[Toxic Megacolon: A rare complication of chronic constipation. Three Pediatric Cases]

INTRODUCTION

Chronic constipation is a frequent pathology in the pediatric age that affects the quality of life of pa tients and their families. Its management is usually complex and long associated with poor adheren ce. Toxic megacolon is a serious, potentially lethal disease when chronic constipation is left untreated or poor adherence to treatment.

OBJECTIVE

To report 3 pediatric cases of toxic megacolon as a com plication of poorly managed chronic constipation.

CLINICAL CASES

Three males patients, aged 6 to 13 years, with a history of chronic constipation and poor adherence to treatment are discussed. They were admitted to the emergency department with clinical findings of toxic megacolon (intestinal dilation and signs of systemic toxicity). Given their condition, all patients required management in the critical patient unit (CPU) and early surgical intervention, undergoing ostomy. All presented fa vorable outcome, performing stoma reversal surgery between 8-24 months later. In all cases, organic cause of the constipation was ruled out.

CONCLUSIONS

Toxic megacolon is an infrequent but highly morbid and potentially lethal disease. It requires a high index of suspicion as well as multidisciplinary medical-surgical management.

Communicating multiple tubular enteric duplication with toxic megacolon in an infant: A case report

RATIONALE

Gastrointestinal tract duplication is a rare congenial anomaly which can be found anywhere along the gastrointestinal tract. While many patients are incidentally diagnosed during operation, in some cases it can present with severe gastrointestinal symptoms. In this case report, the patient presented with signs of toxic megacolon leading to rapid aggravation of inflammatory shock.

PATIENT CONCERNS

A 49-day old male infant presented with fever, poor feeding, and severe abdominal distension.

DIAGNOSIS

Abdominal ultrasonography was done. During the examination, a foley catheter was inserted through the anus to evaluate bowel patency and enable rectal decompression. The tip of the foley catheter was located in a separate narrower tubular lumen adjacent to the distended rectum. These findings suggested possibility of a tubular duplication cyst of the rectum as the culprit for the bowel obstruction.

INTERVENTIONS

The patient underwent emergency laparotomy. Findings showed multiple tubular intestinal duplications involving the ileum, appendix, cecum, descending colon, sigmoid colon and rectum. The true lumen of the rectosigmoid colon was completely collapsed while the adjacent tubular cyst remained severely distended and stool passage was not possible. Decompression of the sigmoid colon was done with loop colostomy with both the wall of the true bowel and enteric cyst forming the colostomy orifice.

OUTCOMES

After 40 days of postoperative care, the patient was discharged with no immediate complications. Four months after the initial operation, colostomy take-down and transanal rectal common wall division was done. No complications were observed.

LESSONS

To our knowledge, this is the first case to be reported where a rare presentation of intestinal duplication resulted in an acute presentation toxic megacolon. Such emergency cases can be effectively treated with emergency surgical bowel decompression and elective common wall division.

Fulminant ulcerative colitis in a healthy pregnant woman

This case report concerns a 25-year-old patient with 6-7 bloody stools/d, abdominal pain, tachycardia, and weight loss occurring during the third trimester of pregnancy. Severe ulcerative colitis complicated by toxic megacolon and gravidic sepsis was diagnosed by clinical evaluation, colonoscopy, and rectal biopsy that were performed safely without risk for the mother or baby. The patient underwent a cesarean section at 28+6 wk gestation. The baby was transferred to the neonatal intensive care unit of our hospital and survived without complications. Fulminant colitis was managed conservatively by combined colonoscopic decompression and medical treatment. Although current European guidelines describe toxic megacolon as an indication for emergency surgery for both pregnant and non-pregnant women, thanks to careful monitoring, endoscopic decompression, and intensive medical therapy with nutritional support, we prevented the woman from having to undergo emergency pancolectomy. Our report seems to suggest that conservative management may be a helpful tool in preventing pancolectomy if the patient’s condition improves quickly. Otherwise, surgery is mandatory.

Toxic megacolon and human Cytomegalovirus in a series of severe ulcerative colitis patients

BACKGROUND

Human Cytomegalovirus (HCMV) infection has been reported to be a cause of refractory ulcerative colitis (UC). Toxic megacolon (TM) is a rare but severe complication of an acute attack of UC.

OBJECTIVES

Aim of this study is to evaluate in a case-control study the association between HCMV and TM.

STUDY DESIGN

All patients who were admitted at Medicine Department of V. Cervello Hospital in Palermo (tertiary referral center) for a severe UC flare-up complicated by the onset of TM (diameter of the transverse colon>6 cm) between January 1990 and November 2011 were identified through the electronic database. A total of 24 consecutive patients (16 male/8 female) with TM were identified. Each case of TM were individually matched by sex, age, extent of the underlying disease to 24 severe UC controls who did not develop TM. A further non matched control population of 48 severe UC was included. Haematoxilin and eosin stain, immunohistochemical procedure and nested polymerase chain reaction were performed to detect HCMV genes and proteins on rectal biopsies or surgical specimens. Pp65 antigenemia was performed in order to diagnose any possible systemic infection. HCMV frequency was compared between patients with and without TM during follow-up, using Fisher's Exact test.

RESULTS AND CONCLUSIONS

HCMV was detected in histological specimens of 11 patients (46%) with TM compared to 2 (9%) severe UC matched controls (P = 0.0078) and 7 (14%) unmatched controls (p = 0,003). In severe colitis the presence of HCMV is more frequently associated with TM.

[Frequency, clinical evolution and prognosis of toxic megacolon]

INTRODUCTION

Toxic megacolon (MT) is a potentially lethal complication of inflammatory, ischemic and infectious colitis. Usually it is related to ulcerative nonspecific colitis or Crohn disease. Recently it has been observed an increased in pseudomembranous colitis as cause of TM. The aim of this study is to describe the frequency, clinical evolution and prognosis of patients with TM.

METHODS

Retrospective study, from January 2009 to January 2014 1500 patients were hospitalized in the Department of Coloproctology. We included 13 of 1500 patients with diagnosis of TM according to Jalan criteria and surgically corroborated. To determine the averages descriptive statistics was used.

RESULTS

We studied 13 patients with TM (79.9% male and 20.1% female), the average age was 47.69±18.3 years. The most frequently associated diseases were: nonspecific ulcerative colitis (30.8%), pseudomembranous colitis (30.8%), neutropenic colitis (23.1%), Crohn Disease (7.7%) and ischemic colitis (7.7%). Subtotal colectomy plus terminal ileostomy was done in 84.6%, extended right hemicolectomy with ileostomy plus mucous fistula in 7.7% and extended right hemicolectomy with ileostomy plus Hartmann pouch in 7.7%. The mortality was 61.5%. The prevalence in the 5 years was 13 of 1500 (0.86%) patients.

CONCLUSIONS

The prevalence of TM is low with a high mortality. A prompt diagnosis and treatment can improve the poor prognosis in these patients.

Surgical Management of Toxic Megacolon

BACKGROUND/AIMS

Toxic megacolon carries still a substantial mortality and the decision when to per form emergent colectomy needs precise predictors outcome.

METHODOLOGY

Thirty-two patients with toxic megacolon were identified from a computer database, and their clinical variables were analysed both univariate and multivariate analysis.

RESULTS

30-day mortality was 16%, being 17% for the patients with Clostridium difficile colitis and 13% for the patients with inflammatory bowel diseases. Diabetes, MPI class II, ASA classes 4-5, increase serum creatinine level, fever over 39 degrees, renal failure, gangrenous bowel and vasopressor requirement significantly associated with in univariate analysis, but only MPI class II and ASA classes 4-5 were independent predictors of mortality. Major complications occurred in 53% of the patients and they associated with respiratory failure, development of shock and vasopressor requirement. Surgical intensive care was needed by the patients who developed respiratory failure, shock or anaemia the hospital treatment was longer in patients with Clostridium difficile colitis.

CONCLUSION

Development of signs of organ failures or shock are associated with poorer outcome in patients with toxic megacolon and the patients should be urgently operated, when these signs occur.

Toxic megacolon in ulcerative rectocolitis. Current trends in clinical evaluation, diagnosis and treatment

Toxic megacolon is a clinical condition associated to high risk of colonic perforation, that significantly increases--even triplicates--the megacolon-related mortality when causing diffuse peritonitis. Abdominal and pelvic helical CT scan proved to be a fundamental diagnostic tool, in defining the colic dilatation and perforation. Conservative treatment is initially indicated in the event of toxic megacolon arising at the onset of a severe or toxic colitis. However it should be avoided when the toxic megacolon appears on corticosteroid therapy. Non operative management must not exceed 48 hours. The rationale of this strategy lies on the fact that early surgery is burdened by a mortality rate that, although moderate, is still higher than medical treatment. Nevertheless, successful conservative management does not exempt from surgery, which must be performed as soon as possible, in an elective setting, to prevent the recurrence of toxic megacolon. In emergency total colectomy and end ileostomy is the gold standard procedure. Bowel continuity will be restored, evaluating case by case, by performing an ileorectal anastomosis or proctectomy and ileoanal pouch anastomosis. Primary ileorectal anastomosis should be reserved to selected cases. In the elective setting, after proper therapy and regression of toxic megacolon, proctocolectomy and ileoanal pouch anastomosis is indicated.

Oral tacrolimus for megacolon in patients with severe ulcerative colitis

Toxic megacolon is an infrequent but life-threatening complication that occurs most commonly in patients with severe ulcerative colitis. Intravenous steroids are often recommended for patients with toxic megacolon secondary to ulcerative colitis. However, steroid dependency may mask the presence of intra-abdominal sepsis and is associated with refractoriness, during which cytomegalovirus reactivation may occur. In this report, we present two rare cases of megacolon accompanying pancolonic severe ulcerative colitis that were successfully treated with oral tacrolimus, including one steroid-naïve patient. In cases of ulcerative colitis with megacolon, treatment with oral tacrolimus is recommended, thereby avoiding steroid dependency and improving the long-term prognosis.

[Toxic megacolon complicated by ulcerative colitis in six patients: a case report and literature review]

OBJECTIVE

To summarize the clinical features of ulcerative colitis (UC) complicated by toxic megacolon for early diagnosis and proper treatment.

METHODS

Six cases of toxic megacolon in the patients suffered from UC in Peking Union Medical College Hospital from 1983 to 2010 were analyzed, and related literature was searched and reviewed.

RESULTS

The incidence of the toxic megacolon in the patients with UC in our center was 0.7%(6/824), which was lower than those reported in the literature. There were always risk factors triggering the disease. The prognosis of the patients was poor, even after medical care and surgery intervention. Evaluation of the patients and making right timing to perform the surgery would improve the prognosis of the patients in foreign literature.

CONCLUSION

It's crucial to make early diagnosis of the toxic megacolon in the patients suffered from UC. The right choice and timing to perform urgent surgery or selective surgery may improve their prognosis.

Toxic megacolon associated with cytomegalovirus infection in a patient with steroid-naïve ulcerative colitis

Most cases of cytomegalovirus (CMV) colitis in patients with inflammatory bowel disease (IBD) occur in those treated with immunosuppressants and/or corticosteroids. We herein present the case of a 57-year-old man with toxic megacolon associated with CMV colitis in corticosteroid-naïve ulcerative colitis (UC). To date, there have been only eight previous case reports of CMV colitis in steroid-naïve UC. We discuss the need to consider CMV colitis when making a differential diagnosis of patients with refractory UC who are not receiving corticosteroid treatment.

[Treatment outcomes in patients with toxic megacolon]

BACKGROUND

The aim of the study was to analyze data of patients threated by surgical intervention for toxic megacolon in period from 2005 till 2009 on 1st. dept. of Surgery of 1st. Faculty of Medicine, Charles University in Prague. Pre-disponding illness of toxic megacolon was studied intimately and evaluation of postoperative course especially for morbidity and letality was estimated.

PATIENTS AND METHODS

Composit retrospective and prospective analysis of patients that underwent operation for diagnose of toxic megacolon. 19 patients were involved in the study and the method of surgical treatment was subtotal colectomy with formation of terminal ileostomy and rectal occlusion in macroscopically disease-free rectal segment in every case.

RESULTS

Determined collection involved 19 patients, 13 male and 6 female patients with mean age of 51 years. The most frequent reason for toxic megacolon occurrence was ulcerative colitis (36.8%, 7 patients), then pseudomembranous colitis (26.3%, 5 patients) and ischemic colitis (15.8%, 3 patients). The method of surgical treatment was subtotal colectomy with formation of terminal ileostomy and rectal occlusion in macroscopically disease-free rectal segment in every case.

Toxic megacolon secondary to Clostridium difficile colitis. Case report

The incidence and severity of Clostridium difficile colitis has markedly increased in recent years. The spectrum of Clostridium difficile infection ranges from asymptomatic colonization to fulminant colitis requiring immediate surgery. Medical therapy failure and the presence of toxic megacolon dictate urgent surgical treatment with unfortunate high mortality rates (35% to 57%). We broach herein a case of toxic megacolon secondary to colitis due to Clostridium difficile infection in which early diagnosis and prompt surgical treatment led to a successful outcome.

[Toxic megacolon secondary to Clostridium difficile-associated pseudomembranous colitis]

A 78-year-old male without pre-existing comorbidity who underwent revision of a hip arthroplasty developed abdominal pain and distension, diarrhoeas, pyrexia and leucocytosis after only 5 days' postoperative treatment with cefuroxime and gentamycine. Abdominal computed tomography demonstrated severe colonic dilation, inflammation and oedema consistent with toxic megacolon. Stool samples were positive for Clostridium difficile. Oral vancomycine treatment and colonic decompression were inefficient. Subtotal colectomy was performed after which the condition improved.

[Toxic megacolon--the position of the internist]

Toxic megacolon is a rare but typical complication of ulcerative colitis. But also every inflammatory bowel disease may be cause of toxic megacolon, including especially Crohn's colitis and pseudomembranous colitis (PMC). There is to mention, that PMC becomes more frequent and more important in the last years. Toxic megacolon is defined by radiological, clinical and labaratory criteria: colonic distension (<6 cm), fever, tachycardia, hypotension, electrolyte disturbances, leucocytosis and anemia. Intensive medical therapy is primarly the therapy of choice, but clinical parameters should be closely monitored. In patients with ulcerative colitis high dosis of corticosteroids are given intravenously. If there is no clinical improvement after 48 to 72 hours, colectomy is required. The use of alternative therapies like cyclosporine or infliximab has to be discussed as possible before toxic megacolon occurs.

[Toxic megacolon--surgical point of view]

Toxic megacolon is an infrequent, but potentially fatal complication of a fulminant colitis. Toxic colonic dilatation, also caused by ischaemic or infectious inflammation like pseudomembranous colitis, mostly occur in patients with inflammatory bowel disease. Toxic mega-colon is defined as segmental or total colonic distension of >6 cm with the presence of clinical signs of acute colitis and systemic toxicity. Because of the associated high morbidity and mortality the early diagnosis and the management play an important role. The free perforation means a fourfold increase in the mortalitiy of the acute colitis. Recognition of toxic megacolon is underlaying by x-ray of the abdomen with colonic distension and a lack of haustral pattern. Accompanying distension of the small bowel can predict the development of the disease. CT scanning shows a diffuse wall thickening, pericolic inflammation and abnormal haustral pattern and can also detect subclinical perforation or abscesses. The management of toxic megacolon should be with intravenous parenteral nutrition, adaequate supplementation of intravenous fluids and correction of electrolytes abnormalities and the therapy of colitis with corticosteroids. Antibiotics are indicated in infectious disease or bacteriemia and also in colonic perforation. Surgical intervention is indicated by the onset of signs of progression of the disease and complications as perforation, uncontrollable bleeding or distension. The surgical procedure of choice is colectomy and ileostomy. The mortality and morbidity was decreased by avoiding rectal excision. The rectum is closed as a Hartmann's procedure or a mucous fistula is created. A secondary ileoanal pouch can be created at a later date. The interdisciplinary approach with optimal timing of surgical intervention can decrease the morbidity and mortality of toxic megacolon.

Trombosis venosa masiva abdominal con insuficiencia hepática aguda y megacolon tóxico como presentación de colitis ulcerosa

The prevalence of systemic thromboembolic complications is higher in patients with inflammatory bowel disease than in the general population. This hypercoagulable state is due to an increased production of procoagulant substances proportionally related to the inflammatory activity of the disease, although recent reports have focused on the presence of inherited thrombophilic disorders in this entity. We present the case of a 32-year-old woman with no relevant medical history who presented with massive abdominal vein thrombosis, including suprahepatic, portal, splenic and superior mesenteric veins, and secondary acute liver failure in her first ulcerative colitis flare and who later developed toxic megacolon requiring emergency total colectomy despite steroids and cyclosporine. Anticoagulant therapy achieved complete resolution of suprahepatic thrombosis and partial resolution in the splenic and superior mesenteric veins, with final cavernous transformation of the portal vein.

Colonic obstruction due to giant inflammatory polyposis in a patient with ulcerative colitis

A 32-year-old Japanese woman with a 14-month history of ulcerative colitis (UC), pancolitis type, was referred to our institution, because of abdominal distention. Plain abdominal X-ray and computed tomography (CT) showed marked dilatation of the right side of the colon. The patient was treated by immediate total colectomy, with the diagnosis of toxic megacolon. Macroscopically, there was a constricting lesion with giant polyposis in the middle part of the transverse colon. Histologically, there was transmural inflammation with a thickened proper muscular layer overlaid by inflammatory polyposis. This case suggests that giant polyposis in UC patients may result in severe stenosis and that such a condition should not be misinterpreted as toxic megacolon or as colitic cancer.