[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.

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.