TM may occur in patients suffering from inflammatory bowel disease or other types of colitis. Thus, patients typically report prior gastrointestinal illness and treatment consistent with risk factors for TM. They should be queried regarding the use of antimotility agents.

TM patients present with constitutive symptoms such as high fever, chills, tachycardia, volume depletion, and reduced levels of consciousness. Patients are acutely ill and often claim abdominal cramps, diarrhea with blood or constipation. A physical examination reveals painful abdominal distention and reduced bowel sounds. Diffuse abdominal rigidity and rebound tenderness indicate peritonitis and may be noted in the case of intestinal perforation. Here, septic shock and multiple organ failure may ensue [6].

• Fever

  It also occurs in typhoid fever, acute bacillary dysentery, amebic colitis, ischemic colitis, pseudomembranous colitis and severe salmonellosis. [ncbi.nlm.nih.gov]

  It is characterized by a very dilated colon (megacolon), accompanied by abdominal distension (bloating), and sometimes fever, abdominal pain, or shock. [en.wikipedia.org]

  Physical Exam/Signs General appearance, Vitals Altered mental status, Fever, Hypotension Abd/GI/GU Abdominal tenderness, distention Diminished bowel sounds Cardiac Tachycardia Labs/Tests CBC, CMP, ABG, CRP, ESR Blood culture Stool testing (including [fprmed.com]

• Anemia

  […] associated with ulcerative colitis Hemolytic anemia w ulcerative colitis Hemolytic anemia, with ulcerative colitis Intestinal obstruction due to ulcerative colitis Mild chronic ulcerative colitis Moderate chronic ulcerative colitis Rectal hemorrhage [icd9data.com]

  abdominal distension, diarrhea, bloody diarrhea, and constipation), plain x-rays of the abdomen (segmental or total colonic dilation), and the presence of such criteria (fever, high heart rate, increased white blood cell count, C reactive protein, anemia [ncbi.nlm.nih.gov]

  […] disease Clinical Abdominal pain, distension, fever, tachycardia, fatigue, dehydration, ↓ bowel sounds, tympany, rebound tenderness, hypotension Contributing factors Laxatives, opiate use, anticholinergics, hypopotassemia Lab Leukocytosis–> 20,000/mm3, anemia [medical-dictionary.thefreedictionary.com]

• Malaise

  Presenting symptoms and signs included diarrhea, 100 percent; malaise, 91 percent; abdominal pain, 82 percent; abdominal distention, 82 percent; abdominal tenderness, 72 percent; anemia less than 12 gm, 72 percent; albumin less than 3 gm, 64 percent; [ncbi.nlm.nih.gov]

  Systemic findings such as fever, nausea, anorexia and malaise are usually also present in the latter. 3 Our patient progressed rapidly from mild colitis to toxic megacolon with an abrupt clinical deterioration. [revistagastroenterologiamexico.org]

  Systemic symptoms and signs, more common with extensive UC, include malaise, fever, anemia, anorexia, and weight loss. [merckmanuals.com]

• Recurrent Infection

  Among people who are successfully treated (with further antibiotics) for a C. diff infection, one in five will experience a recurrence of the infection. [charlestoncitypaper.com]

• Abdominal Pain

  It is characterized by a very dilated colon (megacolon), accompanied by abdominal distension (bloating), and sometimes fever, abdominal pain, or shock. [en.wikipedia.org]

  A 43 year old woman in remission from acute myeloid leukaemia developed abdominal pain, severe melaena, diarrhoea and gram-negative septicaemia whilst severely pancytopenic following consolidation chemotherapy. [ncbi.nlm.nih.gov]

• Abdominal Distension

  This report describes the occurrence of toxic megacolon in two young children with Salmonella colitis manifesting as abdominal distension, diarrhea and fever. [ncbi.nlm.nih.gov]

  The gas within the colon begins to build up and causes severe abdominal distension. This distension can result in a perforation (or hole) in the intestine which allows feces to leak into the abdominal cavity. [fromnewtoicu.com]

• Nausea

  […] disease Morbidity/Mortality Mortality from toxic megacolon caused by C. difficile is 31-100% Mortality from toxic megacolon caused by Inflammatory Bowel Disease is 19-45% Diagnostics History/Symptoms Abdominal pain Diarrhea Constipation/obstipation Nausea [fprmed.com]

  Symptoms Signs and symptoms of pseudomembranous colitis may include: Diarrhea that can be watery or even bloody Abdominal cramps, pain or tenderness Fever Pus or mucus in your stool Nausea Dehydration Symptoms of pseudomembranous colitis can begin as [mayoclinic.org]

  On day +11, he suffered new abdominal cramping, nausea with vomiting, and increased diarrhea. [nature.com]

  Systemic findings such as fever, nausea, anorexia and malaise are usually also present in the latter. 3 Our patient progressed rapidly from mild colitis to toxic megacolon with an abrupt clinical deterioration. [revistagastroenterologiamexico.org]

  Etiological factors cause a neural and/or motor dysfunction of the bowel → bowel dysmotility → progressive colonic dilation Clinical features Recurrent episodes of: Constipation Abdominal pain and distention ( bloating ) Anorexia, early satiety, and nausea [amboss.com]

• Severe Abdominal Pain

  Complications may include: Perforation of the colon Sepsis Shock Death Go to the emergency room or call the local emergency number (such as 911) if you develop severe abdominal pain, especially if you also have: Bloody diarrhea Fever Frequent diarrhea [nlm.nih.gov]

  Perforation of the colon Sepsis ShockEmergency action may be required if severe abdominal pain develops, particularly if it is accompanied by fever, rapid heart rate, tenderness when the abdomen is pressed, bloody diarrhea, frequent diarrhea, or painful [en.wikipedia.org]

  When to Call a Doctor EMERGENCY See a doctor right away for severe abdominal pain and distention with fever. [healthcommunities.com]

  In case of poor response to conservative therapy, a colectomy is usually required. [4] Complications A pathological specimen showing toxic megacolon Perforation of the colon [5] Sepsis Shock Emergency action may be required if severe abdominal pain develops [ipfs.io]

• Abdominal Tenderness

  Abdominal pain Abdominal bloating Abdominal tenderness Fever Tachycardia (rapid heart rate) DehydrationThere may be signs of septic shock. A physical examination reveals abdominal tenderness and possible loss of bowel sounds. [en.wikipedia.org]

  Signs and symptoms Abdominal pain Abdominal bloating Abdominal tenderness Fever Tachycardia (rapid heart rate) Dehydration There may be signs of septic shock. A physical examination reveals abdominal tenderness and possible loss of bowel sounds. [ipfs.io]

  However, a former history and physical exam will also be conducted which will include assessing abdominal tenderness and listening for bowel sounds. [belmarrahealth.com]

  Presenting symptoms and signs included diarrhea, 100 percent; malaise, 91 percent; abdominal pain, 82 percent; abdominal distention, 82 percent; abdominal tenderness, 72 percent; anemia less than 12 gm, 72 percent; albumin less than 3 gm, 64 percent; [ncbi.nlm.nih.gov]

• Tachycardia

  Clinical criteria for toxic megacolon (Jalan's criteria) Main criteria (at least 3 of the following) Fever > 101.5 °F Tachycardia (HR > 120 bpm) Leukocytosis (WBC > 10.5) Anemia PLUS at least one of the following Dehydration Altered level of consciousness [fprmed.com]

  TM patients present with constitutive symptoms such as high fever, chills, tachycardia, volume depletion, and reduced levels of consciousness. Patients are acutely ill and often claim abdominal cramps, diarrhea with blood or constipation. [symptoma.com]

  233 Supraventricular Tachycardia 242 Temporary Cardiac Pacing 253 Permanent Pacemakers and Antiarrhythmic Devices 261 Evaluation of the Low to Intermediate Risk Patient with 267 PULMONARY PROBLEMS IN THE INTENSIVE CARE UNIT 273 Status Asthmaticus 282 [books.google.com]

  Findings from his physical examination were unremarkable except for pallor and tachycardia. A proctosigmoidoscopy was diagnostic of ulcerative colitis. [jamanetwork.com]

  Fever (P= 0.005), tachycardia (P= 0.0001), dehydration (P= 0.01), and electrolyte abnormalities (P= 0.0002) were more common in children with TMC than controls. [ncbi.nlm.nih.gov]

• Hypotension

  Mental alteration and hypotension may be less common in children than in adults. TMC in children with IBD is associated with poor outcome, with a high rate of corticosteroid failure. [ncbi.nlm.nih.gov]

  Mortality from toxic megacolon caused by Inflammatory Bowel Disease is 19-45% Diagnostics History/Symptoms Abdominal pain Diarrhea Constipation/obstipation Nausea/vomiting Fever Physical Exam/Signs General appearance, Vitals Altered mental status, Fever, Hypotension [fprmed.com]

In 1969, Jalan and colleagues defined diagnostic criteria for TM [7]. They are still used today and comprise the following:

• Radiographic evidence of non-obstructive dilatation of the ascending or transverse colon to >6 cm (to >5.5 cm in children [8])

Plus either three of the following:

• Fever (>38.5 °C)
• Tachycardia (>120/min)
• Leukocytosis (>10.5 x 103/μL)
• Anemia

As well as either one of the following:

• Dehydration
• Hypotension
• Reduced consciousness
• Electrolyte imbalances

Diagnostic measures should be undertaken accordingly.

• Plain radiography is usually sufficient to identify colonic distension. Nevertheless, computed tomography is more sensitive with regards to the detection of perforation, abscesses or ascending pylephlebitis [4] [9]. Additionally, images obtained by means of computed tomography may depict diffuse colonic wall thickening, edematous haustral folds separated by transverse mucosal ridges (accordion sign, requires use of contrast agents), and hyperemic mucosa over edematous submucosa (target sign) [3].
• Laboratory analyses of blood samples should be performed and may additionally reveal enhanced concentrations of inflammatory marker C-reactive protein and erythrocyte sedimentation rate. Hypoalbuminemia and hypokalemia are related to a poor prognosis. Analyses of stool samples are recommended [10].

Hematocrit, serum levels of electrolytes, and acid-base status should be assessed repeatedly in order to monitor a patient's response to therapy. At somewhat longer intervals, abdominal radiography should be repeated to evaluate the condition of the colon and the risk of perforation.

• Pneumoperitoneum

  There is hepatic portal-venous gas (white arrows) There is intramural gas (black arrows) Pneumoperitoneum Patients who demonstrate plain film evidence of toxic megacolon are more likely to have pneumoperitoneum. [wikiradiography.net]

  There may be signs of pneumoperitoneum if dilatation has progressed to cause perforation. barium studies and colonoscopy should be avoided, due to the risk of perforation Promoted articles (advertising) [radiopaedia.org]

  If perforation occurs, radiographic signs of a pneumoperitoneum may be apparent on the supine and/or lateral decubitus radiographs. [13] Clinical examination is not accurate in the detection of perforation in the setting of toxic megacolon. [emedicine.medscape.com]

The incidence and treatment of Toxic Megacolon secondary to C. difficile is reviewed. Early diagnosis and treatment with colonoscopic decompression may obviate the need for surgery. [ncbi.nlm.nih.gov]

This article discusses the pathophysiology, clinical manifestation, diagnosis, treatment, and prognosis for toxic megacolon secondary to pseudomembranous colitis. [ncbi.nlm.nih.gov]

Toxic Megacolon Background Total or segmental dilatation of the colon by > 6 cm WITH systemic toxicity AND inflammatory or infectious etiology of the underlying disease Distinguished from other causes of colonic dilatation (Hirschsprung's disease, pseudo-obstruction [fprmed.com]

Cytomegalovirus (CMV) infection, which has been shown to complicate the course of ulcerative colitis (UC), has been implicated as a possible etiologic factor in the exacerbation of UC, especially in toxic megacolon. [ncbi.nlm.nih.gov]

Clinical Practice Guidelines for Clostridium difficile infection in adults: Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). [degruyter.com]

Epidemiology and outcome of zygomycosis: A review of 929 reported cases. [ivyunion.org]

Lately, the epidemiology has shifted toward infectious causes, specifically due to an increase of Clostridium difficile-associated colitis possibly due to the extensive (ab)use of broad-spectrum antibiotics. [ncbi.nlm.nih.gov]

Term Definition potentially lethal complication of inflammatory bowel dz or infectious colitis, characterized by non-obstructive dilatation w systemic toxicity Term Congenital aganglionic megacolon: AKA Definition Term 3 points of epidemiology for Hirschsprung's [flashcardmachine.com]

Emerg Infect Dis 2011; 17 (6) 976-982 10 Cohen SH, Gerding DN, Johnson S, et al; Society for Healthcare Epidemiology of America; Infectious Diseases Society of America. [doi.org]

This article discusses the pathophysiology, clinical manifestation, diagnosis, treatment, and prognosis for toxic megacolon secondary to pseudomembranous colitis. [ncbi.nlm.nih.gov]

Despite increased knowledge on the pathophysiological process, many aspects remain rather unclear, especially concerning IBD. [books.google.ro]

[…] those who have undergone a major surgical procedure Idiopathic ; possible factors include: Electrolyte imbalance Trauma ; major surgery Hypothyroidism Drugs ; (e.g., anticholinergic drugs, opioid analgesics, antipsychotics, calcium channel blockers ) Pathophysiology [amboss.com]

[…] etiology of the underlying disease Distinguished from other causes of colonic dilatation (Hirschsprung's disease, pseudo-obstruction, ileus) by the presence of an inflammatory precipitant and systemic manifestations Clinical criteria for toxic megacolon Pathophysiology [fprmed.com]

In our opinion this technique seems to be a substantial improvement in the treatment of "toxic megacolon" and may even help to prevent ileotomy-colotomy in some cases. [ncbi.nlm.nih.gov]

The objective of treatment is to decompress the bowel and to prevent swallowed air from further distending the bowel. [en.wikipedia.org]

Mills says it could be used preventatively before a patient ever comes to the hospital. [charlestoncitypaper.com]

You may receive antibiotics to prevent sepsis (a severe infection). If the condition does not improve, it can be fatal. Colon surgery is usually needed in such cases. [nlm.nih.gov]

Following your doctor’s advice will help control the symptoms of IBD, prevent infections, and reduce the likelihood that you’ll develop toxic megacolon. [healthline.com]

Toxic megacolon (TM) is a severe inflammatory disorder affecting parts of or the entire colon. This condition is defined as a non-obstructive dilatation of the colon to diameters exceeding 6 cm and concomitant symptoms of systemic toxicity [1]. TM may complicate cases of ulcerative colitis (up to 10%), Crohn disease (up to 5%), pseudomembranous colitis (up to 3%), and, less frequently, other types of colitis [2] [3]. It has been suggested that chemotherapeutics, narcotics, anticholinergic and antidiarrheal drugs, discontinuation of steroid administration, and diagnostic measures like colonoscopy may predispose colitis patients for TM, but scientific evidence supporting these hypotheses is scarce.

Mortality rates have been reported to amount to 19% and patients require immediate medical attention to increase their chances of survival. The underlying colitis needs to be treated and disturbances of fluid, electrolyte, and acid-base balance have to be corrected. At the same time, any medication interfering with peristalsis should be withdrawn. Colonic decompression or surgery may become necessary upon disease progression [4] [5].

1. Sheth SG, LaMont JT. Toxic megacolon. Lancet. 1998;351(9101):509-513.
2. Woodhouse E. Toxic Megacolon: A Review for Emergency Department Clinicians. J Emerg Nurs. 2016.
3. Autenrieth DM, Baumgart DC. Toxic megacolon. Inflamm Bowel Dis. 2012;18(3):584-591.
4. Gan SI, Beck PL. A new look at toxic megacolon: an update and review of incidence, etiology, pathogenesis, and management. Am J Gastroenterol. 2003;98(11):2363-2371.
5. Miniello S, Marzaioli R, Balzanelli MG, et al. Toxic megacolon in ulcerative rectocolitis. Current trends in clinical evaluation, diagnosis and treatment. Ann Ital Chir. 2014;85(1):45-49.
6. Dobson G, Hickey C, Trinder J. Clostridium difficile colitis causing toxic megacolon, severe sepsis and multiple organ dysfunction syndrome. Intensive Care Med. 2003;29(6):1030.
7. Jalan KN, Sircus W, Card WI, et al. An experience of ulcerative colitis. I. Toxic dilation in 55 cases. Gastroenterology. 1969;57(1):68-82.
8. Benchimol EI, Turner D, Mann EH, et al. Toxic megacolon in children with inflammatory bowel disease: clinical and radiographic characteristics. Am J Gastroenterol. 2008;103(6):1524-1531.
9. Imbriaco M, Balthazar EJ. Toxic megacolon: role of CT in evaluation and detection of complications. Clin Imaging. 2001;25(5):349-354.
10. Levine CD. Toxic megacolon: diagnosis and treatment challenges. AACN Clin Issues. 1999;10(4):492-499.