Makindo Medical Notes.com

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

About

• A potentially lethal endpoint to severe colitis.
• A colorectal surgeon should review those with acute severe ulcerative colitis early in their stay

Aetiology

• 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.

Causes

• Inflammatory bowel disease (UC or CD)
• Pseudo membranous colitis with C difficile infection
• Ischaemic colitis, Radiation colitis

Clinical

• 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

Investigations

• 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.

References