infarction), traumatic brain injury, opioids, calcium channel blockers, anticholinergics, coronary artery bypass grafting, caesarean section, two reported laparoscopic cholecystectomies in the literature, inguinal and ventral hernia repair, hip and knee surgery, and rarely after lumbar or cervical discectomy [3].
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Acta Neurochir (2014) 156:787–788
Fig. 1 a Abdominal X-ray with contrast demonstrates mainly caecum, ascending colon and also some small bowel dilatation, arrows show the peritoneal catheter and the nasogastric tube. b Abdominal CT Topogram
The predisposing factors produce an autonomic imbalance in favor of the parasympathetic nervous system, which results in colonic atony and features of pseudo-obstruction [2]. After excluding a mechanical obstruction, there is the possibility to manage Ogilvie’s syndrome conservatively. Management includes keeping the patient nil by mouth, insertion of a nasogastric and rectal tube, IV fluids, correction of any underlying electrolyte imbalance, and discontinuation of medication that can adversely affect bowel motility. IV neostigmine (a reversible acetylcholinesterase inhibitor that enhances bowel motor activity) can be given to try to achieve colonic decompression if mechanical obstruction, ischemia and perforation have been excluded. In case of persistence of symptoms, colonoscopy or surgical decompression is warranted. To the best of our knowledge, in the absence of previous reports in the literature, this is the first reported case to develop ACPO after VP shunt surgery.
VP shunt surgery, despite the minimal abdominal intervention, can cause Ogilvie’s syndrome. Early diagnosis is the foundation to a successful treatment of the condition. Conflict of interest None.
References 1. Chung JJ, Yu JS, Kim JH, Nam SJ, Kim MJ (2009) Intraabdominal complications secondary to ventriculoperitoneal shunts: CT findings and review of the literature. AJR Am J Roentgenol 193(5):1311–1317 2. Dorudi S, Berry AR, Kettlewell MG (1992) Acute colonic pseudoobstruction. Br J Surg 79:99–103 3. Tenofsky PL, Beamer RL, Smith RS (2000) Ogilvie syndrome as a postoperative complication. Arch Surg 135:682–689
LETTER TO THE EDITOR - ABSTRACT
Ogilvie’s syndrome following ventriculoperitoneal shunt surgery for normal pressure hydrocephalus Miki Katzir & Sergey Abeshaus & Moshe Attia & Menashe Zaaroor
Received: 16 November 2013 / Accepted: 22 January 2014 / Published online: 9 February 2014 # Springer-Verlag Wien 2014
Dear Editor, We would like to present a patient that has developed acute colonic pseudo-obstruction (ACPO) following ventriculoperitoneal shunt (VP shunt) surgery. Sir William Ogilvie first described ACPO in 1948. He reported two patients with chronic colonic dilatation associated with malignant infiltration of the celiac plexus. Ogilvie related the condition to the lack of sympathetic tone. A 73-year-old male was admitted to our emergency department after a tonic clonic seizure. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a clinoid meningioma, cerebellopontine angle tumour and a communicating hydrocephalus. Several months before admission, the patient developed the Hakim and Adams triad of normal pressure hydrocephalus (NPH)-magnetic gait, urinary incontinence and slight mental decline. The patient’s symptoms were related mainly to the hydrocephalus and the presenting seizure to the meningioma. The patient underwent a VP shunt surgery; abdominal incision length was 2 cm. Immediate postoperative hours were unremarkable. In the morning of the first postoperative day, the patient developed marked abdominal distension, first without and later with generalized crampy abdominal pain, tympanic abdomen and no bowel sounds or movements. Blood tests showed slight leukocytosis and elevated lactic acid (2.9 mmol/L); the remaining parameters, electrolytes, kidney M. Katzir (*) : S. Abeshaus : M. Attia : M. Zaaroor Department of Neurosurgery, Rambam Health Care Campus, Haaliya Hasnia 8, Haifa, Israel 31096 e-mail: [email protected]
and liver function tests, were within normal limits. He was managed conservatively by maintaining fluid and electrolyte balance and placing a nasogastric tube. Abdominal X-ray and a CT scan of the abdomen did not demonstrate evidence of mechanical obstruction or caecal/sigmoid volvulus, but demonstrated mainly caecum, ascending colon and also some small bowel dilatation (Fig. 1a and b). At later blood tests in the next several days, the lactic acid value and leukocyte count returned to normal. On the fourth postoperative day, the abdominal tenderness and guarding started to resolve, and the patient passed some feces and flatulence. Sixty-seven percent of the patients diagnosed with Ogilvie are male with a mean age of 68.9 years [3]. Common abdominal VP shunt complications include subcutaneous collection of cerebrospinal fluid (CSF), peritoneal pseudocyst, bowel perforation, intestinal volvulus and migration of the distal catheter to different sites [1]. Ogilvie’s syndrome has not previously been in the differential diagnosis for abdominal distension and pain following VP shunt surgery. Our patient had a short period of gradually increasing painless abdominal distension without vomiting, which was not accompanied by any mechanical obstruction to the small or large bowel. Medical and surgical aetiologies associated with this syndrome include infections (pneumonia/sepsis), nonoperative trauma and cardiac diseases (heart failure/myocardial infarction), traumatic brain injury, opioids, calcium channel blockers, anticholinergics, coronary artery bypass grafting, caesarean section, two reported laparoscopic cholecystectomies in the literature, inguinal and ventral hernia repair, hip and knee surgery, and rarely after lumbar or cervical discectomy [3].
788
Acta Neurochir (2014) 156:787–788
Fig. 1 a Abdominal X-ray with contrast demonstrates mainly caecum, ascending colon and also some small bowel dilatation, arrows show the peritoneal catheter and the nasogastric tube. b Abdominal CT Topogram
The predisposing factors produce an autonomic imbalance in favor of the parasympathetic nervous system, which results in colonic atony and features of pseudo-obstruction [2]. After excluding a mechanical obstruction, there is the possibility to manage Ogilvie’s syndrome conservatively. Management includes keeping the patient nil by mouth, insertion of a nasogastric and rectal tube, IV fluids, correction of any underlying electrolyte imbalance, and discontinuation of medication that can adversely affect bowel motility. IV neostigmine (a reversible acetylcholinesterase inhibitor that enhances bowel motor activity) can be given to try to achieve colonic decompression if mechanical obstruction, ischemia and perforation have been excluded. In case of persistence of symptoms, colonoscopy or surgical decompression is warranted. To the best of our knowledge, in the absence of previous reports in the literature, this is the first reported case to develop ACPO after VP shunt surgery.
VP shunt surgery, despite the minimal abdominal intervention, can cause Ogilvie’s syndrome. Early diagnosis is the foundation to a successful treatment of the condition. Conflict of interest None.
References 1. Chung JJ, Yu JS, Kim JH, Nam SJ, Kim MJ (2009) Intraabdominal complications secondary to ventriculoperitoneal shunts: CT findings and review of the literature. AJR Am J Roentgenol 193(5):1311–1317 2. Dorudi S, Berry AR, Kettlewell MG (1992) Acute colonic pseudoobstruction. Br J Surg 79:99–103 3. Tenofsky PL, Beamer RL, Smith RS (2000) Ogilvie syndrome as a postoperative complication. Arch Surg 135:682–689
