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Toxic Megacolon Treatment & Management

  • Author: Deepika Devuni, MBBS; Chief Editor: Julian Katz, MD  more...
Updated: Jan 03, 2016

Approach Considerations

Communicating with the patient and the patient's family at all times is imperative. Toxic megacolon (toxic colitis), or TM (TC), can be fatal, and clear lines of communication are essential.

Treatment of TM (TC) includes 3 main goals: (1) reduce colonic distention to prevent perforation, (2) correct fluid and electrolyte disturbances, and (3) treat toxemia and precipitating factors. Careful and frequent monitoring of the patient is required, and, initially, CBCs, electrolytes, and abdominal radiographs should be checked every 12 hours. If the patient is malnourished, consider parenteral nutrition.

During the initial resuscitation, fluid replacement, electrolyte repletion, and transfusion should be aggressive. Broad-spectrum intravenous (IV) antibiotics with coverage equivalent to ampicillin, gentamicin, and metronidazole should be initiated. All medications that may affect colonic motility—including narcotics, antidiarrheals, and anticholinergic agents—must be stopped.

The patient with TM (TC) should be put on bowel rest, and a nasogastric tube (NGT) or long intestinal tube should be placed to assist with gastrointestinal decompression. Long suction tubes may be more helpful for colonic decompression, but they should be placed into the ileum under fluoroscopic guidance.

The patient should be started on IV steroids. IV hydrocortisone is necessary for patients who are taking corticosteroids or who have been recently treated with corticosteroids.

It is important to recognize that although symptomatic improvement may correspond to improvement in the disease process, this is not always the case. Cessation of bowel movements may indicate worsening of the patient's condition. Including repeated abdominal plain films in the evaluation of the clinical picture remains essential.

Any possible triggers for TM (TC) should be stopped, including narcotics, antidiarrheals, and anticholinergics.

Rolling techniques (knee-elbow and prone) may be performed to assist in redistribution of colonic gas and decompression.[26, 27]


Some reports indicate that cyclosporine A may be beneficial in the treatment TM (TC) or of severe ulcerative colitis, with data suggesting that cyclosporine may provide an initial response rate of as high as 80%. After a variable follow-up period, the durable response rate decreases to approximately 40%.

Although further studies are needed, cyclosporine therapy may obviate the need for urgent colectomy, allowing an elective subtotal colectomy or proctocolectomy to be performed under more controlled circumstances.[28]

However, cyclosporine also has significant adverse effects, including immunosuppression and opportunistic infections, hypertension, renal toxicity, and neurologic complications.

Additional therapies

Some experimental therapies under study may help patients with TM (TC) to avoid surgery. A case report showed that the use of infliximab, an anti–TNF-alpha monoclonal antibody, was successful in the treatment of TM (TC) in a patient whose condition failed to respond to usual treatment and who refused surgery.[29, 30]

Leukocytapheresis (LCAP) has been reported to be effective against TM (TC). A series of 6 patients whose conditions had failed to improve after treatment with antibiotics and high-dose steroids were enrolled in a study.[31] In 4 cases, the TM (TC) resolved by the morning after initiation of treatment with LCAP. In 2 patients, the TM (TC) resolved approximately 40 hours later. Improvement continued in 4 of the 6 patients.[31]

Hyperbaric oxygen has also been reported to be of use in the treatment of TM (TC),[32] but further studies are needed to confirm these results.

Shetler et al demonstrated that colonoscopic decompression and intracolonic vancomycin administration in the management of severe, acute, pseudomembranous colitis associated with ileus and TM (TC) is feasible, safe, and effective in approximately 57-71% of cases.[33]

Tacrolimus was successfully used in 1 case study in a patient with steroid-refractory ulcerative colitis complicated by TM (TC). Further studies are needed to validate the use.[34]

Intravenous immune globulin (IVIG) may potentially be a last-line adjunct therapy in patients with severe complicated, refractory C difficile infection (eg, shock, ileus, megacolon), taking into account the possibility of adverse effects.[35]


Consultation with a gastroenterologist and surgeon is required in cases of TM (TC). Depending on the health-care setting, consultations a nutritionist and an infectious disease specialist may also be needed.


Patients with TM (TC) should primarily be at bed rest.



Early surgical consultation is essential for cases of toxic megacolon (toxic colitis), or TM (TC). Indications for urgent operative intervention include free perforation, massive hemorrhage (6-8U packed red blood cells), increasing toxicity, and progression of colonic dilatation. Most authors recommend colectomy if persistent dilatation is present or if no improvement is observed on maximal medical therapy after 24-72 hours.

The rationale for early intervention is based on a 5-fold increase in mortality after free perforation. The mortality rate for nonperforated, acute toxic colitis is about 4%; if perforation occurs, the mortality is approximately 20%. Significant independent predictors of mortality include Mannheim peritonitis index (MPI) class II and American Society of Anesthesiologists (ASA) classes 4-5.[36]

Some physicians provide up to 7 days of medical therapy if the patient demonstrates clinical improvement despite persistent colonic dilatation. The authors recommend a strategy of early surgical intervention to minimize the incidence of colonic perforation. If no improvement occurs over 48-72 hours with medical therapy, perform surgical resection.

Whether to perform a total proctocolectomy or a subtotal colectomy with the rectum left behind is debated.[37, 38] The preference in the literature is to perform a subtotal colectomy; this is due to the following reasons:

  • The patient is usually very ill, and not lengthening the operation is prudent if at all possible
  • Subtotal colectomy preserves the possibility for an ileal pouch anal anastomosis
  • Approximately 50% of patients with Crohn disease have minimal involvement of the rectum

Performing a total proctocolectomy in a patient who is acutely ill and toxic and on high-dose steroids increases the risk of complications, morbidity, and mortality.

Terminate the resection at the sacral promontory, and perform either a mucus fistula or a stapled rectal stump. If a stapled rectal stump is performed, keeping a rectal tube in place for 2-3 days may reduce the incidence of rectal stump blowout.

Because the surgical treatment of TM (TC) 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.

Contributor Information and Disclosures

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

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, New York Academy of Sciences

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, Association of American Physicians

Disclosure: Received consulting fee from Springer for consulting; Received consulting fee from Gilead for review panel membership; Received honoraria from Vertex for speaking and teaching; Received honoraria from Bristol-Myers Squibb for speaking and teaching; Received royalty from Springer for review panel membership; Received honoraria from Merck for speaking and teaching.

Lisa M Rossi, MD Fellow, Department of Gastroenterology-Hepatology, University of Connecticut School of 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, Physicians for Social Responsibility

Disclosure: Nothing to disclose.


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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