Ogilvie Syndrome A Gastrointestinal Clinical Case Study Holy

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 > 12 cm “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 (1 g/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 & 21 g 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 -40 kcals/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 2 nd, 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 -68 g (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, D 5 NS @ 100 ml/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 @ 100 ml/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

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