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Acute Megacolon Treatment & Management

  • Author: Roberto M Gamarra, MD; Chief Editor: BS Anand, MD  more...
 
Updated: Dec 09, 2014
 

Medical Care

Conservative management is preferred when the patient is clinically stable. Consider the following:

  • The underlying cause is treated, if possible, such as correction of any electrolyte/metabolic abnormalities and removal of medications that may decrease colonic motility (eg, narcotics, anticholinergic agents, calcium channel antagonists).
  • Oral feeding should be discontinued, and intravenous fluids should be initiated.
  • If nausea and vomiting are present, nasogastric decompression should be initiated.

Decompression

Use of a rectal tube

Decompression using a rectal tube may assist in the treatment only if the sigmoid colon is involved. When such tubes are used, anecdotal experience has demonstrated that frequent position changes for the patient may help improve decompression. Complications with these rectal tubes include tube obstruction and colonic/rectal ulceration.

Colonoscopic decompression

If the dilatation persists or worsens, colonoscopic decompression with or without placement of a tube in the right colon should be considered. Although the placement of a decompression tube per rectum is generally suggested, some experts believe that the tube often becomes obstructed with stool and ceases to work after a short time. Randomized controlled trials of the efficacy of colonoscopic decompression are lacking. The resolution of ileus, perforation, and mortality rates are similar between endoscopic and conservative management.

Neostigmine

Neostigmine (adrenergic antagonist) has been demonstrated in noncontrolled and controlled studies to improve acute colonic megacolon. Whether a trial of neostigmine should be performed before or after colonoscopic decompression is unclear.

The major indication for its use is failure of conservative therapy after 72 hours. Failure of conservative therapy is generally defined by a cecal diameter of greater than 9 cm.

Contraindications include bradycardia, systolic blood pressure of less than 90 mm Hg, active bronchospasm, serum creatinine level of greater than 3 mg/dL, and evidence of bowel perforation.

Adverse events include abdominal cramping (17%), excessive salivation (13%), transient bradycardia (6%), diaphoresis (4%), and nausea and vomiting (4%). Based on expert opinion, a starting dose of 1 mg may reduce the likelihood of bradycardia.

Cardiac monitoring of patients during treatment with neostigmine is generally recommended, and atropine should be at the bedside.

A second dose of neostigmine should be considered if there is a partial or minimal response to the initial administration.

Of note, although neostigmine often induces clinical decompression, this decompression has not been shown to reduce perforation and mortality rates.

Urgency

The urgency of management often depends on the size of the colon and the rate of change of the cecal diameter. Some experts believe that regardless of the criteria used for defining acute megacolon, the diameter of the cecum is the most important criterion because the cecum is generally the area that perforates. While the diameter at which the cecum perforates is variable, expert experience indicates that the cecum rarely perforates at a diameter of less than 12 cm.

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Hospitalization

Once relieved, close follow-up care, including physical examination and maintenance of a normal electrolyte balance, is important.

Avoid using agents that slow transit time, such as opiates and anticholinergics.

Diet and activity

Most patients are in the hospital when acute pseudo-obstruction is diagnosed, and bowel rest should be instituted. Parenteral nutrition may be considered depending on the patient's nutritional status.

Because many of the cases of acute pseudo-obstruction occur postoperatively, patients tend to be at bed rest. Remembering to continue prophylaxis for deep venous thrombosis, per the individual physician's protocol, is important; however, if the patient is not severely ill, is not in severe pain, and is stable to ambulate, no reason exists for the patient to remain in bed.

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Surgical Care

In view of the high rate of recurrence of colonic dilation following medical and endoscopic therapies, other therapeutic modalities have been proposed.

Percutaneous cecostomy may successfully allow for colonic decompression, but complications with this procedure are high.

Surgical options include cecostomy, colostomy, or colectomy, although surgical therapies are associated with even poorer outcomes. A colectomy is indicated if perforation or colonic ischemia is present.[5]

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Contributor Information and Disclosures
Author

Roberto M Gamarra, MD Consulting Gastroenterologist, Digestive Health Associates, PLC

Roberto M Gamarra, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Crohn's and Colitis Foundation of America

Disclosure: Nothing to disclose.

Coauthor(s)

Michael H Piper, MD Clinical Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Wayne State University School of Medicine; Consulting Staff, Digestive Health Associates, PLC

Michael H Piper, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, Michigan State Medical Society

Disclosure: Nothing to disclose.

David Manuel, MD Affiliate Faculty, Department of Medicine, Loyola University Health System; Gastroenterologist, Digestive Health Center

David Manuel, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Crohn's and Colitis Foundation of America

Disclosure: Nothing to disclose.

Ross A Heil, DO Fellow, Department of Gastroenterology, St John Providence Health System

Ross A Heil, DO is a member of the following medical societies: American College of Osteopathic Internists, American Medical Association, American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, American Gastroenterological Association

Disclosure: Received grant/research funds from Novartis for other; Received grant/research funds from Bayer for other; Received grant/research funds from Otsuka for none; Received grant/research funds from Bristol Myers Squibb for other; Received none from Scynexis for none; Received grant/research funds from Salix for other; Received grant/research funds from MannKind for other.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

Terence David Lewis, MBBS, MBBS 

Terence David Lewis, MBBS, MBBS is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, California Medical Association, Royal College of Physicians and Surgeons of Canada, Sigma Xi

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author, Clifford Y Ko, MD, MS, to the development and writing of this article.

References
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