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Toxic Megacolon

Toxic megacolon is a severe inflammatory disorder of the large intestine. This condition usually compromises all layers of the intestinal wall and may spread to the peritoneum, thus giving rise to life-threatening systemic disease.


Presentation

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]
  • Patients with toxic megacolon were defined as those having toxic appearance, diarrhea, high fever ( 39 degrees C) and marked colon dilatation with maximal diameter 1.5 times the width of the vertebra body of the first lumbar spine (L1-VB).[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]
  • Abstract A 40-year-old man with bacteriologically documented typhoid fever who was receiving correct antibiotic treatment developed toxic megacolon.[ncbi.nlm.nih.gov]
  • Colitis is a rare manifestation of enteric fever in children. Toxic megacolon complicating typhoid colitis is even rarer and requires early recognition and aggressive management due to the high mortality associated with this condition.[ncbi.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]
  • Initial investigations revealed anemia (11, 55%), leukocytosis (11, 55%), and elevated levels of C-reactive protein ranging from 25.0 mg/L to 483.0 mg/L with a mean /- SD of 185.7 /- 129.1 mg/L (normal range, 8 mg/L) (20, 100%).[ncbi.nlm.nih.gov]
  • 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]
  • […] comprise the following: Radiographic evidence of non-obstructive dilatation of the ascending or transverse colon to 6 cm (to 5.5 cm in children) Plus either three of the following: Fever ( 38.5 C) Tachycardia ( 120/min) Leukocytosis ( 10.5 x 103/μL) Anemia[symptoma.com]
  • 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]
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]
Constitutional Symptom
  • 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]
Wound Infection
  • This was an unusual cause of a postoperative wound infection. This case highlights the importance of early and accurate identification, debridement, and systemic antifungals to prevent widespread infection.[ncbi.nlm.nih.gov]
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 72-year-old woman without significant medical history was admitted with abdominal pain, high fever, leukocytosis, bloody diarrhea and marked dilation of the transverse, descending and sigmoid colon.[ncbi.nlm.nih.gov]
  • 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]
  • The admission symptoms were fever, abdominal pain and bloody diarrhoea. The evolution was defavorable under antibiotics and sulfasalazine.[ncbi.nlm.nih.gov]
  • While neutropenic he presented with pyrexia, abdominal pain and massive abdominal distention. He was treated with intravenous antibiotics and antifungals according to our usual institutional protocol without any response.[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]
  • Seven days after admission, he developed septic shock, abdominal distension, and paralytic ileus without diarrhea. Pseudomembranous colitis due to C. difficile was confirmed by microbiological and radiological studies.[ncbi.nlm.nih.gov]
  • The diagnosis TM was determined on the basis of clinical information (abdominal pain or tenderness, abdominal distension, diarrhea, bloody diarrhea, and constipation), plain x-rays of the abdomen (segmental or total colonic dilation), and the presence[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]
  • 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]
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]
  • 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]
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]
Abdominal Bloating
  • 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]
  • He also reported abdominal bloating, diarrhea and nausea. In his past medical history he had two episodes of acute diverticulitis over the past 2 years.[karger.com]
Tachycardia
  • 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]
  • 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]
  • 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]
  • 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]
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]
  • ., arrhythmia, heart block, or hypotension). Other morbidities include conditions secondary to anticholinergic effects (central and peripheral) and respiratory complications.[ncbi.nlm.nih.gov]
  • Patients have distension of the colon and signs of toxicity such as elevated temperature, hypotension, decreased level of consciousness and electrolyte imbalances.[ncbi.nlm.nih.gov]
  • […] 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, dehydration, electrolyte disturbances, hypotension[ncbi.nlm.nih.gov]
  • […] percent; abdominal distention, 82 percent; abdominal tenderness, 72 percent; anemia less than 12 gm, 72 percent; albumin less than 3 gm, 64 percent; tachycardia greater than 100, 55 percent; fever greater than 38.5 degrees celsius, 45 percent; shock or hypotension[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]
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]

Workup

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:

As well as either one of the following:

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]

Treatment

  • Following colectomy, he was treated with 2 wk of antifungal treatment. He recovered well and was discharged home.[ncbi.nlm.nih.gov]
  • Abstract A 40-year-old man with bacteriologically documented typhoid fever who was receiving correct antibiotic treatment developed toxic megacolon.[ncbi.nlm.nih.gov]
  • This is the first report of treatment of Crohn disease-associated toxic megacolon with infliximab.[ncbi.nlm.nih.gov]
  • Medical therapy failure and the presence of toxic megacolon dictate urgent surgical treatment with unfortunate high mortality rates (35% to 57%).[ncbi.nlm.nih.gov]
  • 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]

Prognosis

  • Most cases are self-limited with good prognosis. The association between rotavirus and toxic megacolon has never been mentioned in the literature. We report a case of toxic megacolon secondary to rotavirus gastroenteritis.[ncbi.nlm.nih.gov]
  • Differentiation between these two catastrophic forms of colitis is important in respect to prognosis and long-term results. Medical management of toxic megacolon may be initially successful in either type of colitis.[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]
  • A prompt diagnosis and treatment can improve the poor prognosis in these patients.[ncbi.nlm.nih.gov]

Etiology

  • In this report the authors discuss the etiology of toxic megacolon and disseminated intravascular coagulation in ulcerative colitis surinfected by cytomegalovirus.[ncbi.nlm.nih.gov]
  • The presumed etiology is chronic use of a proton pump inhibitor. This was addressed in a 2012 "white paper" warning issued by the Food and Drug Administration.[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • Two thirds of patients with toxic megacolon had PC as the underlying etiology.[ncbi.nlm.nih.gov]

Epidemiology

  • 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]
  • Management of Chronic Peripheral Arterial Occlusive Disease 1811 Visceral Artery Occlusive Disease Mesenteric Occlusive Disease 1827 Acute Arterial Occlusions 1837 Venous and Lymphatic Disease 1847 Vascular Access for Hemodialysis 1861 The Diabetic Foot Epidemiology[books.google.com]
Sex distribution
Age distribution

Pathophysiology

  • This article discusses the pathophysiology, clinical manifestation, diagnosis, treatment, and prognosis for toxic megacolon secondary to pseudomembranous colitis.[ncbi.nlm.nih.gov]
  • The pathophysiological mechanisms leading to toxic colonic dilatation are incompletely understood. The main characteristics of toxic megacolon are signs of systemic toxicity and severe colonic distension.[ncbi.nlm.nih.gov]
  • […] 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]
  • Pathophysiology Although the precise pathophysiology of toxic megacolon/colitis TM (TC) is unproven, several factors may contribute to its development and precipitation.[emedicine.medscape.com]

Prevention

  • The objective of treatment is to decompress the bowel and to prevent swallowed air from further distending the bowel.[en.wikipedia.org]
  • This finding may justify immunotherapy for older children with TM associated with non-typhoid Salmonella infection in order to prevent this complication.[ncbi.nlm.nih.gov]
  • This case highlights the importance of early and accurate identification, debridement, and systemic antifungals to prevent widespread infection.[ncbi.nlm.nih.gov]
  • 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]
  • 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]

Summary

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].

References

Article

  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.

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Last updated: 2019-06-28 12:18