- Sunil G Sheth, MD
Sunil G Sheth, MD
- Assistant Professor of Medicine
- Harvard Medical School
- J Thomas Lamont, MD
J Thomas Lamont, MD
- Editor-in-Chief — Gastroenterology and Hepatology
- Section Editor — Anorectal Disorders and Misc. Lower GI Disease; Nutrition, Malabsorption, and Misc. Upper GI Disease
- Professor of Medicine
- Harvard Medical School
- Section Editors
- Martin Weiser, MD
Martin Weiser, MD
- Section Editor — Colorectal Surgery
- Attending Surgeon
- Memorial Sloan Kettering Cancer Center
- Professor of Surgery
- Weill Cornell Medical School
- Paul Rutgeerts, MD, PhD, FRCP
Paul Rutgeerts, MD, PhD, FRCP
- Section Editor — Inflammatory Bowel Disease
- Emeritus Professor of Medicine
- University Hospital, Leuven, Belgium
Toxic megacolon is a potentially lethal complication of inflammatory bowel disease (IBD) or infectious colitis that is characterized by total or segmental nonobstructive colonic dilatation plus systemic toxicity [1-3]. Colonic dilatation is also observed in patients with congenital megacolon (Hirschsprung's disease), idiopathic or acquired megacolon occurring with chronic constipation of any etiology, and intestinal pseudoobstruction, a manifestation of diffuse gastrointestinal dysmotility of various causes. However, the lack of systemic toxicity distinguishes these presentations from true toxic megacolon. (See "Acute colonic pseudo-obstruction (Ogilvie's syndrome)".)
The precise incidence of toxic megacolon is unknown. The incidence in ulcerative colitis and Crohn's disease was approximately 1 to 5 percent three decades ago , but has gradually decreased because of earlier recognition and intensive management of severe colitis. Clinically symptomatic Clostridium difficile infection occurs in approximately 1 percent of all hospitalized patients; a few of these may develop severe colitis with toxic megacolon [5-7]. (See "Clostridium difficile infection in adults: Clinical manifestations and diagnosis".)
Although most commonly recognized as a complication of inflammatory bowel disease (IBD), toxic megacolon may also occur with infectious colitides of diverse etiology, ischemic colitis, volvulus, diverticulitis, and obstructive colon cancer (table 1).
●Clinical features that suggest IBD as a cause of toxic megacolon include a preceding history of diarrhea, bloody stools, abdominal pain, perianal disease, or extraintestinal manifestations such as arthritis, iritis, skin disease, or liver disease. (See "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults" and "Clinical manifestations, diagnosis and prognosis of Crohn disease in adults".)
●Risk factors for the development of severe colitis in patients with C. difficile infection include malignancy, chronic obstructive pulmonary disease, immunosuppressive therapy, renal failure, or exposure to antiperistaltic medications or clindamycin . Toxic megacolon has been described in patients with recurrent C. difficile .
- Sheth SG, LaMont JT. Toxic megacolon. Lancet 1998; 351:509.
- Fazio VW. Toxic megacolon in ulcerative colitis and Crohn's colitis. Clin Gastroenterol 1980; 9:389.
- Jalan KN, Sircus W, Card WI, et al. An experience of ulcerative colitis. I. Toxic dilation in 55 cases. Gastroenterology 1969; 57:68.
- Grieco MB, Bordan DL, Geiss AC, Beil AR Jr. Toxic megacolon complicating Crohn's colitis. Ann Surg 1980; 191:75.
- Rubin MS, Bodenstein LE, Kent KC. Severe Clostridium difficile colitis. Dis Colon Rectum 1995; 38:350.
- Trudel JL, Deschênes M, Mayrand S, Barkun AN. Toxic megacolon complicating pseudomembranous enterocolitis. Dis Colon Rectum 1995; 38:1033.
- Berman L, Carling T, Fitzgerald TN, et al. Defining surgical therapy for pseudomembranous colitis with toxic megacolon. J Clin Gastroenterol 2008; 42:476.
- Louie TJ. Treatment of first recurrences of Clostridium difficile-associated disease: waiting for new treatment options. Clin Infect Dis 2006; 42:765.
- Surawicz CM, Haggitt RC, Husseman M, McFarland LV. Mucosal biopsy diagnosis of colitis: acute self-limited colitis and idiopathic inflammatory bowel disease. Gastroenterology 1994; 107:755.
- Nayar DM, Vetrivel S, McElroy J, et al. Toxic megacolon complicating Escherichia coli O157 infection. J Infect 2006; 52:e103.
- McGregor A, Brown M, Thway K, Wright SG. Fulminant amoebic colitis following loperamide use. J Travel Med 2007; 14:61.
- Hommes DW, Sterringa G, van Deventer SJ, et al. The pathogenicity of cytomegalovirus in inflammatory bowel disease: a systematic review and evidence-based recommendations for future research. Inflamm Bowel Dis 2004; 10:245.
- Cooper HS, Raffensperger EC, Jonas L, Fitts WT Jr. Cytomegalovirus inclusions in patients with ulcerative colitis and toxic dilation requiring colonic resection. Gastroenterology 1977; 72:1253.
- Mourelle M, Casellas F, Guarner F, et al. Induction of nitric oxide synthase in colonic smooth muscle from patients with toxic megacolon. Gastroenterology 1995; 109:1497.
- Mourelle M, Vilaseca J, Guarner F, et al. Toxic dilatation of colon in a rat model of colitis is linked to an inducible form of nitric oxide synthase. Am J Physiol 1996; 270:G425.
- Schwörer H, Bohn M, Waezsada SY, et al. Successful treatment of megacolon associated with colitis with a nitric oxide synthase inhibitor. Am J Gastroenterol 2001; 96:2273.
- Norland CC, Kirsner JB. Toxic dilatation of colon (toxic megacolon): etiology, treatment and prognosis in 42 patients. Medicine (Baltimore) 1969; 48:229.
- Arienti V, Campieri M, Boriani L, et al. Management of severe ulcerative colitis with the help of high resolution ultrasonography. Am J Gastroenterol 1996; 91:2163.
- Mukai JK, Janower ML. Diagnosis of pseudomembranous colitis by computed tomography: a report of two patients. Can Assoc Radiol J 1987; 38:62.
- Gan SI, Beck PL. A new look at toxic megacolon: an update and review of incidence, etiology, pathogenesis, and management. Am J Gastroenterol 2003; 98:2363.
- Caprilli R, Vernia P, Colaneri O, Torsoli A. Blood pH: a test for assessment of severity in proctocolitis. Gut 1976; 17:763.
- Alemayehu G, Järnerot G. Colonoscopy during an attack of severe ulcerative colitis is a safe procedure and of great value in clinical decision making. Am J Gastroenterol 1991; 86:187.
- Dieterich DT, Rahmin M. Cytomegalovirus colitis in AIDS: presentation in 44 patients and a review of the literature. J Acquir Immune Defic Syndr 1991; 4 Suppl 1:S29.
- Dickinson RJ, Ashton MG, Axon AT, et al. Controlled trial of intravenous hyperalimentation and total bowel rest as an adjunct to the routine therapy of acute colitis. Gastroenterology 1980; 79:1199.
- Meyers S, Sachar DB, Goldberg JD, Janowitz HD. Corticotropin versus hydrocortisone in the intravenous treatment of ulcerative colitis. A prospective, randomized, double-blind clinical trial. Gastroenterology 1983; 85:351.
- Present DH, Wolfson D, Gelernt IM, et al. Medical decompression of toxic megacolon by "rolling". A new technique of decompression with favorable long-term follow-up. J Clin Gastroenterol 1988; 10:485.
- Panos MZ, Wood MJ, Asquith P. Toxic megacolon: the knee-elbow position relieves bowel distension. Gut 1993; 34:1726.
- Caprilli R, Vernia P, Latella G, Torsoli A. Early recognition of toxic megacolon. J Clin Gastroenterol 1987; 9:160.
- Bolton RP, Culshaw MA. Faecal metronidazole concentrations during oral and intravenous therapy for antibiotic associated colitis due to Clostridium difficile. Gut 1986; 27:1169.
- Fischer M, Sipe BW, Rogers NA, et al. Faecal microbiota transplantation plus selected use of vancomycin for severe-complicated Clostridium difficile infection: description of a protocol with high success rate. Aliment Pharmacol Ther 2015; 42:470.
- Gweon TG, Lee KJ, Kang DH, et al. A case of toxic megacolon caused by clostridium difficile infection and treated with fecal microbiota transplantation. Gut Liver 2015; 9:247.
- Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis 2007; 45:302.
- Triadafilopoulos G, Hallstone AE. Acute abdomen as the first presentation of pseudomembranous colitis. Gastroenterology 1991; 101:685.
- Beaugerie L, Ngô Y, Goujard F, et al. Etiology and management of toxic megacolon in patients with human immunodeficiency virus infection. Gastroenterology 1994; 107:858.
- Davidson T, Allen-Mersh TG, Miles AJ, et al. Emergency laparotomy in patients with AIDS. Br J Surg 1991; 78:924.
- Boulton R, Hamilton M, Lewis A, et al. Fulminant ulcerative colitis in pregnancy. Am J Gastroenterol 1994; 89:931.
- Truelove SC, Willoughby CP, Lee EG, Kettlewell MG. Further experience in the treatment of severe attacks of ulcerative colitis. Lancet 1978; 2:1086.
- Anderson JB, Turner GM, Williamson RC. Fulminant ulcerative colitis in late pregnancy and the puerperium. J R Soc Med 1987; 80:492.
- Ausch C, Madoff RD, Gnant M, et al. Aetiology and surgical management of toxic megacolon. Colorectal Dis 2006; 8:195.
- Danovitch SH. Fulminant colitis and toxic megacolon. Gastroenterol Clin North Am 1989; 18:73.
- Kerstens J, Diebels I, de Gheldere C, Vanclooster P. Blowhole Colostomy for Clostridium difficile-Associated Toxic Megacolon. Case Rep Surg 2016; 2016:5909248.
- Strauss RJ, Flint GW, Platt N, et al. The surgical management of toxic dilatation of the colon: a report of 28 cases and review of the literature. Ann Surg 1976; 184:682.
- Greenstein AJ, Kark AE, Dreiling DA. Crohn's disease of the colon. III. Toxic dilatation of the colon in Crohn's colitis. Am J Gastroenterol 1975; 63:117.
- Flatmark A, Fretheim B, Gjone E. Early colectomy in severe ulcerative colitis. Scand J Gastroenterol 1975; 10:427.
- Tapani MJ, Olavi KH. Surgical Management of Toxic Megacolon. Hepatogastroenterology 2014; 61:638.
- Snowden JA, Young MJ, McKendrick MW. Dilatation of the colon complicating acute self-limited colitis. Q J Med 1994; 87:55.
- Nitric oxide
- CLINICAL MANIFESTATIONS
- Laboratory studies
- Therapy of toxic megacolon in patients with IBD
- Medical therapy in patients with other disorders
- SUMMARY AND RECOMMENDATIONS