Toxic Megacolon Clinical Presentation

  • Author: Deepika Devuni, MBBS; Chief Editor: Julian Katz, MD   more...
 
Updated: Mar 29, 2012
 

History

Patients with toxic megacolon (toxic colitis), or TM (TC), typically have signs and symptoms of acute colitis that may be refractory to treatment. Common complaints include diarrhea, abdominal pain, rectal bleeding, tenesmus, vomiting, and fever. The patient may already have a diagnosis of inflammatory bowel disease or another cause of colitis, although in some patients, TM (TC) may be the initial presentation of inflammatory bowel disease.

A careful history may reveal recent travel, antibiotic use, chemotherapy, or immunosuppression. Patients are usually very ill, with the toxic definition including some or all of the following symptoms:

  • High fever
  • Abdominal pain and tenderness
  • Tachycardia
  • Dehydration

The diagnostic criteria developed by Jalan et al may be helpful to guide the history of patient suspected of having toxic megacolon (toxic colitis). They are as follows[3] :

  • Radiographic evidence of colonic dilatation - The classic finding is more than 6cm in the transverse colon
  • Three of the following - Fever (>101.5°F), tachycardia (>120 beats/min), leukocytosis (>10.5 x 103/μL), or anemia
  • One of the following - Dehydration, altered mental status, electrolyte abnormality, or hypotension
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Physical Examination

The vital signs in a patient with toxic megacolon (toxic colitis), or TM (TC) generally reveal tachycardia and fever. If the condition is severe, the patient may be hypotensive or tachypneic.

In inflammatory colitides (ie, ulcerative colitis, Crohn colitis), physical findings may be minimal, because high-dose steroids are routinely used; however, the abdomen maybe distended, and bowel sounds are usually decreased. Signs of perforation may also be masked by high-dose steroids, as in inflammatory bowel disease. With toxemia, patients may be obtunded.

Peritoneal signs may indicate perforation. They include the following:

  • Rebound
  • Rigidity
  • Peritoneal irritation

The form of megacolon usually associated with ulcerative colitis is defined by a transverse colon that is 6cm or more in diameter, with loss of haustration.

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Contributor Information and Disclosures
Author

Deepika Devuni, MBBS  Resident Physician, Department of Internal Medicine, University Of Connecticut School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Lisa M Rossi, MD  Fellow, Department of Gastroenterology-Hepatology, University of Connecticut School of Medicine

Disclosure: Nothing to disclose.

George Y Wu, MD, PhD  Professor, Department of Medicine, Director, Hepatology Section, Herman Lopata Chair in Hepatitis Research, University of Connecticut School of Medicine

George Y Wu, MD, PhD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, American Medical Association, American Society for Clinical Investigation, and Association of American Physicians

Disclosure: Springer Consulting fee Consulting; Gilead Consulting fee Review panel membership; Vertex Honoraria Speaking and teaching; Bristol-Myers Squibb Honoraria Speaking and teaching; Springer Royalty Review panel membership; Merck Honoraria Speaking and teaching

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, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of GI, Hepatology, and Nutrition at North Shore University Hospital/Long Island Jewish Medical Center; Professor, Department of Medicine, Hofstra North Shore-LIJ 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, and American Gastroenterological Association

Disclosure: Novartis Grant/research funds Other; Bayer Grant/research funds Other; Otsuka Grant/research funds None; Bristol Myers Squibb Grant/research funds Other; Scynexis None None; Salix Grant/research funds Other; MannKind Other

Terence David Lewis, MBBS, FRACP, FRCPC, FACP Program Director, Internal Medicine Residency, & Assistant Chairman, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Loma Linda University Medical Center

Terence David Lewis, MBBS, FRACP, FRCPC, FACP 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, and Sigma Xi

Disclosure: Nothing to disclose.

Jerome H Liu, MD Staff Physician, Department of Surgery, University of California at Los Angeles Medical Center

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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A 22-year-old man presented with abdominal pain, passage of blood and mucus per rectum, abdominal distention, fever, and disorientation. Findings from sigmoidoscopy confirmed ulcerative colitis. Abdominal radiographs obtained 2 days apart show mucosal edema and worsening of the distention in the transverse colon. The patient's clinical condition deteriorated over the next 36 hours despite steroid and antibiotic therapy, and the patient had to undergo a total colectomy and ileostomy.
A 72-year-old woman presented with vomiting and abdominal distention. The supine (right) and erect (left) plain abdominal radiographs show gross dilatation of the colon with multiple air-fluid levels. On further questioning, the patient revealed that she was taking diuretics for hypertension. Blood biochemical tests revealed markedly lowered potassium levels. After potassium replacement therapy, the patient's pseudo-obstruction completely resolved.
Gross pathology specimen from a case of pseudomembranous colitis demonstrating characteristic yellowish plaques.
Computed tomography scan from a patient with pseudomembranous colitis demonstrating the classic accordion sign.
Plain abdominal radiograph from a patient with known ulcerative colitis who presented with an acute exacerbation of his symptoms. This image shows thumbprinting in the region of the splenic flexure of the colon.
Increased postrectal space is a known feature of ulcerative colitis.
 
 
 
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