Toxic megacolon: Difference between revisions
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==Background==
==Clinical Pearls==
*Inflammation of intestinal smooth muscle causes colon dilation<ref>Tintinalli. Emergency Medicine. 7th Edition, 2011.</ref>
*Colonic Dilation ≥6cm
*Untreated, can lead to perforation
*Therapy: Fluids, Electrolyte Repletion, Steroids, Antibiotics, Surgical Consultation
*Usually associated with infectious colitis or [[Crohn's disease]] or [[Ulcerative Colitis]]
*AVOID anticholingerics, anti-motility agents, opiates


===Triggers===
==Causes==
*Anti-motility agents
*Most commonly IBD
*Anticholinergics
**[[Ulcerative Colitis]] >>> [[Crohn's disease]]
*Narcotics
*Bacterial
*Pregnancy
**Salmonella, Shigella, Campylobacter, C. Diff, Yersnia, E. Coli
*Enemas
*Viral
*Recent colonoscopy
**CMV, Rotavirus
*Fungal/Protozoa
**Aspergillus, Entamoeba, Cryptosporidium
*Drugs
**Anti-motility agents, Anticholinergics, Narcotics
*Less Common Causes
**Ischemic Colitis, Collagenous Colitis, Obstructive Colorectal Cancer, Colonic Lymphoma, [[Kaposi's Sarcoma]], Chemotherapy
*Pediatric Population
**[[Hirschsprung's Disease]], [[Hemolytic Uremic Syndrome]] (HUS)
*HIV/AIDS Population
**CMV, C. Diff


==Clinical Features==
==Clinical Features==
*[[Abdominal Pain]]
*[[Abdominal Pain]] ± Distention
*[[Fever]]
*[[Fever]]
*[[Tachycardia]]
*[[Tachycardia]]
*[[Diarrhea]]
*[[Diarrhea]], ± Bloody
*Distended abdomen
*Hypotension
*[[Hypokalemia]]
*Altered Mental Status (AMS)
*[[Hypomagnesemia]]
*[[Bowel perforation]]
*[[Bowel perforation]]
**[[Peritonitis]]
**[[Peritonitis]]
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==Differential Diagnosis==
==Differential Diagnosis==
*[[Small bowel obstruction]]
*[[Small bowel obstruction]]
*Large Bowel Obstruction
*[[Large Bowel Obstruction]]
*Constipation
**Volvulus, Neoplastic Disease, Paralytic ileus, Pseudo-obstruction
*Colitis
**Infectious, Inflammatory, Ischemic


{{Colitis DDX}}
==Diagnosis==
*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


==Diagnosis==
*X-ray showing colon > 6 cm diameter
**Can also see loss of haustra, "thumb-printing" (bowel edema)
*Labs:
*Labs:
**leukocytosis
**Leukocytosis
**electrolyte disturbances
**Electrolyte disturbances: Hypokalemia, Hypomagnesemia
**anemia
**Elevated ESR/CRP
**hypoalbuminemia
**Anemia
**Hypoalbuminemia


==Management==
==Management==
*Fluid hydration
*Fluid Resuscitation
*IV [[corticosteroids]]
*IV [[corticosteroids]]
*Antibiotics to cover bowel flora<ref>Rosen's Emergency Medicine. Philadelphia, PA. 2014.</ref>
**Hydrocortisone IV 100 mg q6h
**Mild to moderate disease
*Triple Antibiotic Therapy
***[[Ciprofloxacin]] 400 mg IV q12h AND [[metronidazole]] 1 g IV q12h
**Ampicillin 2 g IV q6h PLUS Metronidazole 500 mg IV q6h PLUS Gentamicin 7mg/kg q24h or Ciprofloxacin 400 mg IV q12h
***[[Ticarcillin-clavulanate]] 3.1 g IV q6h
**OR [[Imipenem]] 500 mg IV q6h
**Severe disease
*Electrolyte Repletion
***[[Ampicillin]] 2 g IV q6h AND [[metronidazole]] 500 mg IV q6h AND [[gentamicin]] 7mg/kg q24h  
**Aggressively treat hypokalemia and hypomagnesemia because these can exacerbate dilation
***[[Imipenem]] 500 mg IV q6h
*Emergent Surgical Consultation
*Early surgical consultation if no improvement in 24-48 hours
 
*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, opiates which can worsen dilation
**Sulfasalazine or 5-aminosalicylate (5-ASA) unhelpful
**Nasogastric (NG) Tube NOT effective in reducing colonic distention


==Disposition==
==Disposition==
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*[[Crohn's disease]]
*[[Crohn's disease]]
*[[Ulcerative Colitis]]
*[[Ulcerative Colitis]]
==External Links==


==References==
==References==
<references/>
<references/>
*Autenrieth, Daniel M., and Daniel C. Baumgart. "Toxic Megacolon." Inflammatory Bowel Diseases 18.3 (2012): 584-91.
*Rosen, Peter, and John A. Marx. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia: Elsevier Saunders, 2014.


[[Category:GI]]
[[Category:GI]]

Revision as of 12:29, 23 October 2015

Clinical Pearls

  • Colonic Dilation ≥6cm
  • Therapy: Fluids, Electrolyte Repletion, Steroids, Antibiotics, Surgical Consultation
  • AVOID anticholingerics, anti-motility agents, opiates

Causes

  • Most commonly IBD
  • Bacterial
    • Salmonella, Shigella, Campylobacter, C. Diff, Yersnia, E. Coli
  • Viral
    • CMV, Rotavirus
  • Fungal/Protozoa
    • Aspergillus, Entamoeba, Cryptosporidium
  • Drugs
    • Anti-motility agents, Anticholinergics, Narcotics
  • Less Common Causes
    • Ischemic Colitis, Collagenous Colitis, Obstructive Colorectal Cancer, Colonic Lymphoma, Kaposi's Sarcoma, Chemotherapy
  • Pediatric Population
  • HIV/AIDS Population
    • CMV, C. Diff

Clinical Features

Differential Diagnosis

Diagnosis

  • 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 disturbances: Hypokalemia, Hypomagnesemia
    • Elevated ESR/CRP
    • Anemia
    • Hypoalbuminemia

Management

  • Fluid Resuscitation
  • IV corticosteroids
    • Hydrocortisone IV 100 mg q6h
  • Triple Antibiotic Therapy
    • Ampicillin 2 g IV q6h PLUS Metronidazole 500 mg IV q6h PLUS Gentamicin 7mg/kg q24h or Ciprofloxacin 400 mg IV q12h
    • OR Imipenem 500 mg 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, opiates 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

  • Autenrieth, Daniel M., and Daniel C. Baumgart. "Toxic Megacolon." Inflammatory Bowel Diseases 18.3 (2012): 584-91.
  • Rosen, Peter, and John A. Marx. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia: Elsevier Saunders, 2014.
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