Ogilvie's syndrome

Sir,

I read with great interest the article entitled “Ogilvie's syndrome following cesarean delivery: The Dubai's case” by Strahil Kotsev.[1] I would like to congratulate the author for his nice effort in reporting such a case in Arabian population and pointing out that Arabian population is also not immune to such entity. However, I have a few observations in this connection and would like to add some interesting points too. Sir William Heneage Ogilvie first described this syndrome in 1948 in 2 patients with advanced abdominal malignancies. Diagnosis could have been made preoperatively if the condition was highly suspected in this particular case. Plain abdominal radiograph taken at the first instance showed proximal colonic dilatation (cecum, ascending colon, and transverse colon) with cutoff at the splenic flexure. Predominant colonic distension at the right side with cutoff at the splenic flexure is frequently observed in the colonic pseudo-obstruction and typical of Ogilvie's syndrome.[2] Clinical and radiologic picture is quite diagnostic of this condition. Rectal/flatus tube was a part of management in this particular case. I would like to state here that placement of a rectal tube is rarely effective as dilation predominantly involve proximal colon in Ogilvie's syndrome. I do completely agree with the author that 9–10 cm diameter of cecum and colon is an indication for nonsurgical treatment.[1] Vanek and Al-Salti[3] did not find any case of cecal perforation in patients with a cecal diameter <12 cm. The risk of perforation is directly proportional to the diameter of the colon (7% risk with 12–14 cm and 23% with >14 cm). However, one report showed that duration of significant cecal dilatation is more predictive of ischemia rather than diameter per se.[4] Pharmacologic management with parasympathomimetic drugs enhancing gut motility has been described in the treatment of Ogilvie's syndrome.[1] Neostigmine is extremely effective and is associated with only 20% recurrence rate. Neostigmine may produce transient but profound bradycardia and may not be suitable for patients with cardiopulmonary disease. Colonoscopic decompression is also effective but is associated with up to 40% recurrence rate and is technically challenging since the colon is unprepared and patient is critically ill.