Chronic Megacolon Treatment & Management
- Author: David Manuel, MD; Chief Editor: BS Anand, MD more...
Managing patients with chronic megacolon requires a multidisciplinary approach, including the primary care provider, a gastroenterologist, a nutritionist/dietitian, and possibly a surgeon.
In the absence of perforation, initial management is conservative. Some experts believe a role exists for as-needed fecal disimpaction and for evacuation by enemas and suppositories.
Pay close attention to exclusion of any underlying cause. If identified, correct electrolyte/metabolite abnormalities, and remove medications that may influence colonic motility (eg, narcotics, anticholinergic agents, calcium channel antagonists).
The use of biofeedback for a colonic inertia etiology for chronic megacolon is probably not effective, although successful treatment of functional outlet obstruction with biofeedback has been reported.
In patients requiring hospitalization, decompression using nasogastric tubes and rectal tubes may assist in treatment. When such tubes are used, anecdotal experience has demonstrated that frequent position changes for the patient may help to improve decompression.
If the dilatation persists or worsens, colonoscopic decompression can be attempted, with consideration of placement of a decompression tube, per rectum, to the right side of the colon. Unfortunately, following decompression, the dilatation usually recurs; therefore, decompression with colonoscopy must be carefully considered, as it is not without risk in an unprepared, dilated colon. Many gastroenterologists no longer consider placement of a drainage tube at the time of colonoscopy, as it nearly always becomes clogged with stool and rapidly ceases to function.
Maintenance of a strict bowel habit retraining program is important. Therefore, beyond the above options for the treatment of acute megacolon, the recommended regimen for chronic megacolon in a stable patient is as follows:
Empty the bowel (eg, osmotic laxatives, enemas, suppositories, cathartics, digital disimpaction).
Practice a bowel habit retraining program (eg, scheduled times for defecation, increased physical activity if possible).
Consume bulking agents/bowel agents.
Slowly alter/individualize the regimen.
Surgical care is generally recommended if the dilatation is persisting or worsening after the above medical measures have been exhausted.
Megacolon operative options include total abdominal colectomy with ileorectal anastomosis, total proctocolectomy with ileostomy, and total proctocolectomy with ileoanal anastomosis, depending on the site of the colon affected.
Total abdominal colectomy with ileorectal anastomosis is the operation of choice of megacolon with normal-sized rectum.
Patients with acquired, nonacute megacolon should follow a high-fiber, high-fluid intake diet, which usually helps to decrease constipation. Some patients with severe constipation state that a high-fiber diet produces greater difficulty with bloating and constipation.
Camilleri M. Acute and chronic pseudo-obstruction. Felman M, Friedman LS, Sleisenger MH, eds. Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 8th ed. Philadelphia, Pa: Saunders; 2007. 2679-702.
Camilleri M. Dysmotility of the small intestine and colon. Yamada T, ed. Textbook of Gastroenterology. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003. Vol 1: 1486-529.
Wallukat G, Munoz Saravia SG, Haberland A, et al. Distinct patterns of autoantibodies against G-protein-coupled receptors in Chagas' cardiomyopathy and megacolon. Their potential impact for early risk assessment in asymptomatic Chagas' patients. J Am Coll Cardiol. 2010 Feb 2. 55(5):463-8. [Medline].
Sanchez-Mejias A, Fernandez RM, Lopez-Alonso M, Antinolo G, Borrego S. New roles of EDNRB and EDN3 in the pathogenesis of Hirschsprung disease. Genet Med. 2010 Jan. 12(1):39-43. [Medline].
da Silveira AB, de Araujo FF, Freitas MA, et al. Characterization of the presence and distribution of Foxp3(+) cells in chagasic patients with and without megacolon. Hum Immunol. 2009 Jan. 70(1):65-7. [Medline].
da Silveira AB, Freitas MA, de Oliveira EC, et al. Glial fibrillary acidic protein and S-100 colocalization in the enteroglial cells in dilated and nondilated portions of colon from chagasic patients. Hum Pathol. 2009 Feb. 40(2):244-51. [Medline].
Ribeiro BM, Crema E, Rodrigues V Jr. Analysis of the cellular immune response in patients with the digestive and indeterminate forms of Chagas' disease. Hum Immunol. 2008 Aug. 69(8):484-9. [Medline].
Martucciello G. Hirschsprung's disease, one of the most difficult diagnoses in pediatric surgery: a review of the problems from clinical practice to the bench. Eur J Pediatr Surg. 2008 Jun. 18(3):140-9. [Medline].
Orno AK, Lovkvist H, Marsal K, von Steyern KV, Arnbjornsson E. Sonographic visualization of the rectoanal inhibitory reflex in children suspected of having Hirschsprung disease: a pilot study. J Ultrasound Med. 2008 Aug. 27(8):1165-9. [Medline].
Ohkubo H, Masaki T, Matsuhashi N, et al. Histopathologic findings in patients with idiopathic megacolon: a comparison between dilated and non-dilated loops. Neurogastroenterol Motil. 2014 Apr. 26(4):571-80. [Medline].
Barnes PR, Lennard-Jones JE, Hawley PR, Todd IP. Hirschsprung's disease and idiopathic megacolon in adults and adolescents. Gut. 1986 May. 27(5):534-41. [Medline].
de Oliveira GM, de Melo Medeiros M, et al. Applicability of the use of charcoal for the evaluation of intestinal motility in a murine model of Trypanosoma cruzi infection. Parasitol Res. 2008 Mar. 102(4):747-50. [Medline].
Harari D, Minaker KL. Megacolon in patients with chronic spinal cord injury. Spinal Cord. 2000 Jun. 38(6):331-9. [Medline].
Krishnamurthy S, Heng Y, Schuffler MD. Chronic intestinal pseudo-obstruction in infants and children caused by diverse abnormalities of the myenteric plexus. Gastroenterology. 1993 May. 104(5):1398-408. [Medline].
Lane RH, Todd IP. Idiopathic megacolon: a review of 42 cases. Br J Surg. 1977 May. 64(5):307-10. [Medline].
Manoel-Caetano Fda S, Carareto CM, Borim AA, Miyazaki K, Silva AE. kDNA gene signatures of Trypanosoma cruzi in blood and oesophageal mucosa from chronic chagasic patients. Trans R Soc Trop Med Hyg. 2008 Nov. 102(11):1102-7. [Medline].
Metcalf AM, Phillips SF, Zinsmeister AR, et al. Simplified assessment of segmental colonic transit. Gastroenterology. 1987 Jan. 92(1):40-7. [Medline].
Miyamoto M, Egami K, Maeda S, et al. Hirschsprung's disease in adults: report of a case and review of the literature. J Nippon Med Sch. 2005 Apr. 72(2):113-20. [Medline].
Nicholls RJ, Kamm MA. Proctocolectomy with restorative ileoanal reservoir for severe idiopathic constipation. Report of two cases. Dis Colon Rectum. 1988 Dec. 31(12):968-9. [Medline].
Porter NH. Megacolon: A physiological study. Proc R Soc Med. 1961. 54:1043.
Preston DM, Lennard-Jones JE, Thomas BM. Towards a radiologic definition of idiopathic megacolon. Gastrointest Radiol. 1985. 10(2):167-9. [Medline].
Stabile G, Kamm MA, Hawley PR, Lennard-Jones JE. Colectomy for idiopathic megarectum and megacolon. Gut. 1991 Dec. 32(12):1538-40. [Medline].
Stryker SJ, Pemberton JH, Zinsmeister AR. Long-term results of ileostomy in older patients. Dis Colon Rectum. 1985 Nov. 28(11):844-6. [Medline].
Yadav AK, Mishra K, Mohta A, Agarwal S. Hirschsprung's disease: is there a relationship between mast cells and nerve fibers?. World J Gastroenterol. 2009 Mar 28. 15(12):1493-8. [Medline]. [Full Text].
O'Dwyer RH, Acosta A, Camilleri M, Burton D, Busciglio I, Bharucha AE. Clinical features and colonic motor disturbances in chronic megacolon in adults. Dig Dis Sci. 2015 Aug. 60 (8):2398-407. [Medline].
Singer CE, Cosoveanu CS, Ciobanu MO, et al. Hirschprung's disease in different settings - a series of three cases from a tertiary referral center. Rom J Morphol Embryol. 2015. 56 (3):1195-200. [Medline].