Toxic Megacolon in Crohn’s Colitis
Savio George Barreto, Shailesh V. Shrikhande in Dilemmas in Abdominal Surgery, 2020
Toxic megacolon is a condition traditionally characterized by gross colonic distension in the setting of severe colitis culminating in septic shock. It may occur as a consequence of either inflammatory bowel disease (more so in ulcerative colitis than Crohn’s disease) or infective colitis (e.g. cytomegalovirus or Clostridium difficile) characterized by gross segmental or pancolonic distension greater than 6 cm [1]. The muco-submucosal barrier is lost with severe pancolonic inflammation resulting in colonic dysmotility, colonic dilation, fecal stasis, and bacterial translocation. This functional obstruction runs the risk of a megacolon and perforation of a thin-walled ascending colon and cecum. Often in pancolitis, diarrhea, with or without blood, prevails. Septic shock in colitis may not necessarily be accompanied by a megacolon. Hence, we tend to use the term “toxic colitis” to describe the condition of severe colitis causing shock, despite maximal antibiotic and anti-inflammatory treatment. Toxicity and the entity of a megacolon may exist independent of each other.
Diagnosis of IBD
Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams in Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
Toxic megacolon is the most severe complication of UC which is potentially fatal. It is defined as a mid-transverse colonic dilation >5.5 cm in the presence of acute colitis and signs of systemic toxicity. It happens when inflammation extends from the superficial mucosa into the submucosal and muscular layers of the colon, producing muscle paralysis and precipitating dilation along with a thinning of colonic wall. Patients may present with toxic megacolon during a relapse of established UC, but often during their first flare or within two to three months of diagnosis. Toxic megacolon occurs more commonly in the setting of extensive colitis but can also occur with left-sided colitis. Signs of colitis predominate before the onset of toxic megacolon. These include diarrhoea, rectal bleeding, fevers and abdominal cramping. The onset of toxic megacolon may be heralded by abdominal distension, obstipation, reduced bowel sounds and constitutional symptoms such as fever, tachycardia, hypotension or even mental change. The abdomen can be extremely tender either locally or diffusely suggesting bowel dilatation or peritoneal inflammation due to perforating inflammation.17
Bowel disorders
Henry J. Woodford in Essential Geriatrics, 2022
Culture of the organism is difficult (and hence its name), is more expensive and takes longer (up to three days). Sigmoidoscopy may detect the pseudomembranes of PMC but the disease sometimes only affects the more proximal large bowel. Therefore, a colonoscopy would be required to adequately exclude all such changes. Given the frailty of this population and the increased risk of colonic perforation in the presence of inflammation, this procedure is rarely justified. A plain abdominal X-ray should be performed if megacolon is suspected. Abdominal CT scanning can show changes consistent with colitis. Repeat stool testing to look for clearance of toxins following symptom resolution is not appropriate as it may remain positive for several weeks even when the infection has resolved. Stool type and frequency should be monitored using the Bristol Stool Scale.
Hematopoietic stem cell transplantation for inherited bone marrow failure syndromes: alternative donor and disease-specific conditioning regimen with unmanipulated grafts
Published in Hematology, 2021
Yue Lu, Min Xiong, Rui-Juan Sun, Yan-Li Zhao, Jian-Ping Zhang, Xing-Yu Cao, De-Yan Liu, Zhi-Jie Wei, Jia-Rui Zhou, Dao-Pei Lu
The general characteristics of the SCN patients and donors are summarized in Tables 4 and 5. The male to female ratio was 5–3. The median age at diagnosis and HSCT was 2 months (range: 1 week–1 year) and 3.1 years (range: 2.1 years–15 years). The median disease course pre-HSCT was 3 years (range: 8 months–15 years). The median absolute neutrophil count (ANC) in PB was 150 (20–300)/L. Two patients had a family history – one with a congenital megacolon and one with development retardation. All patients had uncontrolled recurrent infection prior to HSCT. Lobectomy was performed in one patient due to severe pulmonary infection. One patient had colonic resection due to repeated infection of a congenital megacolon. ELANE deleterious genes mutations were detected in all patients. Two patients had mutations that were traced back to their parents. All patients received G-CSF treatment for a median of 36 months (range: 24 m–120 m) before HSCT and doses above the median dose of 8 μg/kg/day (range: 5–16 μg/kg/day).
Paediatric inflammatory bowel disease: review with a focus on practice in low- to middle-income countries
Published in Paediatrics and International Child Health, 2019
Anthony Mark Dalzell, Muhammad Eyad Ba’Ath
In UC, unresponsiveness to intravenous steroid therapy, anaemia and the need for blood transfusion are major predictors of colectomy [81]. In some studies, the rectal sparing type has been identified as an independent risk factor for urgent/emergent surgery in surgically treated patients with UC [82]. Acute indications include toxic megacolon which is rare in children. Surgical options in UC include total or subtotal colectomy with ileorectal anastomosis and subsequent lifelong surveillance of the rectal pouch. If total colectomy with rectal mucosectomy is to be performed, then reconstruction options include J-pouch ileo-anal anastomosis, straight ileo-anal anastomosis and permanent ileostomy which is usually necessary in about 10% of patients [80]. In toxic megacolon, blow-hole colostomy (construction of a side hole through the colon wall which is sutured to the skin and allows the colon to decompress, thus avoiding perforation) might be an option if a patient is too sick to tolerate a more extensive procedure.
Adjuvant use of combination of antibiotics in acute severe ulcerative colitis: A placebo controlled randomized trial
Published in Expert Review of Anti-infective Therapy, 2021
Shubhra Mishra, Harshal S Mandavdhare, Harjeet Singh, Arup Choudhury, Jimil Shah, Sant Ram, Dimple Kalsi, Jayanta Samanta, Kaushal K Prasad, Arun K Sharma, Usha Dutta, Vishal Sharma
The clinical features of each patient including the stool frequency, severity of bleeding, signs and symptoms of systemic toxicity, cause of exacerbation, disease characteristics (duration and extent, previous medications) were recorded in a predesigned case report form. An unprepared sigmoidoscopy with minimal air insufflation was performed and biopsies were taken for exclusion of CMV colitis. The severity at the time of presentation was also assessed using the complete Mayo score (>10: severe, 6–10: moderate, 3–5: mild, <3: remission) [14]. Stool routine microscopy, culture, and ELISA for Clostridioides difficile (CDI) were performed on admission. Patients underwent daily abdominal X-ray to rule out megacolon. Inflammatory biomarkers including serum CRP, serum procalcitonin, and fecal calprotectin were measured on admission and on day three of treatment. Partial Mayo score for ulcerative colitis was also calculated on day three and the difference from day one was noted.