Toxic Megacolon Follow-up

  • Author: Deepika Devuni, MBBS; Chief Editor: Julian Katz, MD   more...
 
Updated: Jan 5, 2012
 

Complications

  • The complication of toxic megacolon (toxic colitis) one must constantly be alert for is perforation, even in the absence of colonic dilatation.
  • Numerous studies have demonstrated that classic physical signs of peritonitis are absent in the majority of patients with free perforation, possibly because of the effects of steroids.
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Prognosis

  • A few studies have shown that the prognosis is poor with medical management of toxic megacolon (toxic colitis). A study by Grant and Dozois followed the clinical course and ultimate outcome in 38 patients with toxic megacolon (toxic colitis) who were successfully treated nonoperatively.[26] Thirty-two patients had ulcerative colitis and 6 had Crohn disease, with complete follow-up, ranging 3-22 years (average 13 y). Eleven of 38 patients (29%) eventually suffered a second episode of fulminant acute colitis or recurrent toxic megacolon (toxic colitis). Ultimately, a total of 18 patients (47%) underwent colon resection, which was performed on an emergency or urgent basis in 15 patients.[26]
  • The survival prognosis of toxic megacolon (toxic colitis) should be excellent in the absence of perforation. If perforation occurs, the mortality is approximately 20%.
  • In the case of ulcerative colitis, a proctocolectomy cures patients of the disease.
  • In the case of Crohn disease, proctocolectomy does not necessarily cure the patient, because Crohn disease can occur in any portion of the gastrointestinal tract.
  • With use of TNF-alpha inhibitors, hopefully more cases can be managed medically in future. More studies are needed.
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Patient Education

  • Educating the patient about toxic megacolon (toxic colitis) is crucial.
  • First, educate the patient about toxic megacolon (toxic colitis) and the causes of the disease.
    • The most common cause of toxic megacolon (toxic colitis) is inflammatory bowel disease. However, with the rising incidence of C difficile, pseudomembranous colitis must always be considered, even in patients with inflammatory bowel disease.
    • Educate the patient about ulcerative colitis, Crohn disease, and indeterminate colitis.
    • The patient should be clearly informed that, if an operation is required for this acute problem, an ostomy likely will be the procedure needed, regardless of the cause.
  • Secondly, educate the patient about the operation.
    • Patients require at least a temporary, and possibly a permanent, ostomy.
    • Most patients require a thoughtful, compassionate discussion regarding this aspect. The psychologic aspects of dealing with an ostomy can be extremely difficult.
  • Finally, educate patients so they understand that this disease is a process that may require several months to overcome if an operation is needed and that a 2-stage or 3-stage procedure is usually required.
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Contributor Information and Disclosures
Author

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

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

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

Disclosure: Nothing to disclose.

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.

Specialty Editor Board

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.

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

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

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

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.

References

  1. Strong SA. Management of acute colitis and toxic megacolon. Clin Colon Rectal Surg. Dec 2010;23(4):274-84. [Medline]. [Full Text].

  2. Marshak RH, Lester LJ. Megacolon a complication of ulcerative colitis. Gastroenterology. Dec 1950;16(4):768-72. [Medline].

  3. Jalan KN, Sircus W, Card WI, et al. An experience of ulcerative colitis. I. Toxic dilation in 55 cases. Gastroenterology. Jul 1969;57(1):68-82. [Medline].

  4. Moulin V, Dellon P, Laurent O, Aubry S, Lubrano J, Delabrousse E. Toxic megacolon in patients with severe acute colitis: computed tomographic features. Clin Imaging. Nov-Dec 2011;35(6):431-6. [Medline].

  5. Autenrieth DM, Baumgart DC. Toxic megacolon. Inflamm Bowel Dis. Aug 29 2011;[Medline].

  6. Mourelle M, Casellas F, Guarner F, et al. Induction of nitric oxide synthase in colonic smooth muscle from patients with toxic megacolon. Gastroenterology. Nov 1995;109(5):1497-502. [Medline]. [Full Text].

  7. Mourelle M, Vilaseca J, Guarner F, Salas A, Malagelada JR. Toxic dilatation of colon in a rat model of colitis is linked to an inducible form of nitric oxide synthase. Am J Physiol. Mar 1996;270(3 pt 1):G425-30. [Medline].

  8. Guslandi M. Nitric oxide and inflammatory bowel diseases. Eur J Clin Invest. Nov 1998;28(11):904-7. [Medline].

  9. Greenstein AJ, Sachar DB, Gibas A, et al. Outcome of toxic dilatation in ulcerative and Crohn's colitis. J Clin Gastroenterol. Apr 1985;7(2):137-43. [Medline].

  10. Jalan KN, Sircus W, Card WI, et al. An experience of ulcerative colitis. I. Toxic dilation in 55 cases. Gastroenterology. Jul 1969;57(1):68-82. [Medline].

  11. Roy MA. Inflammatory bowel disease. Surg Clin North Am. Dec 1997;77(6):1419-31. [Medline].

  12. Bartlett JG, Perl TM. The new Clostridium difficile--what does it mean?. N Engl J Med. Dec 8 2005;353(23):2503-5. [Medline].

  13. Shimada Y, Iiai T, Okamoto H, et al. Toxic megacolon associated with cytomegalovirus infection in ulcerative colitis. J Gastroenterol. 2003;38(11):1107-8. [Medline].

  14. Wodzinski MA, Snowden JA, Reilly JT. Toxic megacolon complicating chemotherapy for acute myeloid leukaemia. Postgrad Med J. Dec 1994;70(830):921-3. [Medline].

  15. Fitzgerald SC, Conlon S, Leen E, Walsh TN. Collagenous colitis as a possible cause of toxic megacolon. Ir J Med Sci. Mar 2009;178(1):115-7. [Medline].

  16. Maconi G, Sampietro GM, Ardizzone S, et al. Ultrasonographic detection of toxic megacolon in inflammatory bowel diseases. Dig Dis Sci. Jan 2004;49(1):138-42. [Medline].

  17. Panos MZ, Wood MJ, Asquith P. Toxic megacolon: the knee-elbow position relieves bowel distension. Gut. Dec 1993;34(12):1726-7. [Medline]. [Full Text].

  18. Present DH, Wolfson D, Gelernt IM, et al. Medical decompression of toxic megacolon by "rolling." A new technique of decompression with favorable long-term follow-up. J Clin Gastroenterol. Oct 1988;10(5):485-90. [Medline].

  19. Actis GC, Ottobrelli A, Pera A, et al. Continuously infused cyclosporine at low dose is sufficient to avoid emergency colectomy in acute attacks of ulcerative colitis without the need for high-dose steroids. J Clin Gastroenterol. Jul 1993;17(1):10-3. [Medline].

  20. Sriram PV, Reddy KS, Rao GV, Santosh D, Reddy DN. Infliximab in the treatment of ulcerative colitis with toxic megacolon. Indian J Gastroenterol. Jan-Feb 2004;23(1):22-3. [Medline].

  21. Sawada K, Egashira A, Ohnishi K, et al. Leukocytapheresis (LCAP) for management of fulminant ulcerative colitis with toxic megacolon. Dig Dis Sci. Apr 2005;50(4):767-73. [Medline].

  22. Kuroki K, Masuda A, Uehara H, Kuroki A. A new treatment for toxic megacolon. Lancet. Sep 5 1998;352(9130):782. [Medline].

  23. Shetler K, Nieuwenhuis R, Wren SM, Triadafilopoulos G. Decompressive colonoscopy with intracolonic vancomycin administration for the treatment of severe pseudomembranous colitis. Surg Endosc. Jul 2001;15(7):653-9. [Medline].

  24. Heppell J, Farkouh E, Dube S, et al. Toxic megacolon. An analysis of 70 cases. Dis Colon Rectum. Dec 1986;29(12):789-92. [Medline].

  25. Lee EC, Truelove SC. Proctocolectomy for ulcerative colitis. World J Surg. 1980;4(2):195-201. [Medline].

  26. Grant CS, Dozois RR. Toxic megacolon: ultimate fate of patients after successful medical management. Am J Surg. Jan 1984;147(1):106-10. [Medline].

  27. [Best Evidence] Andrews JM, Travis SP, Gibson PR, Gasche C. Systematic review: does concurrent therapy with 5-ASA and immunomodulators in inflammatory bowel disease improve outcomes?. Aliment Pharmacol Ther. Mar 1 2009;29(5):459-69. [Medline].

  28. [Best Evidence] Bossa F, Latiano A, Rossi L, et al. Erythrocyte-mediated delivery of dexamethasone in patients with mild-to-moderate ulcerative colitis, refractory to mesalamine: a randomized, controlled study. Am J Gastroenterol. Oct 2008;103(10):2509-16. [Medline].

  29. [Best Evidence] Feagan BG, Panaccione R, Sandborn WJ, et al. Effects of adalimumab therapy on incidence of hospitalization and surgery in Crohn's disease: results from the CHARM study. Gastroenterology. Nov 2008;135(5):1493-9. [Medline].

  30. Gan SI, Beck PL. A new look at toxic megacolon: an update and review of incidence, etiology, pathogenesis, and management. Am J Gastroenterol. Nov 2003;98(11):2363-71. [Medline].

  31. [Best Evidence] Kruis W, Kiudelis G, Racz I, et al. Once daily versus three times daily mesalazine granules in active ulcerative colitis: a double-blind, double-dummy, randomised, non-inferiority trial. Gut. Feb 2009;58(2):233-40. [Medline]. [Full Text].

  32. Levine CD. Toxic megacolon: diagnosis and treatment challenges. AACN Clin Issues. Nov 1999;10(4):492-9. [Medline].

  33. [Best Evidence] Lichtenstein GR, Bengtsson B, Hapten-White L, Rutgeerts P. Oral budesonide for maintenance of remission of Crohn's disease: a pooled safety analysis. Aliment Pharmacol Ther. Mar 15 2009;29(6):643-53. [Medline].

  34. Morris JB, Zollinger RM Jr, Stellato TA. Role of surgery in antibiotic-induced pseudomembranous enterocolitis. Am J Surg. Nov 1990;160(5):535-9. [Medline].

  35. Present DH. Toxic megacolon. Med Clin North Am. Sep 1993;77(5):1129-48. [Medline].

  36. Sheth SG, LaMont JT. Toxic megacolon. Lancet. Feb 14 1998;351(9101):509-13. [Medline].

  37. Weissleder, R, Rieumont MJ, Wittenberg J. Primer of Diagnostic Imaging. 2nd ed. St. Louis, Mo: Mosby; 1997:192.

 
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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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