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Chronic Megacolon Workup

  • Author: David Manuel, MD; Chief Editor: BS Anand, MD  more...
 
Updated: Mar 28, 2016
 

Laboratory Studies

Laboratory studies are important to exclude other etiologies, including electrolyte abnormalities (eg, calcium, magnesium, phosphorus).

Thyroid function tests should also be performed.

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Imaging Studies

Abdominal plain films are useful for initial screening and assessment of severity.

After plain films reveal the megacolon, water-soluble contrast enema may be helpful for a number of reasons, as follows[9] :

  • Accurately assesses the size of the colon
  • Helps to differentiate the presence of megacolon, megarectum, or both
  • Helps to define the anatomy
  • Can be used therapeutically to evacuate the colon

Distinguishing a colonic inertia etiology from that of a functional outlet obstruction is probably best accomplished by colonic marker transit studies. Numerous ways to perform this test are available. Note the following:

  • One method is to instruct the patient to consume 30 g of dietary fiber daily and to stop using laxatives, enemas, and all other nonessential medications for at least 2 days prior to (as well as during) the test.
  • The patient swallows the markers, and abdominal plain films are obtained on days 1, 3, and 5.
  • Patients with colonic inertia tend to have markers distributed throughout the large bowel from cecum to rectum, while patients with outlet obstruction exhibit markers proceeding normally through the colon but accumulating in the rectum.
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Other Tests

Anorectal manometry may help to distinguish congenital from acquired megacolon. The presence of a rectoanal inhibitory response means that there are intact ganglia, and the patient does not have Hirschsprung disease. If the inhibitory response is absent, a rectal biopsy is still needed to confirm the diagnosis of Hirschsprung disease.

Pudendal nerve latency testing may elucidate problems related to peristaltic movement, anatomical and/or mechanical problems with evacuation, and nerve-associated problems with defecation.

Colonoscopy should be used to rule out an obstructive/mechanical cause of colonic dilatation.

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Histologic Findings

Histology is helpful for determining the etiology of the condition. Although full-thickness biopsy is the criterion standard to establish a diagnosis of Hirschsprung disease, mucosal suction biopsy is adequate in most instances. The absence of ganglion cells is characteristic of Hirschsprung disease, and specific stains for acetylcholinesterase are used to highlight abnormal morphology. Other than Hirschsprung disease, however, the presence of ganglion cells does not specify one cause over another. For most cases, there is no indication for histology because Hirschsprung disease is not considered or excluded by normal manometric findings.

Ohkubo et al reported that histopathologic abnormalities may precede the clinical manifestations of idiopathic megacolon.[10] They compared histopathologic features of dilated and nondilated loops in 53 full-thickness samples from 31 patients with idiopathic megacolon with 16 samples from 8 controls and defined hypoganglionosis as fewer than 60 ganglion cells/cm. The investigators noted the presence of neuropathy in 61.3% of patients (n=19), myopathy in 35.5% (n=11), and mesenchymopathy in 32.2% (n=10), with some overlap of subtypes. In most cases, there were similar histopathologic abnormalities between the dilated and nondilated loop samples.[10]

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

Clifford Y Ko, MD, MS Professor, Department of Surgery, University of California, Los Angeles, David Geffen School of Medicine

Clifford Y Ko, MD, MS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Colon and Rectal Surgeons, Association for Academic Surgery, California Medical Association, New York Academy of Sciences

Disclosure: Nothing to disclose.

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.

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.

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.

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