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
Emergency Surgery
Tjun Tang, Elizabeth O'Riordan, Stewart Walsh in Cracking the Intercollegiate General Surgery FRCS Viva, 2020
The abdominal x-ray shows a dilated transverse colon measuring 9 cm. His WCC is 18. What is the diagnosis?Acute colitis is diagnosed using Truelove and Witt's criteria (more than six bloody stools, Hb < 10.5, ESR > 30, temp > 37.8°C, HR > 90).Toxic megacolon is diagnosed if there is: >6 cm transverse colonic dilatationAny three of fever, tachycardia, leucocytosis, anaemiaAny one of dehydration, altered mental status, electrolyte abnormality or hypotensionThe microscopic hallmark is inflammation extending beyond the mucosa.
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.
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.
Clinical management of severe, fulminant, and refractory Clostridioides difficile infection
Published in Expert Review of Anti-infective Therapy, 2020
Yao-Wen Cheng, Monika Fischer
In a retrospective cohort study by Hocquart and colleagues, patients admitted for CDI were compared based on therapy [96]. Among the roughly 60% of patients with SCDI in the study, 3-month mortality was 12.1% in patients receiving FMT within 2–4 days of diagnosis and 42.2% among those who received standard anti-CDI therapy (p < 0.0001). No patients in this cohort underwent surgery and the authors concluded that just two patients with SCDI would need FMT to save one life. These results were replicated at 3 other centers including the Mount Sinai Hospital [97], Gemelli Hospital [95], and Indiana University [94]. All reports showed decreased mortality in hospitalized patients with severe and fulminant CDI receiving FMT. In most cases, multiple or sequential FMTs were needed in combination with anti-CDI antibiotics such as vancomycin or fidaxomicin per a previously published pseudomembrane-driven colonoscopic FMT protocol [89]. FMT can be safely administered via careful colonoscopy even in patients with toxic megacolon, often leading to rapid and dramatic improvement in clinical symptoms. Screened and frozen stool-derived microbiota is now available from several stool bank allowing for prompt treatment of such patients.
Current updates in management of Clostridium difficile infection in cancer patients
Published in Current Medical Research and Opinion, 2019
Muhammad Aziz, Rawish Fatima, Lindsey N. Douglass, Omar Abughanimeh, Shahzad Raza
Diarrhea is particularly challenging in cancer patients, as it can be associated with chemotherapy itself or infectious etiology12. Diarrhea-related complications include dehydration, electrolytes disturbances, kidney failure, labile blood pressure, hypovolemic shock, and death. CDI not only poses these challenges, but is also associated with toxic megacolon, that can be lethal if not treated appropriately13. The recurrence rate for CDI is particularly high in the cancer population, as demonstrated by Chung et al.14 (20.4% vs 9.5%; p = .005), with cancer being an independent risk factor for recurrence (OR = 2.66; 95% CI = 1.34–5.29; p = .005). Mortality directly attributable to CDI in cancer patients was shown to be high compared to cancer patient without CDI (9.3% vs 7.4%, respectively, p < .0001). Cancer patients with CDI had a prolonged hospital stay as compared to those without infection (9 days vs 4 days, p < .0001)15.
Related Knowledge Centers
- Large Intestine
- Megacolon
- Bloating
- Fever
- Abdominal Pain
- Shock
- Complication
- Inflammatory Bowel Disease
- Ulcerative Colitis
- Crohn's Disease