An Elderly Woman with Abdomen Distension: Ogilvie's Or Chilaiditi

CASE REPORT

An elderly woman with abdomen distension: Ogilvie’s or Chilaiditi syndrome?

Vitorino Modesto dos santos, érika renata Nascimento Cavalcanti de Oliveira, loana Márquez Andrade, Amanda dantas Prates, rafael Quaresma de lima and Aline sena da Costa

ABsTrACT

Vitorino Modesto dos santos – MD, PhD, Hospital das Forças Armadas and Although Ogilvie’s syndrome, or intestinal pseudo- Universidade Católica de Brasília, Brasília-DF, Brazil obstruction, has been scarcely reported, it is not a érika renata Nascimento Cavalcanti de Oliveira – MD, Hospital das rare condition. With the objective of raising aware- Forças Armadas, Brasília-DF, Brazil ness about this entity, the case study of an 85-year- old woman with hypokalaemia is reported and the loana Márquez Andrade – MD, Hospital das Forças Armadas, Brasília-DF, main findings are emphasised. The differential di- Brazil agnosis between Ogilvie’s and Chilaiditi syndrome Amanda dantas Prates – MD, Hospital das Forças Armadas, Brasília-DF, is highlighted because of the features shared by Brazil these conditions. The patient received general clini- rafael Quaresma de lima – MD, Hospital das Forças Armadas, Brasília- cal support and her hydro-electrolyte balance was DF, Brazil maintained, with a good outcome after four days of Aline sena da Costa – MD, Hospital das Forças Armadas, Brasília-DF, Brazil conservative treatment. Early diagnosis and prompt correction of predisposing factors contributed to Mailing address. Vitorino Modesto dos Santos. Hospital das Forças Armadas. Estrada do Contorno do Bosque s/n, Cruzeiro the successful clinical management of the Ogilvie’s Novo, CEP 70.658-900, Brasília, Distrito Federal, Brazil. Phone: syndrome affecting this fragile elderly patient. +55 61 39662103. Fax: 61 32331599.

E-mail eddress: [email protected] Key words. Ogilvie’s syndrome; Chilaiditi syndrome; abdominal distension; hypokalaemia; intestinal pseudo-obstruction.

Received on October 19, 2012. Accepted on November 30, 2012. RESUMO No potential conflict of interest relevant to this article was Mulher idosa com distensão abdominal: síndrome de reported. Ogilvie ou de Chilaiditi?

Embora a síndrome de Ogilvie ou pseudo-obstrução intestinal tenha sido poucas vezes relatada, não se trata de condição muito rara. Relata-se o estudo de caso de uma mulher de 85 anos com hipocalemia em que os principais aspectos são enfatizados, com o objetivo de aumentar o a pronta correção de fatores predisponentes contribuí- índice de suspeita sobre essa entidade. O diagnóstico di- ram para o sucesso do manuseio clínico da síndrome de ferencial entre as síndromes de Ogilvie e de Chilaiditi é Ogilvie que afetou essa frágil paciente. realçado, em virtude dos aspectos comuns a essas duas condições. A paciente recebeu suporte clínico geral e re- Palavras-chave. Síndrome de Ogilvie; síndrome de posição hidroeletrolítica com bom resultado, após quatro Chilaiditi; distensão abdominal; hipocalemia; pseudo- dias de tratamento conservador. O diagnóstico precoce e -obstrução intestinal.

294 • Brasília Med 2012;49(4):294-297 Vitorino Modesto dos Santos et al. • Ogilvie’s or Chilaiditi syndrome?

iNTrOdUCTiON between Ogilvie’s syndrome and Chilaiditi syndrome is exceedingly rare.7,9 Ogilvie’s syndrome Ogilvie’s syndrome is a rare condition that was more often develops in debilitated, elderly individ- first described in 1948. It is characterized by acute uals due to medication side-effects, metabolic or pseudo-obstruction and massive colon dilation.1,2 neurological disorders, surgery or trauma.1,10 Bowel Chilaiditi syndrome is a rare entity that was first perforation can occur as a severe complication of described in 1910. It consists of hepatodiaphrag- Ogilvie’s syndrome1 and may evolve unnoticed. matic interposition of distended colon.3-5 Similar non-specific gastrointestinal disturbances are observed in both syndromes, including anorexia, ab- CAsE rEPOrT dominal pain, vomiting, bowel distension, air-fluid levels, and constipation. An 85-year-old woman was admitted to the hospital presenting with loss of appetite, asthenia, vom- Four very rare examples of acute abdomen disten- iting, abdominal pain and distension. There was sion have been recently described: pseudopneu- also no elimination of flatus or stools. Her general moperitoneum in Chilaiditi syndrome,6 Ogilvie’s condition was poor. She was pale, dehydrated, and syndrome associated with coronary revasculariza- breathless. There was no use of anticholinergic or tion,2 Chilaiditi syndrome associated with colono- diuretic drugs or any drugs that could cause hypo- scopic mucosal resection,3 and Ogilvie’s syndrome kalaemia. Her abdomen was distended and hyper- associated with Chilaiditi syndrome.7 Interestingly, resonant, but not rigid, and the percussion note at these four patients were elderly individuals (68, 68, the right hypochondrium over the liver area was 74, and 78 years of age, respectively), and differen- also tympanitic. A nasogastric tube was positioned tial diagnosis could be established based on classi- and it drained a large amount of dark fluid. An up- cal abdomen images. per gastrointestinal study revealed severe erosive oesophagitis and a large hiatus hernia with evi- Pseudopneumoperitoneum refers to the pres- dence of recent bleeding. Laboratory data (Table) ence of air under the diaphragm, with no free air showed anaemia, neutrophilia, hypokalaemia and in the abdominal cavity; it can be mistaken for hypochloraemia, without remarkable changes in pneumoperitoneum due to a perforated viscus.6 other electrolytes. Serum protein levels and thy- Pneumoperitoneum can occur in Chilaiditi syn- roid function tests were normal, and blood cul- drome with bowel perforation,8 but the association tures were negative. An abdominal radiography

Table. Laboratory data of an 85-year-old woman with Ogilvie’s syndrome

PArAMETErs MAy 6, 2008 MAy 9, 2008 NOrMAl rANGE Red blood cells (mm3) 4,200000 3,600000 4,200000-5,700000 Haemoglobin (g/dL) 11.6 10.0 13.2-16.9 Haematocrit (%) 33.7 30.0 38.5-49 MCV (f) 80 84 80-97 MCHC (%) 34 33 32-36 White blood cells (mm3) 9500 13700 3900-10000 Neutrophils (%) 81 97 38-80 Platelets (mm3) 284000 272000 140000-390000 Sodium (mmol/L) 135 142 135-145 Potassium (mmol/L) 2.8 4.3 3.5-5.0 Chlorides (mmol/L) 85.1 100.7 98-108 Urea (BUN) (mg/dL) 90.0 63.8 10-45 Creatinine (mg/dL) 0.7 0.7 0.8-1.2 Glucose (mg/dL) 70 77 70-99 MCV – mean corpuscular volume. MCHC – mean corpuscular haemoglobin concentration. Remarkable data are in bold.

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study showed accentuated colon distension conservative management included intravenous (Figure 1). Computed tomography scans revealed hydration with potassium chloride (KCl) adminis- moderate distension of the small intestine and tration and nasogastric suction. On day 4, total par- conspicuous colon air-fluid levels (Figure 2 A-B), enteral nutrition plus KCl 15% was utilised, and on suggesting mechanical obstruction of distal large day 10 oral intakes were reestablished. The patient bowel. However, lower gastrointestinal evalua- showed considerable improvement following this tion ruled out this hypothesis, and the diagnosis of non-invasive treatment. Computed tomography colon pseudo-obstruction was established. Initial images of control confirmed the absence of any intestinal abnormality (Figure 2 C-D). Although her hospital discharge occurred after clinical improvement, her general condition did not allow immedi- ate surgical correction of her large hiatus hernia. Therefore, she was referred to outpatient special- ized surveillance because of possible recurrences.

disCUssiON

Ogilvie’s syndrome is described in a debilitated, elderly, female patient who rapidly improved following continuous nasogastric decompression, total Figure 1. A – upright abdominal radiography showing intravenous nutrition, and potassium reposition.10-12 accentuated colonic distension, with projection of the Hypokalaemia was associated with fluid loss to third- hepatic flexure over the liver area. B – comparative space, lack of appetite and vomiting, associated with aspect of bowel distension at Day 2 of admission. a large hiatus hernia, gastro-oesophageal reflux and severe erosive oesophagitis. Her abdomen was distended and there was hyper-resonance on percussion over the right hypochondrium region. Therefore, it was important to establish a differential diagnosis between Ogilvie’s syndrome and Chilaiditi syndrome, in addition to considering the eventual occurrence of pneumoperitoneum. Hypotheses for tympanic percussion sound over the right hypocondrium include Ogilvie’s syndrome with bowel perforation,1 Ogilvie’s syndrome concomitant with Chilaiditi syndrome,7,9 caecum perforation associated with Chilaiditi syndrome,8 and Chilaiditi syndrome associated with closed-loop small bowel obstruction.4 However, imaging findings of total abdomen and of lower gastrointestinal studies contributed to rule out all those differential possibilities. Figure 2. A and B – computed tomography scans of the abdomen revealing images of conspicuous Another concern was about the caecum diameter of air-fluid levels in the colon (arrows), in addition to 11 cm, which was almost indicative (12 to 14 cm) distension of small bowel loops (asterisks). C and of an emergency surgery.10,12 Nevertheless, prompt D – imaging study of control, after four days of clinical management reduced bowel dilation in conservative treatment, showing total improvement less than 72 hours. As neither massive caecum di- of intestinal changes. lation nor perforation or peritonitis were present,

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decompression techniques or laparotomy were not Blondon et al. was 87.5 years.13 The female patient needed.10,12 Although Ogilvie’s syndrome may oc- described in this work is older than 56.5 years, which cur in isolation, it has been more often associated is the mean age of females with Ogilvie’s syndrome.13 with some other clinical disturbances. Colon and The mortality rate of 85 patients included in four of small bowel functional dilations have been associ- the studies mentioned was 15.3%,10,12,14,15 showing the ated with inhibition of intestinal motility, systemic potential severity of Ogilvie’s syndrome. Debilitated and metabolic disorders, severe diseases, trauma, old people are more prone to hydro-electrolyte dis- and postoperative immobility.10,11 Outcomes are of- orders and to bowel ischaemia; therefore, healthcare ten favorable, with better responses to early con- professionals must be aware of the risk of Ogilvie’s servative procedures, including control of basic syndrome in this age group. disorders, prokinetics, acetyl cholinesterase inhibi- tors, and decompression either by laparoscopy or endoscopy.10,11,13 Non-invasive decompression is the rEFErENCEs first choice, while caecostomy or laparotomy are indicated if pseudo-obstruction is not relieved by 1. Maloney N, Vargas HD. Acute intestinal pseudo-obstruction 10 (Ogilvie’s syndrome). Clin Colon Rectal Surg. 2005;18(2):96-101. clinical measures or if bowel perforation occurs. 2. Yurtman V, Talay S, Dalga S, Aslan Z. Ogilvie syndrome: a rare but lethal intestinal complication of coronary revascularization. Yeh et al. reported the successful conservative Anadolu Kardiyol Derg. 2012;12(5):444-5. 3. Joo YE. Chilaiditi’s sign. Korean J Gastroenterol. 2012;59(3):260-1. treatment of Ogilvie’s syndrome in a 67-year-old 4. Mateo de Acosta Andino DA, Aberle CM, Ragauskaite L, Khair G, male patient with anaemia, high creatinine levels, Streicher A, Bartholomew J, et al. Chilaiditi syndrome complicated and hypokalaemia. Similarly to the patient de- by a closed-loop small bowel obstruction. Gastroenterol Hepatol (N Y). 2012;8(4):274-6. scribed in this work, caecum diameter was around 5. Moaven O, Hodin RA. Chilaiditi syndrome: a rare entity with 11 cm, there was gastrointestinal loss of potassium important differential diagnoses. Gastroenterol Hepatol (N Y). 2012;8(4):276-8. and he underwent nasogastric decompression, par- 6. Lo BM. Radiographic look-alikes: distinguishing between pneu- enteral nutrition, and electrolyte correction. It is moperitoneum and pseudopneumoperitoneum. J Emerg Med. worth mentioning that neostigmine, decompres- 2010;38(1):36-9. 7. Suárez-Grau JM, Rubio Cháves C, López Bernal F, Pareja Ciuró F. sive colonoscopy or surgery were not performed; Colonic pseudo-colonic obstruction (Ogilvie syndrome) in a pa- however, an anal tube, frozen plasma and antibiot- tient with Chilaiditi syndrome. Cir Esp. 2011;89(8):e2. ics were used.10 Atamanalp et al. reviewed the case 8. Aldoss IT, Abuzetun JY, Nusair M, Suker M, Porter J. Chilaiditi syndrome complicated by cecal perforation. South Med J. of 15 patients (53.3% male, mean age 49.9 years) 2009;102(8):841-3. with Ogilvie’s syndrome due to clinical disorders 9. Mathur S, Lakhani OJ, Hathila VP, Duttaroy DD, Vohra AS, (33.3%), abdominal surgery (26.7%) or burns (13.3%); Chauhan HR. Acute colonic peudo-obstruction (Ogilvie syndrome) 14 with Chilaiditi syndrome. Med J Aust. 2008;189(1):42. no cause was found in 26.7%. Krige et al. reviewed 10. Yeh T-L, Hwang L-C, Chang W-H. Successful treatment of acute the case of 29 patients (55.2% male, mean age 63 colonic pseudo-obstruction in an elderly patient. Int J Gerontol. years) with Ogilvie’s syndrome due to severe illness 2009;3(3):181-4. 11. Batke M, Cappell MS. Adynamic ileus and acute colonic pseudo- (79.3%), major surgery or trauma; 74.4% were con- obstruction. Med Clin North Am. 2008;92(3):649-70. servatively treated. Early diagnosis reduced the risk 12. Krige JE, Hudson DA, Kottler RE. Acute colonic pseudo-obstruction. 12 Current diagnosis and management. S Afr Med J. 1989;75(6):271-4. of caecum rupture. Fraisse et al. studied 40 patients 13. Blondon H, Béchade D, Desramé J, Algayres JP. Secretory diar- (60% male; mean age 80.8 years) and found hypo- rhoea with high fecal potassium concentrations: a new mecha- kalaemia in 52.5% of cases.15 Diarrhea was absent in nism of diarrhoea associated with colonic pseudo-obstruction? Report of five patients. Gastroenterol Clin Biol. 2008;32(4):401-4. our patient, but abdominal computed tomography 14. Atamanalp SS, Yildirgan MI, Basoglu M, Aydinli B, Ozturk G. showed conspicuous air-fluid levels, which may Ogilvie’s syndrome: presentation of 15 cases. Turk Med Sci. cause loss of potassium-containing fluids. As previ- 2007;37(2):105-11. 11 15. Fraisse A, Brosse S, Manckoundia P, Popitéan L, Pfitzenmeyer P. ously described, images of adynamic ileum were Ogilvie syndrome in the elderly: retrospective study of 40 cases. seen in our patient, but were not observed by Grassi Presse Med. 2003;32(32):1500-4. et al. in six patients with Ogilvie’s syndrome.16 The 16. Grassi R, Cappabianca S, Porto A, Sacco M, Montemarano E, Quarantelli M, et al. Ogilvie’s syndrome (acute colonic pseudo- average age of men with Ogilvie’s syndrome is 59.9 obstruction): review of the literature and report of 6 additional years,1 while the mean age of males described by cases. Radiol Med. 2005;109(4):370-5.

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