Toxic megacolon

Abstract

Toxic megacolon represents a dreaded complication of mainly inflammatory or infectious conditions of the colon. It is most commonly associated with inflammatory bowel disease (IBD), i.e., ulcerative colitis or ileocolonic Crohn's disease. Lately, the epidemiology has shifted toward infectious causes, specifically due to an increase of Clostridium difficile-associated colitis possibly due to the extensive (ab)use of broad-spectrum antibiotics. Other important infectious etiologies include Salmonella, Shigella, Campylobacter, Cytomegalovirus (CMV), rotavirus, Aspergillus, and Entameba. Less frequently, toxic megacolon has been attributed to ischemic colitis, collagenous colitis, or obstructive colorectal cancer. Toxic colonic dilatation may also occur in hemolytic-uremic syndrome (HUS) caused by enterohemorrhagic or enteroaggregative Escherichia coli O157 (EHEC, EAEC, or EAHEC). The pathophysiological mechanisms leading to toxic colonic dilatation are incompletely understood. The main characteristics of toxic megacolon are signs of systemic toxicity and severe colonic distension. Diagnosis is made by clinical evaluation for systemic toxicity and imaging studies depicting colonic dilatation. Plain abdominal imaging is still the most established radiological instrument. However, computed tomography scanning and transabdominal intestinal ultrasound are promising alternatives that add additional information. Management of toxic megacolon is an interdisciplinary task that requires close interaction of gastroenterologists and surgeons from the very beginning. The optimal timing of surgery for toxic megacolon can be challenging. Here we review the latest data on the pathogenesis, clinical presentation, laboratory, and imaging modalities and provide algorithms for an evidence-based diagnostic and therapeutic approach.

The Management of Inflammatory Bowel Disease in Elderly: Current Evidence and Future Perspectives

“…It is therefore difficult to extrapolate the epidemiology of this complication in the elderly population. According to Autenrieth et al [46], the epidemiology of toxic megacolon has shifted towards infection causes, particularly due to an increase of Clostridium difficile-associated colitis and possible use/abuse of antibiotics. A recent survey conducted in the United States concluded that elderly patients with UC are at increased risk for infectious complications and postoperative venous thromboembolism, and that the length of hospital stay was longer in elderly than in subjects aged < 65 years [47].…”

Clostridium difficile Infection: Clinical Challenges and Management Strategies

“…26 Fulminant colitis occurs in 2% to 5% of patients with CDI but is associated with a mortality rate of 35% to 80%. 27 A lack of diarrhea in a patient with worsening abdominal distention and systemic illness is an ominous finding and is indicative of ileus and intestinal failure. Patients may be hypotensive and require support with vasopressors and may have other signs and symptoms of end organ failure, including respiratory failure and acute kidney failure.…”

“…We think that colonic necrosis or perforation is not primarily associated with the disease process and occurs only as a result of the development of abdominal compartment syndrome or nonocclusive mesenteric ischemia in patients with complicated disease. 27 The aforementioned criteria for classifying patients as having "complicated" disease are defined in the recent guidelines of the American College of Gastroenterology. 26 The guidelines are based on a combination of multivariate analyses, findings of multiple case series, and the recommendations of the European Society of Clinical Microbiology and Infectious Diseases.…”

Clostridium Difficile Infection Complicated By Toxic Megacolon In Immunocompetent Patient

“…Toxic megacolon associated with ICD has an incidence of 0.4-3% [11,12] and a mortality rate of 38-80% [12,13].…”