UMEM Educational Pearls

Category: Visual Diagnosis

Title: What's the diagnosis? Written by John Greenwood, MD

Posted: 4/10/2011 by Haney Mallemat, MD (Emailed: 4/11/2011) (Updated: 4/11/2011)
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60 y/o male transferred from local rehab facility c/o abdominal pain.



Ogilvie's syndrome / Acute colonic pseudo-obstruction (ACPO)

Syndrome of decreased GI motility believed to be an autonomic imbalance (specifically, parasympathetic suppression) predominantly in the cecum and right colon. ACPO is also commonly due to narcotic overuse / abuse. 

Differential diagnosis:

  • Mechanical large bowel obstruction
  • Toxic megacolon / colitis
  • Ileus 

Abdominal XR:

  • Gaseous distention without fluid levels (UNLIKE obstruction)
  • Small bowel dilation is typically absent (UNLIKE ileus)
  • Preserved haustral markings and smooth inner contour (UNLIKE colitis)


  • Treat underlying cause (e.g., discontinue narcotics) 
  • Neostigmine
  • Therapeutic Colonoscopy
  • Surgical decompression (if severe)


Fazel A, Verne GN.  New solutions to an old problem: Acute colonic pseudo-obstruction. JClin Gastroenterol 2005; Vol 39(1): 17-20.

Ozkurt H, Yilmaz F, et al.  Acute colonic pseudo-obstruction (Ogilvie's syndrome): radiologic diagnosis and medical treatment with neostigmine.  Report of 4 cases.  Am J of Emer Med 2009; Vol 27: 757.e1 - 757e4.