OBSTRUCTION & ISCHEMIA • SENIOR RESIDENT / SURGEON

Toxic Megacolon

A critically ill patient with acute colitis and colonic dilation tests the boundary between aggressive medical therapy and timely surgery.

PROTOTYPE REVIEW REQUIRED

The Call

49-year-old man with Crohn's disease

Progressive abdominal pain and distention during treatment for acute colitis, with fever, tachycardia, hypotension, leukocytosis, kidney injury and hypokalemia.

T 39.5 C • HR 132 • BP 89/40

Toxic megacolon is a physiologic diagnosis, not merely a measurement of colon diameter.

Read the Image • Clinical DataACS VISUAL

Toxic megacolon imaging from the ACS image archive.

Make the Decision • Commit to a Plan

Toxic Megacolon

49-year-old man with Crohn's disease

A patient with severe colitis has transverse colon dilation, fever, tachycardia and systemic toxicity but no perforation. Best initial approach?

Despite maximal therapy the patient now needs vasopressors and develops rebound tenderness. What is the best next step?

After subtotal colectomy the patient remains septic with increasing abdominal distention. Best next concern?

Operate for source control, not just decompression.

Recovery requires control of both sepsis and the underlying colitis.

Surgical Pearls

Pitfalls

The colon is 6.5 cm, but the patient's vasopressor requirement is rising and abdominal tenderness is worsening. Which variable should dominate your decision-making?