Physical findings may be reduced or less striking as those with Inflammatory bowel disease will have been given high dose steroids. The transverse colon is more than 6 cm
- A potentially lethal endpoint to severe colitis.
- A colorectal surgeon should review those with acute severe ulcerative colitis early in their stay
- Acute form of colonic distension with a dilated colon (megacolon)
- Severe inflammation deep into the smooth muscle layer
- Resultant ileus and further dilatation correlate with the depth of inflammation.
- Mucosal ulceration which may be deep.
- Inflammatory bowel disease (UC or CD)
- Pseudo membranous colitis with C difficile infection
- Ischaemic colitis, Radiation colitis
- Look unwell, pale, sweating. Dehydration. Fever.
- Abdominal distension (bloating), and sometimes fever
- Abdominal pain, or shock.
- Perforation: Hard abdomen, Rebound Rigidity, Peritoneal irritation
Differentials of colonic dilation
- Hirschsprung disease they are usually systemically well
- Idiopathic megacolon/chronic constipation they are usually systemically well
- Intestinal pseudo-obstruction (Ogilvie syndrome) they are usually systemically well
- Causes of the acute abdomen including large bowel obstruction
- FBC, U&E, CRP, GP and save
- AXR: Toxic megacolon if diameter >6-7 cm in the mid transverse colon with loss of haustral pattern. Mucosal oedema. No faeces.
- CT Abdomen shows colonic dilatation
- Endoscopy avoided usually due to risk of perforation
Management: Joint management with Surgeons/Gastroenterology
- ABC, Resuscitate, IV fluids, Nil by Mouth, NG tube aspiration, Analgesia. ITU bed may be needed.
- Transfuse > 10 g/dl. Nutritional support, IV Antibiotics, VTE prophylaxis. Twice daily abdominal circumference.
- Stop opiates, loperamide, anticholinergic, NSAIDs and any antidiarrhoeals
- Inflammatory Bowel disease: Urgent Gastroenterology review as may be a role for Ciclosporin or Infliximab in those with Inflammatory bowel disease. Continue IV Methylprednisolone. Consider IV Ciclosporin or Infliximab if no response to high dose steroids after 3-5 days reduces the need for surgery. Laparotomy and urgent colectomy if fails to settle.
- Clostridioides difficile infection if present with oral antibiotics which may be continued. Alternatives include IVIG infusion and colonoscopic decompression and intracolonic Vancomycin administration.
- For all: Urgent surgical review. Options may be for total or a subtotal colectomy.