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]

  The rapid widening of the colon may cause the following symptoms to occur over a short period of time: Painful, distended abdomen Fever Diarrhea (usually bloody) The health care provider will perform a physical exam. [nlm.nih.gov]

• Anemia

  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]

  Ulcerative Colitis and Crohn's disease Abdominal plain-film radiography will show colonic dilation KUB shows dilated colon 6 cm At least three of the following: Fever ( 101.5 0 F), Heart rate 120/min, Neutrophilic leukocytosis ( 10.5 x 10 9 /L) and Anemia [smartypance.com]

  […] 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]

• 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]

• Severe Abdominal Pain

  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]

  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]

  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]

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

  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]

  Toxic megacolon is pretty rare, but symptoms such as extreme nausea and vomiting, abdominal distention, discoloration on the abdomen, severe (beyond normal) pain..............get to your doctor and make them aware of this. [crohnsforum.com]

  I was so sick that they started an I.V. in my neck to give me the morphine and nausea medicine to get me to stop screaming and vomiting. [fightlikeagirlclub.com]

• Acute Abdomen

  His hospital course was characterized by the poor response of his symptoms to treatment, and by the subsequent development of intermittent hematochezia and, eventually, acute abdomen. [ncbi.nlm.nih.gov]

  This is the case of a 53 year-old female, with Chronic Renal Insufficiency, was hospitalized due to acute abdomen in a national hospital of social insurance (seguro social ISSS) in El Salvador, the abdominal ultrasound and the cat scan displayed colon [gastrointestinalatlas.com]

  Patients present with fever, abdominal tenderness, and distension or even with an acute abdomen. [clinicalgate.com]

  Acute abdomen and Clostridium difficile colitis: Still a lethal combination. Dig Surg 2000; 17 : 160–163. 12. Trudel, JL, Deschenes, M, Mayrand, S, et al. Toxic megacolon complicating pseudomembranous enterocolitis. [nature.com]

• Tachycardia

  History/Symptoms Abdominal pain Diarrhea Constipation/obstipation Nausea/vomiting Fever Physical Exam/Signs General appearance, Vitals Altered mental status, Fever, Hypotension Abd/GI/GU Abdominal tenderness, distention Diminished bowel sounds Cardiac Tachycardia [fprmed.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]

  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]

• 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]

• Heart Block

  arrhythmia, heart block, or hypotension). Other morbidities include conditions secondary to anticholinergic effects (central and peripheral) and respiratory complications. [ncbi.nlm.nih.gov]

• Lethargy

  He had systemic deterioration with frequent diarrhea and lethargy. Acute fulminant UC associated with toxic megacolon was diagnosed by rectal endoscopy and biopsied specimen. [ncbi.nlm.nih.gov]

• Stupor

  In the acute stage, most patients developed toxic signs such as mental change, ranging from irritability to stupor (20, 100%), fever (19, 95%), tachycardia (20, 100%), abdominal distension (20, 100%), and abnormal stool pattern (19, 95%). [ncbi.nlm.nih.gov]

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]

• Fibrinoid Necrosis

  In addition to classical CMV inclusions. vasculitis manifested in two forms, namely, leukocytoclastic type and fibrinoid necrosis. The patient died shortly thereafter, due to multi-organ system failure. [ncbi.nlm.nih.gov]

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.