Introduction:

Acute colonic pseudo-obstruction, also known as Ogilvie syndrome, is characterized by marked colonic dilation in the absence of a mechanical obstruction. Diagnosis is based on clinical evaluation and radiologic imaging. Management ranges from conservative therapy and pharmacologic intervention to decompression and in severe cases, surgical treatment. Early recognition is critical, as delayed intervention can lead to bowel ischemia or perforation with high associated morbidity and mortality.

Case Presentation:

61-year-old male with multiple comorbidities and residual deficits, was admitted for severe hypokalemia, subsequently developed Ogilvie syndrome during hospitalization. He was treated with potassium supplementation for hypokalemia and loperamide for diarrhea. On hospital day seven, he developed abdominal distention following PEG tube feedings and medication administration. Computed tomography of the abdomen revealed diffuse dilation of the transverse and descending colon with significant stool burden and no evidence of mechanical obstruction, consistent with Ogilvie syndrome. Despite conservative management and decompression attempts, his condition did not improve and was complicated by colonic perforation, ultimately requiring a colectomy.

Discussion/ Conclusion:

In this case, the patient's neurologic deficits and inability to verbalize discomfort, obscured early clinical deterioration, leading to delayed diagnosis and the development of life-threatening complications. This underscores the critical need to improve recognition of non-classical presentations of Ogilvie syndrome-especially outside of postoperative settings. Future efforts should focus on developing tools and protocols that can facilitate earlier identification of atypical cases, particularly in vulnerable populations with limited ability to communicate. Such advancements could enable more timely interventions, potentially preventing adverse outcomes in patients like the one described.