Toxic colitis, with or without megacolon, is an emergent life-threatening complication of inflammatory bowel disease. Its overall incidence in patients with ulcerative colitis is about 10% . Although in the past, toxic colitis was thought to be a rare complication of Crohn's disease compared with ulcerative colitis, recent studies have shown that Crohn's colitis is the etiology in approximately 50% of the cases . The overall incidence of complicated Crohn's disease is about 6%, with an increasing number occurring in Crohn's colitis . The presentation of toxic "fulminant" colitis includes fever, an abrupt onset of bloody diarrhoea, abdominal tenderness, colicky pain, and anorexia . Toxic megacolon is present if, in addition to toxic colitis, either total or segmental dilatation of the colon occurs [31, 32]. Once the diagnosis of toxic colitis is suspected, aggressive medical therapy is initiated. A team approach is required involving both gastroenterologists and surgeons. Prompt surgery is indicated for patients with toxic colitis or megacolon if there is evidence of free perforation, peritonitis, or massive haemorrhage. Surgery may also be indicated to avoid perforation if no clinical improvement occurs with aggressive medical management within 48-72 h. A persistently dilated colon on plain films is also often an indication for operative intervention. The optimal operation involves subtotal colectomy with end ileostomy. This allows removal of the majority of the bowel and avoids an anastomosis in a critically ill patient . Total colectomy was at one time the procedure of choice, but has fallen out of favour due to increased morbidity and mortality. An endoscopic decompression by sigmoido- or colonoscopy can be achieved [33, 34], but it cannot be recommended unless used in a non-surgical candidate. Computed tomography scans should be performed on all patients for whom the diagnosis of toxic megacolon is suspected, as several complications can be identified before clinical or plain film findings. Diffuse colonic wall thickening, submucosal edema and pericolic stranding are all indicative of severe colitis . Timing of surgery regarding toxic megacolon may be crucial, and delay in surgical management can result in perforation and the poor prognosis that accompanies it. The long-term prognosis of medically managed, ulcerative colitis-related toxic megacolon is poor .
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