Acute Colonic Pseudo-Obstruction (Ogilvie) Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Ischemia/perforation?
   Ischemia/perforation/peritonitis; response to 24–48 h of conservative care? (Acute colonic pseudo-obstruction (Ogilvie) = massive colonic dilation (especially cecum/right colon) without mechanical obstruction, from autonomic imbalance; common in hospitalized/postoperative (cesarean, orthopedic)/critically ill/electrolyte disturbance/drugs (opioids, anticholinergics). Perforation risk rises with cecal diameter: <12 cm ~0%, 12–14 cm ~7%, >14 cm ~23%. Diagnosis: plain film (cecal dilation), CT + oral/rectal contrast to exclude mechanical obstruction, check for ischemia/perforation.)
   • Ischemia/perforation/peritonitis or all measures failed → Ischemia/perforation/failure → surgery
   • No ischemia/perforation (conservative/neostigmine first) → No ischemia/perforation · conservative + neostigmine
2. [End] No ischemia/perforation · conservative + neostigmine
   No ischemia/perforation: conservative for 24–48 h first — NPO, NG + rectal tube decompression, correct electrolytes (potassium/magnesium/calcium/phosphate), stop opioids/anticholinergics, position changes, avoid osmotic laxatives (lactulose worsens it); no improvement or cecum ≥10–12 cm → neostigmine 2–2.5 mg IV (cardiac monitoring, atropine ready; contraindicated in bradycardia/hypotension/asthma/mechanical obstruction/ischemia-perforation/urinary obstruction); still not resolving → colonoscopic decompression (unprepped, place a decompression tube), then PEG to prevent recurrence.
3. [End] Ischemia/perforation/failure → surgery
   Ischemia/perforation/peritonitis or failure of conservative + neostigmine + colonoscopy: surgery (cecostomy/percutaneous cecostomy or subtotal colectomy); cecal diameter >12–14 cm sharply raises perforation risk (>14 cm ~23%), perforation mortality is high, timely decompression is key.

Source guidelines & references

• Acute colonic pseudo-obstruction Ogilvie (ASGE/ESGE; NEJM neostigmine RCT; ASCRS)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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