February 10, 2011

Toxic Megacolon Total or segmental nonobstructive

colonic dilatation PLUS systemic toxicity Most commonly transverse colon

Toxic Megacolon:Etiology IBD Infectious colitis

• C. diff• Salmonella, shigella, campylobacter• CMV• Amoebic colitis

Ischemic colitis Volvulus Diverticulitis Obstructive colon cancer

Toxic Megacolon: Precipitating Factors

Hypokalemia Antimotility agents Opiates Anticholinergics Antidepressants Barium enema Colonoscopy

Clinical Manifestations Toxic appearing Altered sensorium Hypotension/tachycardia Fever Abd distension and tenderness +/- peritoneal signs

Diagnosis Radiographic colonic distention PLUS 3 of following

• Fever>38• Tachycardia• Leukocytosis• Anemia

PLUS at least 1 of the following• Dehydration• Altered sensorium• Electrolyte disturbances• Hypotension

Treatment Goal: reduce severity of colitis

• Restore normal motility• Decrease likelihood of perforation

Medical therapy is successful in preventing surgery in 50%

Surgical team should be consulted

Treatment Complete bowel rest NG tube ICU monitoring Serial abdominal exams CBC, lytes, KUB q 12 Appropriate treatment if IBD present

• Steroids Avoid steroids for infectious etiology

Treatment Broad spectrum abx

• Third-generation cephalosporin• Metronidazole

Discontinue • Antimotility meds• Opiates• Anticholinergics

Generous IVF

Surgery: Indications Perforation No improvement in 3 days

Nutrition TPN if needed Resume enteral feedings with first

signs of improvement• Mucosal healing• Motility

C. Diff and Toxic Megacolon

Stop offending agent Vancomycin PO Flagyl IV