Follow-up
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.
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.22 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.22
- 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.
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.
Miscellaneous
Medicolegal Pitfalls
- Communicating with the patient and patient's family at all times is imperative. Toxic megacolon (toxic colitis) can be fatal, and clear lines of communication are essential.
- Because the surgical treatment for toxic megacolon (toxic colitis) requires an ostomy, the patient must give clear, informed consent. In addition, discussing the implications of an ostomy with the patient and the patient's family is helpful. Also, it is important to tell the patient that surgical treatment may be staged such that reoperation is required in the future.
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References
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[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].
[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].
[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].
[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].
[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].
Further Reading
Related eMedicine Topics
- Crohn Disease
- Inflammatory Bowel Disease
- Toxic Megacolon [in the Radiology section]
- Ulcerative Colitis
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].
- 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].
- 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].
- 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].
- 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].
Clinical Trials
- Hirschsprung Disease Genetic Study
- Infliximab to Treat Crohn's-Like Inflammatory Bowel Disease in Chronic Granulomatous Disease
- Immune Regulation in Ulcerative Colitis or Crohn's Disease
- Open Label Study for Adults With Pyoderma Gangrenosum and Inflammatory Bowel Disease
- Probiotic Prophylaxis of Hirschprung's Disease Associated Enterocolitis (HAEC)
National Guidelines Clearinghouse
- ACR Appropriateness Criteria® Crohn's disease. American College of Radiology - Medical Specialty Society. 1998 (revised 2005). 11 pages. NGC:004772
- ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease. American Society for Gastrointestinal Endoscopy - Medical Specialty Society. 2006 Apr. 8 pages. NGC:004977
- Practice parameters for the surgical management of Crohn's disease. American Society of Colon and Rectal Surgeons - Medical Specialty Society. 2007 Nov. 12 pages. NGC:006461
- Practice parameters for the surgical treatment of ulcerative colitis. American Society of Colon and Rectal Surgeons - Medical Specialty Society. 1997 (revised 2005 Nov). 13 pages. NGC:005612
Keywords
toxic megacolon, megacolon, dilated toxic colitis, fulminant dilated colitis, colonic dilatation, colitides, Hirschsprung disease, ulcerative colitis, Crohn disease, amebic dysentery, clostridium enterocolitis, idiopathic megacolon, chronic constipation, intestinal pseudoobstruction, intestinal pseudo-obstruction, Ogilvie syndrome, acute toxic colitis
Follow-up: Megacolon, Toxic