Toxic megacolon overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farima Kahe M.D. [2]
Overview
Toxic megacolon was first discovered by Marshak and Lester in 1950. Jalen criteria was developed by Jalen et al to diagnose toxic megacolon in 1969. Toxic megacolon results from severe inflammation extending into the smooth-muscle layer and paralyses the colonic smooth muscle leading to dilatation. The extent of dilatation associated with the depth of inflammation and ulceration. Nitric oxide, an inhibitor of smooth-muscle tone, has an important role in the pathogenesis of toxic megacolon. Nitric oxide is produced by neutrophils and smooth-muscle cells in the inflamed colon. The most common cause of toxic megacolon include inflammatory bowel disease and Clostridium difficile pseudomembranous colitis. The most common cause of toxic megacolon include inflammatory bowel disease and Clostridium difficile pseudomembranous colitis. The precise incidence of toxic megacolon is unknown in general population. The incidence of toxic megacolon in the associated disorders including ulcerative colitis and Crohn's disease is 1000-2500 in 100,000 cases and 4400-6300 in 100,000 cases, respectively. The mortality rate of toxic megacolon associated with Clostridium difficile is approximately 38%-80%. Common risk factors in the development of toxic negacolon include discontinuation of steroids, use of barium enemas, colonoscopy, chemotherapy, antidiarrheal drugs, anticholinergic drugs, narcotics, Severe chronic obstructive pulmonary disease, organ transplantation, cardiothoracic procedures, diabetes mellitus, immunosuppression, renal failure. If left untreated, toxic megacolon in patients with ulcerative colitis lead to death in 0.2% patients. Common complications of toxic megacolon include perforation, bleeding, shock, sepsis. Prognosis is generally good. The diagnostic criteria for toxic megacolon is Jalan diagnostic criteria. Common symptoms of toxic megacolon include abdominal pain and cramping, diarrhea and fever. Less common symptoms include constipation and disorientation.Patients with toxic megacolon usually appear ill. Physical examination of patients with toxic megacolon is usually remarkable for abdominal pain, rebound tenderness and guarding, hypotension and tachycardia. Laboratory findings consistent with the diagnosis of toxic megacolon include anemia and leukocytosis. Some patients with toxic megacolon may have elevated concentration of Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) , which is usually suggestive of inflammation. An x-ray may be helpful in the diagnosis of toxic megacolon. Findings on an x-ray diagnostic of toxic megacolon include dilated transverse colon (>6cm), thumbprinting, free intraperitoneal air and intraluminal soft-tissue masses. Ultrasound may be helpful in the diagnosis of toxic megacolon. Findings on an ultrasound suggestive of toxic megacolon include loss of haustra coli of the colon, hypoechoic and thickened bowel walls with irregular internal margins in the sigmoid and descending colon and significant dilation of the transverse colon. Abdominal CT scan may be helpful in the diagnosis of toxic megacolon. Findings on CT scan diagnostic of toxic megacolon include dilated transverse colon, loss of colonic haustrations, segmental parietal thinning,Intraluminal soft-tissue masses. Medical therapy of toxic megacolon include stablizing the patient, decompression and medications. Medications for toxic megacolon include corticosteroids, immunosuppresants and antibiotics. The mainstay of treatment for toxic megacolon is medical therapy. Surgery is usually reserved for patients with either failed medical therapy, progressive toxicity or dilation and signs of perforation. There are no established measures for the prevention of toxic megacolon.
Historical Perspective
Toxic megacolon was first discovered by Marshak and Lester in 1950. Jalen criteria was developed by Jalen et al to diagnose toxic megacolon in 1969.
Classification
There is no established system for the classification of toxic megacolon.
Pathophysiology
Toxic megacolon results from severe inflammation extending into the smooth-muscle layer and paralyses the colonic smooth muscle leading to dilatation. The extent of dilatation associated with the depth of inflammation and ulceration. Nitric oxide, an inhibitor of smooth-muscle tone, has an important role in the pathogenesis of toxic megacolon. Nitric oxide is produced by neutrophils and smooth-muscle cells in the inflamed colon.
Causes
The most common cause of toxic megacolon include inflammatory bowel disease and Clostridium difficile pseudomembranous colitis.
Differentiating ((Page name)) from Other Diseases
Epidemiology and Demographics
The precise incidence of toxic megacolon is unknown in general population. The incidence of toxic megacolon in the associated disorders including ulcerative colitis and Crohn's disease is 1000-2500 in 100,000 cases and 4400-6300 in 100,000 cases, respectively. The mortality rate of toxic megacolon associated with Clostridium difficile is approximately 38%-80%.
Risk Factors
Common risk factors in the development of toxic negacolon include discontinuation of steroids, use of barium enemas, colonoscopy, chemotherapy, antidiarrheal drugs, anticholinergic drugs, narcotics, Severe chronic obstructive pulmonary disease, organ transplantation, cardiothoracic procedures, diabetes mellitus, immunosuppression, renal failure.
Screening
There is insufficient evidence to recommend routine screening for toxic megacolon.
Natural History, Complications, and Prognosis
If left untreated, toxic megacolon in patients with ulcerative colitis lead to death in 0.2% patients. Common complications of toxic megacolon include perforation, bleeding, shock, sepsis. Prognosis is generally good.
Diagnosis
Diagnostic Criteria
The diagnostic criteria for toxic megacolon is Jalan diagnostic criteria. It is based on clinical findings, physical exam signs and lab findings.
History and Symptoms
Common symptoms of toxic megacolon include abdominal pain and cramping, diarrhea and fever. Less common symptoms include constipation and disorientation.
Physical Examination
Patients with toxic megacolon usually appear ill. Physical examination of patients with toxic megacolon is usually remarkable for abdominal pain, rebound tenderness and guarding, hypotension and tachycardia.
Laboratory Findings
Laboratory findings consistent with the diagnosis of toxic megacolon include anemia and leukocytosis. Some patients with toxic megacolon may have elevated concentration of Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) , which is usually suggestive of inflammation.
Electrocardiogram
An ECG may be helpful in the diagnosis of toxic megacolon. Findings on an ECG suggestive of toxic megacolon include sinus tachycardia.
X-ray
An x-ray may be helpful in the diagnosis of toxic megacolon. Findings on an x-ray diagnostic of toxic megacolon include dilated transverse colon (>6cm), thumbprinting, free intraperitoneal air and intraluminal soft-tissue masses.
Ultrasound
Ultrasound may be helpful in the diagnosis of toxic megacolon. Findings on an ultrasound suggestive of toxic megacolon include loss of haustra coli of the colon, hypoechoic and thickened bowel walls with irregular internal margins in the sigmoid and descending colon and significant dilation of the transverse colon.
CT scan
Abdominal CT scan may be helpful in the diagnosis of toxic megacolon. Findings on CT scan diagnostic of toxic megacolon include dilated transverse colon, loss of colonic haustrations, segmental parietal thinning,Intraluminal soft-tissue masses.
MRI
There are no MRI findings associated with toxic megacolon.
Other Imaging Findings
There are no other imaging findings associated with toxic megacolon.
Other Diagnostic Studies
There are no other diagnostic studies associated with toxic megacolon.
Treatment
Medical Therapy
Medical therapy of toxic megacolon include stablizing the patient, decompression and medications. Medications for toxic megacolon include corticosteroids, immunosuppresants and antibiotics.
Surgery
The mainstay of treatment for toxic megacolon is medical therapy. Surgery is usually reserved for patients with either failed medical therapy, progressive toxicity or dilation and signs of perforation.
Primary Prevention
There are no established measures for the primary prevention of toxic megacolon.
Secondary Prevention
There are no established measures for the secondary prevention of toxic megacolon.