Acute Colonic Pseudo-Obstruction Following Total Abdominal Hysterectomy Utilizing Spinal Anesthesia: A Case Report and Review of Ogilvie’s Syndrome in the OB/GYN Population

Purpose: To increase awareness and management of Acute Colonic Pseudo-Obstruction (ACPO), a rare complication that can be associated with spinal anesthesia commonly used in OB/Gyn surgeries. Methods: This is a case report describing the hospital course of a patient undergoing total abdominal hysterectomy and bilateral salpingectomy (TAH-BS) with spinal anesthesia, who developed ACPO with colonic perforation. A literature review was conducted to review the incidence, presentation, and management of ACPO and highlight the importance of recognizing this complication. Results: The patient was a 45-year-old G2P2 who presented for scheduled TAH-BS for abnormal uterine bleeding (AUB). The patient’s past surgical history was significant for two prior cesarean sections, an appendectomy, and an open umbilical hernia repair that was done through a large midline incision for unknown reasons. This patient received a Duramorph spinal before her procedure. Intraoperative findings included dense adhesions from the anterior abdominal wall to the lower uterine segment and a 2 cm right ovarian simple cyst. Given location of anterior adhesions, an Alexis-O retractor could not be placed. Instead, the bowel was packed with moist laparotomy sponges and the occasional use of hand-held retractors. The uncomplicated procedure was completed in under two hours. On postoperative day 1 (POD1), the patient’s pain was controlled, she was tolerating a diet without nausea or vomiting, voiding spontaneously, and reported flatus. Her abdominal exam was benign and labs were notable for a white blood cell count (WBC) of 15.43. On POD2, the patient’s status was grossly unchanged. On POD3, the patient’s condition worsened with increased pain overnight, new nausea, and one episode of emesis that was improving with medications. The exam was now significant for moderate distension, tenderness to palpation, and diminished and high-pitched bowel sounds. Her WBC was also increasing. The patient was made NPO and given a Dilaudid PCA and scheduled IV Toradol for pain. A CT A/P showed a dilated proximal colon with her cecal pole measuring 8 cm in diameter and dilated distal ileal loops consistent with ileus (no signs of mechanical obstruction or evidence of pneumatosis). A nasogastric (NG) tube was not placed as patient declined. On POD4, the patient was stable overall but still symptomatic. That evening, the team was alerted of patient’s acutely worsening pain control. A CT Urogram was done to rule out possible bladder/ureter injury and showed similar dilated proximal colon and cecum with cecal diameter now measuring up to 10.9 cm. Moderate volume pneumoperitoneum and slight interval increase in small volume abdominopelvic free fluid and pseudo-pneumatosis in region of the cecum was noted. The findings were concerning for possible bowel perforation, suspected at the proximal colon/cecum. Acute care surgery was consulted at this time and they elected to take the patient to the OR for an emergent exploratory laparotomy and proceeded with a right hemicolectomy with handsewn ileocolonic anastomosis. They noted turbid fluid in the abdomen upon entry and a normal-appearing small bowel with small mesenteric rents without compromise to bowel viability. There was, however, a large area of full-thickness necrotic tissue involving the ascending colon and cecum with perforation and spillage of stool noted once cecum was reflected medially. Conclusions: ACPO, also known as Ogilvie’s syndrome, is characterized by colon dilation with decreased or absent peristaltic activity without any evidence of mechanical/anatomic obstruction. Estimated incidence is approximately 100 cases out of 100,000 admissions. Thought to occur most commonly in elderly (>60 years old) and severely ill individuals, particularly men, this condition also develops following surgery, including OB/GYN surgery. A large retrospective series found that the most common predisposing conditions for ACPO were nonoperative trauma, infection, and cardiac disease and that hip surgery and cesarean sections were the most common surgical procedures. Gynecologic cancers and benign gynecologic conditions were also found to be associated with ACPO. The mechanism of ACPO is still uncertain, but a leading hypothesis is impairment of the autonomic nervous system that occurs with trauma, spinal anesthesia, and other pharmacologic agents—noting that spinal anesthesia is common in OB/GYN surgeries. This case highlights the need for awareness of ACPO in the postoperative period, particularly in cases where spinal anesthetic is utilized or other motility-modifying pain regimens regardless of patient age or other co-morbidities to avoid severe complications. Colonic ischemia and perforation risk increases when cecal diameter exceeds 10-12cm on CT and duration is >6 days, but as demonstrated in this case, can occur with less. Initial management for cases where cecal diameter is 12cm may warrant treatment with neostigmine, cecal decompression, or surgery. Colonic ischemia and perforation are the two main complications of ACPO which develops in 3-15% of patients. In the absence of complications, mortality is 15% and with complications, mortality is 36 to 44%.