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Toxic colitis and toxic megacolon

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Last reviewed:
November 2018

Last updated:

April 

2018

Summary

Toxic colitis with dilated colon is referred to as toxic megacolon; dilatation 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 3 of the following 4 features: fever >101.5°F (38.6°C), heart rate >120 bpm, WBC count >10,500/microliter, 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 often warranted.

Definition

Toxic colitis (TC) with an associated megacolon (colonic distention above 6 cm) is often referred to as "toxic megacolon" (TM). It is a potentially lethal complication of acute colitis, and is defined as total or segmental nonobstructive colonic distention associated with systemic toxicity.


[1]

TM 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

  • hx of inflammatory bowel disease
  • hx of exposure to infectious agents
  • hx of recent antibiotic use
  • hx of HIV/AIDS/immunosuppressed state
  • fevers/chills
  • tachycardia
  • mental status changes
  • hypotension
  • abdominal distention
Full details

Other diagnostic factors

  • diarrhea
  • abdominal pain
  • abdominal tenderness
Full details

Risk factors

  • ulcerative colitis (UC)
  • Crohn colitis
  • pseudomembranous colitis
  • infectious colitis
  • HIV/AIDS/immunosuppression
  • discontinuation of medications for inflammatory bowel disease
  • antimotility agents
  • chemotherapy/chemical immunosuppression
  • electrolyte abnormalities
Full details

Diagnostic investigations

1st investigations to order

  • CBC
  • serum electrolytes
  • serum albumin levels
  • serum lactic acid
  • stool studies
  • CT abdomen/pelvis
  • abdominal x-ray
  • chest x-ray


Full details

Investigations to consider

  • C-reactive protein (CRP)
  • ESR
  • blood cultures
  • sigmoidoscopy
  • rectal biopsy
  • surgical specimen


Full details

Treatment algorithm

ACUTE

all patients

Contributors

Authors

VIEW ALL

Jan Rakinic, MD

Chief

Colorectal Surgery

Department of Surgery

Southern Illinois University School of Medicine

Springfield

IL

Disclosures

JR is an author of a reference cited in this monograph.

V. Prasad Poola, MD

Assistant Professor of Surgery

Department of Surgery

Southern Illinois University School of Medicine

Springfield

IL

Disclosures

VPP declares that he has no competing interests.

Acknowledgements

Dr Jan Rakinic and Dr V. Prasad Poola would like to gratefully acknowledge Dr Scott A. Strong, Dr Mukta V. Krane, and Dr Alessandro Fichera, previous contributors to this monograph. SAS, MVK, and AF declare that they have no competing interests.

Peer reviewers

VIEW ALL

Sharon Stein, MD

Assistant Professor of Surgery

Division of Colon and Rectal Surgery

University Hospital Case Medical Center

Cleveland

OH

Disclosures

SS received a fee for educational courses on laparoscopic surgery, paid for in part by Covidien, Olympus, and Applied Medical.

David J. Hackam, MD, PhD

Associate Professor of Pediatric Surgery

University of Pittsburgh School of Medicine

Pittsburgh

PA

Disclosures

DJH declares that he has no competing interests.

James Wheeler, MB, BCh, MD, FRCS

Consultant

Colorectal Surgeon

Addenbrookes Hospital

Cambridge

UK

Disclosures

JW declares that he has no competing interests.

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Drugs & Diseases
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Gastroenterology

Chronic Megacolon Clinical Presentation

Updated: Mar 28, 2016
  • Author: David Manuel, MD; Chief Editor: BS Anand, MD  more…
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Sections
Chronic Megacolon
  • Sections
    Chronic Megacolon
  • Overview
    • Background
    • Pathophysiology
    • Etiology
    • Epidemiology
    • Prognosis
    • Patient Education
    • Show All
  • Presentation
  • DDx
  • Workup
    • Laboratory Studies
    • Imaging Studies
    • Other Tests
    • Histologic Findings
    • Show All
  • Treatment
    • Medical Care
    • Surgical Care
    • Diet
    • Show All
  • Medication
    • Medication Summary
    • Laxatives
    • Show All
  • References

Presentation

History and Physical Examination

Historically, chronic megacolon has been categorized into 2 groups, according to when symptoms begin. The congenital group experiences onset of constipation before age 1 year. The acquired group develops symptoms after age 10 years until adulthood.

Physical examination generally reveals a distended abdomen, which may or may not be tense. Tympany is invariably present.

Digital rectal examination may demonstrate a hard mass of stool just above the anorectal ring. Digital rectal examination in a patient with Hirschsprung disease may bring about a large gush of retained fecal material.

Megarectum with a rectum distended with stool, if chronic, tends to cause the anus to gape open secondary to the dysfunction of the internal sphincter mechanism. These patients may present with factitious diarrhea secondary to overflow incontinence.

Differential Diagnoses
 

 
References

  1. Camilleri M. Acute and chronic pseudo-obstruction. Felman M, Friedman LS, Sleisenger MH, eds. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 8th ed. Philadelphia, Pa: Saunders; 2007. 2679-702.

  2. Camilleri M. Dysmotility of the small intestine and colon. Yamada T, ed. Textbook of Gastroenterology. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003. Vol 1: 1486-529.

  3. Wallukat G, Munoz Saravia SG, Haberland A, et al. Distinct patterns of autoantibodies against G-protein-coupled receptors in Chagas’ cardiomyopathy and megacolon. Their potential impact for early risk assessment in asymptomatic Chagas’ patients. J Am Coll Cardiol. 2010 Feb 2. 55(5):463-8. [Medline] .

  4. Sanchez-Mejias A, Fernandez RM, Lopez-Alonso M, Antinolo G, Borrego S. New roles of EDNRB and EDN3 in the pathogenesis of Hirschsprung disease. Genet Med. 2010 Jan. 12(1):39-43. [Medline] .

  5. da Silveira AB, de Araujo FF, Freitas MA, et al. Characterization of the presence and distribution of Foxp3(+) cells in chagasic patients with and without megacolon. Hum Immunol. 2009 Jan. 70(1):65-7. [Medline] .

  6. da Silveira AB, Freitas MA, de Oliveira EC, et al. Glial fibrillary acidic protein and S-100 colocalization in the enteroglial cells in dilated and nondilated portions of colon from chagasic patients. Hum Pathol. 2009 Feb. 40(2):244-51. [Medline] .

  7. Ribeiro BM, Crema E, Rodrigues V Jr. Analysis of the cellular immune response in patients with the digestive and indeterminate forms of Chagas’ disease. Hum Immunol. 2008 Aug. 69(8):484-9. [Medline] .

  8. Martucciello G. Hirschsprung’s disease, one of the most difficult diagnoses in pediatric surgery: a review of the problems from clinical practice to the bench. Eur J Pediatr Surg. 2008 Jun. 18(3):140-9. [Medline] .

  9. Orno AK, Lovkvist H, Marsal K, von Steyern KV, Arnbjornsson E. Sonographic visualization of the rectoanal inhibitory reflex in children suspected of having Hirschsprung disease: a pilot study. J Ultrasound Med. 2008 Aug. 27(8):1165-9. [Medline] .

  10. Ohkubo H, Masaki T, Matsuhashi N, et al. Histopathologic findings in patients with idiopathic megacolon: a comparison between dilated and non-dilated loops. Neurogastroenterol Motil. 2014 Apr. 26(4):571-80. [Medline] .

  11. Barnes PR, Lennard-Jones JE, Hawley PR, Todd IP. Hirschsprung’s disease and idiopathic megacolon in adults and adolescents. Gut. 1986 May. 27(5):534-41. [Medline] .

  12. de Oliveira GM, de Melo Medeiros M, et al. Applicability of the use of charcoal for the evaluation of intestinal motility in a murine model of Trypanosoma cruzi infection. Parasitol Res. 2008 Mar. 102(4):747-50. [Medline] .

  13. Harari D, Minaker KL. Megacolon in patients with chronic spinal cord injury. Spinal Cord. 2000 Jun. 38(6):331-9. [Medline] .

  14. Krishnamurthy S, Heng Y, Schuffler MD. Chronic intestinal pseudo-obstruction in infants and children caused by diverse abnormalities of the myenteric plexus. Gastroenterology. 1993 May. 104(5):1398-408. [Medline] .

  15. Lane RH, Todd IP. Idiopathic megacolon: a review of 42 cases. Br J Surg. 1977 May. 64(5):307-10. [Medline] .

  16. Manoel-Caetano Fda S, Carareto CM, Borim AA, Miyazaki K, Silva AE. kDNA gene signatures of Trypanosoma cruzi in blood and oesophageal mucosa from chronic chagasic patients. Trans R Soc Trop Med Hyg. 2008 Nov. 102(11):1102-7. [Medline] .

  17. Metcalf AM, Phillips SF, Zinsmeister AR, et al. Simplified assessment of segmental colonic transit. Gastroenterology. 1987 Jan. 92(1):40-7. [Medline] .

  18. Miyamoto M, Egami K, Maeda S, et al. Hirschsprung’s disease in adults: report of a case and review of the literature. J Nippon Med Sch. 2005 Apr. 72(2):113-20. [Medline] .

  19. Nicholls RJ, Kamm MA. Proctocolectomy with restorative ileoanal reservoir for severe idiopathic constipation. Report of two cases. Dis Colon Rectum. 1988 Dec. 31(12):968-9. [Medline] .

  20. Porter NH. Megacolon: A physiological study. Proc R Soc Med. 1961. 54:1043.

  21. Preston DM, Lennard-Jones JE, Thomas BM. Towards a radiologic definition of idiopathic megacolon. Gastrointest Radiol. 1985. 10(2):167-9. [Medline] .

  22. Stabile G, Kamm MA, Hawley PR, Lennard-Jones JE. Colectomy for idiopathic megarectum and megacolon. Gut. 1991 Dec. 32(12):1538-40. [Medline] .

  23. Stryker SJ, Pemberton JH, Zinsmeister AR. Long-term results of ileostomy in older patients. Dis Colon Rectum. 1985 Nov. 28(11):844-6. [Medline] .

  24. Yadav AK, Mishra K, Mohta A, Agarwal S. Hirschsprung’s disease: is there a relationship between mast cells and nerve fibers?. World J Gastroenterol. 2009 Mar 28. 15(12):1493-8. [Medline] . [Full Text] .

  25. O’Dwyer RH, Acosta A, Camilleri M, Burton D, Busciglio I, Bharucha AE. Clinical features and colonic motor disturbances in chronic megacolon in adults. Dig Dis Sci. 2015 Aug. 60 (8):2398-407. [Medline] .

  26. Singer CE, Cosoveanu CS, Ciobanu MO, et al. Hirschprung’s disease in different settings – a series of three cases from a tertiary referral center. Rom J Morphol Embryol. 2015. 56 (3):1195-200. [Medline] .

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      Contributor Information and Disclosures

      Author

      David Manuel, MD Affiliate Faculty, Department of Medicine, Loyola University Health System; Gastroenterologist, Digestive Health Center

      David Manuel, MD is a member of the following medical societies: American College of Gastroenterology , American College of Physicians , American Gastroenterological Association , American Medical Association , American Society for Gastrointestinal Endoscopy , Crohn’s and Colitis Foundation of America

      Disclosure: Nothing to disclose.

      Coauthor(s)

      Michael H Piper, MD Clinical Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Wayne State University School of Medicine; Consulting Staff, Digestive Health Associates, PLC

      Michael H Piper, MD is a member of the following medical societies: Alpha Omega Alpha , American College of Gastroenterology , American College of Physicians , Michigan State Medical Society

      Disclosure: Nothing to disclose.

      Roberto M Gamarra, MD Consulting Gastroenterologist, Digestive Health Associates, PLC

      Roberto M Gamarra, MD is a member of the following medical societies: American College of Gastroenterology , American College of Physicians , American Gastroenterological Association , American Medical Association , American Society for Gastrointestinal Endoscopy , Crohn’s and Colitis Foundation of America

      Disclosure: Nothing to disclose.

      Clifford Y Ko, MD, MS Professor, Department of Surgery, University of California, Los Angeles, David Geffen School of Medicine

      Clifford Y Ko, MD, MS is a member of the following medical societies: American College of Surgeons , American Medical Association , American Society of Colon and Rectal Surgeons , Association for Academic Surgery , California Medical Association , New York Academy of Sciences

      Disclosure: Nothing to disclose.

      Specialty Editor Board

      Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

      Disclosure: Received salary from Medscape for employment. for: Medscape.

      Douglas M Heuman, MD, FACP, FACG, AGAF Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine

      Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases , American College of Physicians , American Gastroenterological Association

      Disclosure: Received grant/research funds from Novartis for other; Received grant/research funds from Bayer for other; Received grant/research funds from Otsuka for none; Received grant/research funds from Bristol Myers Squibb for other; Received none from Scynexis for none; Received grant/research funds from Salix for other; Received grant/research funds from MannKind for other.

      Chief Editor

      BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

      BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases , American College of Gastroenterology , American Gastroenterological Association , American Society for Gastrointestinal Endoscopy

      Disclosure: Nothing to disclose.

      Additional Contributors

      Terence David Lewis, MBBS, MBBS 

      Terence David Lewis, MBBS, MBBS is a member of the following medical societies: American College of Gastroenterology , American College of Physicians , American Gastroenterological Association , American Medical Association , California Medical Association , Royal College of Physicians and Surgeons of Canada , Sigma Xi

      Disclosure: Nothing to disclose.

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      • Sections
        Chronic Megacolon
      • Overview
        • Background
        • Pathophysiology
        • Etiology
        • Epidemiology
        • Prognosis
        • Patient Education
        • Show All
      • Presentation
      • DDx
      • Workup
        • Laboratory Studies
        • Imaging Studies
        • Other Tests
        • Histologic Findings
        • Show All
      • Treatment
        • Medical Care
        • Surgical Care
        • Diet
        • Show All
      • Medication
        • Medication Summary
        • Laxatives
        • Show All
      • References

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