16th Aug 2021

ICRI CASE OF THE WEEK

Contributed by- Dr Srinivas Dandamudi
Consultant Radiologist

Aayush Hospitals, Vijayawada

Copyright : Dr Srinivas Dandamudi
Email : [email protected]

Clinical Notes

• Smt XYZ was a 28yr old lady in hospital
recovering from a caesarean section. She
complained of diffuse abdominal pain and
fullness, and did not pass motion. The
obstetrician observed that her abdomen was
distended. Abdominal radiograph in erect
posture was requested.

What are the two important observations in
these radiographs ?

• A postoperative pneumoperitoneum following
recent surgery may be a normal finding due to
the air introduced during surgery or
postoperative drains. However, a
pneumoperitoneum on plain radiographs may
also be an indicator of anastomotic leakage or
gastrointestinal perforation



• Free air in the post operative radiographs is an
expected finding, but it may also indicate
perforation or anastomotic leakage.

• Beware of free air associated with ileus. Do
not hesitate to do a CT examination if the free
air volume is increasing.

• Free air should disappear in a span of 5 days.
It will disappear slowly in obese patients.

• Increasing free air and ileus are the ominous
findings in the index patient.

• Findings of an initial air height >11.7 mm,
increasing air height over time, and the
presence of ileus on plain radiographs suggest
a high likelihood of anastomotic leakage.

Lee, Chang Ho et al. “Postoperative pneumoperitoneum:
guilty or not guilty?.” Journal of the Korean Surgical
Society vol. 82,4 (2012): 227-31.
doi:10.4174/jkss.2012.82.4.227



• CT examination of abdomen with Oral, rectal
and IV contrast revealed large
pneumoperitoneum with leakage of contrast
from caecum.

• Multiple sieve like perforations identified
during surgery and post operative course is
uneventful

• Hallmark symptom of Ogilvie’s syndrome is
marked abdominal distension developing over
a short time frame

• Signs and symptoms may initially mimic
paralytic ileus. However, in OS, bowel sounds
are often reported to be higher pitched and
hyperactive. In addition, the patient may still
be able to pass small amount of faecal fluid
and flatus.

GONG, D., CHIN, V.. Ogilvie’s Syndrome With Cecal Perforation Post
Caesarean Section: A Case Report. Journal of Clinical Gynecology and
Obstetrics, North America, 7, mar. 2018. Available at:
https://www.jcgo.org/index.php/jcgo/article/view/474/319

• The exact etiology of Ogilvie Syndrome is still poorly
understood. However, the current consensus is that there is
an imbalance of sympathetic and parasympathetic
innervation of the colon . Physiologically, the parasympathetic
system increases the motility of the colon while the
sympathetic system does the exact opposite. In a large
analysis of 400 cases of OS, it was suggested that there is a
temporary neuropraxia of the sacral parasympathetic outflow
(S2-S4) . This finding may help to explain OS post CS; however,
this is yet to be confirmed.

• The cecum, being the part of colon with the thinnest wall and
largest diameter, makes it especially vulnerable to perforation.
This can be explained by the Law of Laplace which states that
the tension in the wall of a hollow viscus is directly
proportional to its radius and intraluminal pressure.

GONG, D., CHIN, V.. Ogilvie’s Syndrome With Cecal Perforation Post
Caesarean Section: A Case Report. Journal of Clinical Gynecology and
Obstetrics, North America, 7, mar. 2018. Available at:
https://www.jcgo.org/index.php/jcgo/article/view/474/319

• Plain abdominal X-ray is the most useful
diagnostic modality that reveals gaseous
distention in colon, mostly involving the
caecum and ascending colon, with or without
fluid levels seen in small bowel.

• Caecal diameter of 9–12 cm warrants ischemia
and subsequent perforation, if not managed
urgently.

Lamiaa Elsebay, Mariam Ahmed Galal, "Ogilvie’s Syndrome after Cesarean
Section: Case Report in Saudi Arabia and Management Approach", Case
Reports in Obstetrics and Gynecology, vol. 2017, Article
https://www.hindawi.com/journals/criog/2017/5328160/