Download 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
• 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)
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.
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
MNT & Treatment
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.
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.
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
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.
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
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
What does the research say?
Success Rates of Method(s) Used
Neostigmine – 91%
Colectomy – 84%
Colonoscopy/Decompression – 64%
Erythromycin – 40%
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
Diagnosis & Plan of Care
for Patient T.D.
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
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
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
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
Follow Up Assessment: June 21, 2013
Level 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
Follow Up Assessment: June 26, 2013
Level 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
Follow Up Assessment: June 28, 2013
Level 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
• 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
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.
• 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
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 pt tol puddings, Greek yogurt, apple sauce & Ensure Clear, PO 2550% 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
• 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
Final Follow Up Assessment: July 23, 2013
Level 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.
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
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
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 Pharmacol Ther. 2005 Nov
15;22(10):917-925. http://www.ncbi.nlm.nih.gov/pubmed/16268965. Accessed August 10, 2013