Fatal Shigella dysentery complicated by toxic megacolon and bone marrow aplasia in a patient with chronic granulocytic leukemia in remission

A patient with Philadelphia positive chronic granulocytic leukemia in clinical remission is described, who developed Shigella dysentery complicated by fatal toxic megacolon, pancytopenia and bone marrow aplasia. The difficulties of differential diagnosis between active ulcerative colitis and Shigella dysentery and problems relating to the management of these two disorders are discussed. Leukocyte function in chronic granulocytic leukemia and its role in infection in these patients is also briefly reviewed. The rare association of bone marrow aplasia and Shigellosis is stressed.

[Toxic megacolon and its surgical treatment. Results in 21 cases (author's transl)]

The authors present their experience of the toxic colonic dilatation after 21 cases. The frequency of this serious syndrom seems to be in augmentation, and is not any more exclusive of the ulcerative colitis. Actually, pathogeny is not yet known. Diagnosis is established by the standard abdominal X Ray. A continuous clinical, radiological and biological survey is essential, in order to avoid perforation, that is the main complication of the toxic dilatation. The surgical treatment becomes imperative as soon as the failure of the limited medical management is recognized. In this series, total colectomy with or without ileo-rectal anastomosis has been considered as the best surgical operation. Ileo-rectal anastomosis would be possibly protected by a temporary ilestomy.

Surgical treatment of toxic megacolon and proposal for a program of therapy

Experience with 12 patients with toxic megacolon that required surgical intervention is described and analyzed. Ten patients had ulcerative colitis and 2 had Crohn's colitis; 9 were treated with corticosteroids before operation. The diagnosis was established by radiologic studies, operative findings and examination of the surgical specimens. The operations performed in these patients were proctocolectomy and ileostomy in five, abdominal colectomy and ileostomy with preservation of the rectum in five, and loop ileostomy and colonic venting in two. All patients had prolonged and complicated recovery periods; 1 died in the postoperative period and 10 reassumed their pre-illness activities. A highly specific therapy program is proposed for managing patients with toxic megacolon.

Toxic megacolon

Toxic megacolon is a clinical entity characterized by fever, tachycardia, and other toxic symptoms and having as its distinguishing feature dilation of a part or all of the colon. It is the result of the acute onset or exacerbation of ulcerative colitis or, less often, granulomatous enterocolitis, amebiasis, or pseudomembranous colitis. The primary inflammatory disease must be accurately identified, and malignant tumors, such as adenocarcinoma and lymphoma, capable of producing clinical findings similar to those of toxic megacolon must be excluded. Aggressive supportive therapy is essential, and early operation to remove the colon is usually necessary to avoid death as a result of this dreaded complication.

Toxic megacolon complicating Crohn's colitis

Toxic megacolon complicating ulcerative colitis has been a well-recognized entity since its original description in 1950. The presence of toxic megacolon frequently has precluded a diagnosis of Crohn's colitis. Recent literature, however, has demonstrated that the incidence of toxic megacolon associated with Crohn's colitis (4.4-6.3%) may be higher than that in ulcerative colitis (1-2.5%). 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. Surgical intervention is indicated if the patient's condition does not improve within 48-72 hours. A subtotal colectomy with an ileostomy and mucous fistula is probably the treatment of choice for most of these extremely ill patients. The influence of the type of colitis on the results of subsequent management of the rectal stump remains unresolved.

Management of toxic megacolon: the significance of early recognition in medical management

Twenty-seven patients with acute toxic dilatation of the colon (TM) as a complication of inflammatory disease of the colon are reported. To emphasize the importance of early recognition and therapy, we separated the patients into two groups: 19 were receiving care by the authors (series A) before the development of TM, and eight were seen in consultation after its onset (series B), TM subsided with medical therapy in 13 episodes among 19 patients in series A and two of eight B. The others underwent surgical therapy. There were no deaths in either group. The differences in management and mortality from other reports suggest a program of surveillance and therapy for this life-threatening situation.

Surgical management of toxic megacolon

Toxic megacolon developed in ten of 220 patients (4.5%) admitted for chronic ulcerative colitis over the past 11 years. Nine of these patients came under the care of the Surgical Department. Only three of these 10 patients had previously been treated with steroids. Steroid therapy reversed the acute process in three patients (33%). All three patients later came to surgery. Toxic megacolon developed during the first episode of ulcerative colitis in seven of ten patients (70%). Three of the seven (43%) had perforated their colons prior to operation. Two patients died after a subtotal colectomy and one without operation. A delayed diagnosis was associated with sepsis in five patients (50%) and with all three deaths. Seven patients survived proctocolectomy. Prolonged medical management without dramatic response appeared to correlate with a high postoperative morbidity. This study supports the concept of aggressive diagnosis and early surgical intervention for toxic megacolon.

Treatment of toxic megacolon

From 1970 to mid-1975, we have operated on 25 consecutive patients with toxic dilatation of the colon with no mortality. This report deals with the principles of management which we follow; primary emphasis is given to aggressive diagnosis and resuscitation, followed by early operative intervention. We prefer total abdominal colectomy with ileostomy and sigmoid mucous fistula for cases of toxic megacolon not complicated by hemorrhage.

[Behcet's disease and toxic megacolon]

The gastrointestinal symptoms of Behçet's disease are ancillary manifestations of this disorder reflected principally in the form of diarrhea, abdominal pain, meteorism, nausea, and loss of appetite. If radiological changes can be detected they generally appear as dilatation of the small intestine or ulceration at different levels of the digestive tract. In our patient the intestinal symptoms started with dilation of the ileum and then toxic megacolon developed. At later follow-up examinations the radiological picture resembled Crohn's disease and ischemic colitis of the entire organ. It has been repeatedly, and wrongly, stated that there is an association between Behçet's disease and Crohn's disease or ulcerative colitis. Rather, it should be assumed that the intestinal manifestations of Behçet's disease correspond to those of Crohn's disease and ulcerative colitis without these diseases being actually present. The evolution towards toxic megacolon may be the consequence of a transmural infection across the colonic wall deriving from the mucosal ulcerations of colon and sigmoid, and proves that toxic megacolon is not a pecific complication of ulcerative colitis but may appear in the course of any acute inflammatory ulcerative lesion of the colonic wall.