What is the most appropriate management for a patient with ulcerative colitis presenting with severe abdominal pain, frequent bloody diarrhea, vomiting, dehydration, and a distended abdomen, along with an elevated white blood cell count and a dilated transverse colon on X-ray?

Toxic Megacolon in Ulcerative Colitis: Immediate Surgical Management Required

This patient requires immediate total colectomy with end ileostomy (Option D) - surgery is mandatory and should not be delayed. 1

Clinical Presentation Indicates Toxic Megacolon

This patient presents with the hallmark features of toxic megacolon complicating ulcerative colitis:

• Dilated transverse colon (15 cm) on plain X-ray with loss of haustrations 1
• Systemic toxicity: Elevated WBC (21.3 × 10^9/L), dehydration, vomiting 1
• Severe abdominal symptoms: Distended abdomen, tenderness, sluggish bowel sounds 1
• Ongoing bloody diarrhea despite medical treatment 1

Why Medical Management (Options A & B) is Contraindicated

Medical therapy with steroids or infliximab is absolutely inappropriate in this clinical scenario. 1

• Patients with toxic megacolon showing clinical deterioration and signs of systemic toxicity require mandatory surgery - delaying for medical therapy increases mortality 1
• The 48-72 hour window for medical therapy trial has already passed (4-day history), and the patient is deteriorating with evidence of toxic megacolon 1
• Prolonged immunosuppressive therapy in this setting is associated with increased morbidity and mortality following subsequent surgery 1

Why Proctocolectomy with Ileal Pouch (Option C) is Wrong

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is contraindicated in the emergency setting. 1

• A staged procedure with subtotal colectomy first is recommended in acute severe colitis, particularly in patients on prolonged steroids or anti-TNF therapy 1
• IPAA is reserved for elective surgery after the patient has recovered from acute illness, normalized nutrition, and had time to consider options 1
• Emergency IPAA carries significantly higher morbidity compared to staged procedures 1

Correct Surgical Approach: Total Colectomy with End Ileostomy

Subtotal colectomy (total abdominal colectomy) with end ileostomy is the definitive surgical treatment of choice. 1

Surgical Technique Considerations:

• Open approach is recommended given the patient's hemodynamic instability (dehydration, systemic toxicity) and toxic megacolon 1
• Laparoscopic approach may be considered only if the patient is hemodynamically stable and local expertise exists 1
• The rectum should be divided at the recto-sigmoid junction or promontory level, leaving adequate length for future procedures 1

Benefits of Staged Approach:

• Immediate relief from colitis burden, allowing recovery of general health and nutrition 1
• Safer procedure even in critically ill patients compared to definitive proctocolectomy 1
• Time for decision-making regarding permanent ileostomy versus future IPAA 1
• Pathology clarification to definitively exclude Crohn's disease 1

Critical Timing

Surgery must not be delayed in this patient. 1

• Delay in surgery is associated with increased risk of surgical complications and mortality 1
• With toxic megacolon showing no clinical improvement and biological signs of deterioration (elevated WBC, ongoing symptoms), surgery is mandatory within 24-48 hours 1
• This patient already has a 4-day history, placing them beyond the window for medical salvage 1

Common Pitfalls to Avoid

• Do not attempt medical rescue therapy with high-dose steroids or biologics in established toxic megacolon with systemic toxicity 1
• Do not perform single-stage proctocolectomy with IPAA in the emergency setting - this significantly increases morbidity 1
• Do not delay surgery waiting for "optimization" - the patient's condition will continue to deteriorate 1