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Ogilvie Syndrome : A Gastrointestinal Clinical Case Study

Ogilvie Syndrome : A Gastrointestinal Clinical Case Study. Holy Family Hospital • Methuen, MA Lindsay Gaucher. Holy Family Hospital. Member of Steward Health Care, the largest fully integrated community care organization in New England. 261 bed acute care hospital

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Ogilvie Syndrome : A Gastrointestinal Clinical Case Study

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  1. Ogilvie Syndrome: A Gastrointestinal Clinical Case Study Holy Family Hospital • Methuen, MA Lindsay Gaucher

  2. Holy Family Hospital • Member of Steward Health Care, the largest fully integrated community care organization in New England. • 261 bed acute care hospital • Serves 20 communities throughout Merrimack Valley & southern New Hampshire. • 1500 employees total • 4 Sodexo registered dietitians (2 FT/2 PT, Sodexo resource help also available)

  3. Role of the Clinical Dietitian • Screen and assess patient’s nutritional needs per prioritized levels of care.  • Make recommendations for the appropriate plan of care/nutritional therapy to best meet patient’s needs.  • Reply to consults for diet education and/or nutrition intervention. • Meal rounds, food service dept in-services, and other related food service duties in addition to clinical responsibilities.

  4. Ogilvie Syndrome • Also known as acute colonic pseudo-obstruction (ACPO), a rare disorder which causes abnormal peristalsis in the colon. • The symptoms mimic mechanical obstruction of the colon, but no physical obstruction is present. • Pathophysiology still somewhat unclear. • Symptoms include nausea, vomiting, abdominal pain & distention/bloating, fever, constipation, and weight loss. • Distension of the colon, especially the cecum • Cecal diameter > 12cm “megacolon” is often associated with perforation

  5. Conservative treatment Patient has abdominal distension, but no evidence of ischemic or perforated bowel. Trial bowel rest (NPO), rectal tube placement, and/or NG tube decompression. Correction of electrolyte imbalances/dehydration, discontinuation of narcotics, & treatment of underlying infection with antibiotics are considered. Rotate antibiotic regimens to help relieve diarrhea, bloating, & overall improve nutrition status. Identify & treat other disorders that may interfere and potentially worsen symptoms. Colonoscopy can be therapeutic but should be selective as it can increase the risk for perforation. MNT & Treatment

  6. Medical Nutrition Therapy: • Encourage small, frequent high protein meals with liquids and soft foods, while avoiding high fat and fiber foods. • Avoiding lactose can help abdominal bloating and discomfort. • Nutritional supplements provide additional calories & protein, and are useful in malnourished patients. • A daily multivitamin, other supplemental vitamins, minerals, & electrolytes as indicated. • Probiotics can promote growth of beneficial bacteria, and relieve symptoms of diarrhea, constipation, bloating, and C diff • Enteral feeding is typically not indicated unless signs of obstruction and colon motility are resolved. Parenteral nutrition is also a choice for some patients, but long term use is not indicated.

  7. Medications: typically include antibiotics, Reglan, as well as cholinesterase inhibitors, such as Neostigmine. • Neostigmine may be initiated if conservative treatment is not enough and the patient is at risk for perforation. • Neostigmine stimulates receptors to increase peristalsis activity within the colon • Contraindicated if: mechanical bowel obstruction, suspected bowel ischemia/perforation, uncontrolled cardiac arrhythmias, renal insufficiency, and severe bronchospasm are present. LABS: • CBC is indicated. Leukocytosis could mean perforation. • Mild electrolyte imbalances are often present and typically signify dehydration. Patient typically presents with hyponatremia and hypokalemia. • Monitor BUN, Creatinine, albumin/pre-albumin as patients tend to present with azotemia & renal/liver insufficiency

  8. Endoscopic Decompression & Surgical Treatment When conservative treatment does not indicate improvement, and the patient presents w/ peritonitis, sepsis, and/or perforation. • Cecostomy can clear the colon of fecal matter • Partial colectomy for ischemic/perforated bowel. *Conservative treatment and/or Neostigmine are often the initial treatment options.

  9. A catheter is inserted into the cecum for which liquid medication is injected through this tube, to help move fecal matter through the colon & out of the body. When there is improvement, the cecomstomy can be closed. http://www.chop.edu/service/radiology/interventional-radiology/percutaneous-cecostomy-tube-placement.html

  10. Acute Colonic Pseudo-obstruction R/O mechanical obstruction Correct fluid/electrolyte issues & sepsis Resolved? Yes No Insert rectal tube/NG tube Resolving? No Yes Endoscopic decompression Resolving? No Yes Surgical Intervention http://www.ncbi.nlm.nih.gov/pubmed/16268965

  11. What does the research say? Success Rates of Method(s) Used Recurrence & Morbidity Risk Colectomy – 18% recurrence rate w/ risk for bleeding, infection, abdominal pain Neostigmine– 20% recurrence rate w/ risk for abdominal pain, cardiac arrhythmia, excess salivation, vomiting Colonoscopy/Decompression – 29% recurrence rate w/risk for pain & perforation Erythromycin – 50% recurrence rate w/ risk for further abdominal pain, liver dysfunction Neostigmine – 91% Colectomy – 84% Colonoscopy/Decompression – 64% Erythromycin – 40%

  12. Diagnosis & Plan of Care for Patient T.D.

  13. Our case study patient: TD • 88 yo female, lives with son & has significant family involvement. No therapeutic diet or diet education, just overall healthy eating. • 5’4, UBW 124-130#. During acute stay, weight recorded as 127#-137# • Nutrition-related PMH includes: Ogilvie Syndrome, sepsis, PNA, UTI, chronic anemia, renal insufficiency • Admission to HFH on 6/5/13 to 7/2/13 for Ogilvie Syndrome & abdominal distension. Screened as level 3: moderate risk • Re-admitted to HFH from rehab hospital on 7/5/13 to 7/25/13 for sepsis, fever, leukocytosis. Screened as level 3: moderate risk

  14. Initial Assessment: June 11, 2013 127#, BMI 21.8 healthy range Estimated needs: Kcals = 1450 (25 kcals/kg) Pro = 58 (1g/kg) Fluid = 1450 (25 ml/kg) Diet order: low fiber, ground w/soft veggies & Ensure Clear TID ? of choking/possible aspiration, MBS ordered per SLP for further eval 25-50% PO intake @ all meals & tol Ensure Clear well. GI symptoms: diarrhea & incontinence Low fiber educ provided with hope of relieving GI symptoms. Bowel med regimen, probiotics, zofran, calcium +D in place, MVI recommended Labs noted: Na 132, K+ 2.8, albumin 2.8

  15. Diagnosis: Chewing/swallowing difficulty likely r/t age & dysphagia AEB SLP rec ground diet/thin liquids Altered nutrition lab values r/t Ogilvie Syndrome AEB Na 132, K+ 2.8, albumin 2.8 Intervention: Continue low fiber, ground diet w/soft veggies or per SLP rec, and Ensure Clear. Monitor electrolytes Nutrition Risk: Level 2, elevated risk

  16. As a Level 2: elevated risk patient, T.D. continues to be followed every 3-5 days. Subsequent follow up assessments on 6/14 & 6/17: • Weight: 4# gain noted x 3 days (131#) likely fluid related. Bi-weekly weights recommended. • SLP rec s/p MBS: dysphagia pureed diet w/ honey thick liquids • Poor --> fair appetite w/ 0-50% PO x 9 days, tol thickened 6 oz Ensure Clear TID to provide additional 600 kcals & 21g pro • Peripheral line placed. PPN rec given pt’s poor PO x 9 days. • Abdominal CT to r/o bowel obstruction confirms Ogilvie Syndrome and suggests possible pyelonephritis • GI symptoms: bloating, distension, & incontinence • Probiotics, calcium+D, flagyl, Zofran, MVI in place

  17. Follow Up Assessment: June 21, 2013Level 2: Elevated risk • 0-50% PO intake remains w/out s/s of dysphagia. Ensure Clear, Ensure Complete, yogurt, and puddings. Further diet educ re: high kcal/high pro options provided to son • GI symptoms: bloating, incontinence, diarrhea • Skin noted with incontinence dermatitis • Rectal tube placed per GI recs for decompression. Per GI, surgical consult warranted if no improvement. • Motility agent initiated • Zofran, erythromycin, calcium+D, MVI, & probiotics in place Diagnosis: Altered GI function r/t Ogilvie’s Syndrome AEB persistent bloating, abd distension, diarrhea

  18. Follow Up Assessment: June 26, 2013Level 2: Elevated risk • PO intake slightly improved to 75% some days w/out s/s of dysphagia. • Tolerating ~2 Ensure supplements daily + eggs and snacks • Continued encouragement by nutrition, pt’s family, and nursing staff • Rectal tube remains in place for decompression • Surgical consult obtained w/ rec for no surgical intervention • Pt’s family and MD wish to continue with conservative treatment and current diet. Enteral/parenteral nutrition not accepted by family/MD. • Labs noted: albumin 3.0, Na 134, K+ 2.9

  19. Follow Up Assessment: June 28, 2013Level 2: Elevated risk • 0-50% PO, increased nutrition needs given new candidiasis, + blood cultures, persistent diarrhea (2+ BM/day). • Weight recorded as 132# • Calories = 1425-1800 (25-40kcals/kg) • Protein = 72 g (1.2 g/kg) • Fluid = 1200-1450 ml (20-25 ml/kg) • Labs noted: WBC 15, Albumin 2.5 • Diagnosis: Inadequate protein-energy intake r/t compromised GI function, physical disability, & increased need w/infection AEB PO intake ~50%, new infection

  20. On July 2nd, patient was D/C’ed to Northeast Rehab Hospital for further monitoring and continuation of HFH POC w/ antibiotics, probiotics, dysphagia pureed diet with honey thick liquids, & rectal tube in place. Patient continued with pureed diet and honey thick liquids, and was eating well per family, “the best she has in the last month.” Patient returns to HFH ICU on 7/5 for UTI, fever, sepsis, +C diff. Transferred to medical floor on 7/15 Screened as Level 3: Moderate risk

  21. Initial Assessment: July 9, 2013 • 124# (8# loss since 6/28), BMI 21.3 • Estimated needs: • Kcals: 1410-1700 (25-30 kcals/kg) • Pro: 56-68g (1-1.2 g/kg) • Fluid: 1410 ml (25 ml/kg) or per team • Diet order: NPO per GI testing • Abd scan: no obstruction or perforation • GI symptoms: diarrhea (q 1-2 hrs) +C diff. Rectal tube remains in place • Braden 12 - Stage 1 pressure right lower ankle noted.

  22. Diagnosis: Altered GI function r/t prev dx of Ogilvie’s Syndrome & +C diff results AEB current NPO order, diarrhea, GI testing • Intervention: 1.) ADAT to pureed diet w/honey thick liq and Ensure Clear 2.) Monitor electrolytes, 3.) Rec alternate nutrition support if PO <50% consistently • Labs noted: WBC 32, hgb 9.2, hct 28.1, GFR 47, BUN 24, Cr 1.1, alb 2.8, K+ 2.8, Na 132, Mg 1.7 – Repletion noted with Mag-ox, K-lor, and KCl in place. +MRSA • Lactinex, Zofran, flagyl, amikacin sulfate, PPI vanco, miconazole, NS @ 100 ml/hr also in place • Nutrition Risk: Level 2 Elevated risk

  23. As a Level 2: elevated risk patient, T.D continues to be followed every 3-5 days. Subsequent follow up assessments on 7/11, 7/16, 7/19: • 130# (6# wt gain since admit x 8 days) • Diet order = Pureed w/ honey thick liquids & Ensure Clear. Pt’s family reports pttol puddings, Greek yogurt, apple sauce & Ensure Clear, PO 25-50% noted. • PO intake + IV fluids + Ensure Clear meets ~90% kcals & 60% protein needs daily • Ongoing diarrhea, +C diff • Braden 12 – Stage 1 pressure remains and is being cared for

  24. Labs noted: K+ 2.8/4.6, Na 132/138, Mg 1.7/2.1 – Repletion noted with Mag-ox, K-lor, and KCl in place. • Nutrition rec continue to monitor lytes and replete as indicated. • + C diff, UTI, fever • Lactinex, flagyl, Zofran, miconazole, vanco, PPI, D5NS @ 100ml/hr to provide additional 408 kcals as dextrose also in place • Diagnosis: In addition to altered GI function, Swallowing difficulty r/t age and dysphagia AEB SLP rec for pureed diet, honey thick liquids

  25. Final Follow Up Assessment: July 23, 2013Level 2: Elevated Risk • 137# (7# gain x 1 week) • 50% PO w/family assistance and no s/s dysphagia. • Patient is more awake, PT eval in patient’s room to assess mobility • 7/22 SLP re-eval to r/o aspiration. Pureed diet w/honey thick liquids indicated. • Labs noted: Na 134, K+ 3.9, Mg 2.1, phos 2.3, WBC 10 (greatly improved) • C diff improved with negative results, UTI & fever improving • Flagyl DC’ed, tigecycline initiated, vanco, miconazole, PPI, NS @ 100ml/hr, and Zofran in place.

  26. DISCHARGE: July 25, 2013 • Patient D/C’ed to Prescott House, LTC facility. • Semi-formed stool, negative C diff results, afebrile. Removal of rectal tube • Nutrition recs: • Continue pureed diet w/honey thick liquids or per SLP recs • Diet education PRN • PPN recommended if <50% PO and family is receptive to this nutrition POC • Monitor GI function/symptoms & adjust regimen to maintain WNL • Diagnosis: Swallowing difficulty r/t age AEB rec continue pureed diet with honey thick liq per SLP

  27. Conclusion The effectiveness of T.D’s POC was indicative of appropriate recommendations given Ogilvie Syndrome, other underlying infection/conditions, as well as close monitoring by the care team. The overall impact of conservative management was positive in this case. With tremendous family involvement & encouragement, T.D. met our nutrition goal of at least 50% PO @ meals without s/s of dysphagia. GI symptoms, C diff, UTI, fever, blood cultures improved slowly with ABX therapy & bowel regimen in place. Notable repletion of electrolyes to ensure all WNL. Colonic decompression proved to be helpful to reduce the risk of perforation

  28. REFERENCES Altaf, A., Zaidi, N.H. Colonic pseudo-obstruction. Department of Surgery, University Hospital, K.A.A. http://cdn.intechopen.com/pdfs/25645/InTech-Colonic_pseudo_obstruction.pdf. Accessed August 10, 2013 Cecostomy. John Hopkin’s Medicine website. http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/cecostomy_135,17/. Accessed August 10, 2013 Intestinal Dysmotility. http://www.tpnteam.com/secure/Intestinal_dysmotility.htm. Accessed August 10, 2013 Intestinal Pseudo-Obstruction. National Digestive Disease Information Clearing House. http://digestive.niddk.nih.gov/ddiseases/pubs/intestinalpo/. Accessed August 10, 2013 Maloney, N., Vargas, H.D. Acute intestinal pseudo-obstruction (Ogilvie’s Syndrome). Clin Colon Rectal Surg. 2005 May; 18(2): 96–101. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780141/ Percutaneous Cecostomy Tube Placement. Children’s Hospital of Philadelphia website. http://www.chop.edu/service/radiology/interventional-radiology/percutaneous-cecostomy-tube-placement.html. Accessed August 10, 2013 Ponec, R.J., Saunders, M.D., Kimmey, M.B. Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med. 1999 Jul 15;341(3): 137-141. http://www.ncbi.nlm.nih.gov/pubmed/10403850. Accessed August 10, 2013 Saunders, M.D., Kimmey, M.B. Systematic review: acute colonic pseudo-obstruction. Aliment PharmacolTher. 2005 Nov 15;22(10):917-925. http://www.ncbi.nlm.nih.gov/pubmed/16268965. Accessed August 10, 2013

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