Toxic Megacolon

Toxic megacolon is an infrequent but potentially fatal complication of ulcerative colitis. The lifetime incidence of toxic megacolon in individuals with ulcerative colitis is 1-2.5% [20], while there is a reported incidence of 7.9% in patients admitted to hospital due to ulcerative colitis [21]. In the majority of patients, toxic megacolon occurs during a relapse of the disease, but there is substantial amount of those who present with toxic megacolon during the first attack. Diagnosis of toxic megacolon is usually established by clinical exam and plain X-rays of the abdomen. Segmental or total colonic distension of

>6 cm in the presence of acute colitis and signs of systemic toxicity are pathognomonic for toxic megacolon. Dilatation of the colon is not by itself an indication for immediate operation. The dilatation may increase, fluctuate or even disappear, leaving the patient still extremely ill requiring urgent surgical treatment. Clinical criteria include any three of the following: fever >38.6 °C, pulse rate >120 beats/min, white blood cell count >10.5 (x109/l) or anaemia with dehydration, mental changes, electrolyte disturbances or hypotension. In some cases, progression to toxic megacolon is clinically manifested in a decreasing number of stools per day. It is very important to notice that a decreasing number of stools do not always mean that the patient is improving and one should always be suspicious about the possibility of progression to toxic megacolon. The management of toxic megacolon is complex and includes both a medical and surgical approach. Medical and surgical treatment should be regarded as complementary, and not as a competitive treatment modality.

In the onset of toxic megacolon, initial treatment should be medical with complete bowel rest, supportive measures, decompressive procedures and intravenous steroids. Some authorities advocate "early surgery" shortly after diagnosis in order to save the patient's life ("save the patient, not the colon"), claiming that mortality rates are reduced from 20-7% with this approach [22]. A recent study favouring surgical treatment shortly after the diagnosis of toxic megacolon without using medical therapy as the first-line treatment, showed no mortality and no major complications in patients less than 65 years old [23].

Although there is some controversy about the use of corticosteroids in patients with toxic megacolon, it is now generally agreed that they should be initiated shortly after the diagnosis is established. Aggressive medical therapy with antibiotics and corticosteroids continued up to 7 days showed to be safe and reduced the need for emergency surgery with more than 50% salvage of colons [24, 25].

Medical treatment can be continued for at least 7 days as long as there are signs of clinical improvement. In case of worsening or signs of complication during medical therapy, surgery should be performed without hesitation. Whereas there is confirmed benefit with cyclosporine in patients with fulminant colitis, little experience is available with its use in toxic megacolon and it is generally not recommended. There have been reports of the utilisation of hyperbaric oxygen [26] in the treatment of toxic megacolon and sporadic attempts of treatment with tacrolimus [27] and leukocytapheresis [28] with claims of improvement in the clinical condition; however, due to limited experience with their use, these modalities are not widely accepted and cannot be recommended for standard practice. The long-term prognosis of medically managed toxic mega-colon is relatively poor since 47-57% of medically successfully treated patients require colectomy during the follow-up period with 83% of them undergoing surgery on an urgent basis. Medical therapy should be considered as a preparation for surgery and more or less as "a bridge" transforming emergency into elective surgery, thus considerably reducing mortality rates. The procedure of choice is total colectomy and ileostomy. The rectal stump is either closed or the sigmoid remnant is exteriorised as a mucous fistula.

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