I recently was asked to provide a report on a patient who developed a bowel rupture some 4 days after a Caesarean Section. She was an older mother on anti-depressants. On day 3 she developed right sided pain above her scar associated with abdominal distension. After she opened her bowels later that day she was discharged from hospital.
She was readmitted the following day with an obvious acute diaphragm and was found to have gas under her diaphragm on X-ray.
A general surgeon performed a laparotomy and found a large perforation of her caecum.
She required a resection of her caecum and adjoining ascending colon and she received a temporary colostomy. The surgeon did not comment on the cause and it was assumed that the obstetrician had 'knicked the bowel' at the time of the Caesarean section.
A more likely explanation is that there was acute caecal dilatation (Ogilvie's Syndrome) which eventually ruptured.
Ogilvie's Syndrome is a rare complication but is found in patients undergoing Caesarean section. It occurs about day 3 or 4 and if unrecognised can lead to colonic rupture (1-3%) and even death (50-70% mortality when perforation occurs). The mechanism is thought to be an abnormality involving the parasympathetic nervous system. Ogilvie described the first 2 cases in patients with retroperitoneal malignancies involving the coeliac plexus of nerves.
Some of the predisposing factors include advanced maternal age, cardiac surgery, burns, Caesarean section, hip surgery, use of antidepressants, use of narcotics, electrolyte disturbances. Patients with Ogilvie's syndrome can have bowel sounds, pass flatus (¬40-50%) and even open their bowels so those signs are not foolproof (hence the term 'pseudo-obstruction').
A plain X-ray will detect most cases by gross dilatation of the caecum and ascending colon. The risk of perforation increases once the diameter of the distended caecum or colon is greater than 10cm.
Fortunately early recognition allows the condition to be treated conservatively either with neostigmine (a parasympathomimetic) or a decompressing colonoscopy.