Toxic megacolon: Difference between revisions
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===Causes=== | ===Causes=== | ||
*Most commonly IBD ([[Ulcerative Colitis]] >>> [[Crohn's disease]]) | *Most commonly IBD ([[Ulcerative Colitis]] >>> [[Crohn's disease]]) | ||
*Bacterial (Salmonella, Shigella, Campylobacter, C. Diff, | *Bacterial ([[Salmonella]], [[Shigella]], [[Campylobacter]], [[C. Diff]], [[Yersinia]], [[E. Coli]]) | ||
*Viral (CMV, [[Rotavirus]]) | *Viral ([[CMV]], [[Rotavirus]]) | ||
*Fungal/Protozoa (Aspergillus, Entamoeba, Cryptosporidium) | *Fungal/Protozoa ([[Aspergillus]], [[Entamoeba]], [[Cryptosporidium]]) | ||
*Drugs (Anti-motility agents, anticholinergics, opioids) | *Drugs (Anti-motility agents, [[anticholinergics]], [[opioids]]) | ||
*Less Common Causes (Ischemic Colitis, Collagenous Colitis, Obstructive Colorectal Cancer, Colonic Lymphoma, [[Kaposi's Sarcoma]], Chemotherapy) | *Less Common Causes (Ischemic [[Colitis]], Collagenous Colitis, Obstructive Colorectal Cancer, Colonic Lymphoma, [[Kaposi's Sarcoma]], Chemotherapy) | ||
*Pediatric Population ([[Hirschsprung's Disease]], [[Hemolytic Uremic Syndrome]]) | *Pediatric Population ([[Hirschsprung's Disease]], [[Hemolytic Uremic Syndrome]]) | ||
*HIV/AIDS Population (CMV, C. Diff)) | *[[HIV[[/AIDS Population (CMV, C. Diff)) | ||
==Clinical Features== | ==Clinical Features== | ||
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*[[Tachycardia]] | *[[Tachycardia]] | ||
*[[Diarrhea]], ± Bloody | *[[Diarrhea]], ± Bloody | ||
*Hypotension | *[[Hypotension]] | ||
*Altered Mental Status (AMS) | *[[Altered Mental Status]] (AMS) | ||
*[[Bowel perforation]] | *[[Bowel perforation]] | ||
**[[Peritonitis]] | **[[Peritonitis]] | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
*[[Small bowel obstruction]] | *[[Small bowel obstruction]] | ||
*[[Large | *[[Large bowel obstruction]] | ||
**Volvulus, Neoplastic Disease, Paralytic ileus, Pseudo-obstruction | **[[Volvulus]], Neoplastic Disease, Paralytic [[ileus]], [[ogilvie's syndrome|Pseudo-obstruction]] | ||
*Colitis | *[[Colitis]] | ||
**Infectious, Inflammatory, Ischemic | **Infectious, Inflammatory, Ischemic | ||
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**Loss of haustra, "thumb-printing" (bowel edema) | **Loss of haustra, "thumb-printing" (bowel edema) | ||
**Air-fluid levels | **Air-fluid levels | ||
*[[Ultrasound: Abdomen|Abdominal Ultrasound]]: | |||
*Abdominal Ultrasound: | |||
**Thin colonic walls with loss of haustra coli | **Thin colonic walls with loss of haustra coli | ||
**Diameter ≥6cm with gaseous content | **Diameter ≥6cm with gaseous content | ||
*Labs: | *Labs: | ||
**Leukocytosis | **[[Leukocytosis]] | ||
**Electrolyte | **[[Electrolyte derangements]]: [[Hypokalemia]], [[Hypomagnesemia]] | ||
**Elevated ESR/CRP | **Elevated ESR/CRP | ||
**Anemia | **[[Anemia]] | ||
**Hypoalbuminemia | **[[Hypoalbuminemia]] | ||
==Management== | ==Management== | ||
*Fluid | *[[Fluid resuscitation]] | ||
*IV [[corticosteroids]] | *IV [[corticosteroids]] | ||
**Hydrocortisone IV 100mg q6h | **[[Hydrocortisone]] IV 100mg q6h | ||
*Triple Antibiotic Therapy | *Triple Antibiotic Therapy | ||
**[[Ampicillin]] 2 g IV q6h '''PLUS''' [[Metronidazole]] 500mg IV q6h '''PLUS''' [[Gentamicin]] 7mg/kg q24h or [[Ciprofloxacin]] 400mg IV q12h '''OR''' | **[[Ampicillin]] 2 g IV q6h '''PLUS''' [[Metronidazole]] 500mg IV q6h '''PLUS''' [[Gentamicin]] 7mg/kg q24h or [[Ciprofloxacin]] 400mg IV q12h '''OR''' | ||
**[[Imipenem]] 500mg IV q6h | **[[Imipenem]] 500mg IV q6h | ||
*Electrolyte | *[[Electrolyte repletion]] | ||
**Aggressively treat hypokalemia and hypomagnesemia because these can exacerbate dilation | **Aggressively treat hypokalemia and hypomagnesemia because these can exacerbate dilation | ||
*Emergent Surgical Consultation | *Emergent Surgical Consultation | ||
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[[Category:GI]] | [[Category:GI]] | ||
[[category:Surgery]] | |||
Revision as of 04:22, 30 September 2019
Background
- Colonic Dilation ≥6cm
- Therapy: Fluids, Electrolyte Repletion, Steroids, Antibiotics, Surgical Consultation
- AVOID anticholingerics, anti-motility agents, opioids
Causes
- Most commonly IBD (Ulcerative Colitis >>> Crohn's disease)
- Bacterial (Salmonella, Shigella, Campylobacter, C. Diff, Yersinia, E. Coli)
- Viral (CMV, Rotavirus)
- Fungal/Protozoa (Aspergillus, Entamoeba, Cryptosporidium)
- Drugs (Anti-motility agents, anticholinergics, opioids)
- Less Common Causes (Ischemic Colitis, Collagenous Colitis, Obstructive Colorectal Cancer, Colonic Lymphoma, Kaposi's Sarcoma, Chemotherapy)
- Pediatric Population (Hirschsprung's Disease, Hemolytic Uremic Syndrome)
- [[HIV[[/AIDS Population (CMV, C. Diff))
Clinical Features
- Abdominal Pain ± Distention
- Fever
- Tachycardia
- Diarrhea, ± Bloody
- Hypotension
- Altered Mental Status (AMS)
- Bowel perforation
Differential Diagnosis
- Small bowel obstruction
- Large bowel obstruction
- Volvulus, Neoplastic Disease, Paralytic ileus, Pseudo-obstruction
- Colitis
- Infectious, Inflammatory, Ischemic
Evaluation
Toxic megacolon on KUB
- Plain abdominal radiographs:
- Colonic Dilation ≥6 cm diameter
- Loss of haustra, "thumb-printing" (bowel edema)
- Air-fluid levels
- Abdominal Ultrasound:
- Thin colonic walls with loss of haustra coli
- Diameter ≥6cm with gaseous content
- Labs:
- Leukocytosis
- Electrolyte derangements: Hypokalemia, Hypomagnesemia
- Elevated ESR/CRP
- Anemia
- Hypoalbuminemia
Management
- Fluid resuscitation
- IV corticosteroids
- Hydrocortisone IV 100mg q6h
- Triple Antibiotic Therapy
- Ampicillin 2 g IV q6h PLUS Metronidazole 500mg IV q6h PLUS Gentamicin 7mg/kg q24h or Ciprofloxacin 400mg IV q12h OR
- Imipenem 500mg IV q6h
- Electrolyte repletion
- Aggressively treat hypokalemia and hypomagnesemia because these can exacerbate dilation
- Emergent Surgical Consultation
- Obtain blood cultures, stool cultures, C. Diff Toxin
- If known cause is C. Diff treat with Vancomycin or Metronidazole
- If known cause is CMV can add Ganciclovir
- Avoid
- Anticholinergics, anti-motility agents, opioids which can worsen dilation
- Sulfasalazine or 5-aminosalicylate (5-ASA) unhelpful
- Nasogastric (NG) Tube NOT effective in reducing colonic distention
Disposition
- Admit