What are the symptoms and treatment options for toxic colon?

Symptoms and Treatment of Toxic Colon

Toxic megacolon is a life-threatening condition characterized by total or segmental colonic dilatation (>6 cm) with signs of systemic toxicity that requires immediate medical attention and often surgical intervention. 1

Clinical Presentation and Symptoms

Key Symptoms

• Diarrhea (loose stools with frequency of ≥3 stools in 24 hours) 2
• Abdominal pain and distension
• Signs of systemic toxicity:
  • Fever
  • Tachycardia
  • Hypotension 1
• Vomiting and absence of stool (ileus) 2

Laboratory Findings

• Marked leukocytosis (>15 × 10⁹/L)
• Decreased blood albumin (<30 g/L)
• Elevated serum creatinine (≥133 μM or ≥1.5 times baseline) 2
• Elevated inflammatory markers 1

Diagnostic Criteria

• Non-obstructive colonic dilation ≥5.5-6 cm on abdominal radiographs
• Signs of systemic toxicity
• Laboratory findings consistent with severe inflammation 1

Management Approach

Initial Medical Management

1. Supportive Care:

   • Bowel rest (NPO status)
   • Aggressive IV fluid resuscitation
   • Correction of electrolyte abnormalities
   • Blood product transfusions as needed
   • Nasogastric decompression
   • Avoid colonoscopy or barium enema 1

2. Pharmacological Treatment:

   • Broad-spectrum antibiotics
   • For Clostridium difficile-associated toxic megacolon:
     • Oral vancomycin 125 mg four times daily for 10 days (can consider increasing to 500 mg four times daily) 2
     • When oral treatment is not possible: parenteral metronidazole combined with intracolonic or nasogastric administration of vancomycin 2
     • Consider intravenous tigecycline as salvage therapy in refractory cases 3

Monitoring

• Close monitoring of vital signs
• Serial abdominal examinations
• Daily assessment of treatment response (stool frequency, consistency, clinical parameters) 2
• Regular monitoring of colonic diameter (predictor of perforation risk) 1

Indications for Surgical Intervention

1. Immediate Surgery Required:

   • Free perforation
   • Life-threatening hemorrhage (unstable patients)
   • Generalized peritonitis
   • Clinical deterioration with signs of shock 2

2. Urgent Surgery Indicated:

   • No clinical improvement after 24-48 hours of medical treatment
   • Biological signs of deterioration despite medical therapy 2
   • Progressive colonic dilation 1

Surgical Approach

• Procedure of Choice: Subtotal colectomy with ileostomy 2, 1
• The rectum can be closed as a Hartmann procedure or a mucous fistula created 1
• This approach eliminates the diseased colon while preserving options for future restoration of intestinal continuity 1

Prognosis and Complications

Complications

• Free perforation (carries 27-57% mortality rate) 1
• Massive hemorrhage
• Septic shock
• Multiorgan failure

Common Pitfalls to Avoid

• Delaying surgical consultation (should be requested on day of admission) 1
• Relying too heavily on medical therapy in deteriorating patients
• Failing to recognize early signs of perforation
• Performing unnecessary diagnostic procedures
• Attempting primary anastomosis in unstable patients 1

Special Considerations

• Patients with inflammatory bowel disease, particularly ulcerative colitis, are at higher risk
• Clostridium difficile ribotype 027 is associated with more severe disease and toxic megacolon 3
• Concurrent malignancy, renal failure, obesity, and immune deficiencies are risk factors for severe evolution 3

Early recognition and prompt, aggressive management are crucial for improving outcomes in toxic megacolon. The decision between medical and surgical management should be made through close collaboration between surgeons and gastroenterologists.