Toxic megacolon: Difference between revisions
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== | ==Background== | ||
[[File:Diameters of the large intestine.png|thumb|Average inner diameters and ranges of different sections of the large intestine.<ref> Nguyen H, Loustaunau C, Facista A, Ramsey L, Hassounah N, Taylor H, et al. (July 2010). "Deficient Pms2, ERCC1, Ku86, CcOI in field defects during progression to colon cancer". Journal of Visualized Experiments (41). doi:10.3791/1931. PMC 3149991. PMID 20689513.</ref>]] | |||
*Colonic Dilation ≥6cm | *Colonic Dilation ≥6cm | ||
*Therapy: Fluids, Electrolyte Repletion, Steroids, Antibiotics, Surgical Consultation | *Therapy: Fluids, Electrolyte Repletion, Steroids, Antibiotics, Surgical Consultation | ||
*AVOID anticholingerics, anti-motility agents, | *AVOID anticholingerics, anti-motility agents, opioids | ||
==Causes== | ===Causes=== | ||
*Most commonly IBD | *Most commonly IBD ([[Ulcerative Colitis]] >>> [[Crohn's disease]]) | ||
*Bacterial ([[Salmonella]], [[Shigella]], [[Campylobacter]], [[C. Diff]], [[Yersinia]], [[E. Coli]]) | |||
*Bacterial | *Viral ([[CMV]], [[Rotavirus]]) | ||
*Fungal/Protozoa ([[Aspergillus]], [[Entamoeba]], [[Cryptosporidium]]) | |||
*Viral | *Drugs (Anti-motility agents, [[anticholinergics]], [[opioids]]) | ||
*Less Common Causes (Ischemic [[Colitis]], Collagenous Colitis, Obstructive Colorectal Cancer, Colonic Lymphoma, [[Kaposi's Sarcoma]], Chemotherapy) | |||
*Fungal/Protozoa | *Pediatric Population ([[Hirschsprung's Disease]], [[Hemolytic Uremic Syndrome]]) | ||
*[[HIV]]/AIDS Population ([[CMV]], [[C. Diff]]) | |||
*Drugs | |||
*Less Common Causes | |||
*Pediatric Population | |||
*HIV/AIDS Population | |||
==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 | ||
== | ==Evaluation== | ||
*Plain | [[File:Toxisches Megacolon bei Colitis ulcerosa.jpg|thumb|Toxic megacolon on [[KUB]]]] | ||
[[File:PMC2365454 ci08001303.png|thumb|CT with toxic megacolon showing submucosal edema and mucosal enhancement of the ascending and descending colon giving the appearance of the “target sign”.]] | |||
[[File:MPX1359 synpic29148.png|thumb|CT showing is diffuse dilation of the colon with air and fluid levels present. There is diffuse wall thickening and enhancement in the rectosigmoid colon. The descending, transverse, and ascending colon are dilated to as much as 8.5cm. These features are consistent with a diagnosis of toxic megacolon.]] | |||
*[[Plain abdominal radiographs]]: | |||
**Colonic Dilation ≥6 cm diameter | **Colonic Dilation ≥6 cm diameter | ||
**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 | **[[Hydrocortisone]] IV 100mg q6h | ||
*Triple Antibiotic Therapy | *Triple Antibiotic Therapy | ||
**Ampicillin 2 g IV q6h PLUS Metronidazole | **[[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 | *[[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 | ||
*Obtain blood cultures, stool cultures, C. Diff Toxin | *Obtain blood cultures, stool cultures, C. Diff Toxin | ||
*If known cause is C. Diff treat with Vancomycin or Metronidazole | *If known cause is C. Diff treat with [[Vancomycin]] or [[Metronidazole]] | ||
*If known cause is CMV can add Ganciclovir | *If known cause is CMV can add Ganciclovir | ||
*Avoid | *Avoid | ||
**Anticholinergics, anti-motility agents, | **Anticholinergics, anti-motility agents, opioids which can worsen dilation | ||
**Sulfasalazine or 5-aminosalicylate (5-ASA) unhelpful | **Sulfasalazine or 5-aminosalicylate (5-ASA) unhelpful | ||
**Nasogastric (NG) Tube NOT effective in reducing colonic distention | **Nasogastric (NG) Tube NOT effective in reducing colonic distention | ||
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==References== | ==References== | ||
<references/> | |||
[[Category:GI]] | [[Category:GI]] | ||
[[category:Surgery]] | |||
Latest revision as of 21:02, 24 September 2025
Background
Average inner diameters and ranges of different sections of the large intestine.[1]
- 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
CT showing is diffuse dilation of the colon with air and fluid levels present. There is diffuse wall thickening and enhancement in the rectosigmoid colon. The descending, transverse, and ascending colon are dilated to as much as 8.5cm. These features are consistent with a diagnosis of toxic megacolon.
- 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
See Also
References
- ↑ Nguyen H, Loustaunau C, Facista A, Ramsey L, Hassounah N, Taylor H, et al. (July 2010). "Deficient Pms2, ERCC1, Ku86, CcOI in field defects during progression to colon cancer". Journal of Visualized Experiments (41). doi:10.3791/1931. PMC 3149991. PMID 20689513.