S3988 ALS Complicated With Ogilvie's Syndrome

Introduction: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease characterized by degeneration of upper and lower motor neurons in the brain and spinal cord. Patients with ALS may present with bulbar symptoms, fasciculations, spasticity, or muscle stiffness. While the disease predominantly affects motor neurons, its effect on autonomic function remains unclear. Here, we present a case of ALS complicated by Ogilvie syndrome (OS), or acute colonic pseudo-obstruction, a rare and potentially serious gastrointestinal manifestation. Case Description/Methods: A 63-year-old man presented after complications from percutaneous endoscopic gastrostomy (PEG) placement. He had progressive dysphagia and a 30 lb weight loss over 4 months. Prior esophagogastroduodenoscopy, esophageal manometry, and barium swallow were unremarkable. A PEG was placed due to severe malnutrition. Following the procedure, the patient developed altered mental status and required intubation. After extubation the next day, he developed abdominal distension. Computed tomography (CT) imaging revealed diffuse colonic dilation and pneumoperitoneum. PEG displacement was initially suspected, but imaging confirmed proper placement. Neurology was consulted, and electromyography findings were consistent with ALS. Riluzole 50 mg twice a day was started. The patient became apneic but improved with BiPAP. Despite this, abdominal distension worsened. Repeat CT showed progressive colonic dilation with persistent pneumoperitoneum. Gastrografin study showed no perforation. He was managed with nasogastric suction, pyridostigmine 60 mg BID, and prucalopride, but symptoms persisted. A decompression tube was placed with partial relief. Tracheostomy was performed to avoid further positive pressure ventilation. Abdominal distension recurred. Imaging showed PEG displacement with tube feeds leaking into the peritoneum. The PEG was removed. Sigmoidoscopy was performed, but inflammation limited surgical options. Referral for percutaneous cecostomy was unsuccessful, and colectomy was declined by the family. The patient was discharged to a long-term acute care (LTAC) facility. Discussion: OS involves acute colonic dilation in the absence of mechanical obstruction, likely due to autonomic dysregulation. Though ALS primarily targets UMN and LMN. The relationship between ALS and OS is poorly defined. Pyridostigmine was tried but showed limited effectiveness. Constipation in patients with ALS should be approached with caution, as it may indicate the development of Ogilvie syndrome.