A patient who survived total colonic ulcerative colitis surinfected by cytomegalovirus complicated by toxic megacolon and disseminated intravascular coagulation

The authors report the case of a patient aged 60-year-old who survived ulcerative colitis complicated by toxic megacolon and disseminated intravascular coagulation. This patient was not known for this ulcerative colitis and was first hospitalised for a suspicion of diverticulitis. The admission symptoms were fever, abdominal pain and bloody diarrhoea. The evolution was defavorable under antibiotics and sulfasalazine. The patient was readmitted 5 days after he left hospital, and the diagnosis of UC was based on colon biopsy made during the first hospitalisation. A treatment with methylprednisolone was started and the patient worsened day by day with apparition of toxic megacolon and disseminated intravascular coagulation. Subtotal colectomy was performed for degradation of general status and coagulation factors. Pathological findings confirmed ulcerative colitis with toxic megacolon. Cytomegalovirus inclusions were demonstrated on the colonic specimen and confirmed by PCR. In this report the authors discuss the etiology of toxic megacolon and disseminated intravascular coagulation in ulcerative colitis surinfected by cytomegalovirus. Mortality of these pathologies is high necessitating rapid diagnosis of cytomegalovirus infection by sigmoid biopsy. Management requires immunosupression interruption and ganciclovir therapy, or surgery in unsuccessful medical treatment.

A new look at toxic megacolon: an update and review of incidence, etiology, pathogenesis, and management

Toxic megacolon (TM) is an infrequent but devastating complication of colitis. Numerous forms of colonic inflammation can give rise to TM but the majority occur in individuals with inflammatory bowel disease (IBD). Recently there has been a marked increase in the number of reports of TM associated with pseudomembranous colitis. Because of the associated high morbidity and mortality, early recognition and management of TM is of paramount importance. The mechanisms involved in development of TM are not clearly delineated, but chemical mediators such as nitric oxide and interleukins may play a pivotal role in the pathogenesis. New evidence suggests that TM and its associated morbidity may be predicted by the extent of small bowel and gastric distension in patients with colitis. CT scanning may also play an important role the management of TM, in that it may be the only noninvasive mode to detect subclinical perforations and abscesses. Management involves close medical attention, supportive care, and treatment of the underlying colitis. Possible exacerbating factors such as narcotic and anticholinergic medications must be withdrawn, and colonic decompression via tube drainage or positional techniques must be considered. Signs of progression or complications of the disease must be treated aggressively with surgical intervention, as delay is associated with even greater risk of mortality.

[Surgical approach is toxic colitis]

Toxic colitis is still a major diagnostic and therapeutic challenge. Mortality rates depend on the severity of the disease and range from 2% to 30%. Interdisciplinary approaches are necessary and structured therapeutic steps from conservative to operative treatment seem to be most effective. The surgical option for toxic colitis usually is subtotal colectomy with closure of the rectal stump or mucus fistula and ileostomy. This procedure allows the reconstructive operation later on. In selected cases and suitable situations a primary colectomy with ilealpouch are also possible depending on local and general effects.

Recurrent pseudomembranous colitis as a cause of recurrent severe sepsis

Clostridium difficile (C. difficile) colitis accounts for nearly 15-20 % of antibiotic-associated diarrhea. Manifestations include asymptomatic carriage, self-limited diarrhea, and pseudomembranous colitis, which is sometimes life-threatening. Despite effective therapy with metronidazole and vancomycin relapse rates are 15-33 %. Although colitis is seen in critically ill patients treated with combinations of broad-spectrum antibiotics, reports describing severe sepsis as a result of C. difficile infection are limited. We describe the case of recurrent severe sepsis due to recurrent local intestinal C. difficile infection as the only identifiable etiology. The mechanism of severe sepsis may be a derangement of the gastrointestinal barrier function. This could result in absorption of microbes or endotoxin or activation of inflammatory cascades in the submucosa of the intestine or liver. In general, for successful treatment of C. difficile infections other than anticlostridial antibiotics should be discontinued. However, in the present case bacterial translocation from the intestine is an attractive explanation for severe sepsis and therefore additional antibiotics had been administered.

[Toxic megacolon]

Toxic megacolon belongs to the severe acute complications of inflammatory bowel diseases. The frequency is 1.6-21.4% among patients with ulcerative colitis and 0.3-2% in those with Crohn's disease. The main characteristics of toxic megacolon are toxemia, sepsis and distension of the colon due to the diminished muscular tone, loss of motor activity and increased amount of colonic gas. Sepsis and/or perforation of the large bowel can complicate this situation. The most important diagnostic procedure is the abdominal X-ray. Should the diameter of colonic distension exceed 60 mm, the diagnosis of toxic megacolon has been confirmed. Conservative treatment of toxic megacolon consists of water and electrolyte replacement, total parenteral nutrition, administration of corticosteroids and broad-spectrum antibiotics and repeat patient's prone positioning. If medical therapy is not successful during the first 72 hours, surgical intervention is indicated. The most common procedure is subtotal colonic resection with creation of an ileostomy. Patients with toxic megacolon should be managed at specialised centers, where cooperation of experienced gastroenterologists, surgeons and intensive care experts is possible.

[Toxic megacolon: report of 2 clinical cases and review of the literature]

The authors present two cases of toxic megacolon. A proctocolectomy with ileostomy was performed in both cases. One of the two cases was detected late; the patient underwent surgery in desperate conditions and died on postoperative day one. The authors regard a prompt diagnosis as fundamental for the correct timing of the surgical approach in patients with toxic megacolon and severe acute colitis. Clinical and laboratory findings and, above all, plain films of the abdomen should be evaluated very carefully. The authors suggest total proctocolectomy with section-suture of the rectal stump at levator level and ileostomy, which makes it possible to avoid postoperative rectal haemorrhages and recurrences.

Toxic megacolon: remember cytomegalovirus

A 63-year-old female retired clerical officer was admitted with a 1-week history of profuse diarrhoea. The patient had been diagnosed with non-Hodgkin's lymphoma 4 years previously, and a human immunodeficiency virus (HIV) test at that time was negative. She had received two regimens of chemotherapy, and had been in remission for 3 months with a normal leukocyte count. The diarrhoea was watery with no blood or mucus, and associated with mild nausea and diffuse left-sided abdominal pain relieved by defaecation. The patient had a mild pyrexia and scanty bowel sounds, but the abdomen was not distended. Full blood count and full biochemistry were normal apart from the white cell count (13.8x109/litre — predominantly neutrophils and monocytes). Initial blood cultures and routine viral serology were negative, but the latter was never repeated. Stool samples were negative for bacteria, parasites and toxins.

[Toxic megacolon]

Toxic megacolon is a serious complication of inflammatory bowel disease, thus its prevention should be performed thoroughly. In patients with severe colitis refractory to maximal oral and topical therapy or who presents with toxicity, intravenous steroids are obligatory. If there is failure to achieve significant improvement within 7-10 days colectomy or treatment with intravenous cyclosporine or azathioprine are mandatory. In addition to maximal medical therapy as for severe colitis including broad spectrum antibiotics, patients with toxic megacolon should be kept nil per os, with small bowel decompression tube (if a small bowel ileus is present) and rotated into the prone or knee-elbow position frequently (evacuation of bowel gas). Any clinical, laboratory, or radiological deterioration require immediate colectomy. The duration of medical treatment of megacolon is controversial if no significant improvement is noted. Some experts support surgery within 72 hours, others take a more observing position if no toxic symptoms are present, but some advocate surgery within 24 hours.

Toxic megacolon: a rare presentation of primary lymphoma of the colon

Primary colonic lymphoma is rare and accounts for less than 1% of colon malignancies. Moreover, diffuse neoplastic invasion of the colon is exceptional. This case describes a patient with primary non-Hodgkin's lymphoma of the colon presenting as toxic megacolon. This unique presentation is the first case reported in the literature of a diffuse colonic lymphoma diagnosed in the setting of a toxic megacolon. Histological confirmation was performed on the piece of colectomy.

Campylobacter jejuni-induced severe colitis--a rare cause of toxic megacolon

The development of toxic megacolon as a sequel of infectious colitis is rare. We have observed the very rare case of a campylobacter jejuni-induced toxic megacolon. A 28-year-old man was admitted with severe enterocolitis and appearance of blood in stools. He had been treated with loperamide without success. Two days after admission stool cultures revealed campylobacter jejuni and then an oral antibiotic therapy was started. On the fifth day clinical performance deteriorated again with development of toxic megacolon and consecutive subtotal colectomy. Rectoscopy before discharge after 13 days showed a normal mucosa. The unusual course with first improvement and then rapid deterioration despite adequate therapy was observed in 4 other cases, which may also be a hint of ensuing megacolon. Even in usually harmless enterocolitis like campylobacter infection, predisposing factors such as loperamide are known to precipitate toxic megacolon and should be considered in clinical practice.

Toxic megacolon secondary to infective colitis in children

BACKGROUND AND PURPOSE

Toxic megacolon is a fulminating and potentially lethal complication of severe colitis. Toxic megacolon secondary to infective colitis in children is rare. We analyzed the clinical course, pathology, treatment, and outcome of toxic megacolon secondary to infective colitis in children.

METHODS

The medical records of all 20 children treated for infective colitis complicated with toxic megacolon during a 12-month (October 1997-October 1998) period were retrospectively reviewed.

RESULTS

There were 10 boys and 10 girls, with a mean (+/- standard deviation, SD) age of 26.2 +/- 12.9 months (range, 6-57 mo). With an initial presentation of nonspecific gastroenteritis syndrome lasting several days, the disease progressed rapidly. 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%). 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%). Salmonella enteritidis (12 patients, 60%) and Clostridium difficile (1, 5%) were isolated from stool samples in some cases. Plain abdominal x-rays revealed severe colonic dilatation. Prolonged hospitalization (mean, 33.6 d) and intensive therapy including a combination of broad-spectrum antibiotics, physical decompression, and total parenteral nutrition were necessary. Three patients (15%) underwent surgical management; the pathologic findings in these patients demonstrated severe transmural inflammation. We believe that bacterial and/or endotoxin translocation played an important role in gut failure. Three patients (15%) in the study died.

CONCLUSION

Toxic megacolon in infective colitis is a fulminating illness that has a high mortality rate. The disease course can be divided into three stages: the acute toxic stage, the gut failure stage, and the convalescence or deterioration stage. Early diagnosis and aggressive management are important.

Complications of inflammatory bowel disease

Complications in inflammatory bowel disease determine the severity of disease as well as the complexities of medical or surgical treatment opportunities. Therefore, in known inflammatory bowel disease, the prevention, the early detection and the adequate therapeutic response to certain complications are important goals in the follow-up of inflammatory bowel disease patients. Disease complications are separated into intestinal and extraintestinal complications. Intestinal complications are somewhat disease specific, which means that they occur exclusively in either Crohn's disease or ulcerative colitis (e.g., enteric fistulas are particularly found in Crohn's disease and toxic megacolon in ulcerative colitis). Most extraintestinal complications occur in both forms of inflammatory bowel disease (e.g., anemia, thromboembolic events or osteoporosis). The current knowledge on pathogenesis, diagnostic tools, prevention and treatment of certain intestinal and extraintestinal complications is reviewed.

Toxic megacolon: diagnosis and treatment challenges

In adults, toxic megacolon is a relatively uncommon but potentially lethal complication of inflammatory bowel disease (IBD), infectious colitis, or ischemic colitis caused by cancer chemotherapeutic agents. Patients have distension of the colon and signs of toxicity such as elevated temperature, hypotension, decreased level of consciousness and electrolyte imbalances. Factors thought to increase the risk include premature discontinuation of IBD medications; procedures that increase colon trauma, such as barium enema and colonoscopy; medications that decrease gastrointestinal motility; and electrolyte imbalances, especially hypokalemia. Differential diagnosis is made based on the patient's history and results of stool cultures and assay for Clostridium difficile toxin. Medical management in the intensive care unit includes careful monitoring, fluid volume and electrolyte replacement, bowel rest and decompression, antibiotic therapy, and cessation of medications that slow gastric motility. Surgical management may be necessary if there are signs of deterioration, perforation, hemorrhage, or sepsis.

A patient who survived total colonic type ulcerative colitis complicated by toxic megacolon, disseminated intravascular coagulation, methicillin-resistant Staphylococcus aureus infection and bilateral femoral phlebothrombosis

We report a patient who survived total colonic type ulcerative colitis (UC) complicated by toxic megacolon (TM), disseminated intravascular coagulation (DIC), methicillin-resistant Staphylococcus aureus infection, and phlebothrombosis. A 69-year-old man was treated for about 4 months under the diagnosis of ischemic colitis at another hospital, and was transferred to our hospital. Based on endoscopic and pathological findings, we strongly suspected UC, and administered salazosulfapyridine and methylprednisolone, but TM and DIC developed, necessitating urgent subtotal colectomy. Despite his elderly age and the severe complications, he recovered and was discharged from our hospital about 4 months after admission. The mortality rate of UC complicated by TM and DIC in elderly patients is high, necessitating rapid initiation of high-dose steroid administration or surgical treatment.

Silver sulfadiazine induced Clostridium difficile toxic megacolon in a burn patient: case report

A 53 yr old diabetic male presented with a 34% total body surface area (TBSA) deep partial- and full-thickness burns. On post burn days 4 and 9, all of his burns were excised and grafted. Although he had only been treated with topical antibiotics, he developed Clostridium difficile colitis after his second surgery that progressed to Toxic Megacolon and perforation. 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.

[Toxic megacolon as a complication of Campylobacter jejuni enterocolitis]

We report the case of a previously healthy 53-year-old white male who developed an extraordinary complication of acute Campylobacter jejuni colitis. Toxic megacolon occurred while the patient was treated with a fluoroquinolone antibiotic and glucocorticoids, which were given for endoscopically suspected Crohn's colitis. During the course of the disease no cause of colitis was found other than C. jejuni. Despite the extreme dilatation, the patient was treated conservatively with parenteral nutrition and repeated decompression colonoscopies and made a full, though slow, and uneventful recovery. Follow-up colonoscopies for up to 4 years showed persistent scarring of the transverse colon, probably due to the extreme dilatation, and mild unspecific inflammation of the terminal ileum without histological evidence of inflammatory bowel disease. A comparison with the 6 previously published cases leads to the following conclusions: in most cases the transverse colon is most severely affected. Treatment with either antimotility agents or systemic glucocorticoids does not seem to promote colonic dilatation. The complication has affected patients of both sexes (4 women, 3 men), in the age range of 21 to 83 years, most of them without an underlying disease. The interval between the start of diarrhea and development of the megacolon ranged widely from 3 to 33 days, as did recovery time (2 days to several months). Three of the 7 patients underwent colectomy for imminent or actual colonic perforation. The delayed recovery of our patient was partly attributed to colonic damage caused by extreme dilatation, leading to ischaemia and subsequent scarring of the mucosa, which persisted. Histologically no Crohn's disease or ulcerative colitis could be found at any stage. A rapid increase in resistance of C. species against fluoroquinolone antibodies has been observed in recent years, due to use of the antibiotics in farming. Our patient's severe illness may partly have resulted from delayed effective antibiotic treatment due to resistance. Antibiotic resistance to common enteropathogens should be considered in the case of unusually prolonged or severe enterocolitis. The level of suspicion for either infection or inflammatory bowel disease should remain high as it may be impossible to distinguish between them on the basis of clinical or endoscopic criteria alone.

[Febrile state, bloody diarrhea and megacolon]

We report about a forty year old female patient with severe bloody diarrhoea and fever over a period of 14 days due to an infection with Salmonella enteritidis. X-ray of the abdomen showed a toxic megacolon. With the diagnosis of an infectious colitis we started therapy with ciprofloxacin i/v. The toxic megacolon progressed despite intensive care and parenteral nutrition. Additionally the patient received metronidazole i/v and in combination with a roll technique in bed in the knee-elbow-position the leucocytosis and the megacolon decreased. A toxic megacolon is in about 3% associated with an infection with Salmonella enteritidis. It is essentially diagnosed by X-ray. Patients should receive intensive care, and because of the high mortality rate an interdisciplinary management is required. The article discusses the major differential diagnosis of the toxic megacolon, as well as the pathogenesis and therapy of Salmonella ent, infection. In case of an infection with Salmonella ent. physicians should acknowledge the possibility of development of a toxic megacolon.

Inflammatory bowel disease

The vast majority of patients with inflammatory bowel disease experience chronic symptoms punctuated by periodic exacerbations requiring adjustments in medical therapy or surgery. True emergencies are fortunately uncommon but have been associated with high rates of morbidity and mortality. Patients presenting with fulminant colitis, toxic megacolon, or perforation require prompt identification as well as intensive medical therapy and monitoring by physicians and surgeons experienced in the care of such patients. Recent advances in the evaluation and treatment of these complicated patients are reviewed.

[Toxic megacolon. Apropos 3 cases]

The authors describe their experience with three cases of toxic megacolon: two cases were complications of an ulcerative colitis and died after surgery; one case was a complication of Crohn's disease and recovered after medical resuscitation treatment. Diagnosis was based on clinical features and direct abdominal X-ray showing an evident dilatation of the colon. The authors think that intense medical treatment has to be carried out in all cases without urgent surgical indication: even if not always successful, a medical therapy will be an appropriate preparation for operation. The authors believe that the operation of choice is colectomy with ileo-rectal anastomosis plus upstream protective ileostomy or right terminal ileostomy plus left iliac sigmoidostomy with subsequent reconstruction of continuity.