Toxic colitis with dilated colon is referred to as toxic megacolon; dilation may be segmental or generalized. Toxic colitis can develop without megacolon.
An acute presentation from inflammatory or infectious colitis with significant morbidity and mortality.
Symptoms and signs of systemic toxicity are always present.
Criteria for the diagnosis include radiographic evidence of acute colitis and three of the following four features: fever >101.5°F (38.6°C), heart rate >120 bpm, white blood cell count >10.5 x 10⁹/L, or anemia. One of the following is also required: volume depletion, mental status changes, electrolyte abnormalities, or hypotension.
Operative treatment is indicated by the presence of complications (perforation, massive rectal bleeding) or lack of clinical improvement after appropriate medical therapy for approximately 72 hours.
Involvement of a multidisciplinary team (gastroenterologist, surgeon, critical care specialist) in treatment planning is warranted.
Toxic colitis with an associated megacolon (colonic distention above 6 cm) is often referred to as toxic megacolon or toxic colitis/toxic megacolon (TC/TM). It is a potentially lethal complication of acute colitis, and is defined as total or segmental nonobstructive colonic distention associated with systemic toxicity. Toxic megacolon differs from other causes of colonic distention (including Hirschsprung disease, congenital megacolon, idiopathic megacolon, acquired megacolon due to chronic constipation, and colonic pseudo-obstruction) by the presence of acute colitis and systemic toxicity.
History and exam
Key diagnostic factors
- history of inflammatory bowel disease
- history of exposure to infectious agents
- history of recent antibiotic use
- history of HIV/AIDS/immunosuppressed state
- mental status changes
- abdominal distention
Other diagnostic factors
- abdominal pain
- abdominal tenderness
- ulcerative colitis (UC)
- Crohn colitis
- pseudomembranous colitis
- infectious colitis
- discontinuation of medications for inflammatory bowel disease
- antimotility agents
- chemotherapy/chemical immunosuppression
- electrolyte abnormalities
1st investigations to order
- serum electrolytes
- serum albumin levels
- serum lactic acid
- stool studies
- CT abdomen/pelvis
- abdominal x-ray
- chest x-ray
Investigations to consider
- erythrocyte sedimentation rate (ESR)
- blood cultures
- rectal biopsy
- surgical specimen
- Colonic pseudo-obstruction
- Acute mesenteric ischemia
- Large bowel obstruction
- WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting
- Update on the treatment guidance document for Clostridium difficile infection
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