Gastroenterology and Hepatology Q14

Answer & Critique

Correct Answer: A

Educational Objective: Treat toxic megacolon.

Key Point

Toxic megacolon is defined by the presence of toxicity and evidence of colonic dilation; it requires prompt surgical treatment.

This patient requires colectomy. He has a history of ulcerative colitis and presents with fever, tachycardia, hypotension, and a dilated colon on abdominal radiography; the diagnosis is toxic megacolon, a life-threatening condition that complicates approximately 5% of acute, severe cases of ulcerative colitis. Toxic megacolon is defined by the presence of toxicity (fever, tachycardia, hypotension, and leukocytosis) along with evidence of colonic dilation. Patients with this condition have an increased risk for complications such as colonic perforation. Intravenous fluid resuscitation, intravenous high-dose corticosteroids, and broad-spectrum antibiotics (for example, a third-generation cephalosporin with metronidazole) should be initiated in patients with toxic megacolon. Management requires close collaboration with a surgeon; therefore, emergent surgical consultation for consideration of subtotal colectomy is required because of the impending risk for perforation and peritonitis in patients with toxic megacolon. Some patients may respond to medical therapy with high-dose glucocorticoids (in addition to intravenous fluids and broad-spectrum antibiotics), but there should be a low threshold for surgical intervention due to the potential harms associated with toxic megacolon.

Colonoscopy is contraindicated because it would increase the risk for perforation and complications related to toxic megacolon.

CT of the abdomen and pelvis is the optimal imaging modality to evaluate suspected toxic megacolon and may better assess for the presence of colonic necrosis; however, in this case, the diagnosis of toxic megacolon can be confidently made based on the patient's presentation and abdominal radiography, and urgent surgical evaluation is necessary.

Stool studies for enteric pathogens may identify a precipitant of toxic megacolon but require a minimum of 24 hours before test results are received. Surgical consultation should not be delayed to wait for results of stool testing.

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