Toxic Megacolon Treatment & Management

Updated: Mar 01, 2018
  • Author: Brian Lin; Chief Editor: Burt Cagir, MD, FACS  more...
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Treatment

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. [30, 31]

Cyclosporine

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. [32]

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. [33, 34]

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. [35] 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. [35]

Hyperbaric oxygen has also been reported to be of use in the treatment of TM (TC), [36] 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. [37]

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. [38]

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. [39]

Consultations

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.

Activity

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

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Colectomy

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. [40]

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. [41, 42] 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.

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