Toxic Megacolon Presentation Final

7/22/2019 Toxic Megacolon Presentation Final

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DMcG: 68 year old man

B/G: bilateral hip replacement, psoriasis

23/08/07: Transferred from Letterkenny

General Hospitaltriple vessel disease

with complete LAD occlusion

24/08/07: CABG x 3uncomplicated

extubated day 1 post op


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Day 3nausea and vomiting, pyrexial

Day 4loose stools

lower sternal wound infection

noted

> flucloxacillin IV commenced

Day 5ongoing vomiting and diarrhoea,

pyrexia 38.9


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Day 6abdominal distension, bowel

sounds present, tachycardic 110

> NPO

> IV fluids and wide bore NG

> CXR and PFA

> general surgical consult


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General surgeryinitial assessment:

> central abdominal pain, diarrhoea

> pyrexial, tachycardic

> abdomen mildly distended, mildly

tender lower abdomen, no guardingor rigidity, bowel sounds.


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PFAdilated large bowel

WCC18

Na133

CRP180

Imp: ?systemic sepsis syndrome

?infective diarrhoea

Advised: antibiotics, micro consult, urgent CT

abdomen/pelvis, stool for CMS


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Day 6norovirus positive

Day 7 morningClostridium difficile positive> flucloxacillin stopped

CT abdomenthick-walled caecum,

ascending colon and descending colon, dilatedtransverse colonconsistent with

pseudomembranous colitis


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Day 7 : deteriorationtachypnoeic,

desaturating, hypotensive, oliguric

S/B anaesthetist immediately

Brought to theatre at 18.30 for total

colectomy and end ileostomy formation


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> grossly dilated, distended colon resected> rectal stump protected with 2-layer

closure> abdominal cavity washed out with saline

> terminal ileostomy fashioned in RIF

> Robinson drain inserted> Transferred to ICU

Commenced on IV tazocin & metronidazole asper microbiology


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ICU day 1 post op:

- anuric requiring CVVHD

- daily proctoscopy to decompress

rectal stump

- requiring inotropic support,intubated and ventilated


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Day 3 post op:

- making urine

- NG feeding commenced 10ml/hr

- stoma functioning

- stopped inotropes- WCC raised - 20


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Day 9extubated, off dialysis

Day 13transferred to cardiothoracic

HDU

Uneventful course

Day 26transferred back toLetterkenny


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Discussion

Clostridium difficile

Diagnosis and management of toxic

megacolon

Medical and surgical treatment

options and outcomes


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Discussion

C difficile is a spore-forming, gram-positive

bacillus first described in 1935 as part of the

normal colonic flora of healthy infants. Asymptomatic carriage in 3-5% of healthy

adults

Leading cause of nosocomial entericinfection

Affects up to 20% of hospitalised patients-

1/3 will become symptomatic


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Pathogenesis

Antibiotic therapy

Disruption of colonic mucosa

C Diff exposure and colonization

Release of toxin A (enterotoxin) and toxin B(cytotoxin)

Mucosal injury and inflammation


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Risk Factors

Advanced age

Antibiotic therapy

Immunosuppressive therapy

Multiple and severe underlying diseases Placement of a nasogastric tube

Recent surgical procedure

Admission to intensive care unit

Prolonged hospital stay

Residing in a nursing home

Sharing a hospital room with a C. diff-infected patient

Use of antacids


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Clinical variants of C. diff

infection Asymptomatic carriage

Antibiotic associated diarrhoea

without colitis

Antibiotic associated colitis withoutpseudomembrane formation

Pseudomembranous colitis

Fulminant colitis


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Causes of Toxic Megacolon

Inflammatory bowel disease

-Ulcerative colitis 46%

-Crohns disease 2%

Infectious colitisBacterial

-Pseudomembranous colitis (Clostridium difficile) 31%

Parasitic

-Amoebiasis 3%

Colitis due to special medical therapy

-Cytotoxic chemotherapy 3%

-Beta mimetics 4%

Ischaemia 11%


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Distribution of aetiology

Time period

Aetiology 1984-94 n (%) 1995-2004 n (%)

IBD 21 (30) 12(17)

Other 10 (14) 27(39)

C. Ausch*, R. D. Madoff, M. Gnant, H. R. Rosen*, J. Garcia-Aguilar, N. Holbling*, F. Herbst, V.Buxhofer*, B. Holzer*, D. A. Rothenberger and R.Schiessel* Aetiology and surgical management of toxicmegacolon. Colorecatal disease (8) 195-201. June 2005


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Diagnosis of Toxic Megacolon

1.Evidence of dilatation:

Clinical: Visible abdominal distension, abdominal tenderness, diarrhoea,bloody diarrhoea, constipation, obstipation, bowel sounds.

Radiological: segmental or total colonic distension >6cm, small bowel

and gastric distension.

2.Evidence of toxicity:

3 of -Pyrexia >38.6 1 of -Dehydration

-Tachycardia >120bpm -Cognitive changes

-Leucocytosis >10.5 x109 -

Electrolyte disturbance

-Anaemia -Hypotension

3. Subsequent pathological confirmation of dilatation andtransmural extension of the inflammatory process

Jalan KN, Sircus W, Card WI, Falconer CW, Bruce CB, Crean GP, McManus JP, Small WP, Smith AN. An experience of ulcerative colitis. I. Toxicdilation in 55 cases. Gastroenterology. 1969 Jul;57(1):6882.


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Management

General

IV fluids

Correct e- abnormalities

Complete bowel rest

Discontinue anticholenergics and narcotics Stool CMS

Blood cultures (bacteraemia in up to 25%)

Decompression

Rectal tube

NG tube

Repositioning manoeuvres

Endoscopy: with extreme caution as risk of perforation

Radiology

Frequent assessment with plain films CT


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Treatment: Medical

Conservative: Stop causative antibiotic

Trial of medical therapy

Oral metronidazole +/- oral vancomycin

IV metronidazole

Bacitracin, teicoplanin

Toxin binding agents eg. Cholestyramine Probiotics

IV immunoglobulin

Faecal reconsistution


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Treatment: SurgicalSave the patient, not the colon

Surgery required in up to 80% of cases in some studies

Reserved for the most severe cases

Absolute indications include:

free perforation; massive haemorrhage; increasingtransfusion requirement; worsening signs of toxicity;progression of colonic dilatation.

Most surgical studies recommend colectomy if there ispersistent colonic distension after 48-72hrs.

Early intervention is associated with lower morbidity andmortality

Surgery of choice is subtotal colectomy with end ileostomyand Hartmann closure of the rectum or sigmoid mucousfistula.


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Outcomes: Morbidity

C. Ausch*, R. D. Madoff, M. Gnant, H. R. Rosen*, J. Garcia-Aguilar, N. Holbling*, F. Herbst, V.Buxhofer*, B. Holzer*, D. A. Rothenberger andR. Schiessel* Aetiology and surgical management of toxicmegacolon. Colorecatal disease (8) 195-201. June 2005


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Outcomes: Mortality

C. Ausch*, R. D. Madoff, M. Gnant, H. R. Rosen*, J. Garcia-Aguilar, N. Holbling*, F. Herbst, V.Buxhofer*, B. Holzer*, D. A.Rothenberger and R. Schiessel* Aetiology and surgical management of toxicmegacolon. Colorecatal disease (8) 195 -201. June 2005


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Outcomes

Perforation is a major factor in and mortality:

8.7% if no perforation, 51% with perforation1

Overall mortality has improved some recentstudies showing no mortality compared with

>50% in 19692

Difficult to show objective difference between

outcome of TM due to IBD and other aetiologies

due to significant changes in aetiology and

recent developments in ICU medicine1 Binderow SR, Wexner SD. Current surgical therapy for mucosal ulcerative colitis. Dis Col Rectum 1994; 37: 61024

2. Jalan KN, Sircus W, Card WI, Falconer CW, Bruce CB, Crean GP, McManus JP, Small WP, Smith AN. An experience of ulcerative colitis. I.

Toxic dilation in 55 cases. Gastroenterology. 1969 Jul;57(1):6882.


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Conclusions

Toxic megacolon complicating

pseudomembranous colitis carries a high

morbidity and mortality rate Early surgical intervention when

conservative and medical treatment have

failed is associated with better outcomesand quality of life

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Toxic Megacolon Presentation Final

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