A 68-year-old man, day 4 after hip fracture fixation, develops abdominal distension. Radiographs show colonic dilatation to the caecum with a caecal diameter of 13 cm and no mechanical obstruction on CT. He is haemodynamically stable and afebrile. Intravenous neostigmine is given. Which finding is the main indication for surgical intervention at this point?
- A Caecal diameter greater than 10 cm
- B Failure of two doses of neostigmine with progressive caecal dilatation or signs of ischaemia ✓
- C Presence of haustra on the radiograph
- D Age over 65 years
Correct answer: B. Failure of two doses of neostigmine with progressive caecal dilatation or signs of ischaemia
Explanation
Ogilvie syndrome (acute colonic pseudo-obstruction) is managed initially with supportive measures and intravenous neostigmine, which induces colonic decompression in most patients within minutes. Surgery is indicated for refractory cases with ongoing caecal expansion, caecal ischaemia, or perforation, where caecostomy or segmental resection is performed. A diameter above roughly 12 cm signals perforation risk warranting treatment, not operation itself, and haustral preservation actually supports pseudo-obstruction over mechanical obstruction.
Reference: Sabiston Textbook of Surgery, 21st ed.
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