Surgical management of acute colitis and toxic megacolon

Management of Severe Colitis and Toxic Megacolon

Severe colitis is a well-defined condition encompassing several etiologies but is most often caused by severe ulcerative colitis or Clostridioides difficile infection. Severe colitis can evolve into toxic colitis, or toxic megacolon when associated with bowel dilation and systemic manifestations, resulting in a life-threatening scenario where multidisciplinary management is often required. Medical management continues to play an important role in the initial treatment of toxic megacolon. However, timely surgical intervention can be lifesaving.

Surgical Management for Patients with Toxic Megacolon due to Ulcerative Colitis

Objectives

The present study reviewed cases of Toxic megacolon (TM) treated in our department, summarized the timing and technique of surgery, and considered key points for surgical management.

Methods

This single-center retrospective study included the medical records of patients clinically diagnosed with TM who underwent surgery between 1985 and 2020. The diagnostic criteria and screening scores for sepsis, such as the systemic inflammatory response syndrome (SIRS) criteria, quick Sequential Organ Failure Assessment (qSOFA) score, and Modified Early Warning Score (MEWS), were validated. The preoperative clinical features and perioperative findings were also investigated.

Results

There were eight male and six female patients. Nine patients (64.3%) satisfied the criteria for toxemia proposed by Narabayashi, and 10 patients (71.4%) fulfilled the SIRS criteria. A positive qSOFA score was confirmed in 1 patient (7.1%). The MEWS was high in 2 patients (14.3%). Intestinal perforation occurred in 2 patients (14.3%), and 1 of them died from disseminated intravascular coagulation. The mortality rate of TM with perforation was 50%. Eleven patients (78.6%) underwent total colectomy with end ileostomy.

Conclusions

TM does not have well-defined diagnostic criteria, in addition to developing sometimes as borderline or fulminant cases, and must be recognized at an early stage, taking various findings into consideration. The criteria proposed by Narabayashi and the SIRS criteria, which met in a high percentage of our cases, are recommended as indicators for determining the toxicity of TM. It is also important to consider surgery in the early stages of TM, even if clinical findings do not meet all the criteria.

Management of Colonic Emergencies

The etiology of colonic emergencies includes a wide-ranging and diverse set of pathologic conditions. Fortunately, for the surgeon treating a patient with one of these emergencies, the surgical management of these various causes is limited to choosing among proximal diversion, segmental colectomy with or without proximal diversion, or a total abdominal colectomy with end ileostomy (or rarely, an ileorectal anastomosis). The nuanced complexity in these situations usually revolves around the nonsurgical and/or endoscopic options and deciding when to proceed to the operating room.

Subtotal colectomy in ulcerative colitis—long term considerations for the rectal stump

BACKGROUND

The initial operation of choice in many patients presenting as an emergency with ulcerative colitis is a subtotal colectomy with end ileostomy. A percentage of patients do not proceed to completion proctectomy with ileal pouch anal anastomosis.

AIM

To review the existing literature in relation to the significant long-term complic-ations associated with the rectal stump, to provide an overview of options for the surgical management of remnant rectum and anal canal and to form a consolidated guideline on endoscopic screening recommendations in this cohort.

METHODS

A systematic review was carried out in accordance with PRISMA guidelines for papers containing recommendations for endoscopy surveillance in rectal remnants in ulcerative colitis. A secondary narrative review was carried out exploring the medical and surgical management options for the retained rectum.

RESULTS

For rectal stump surveillance guidelines, 20% recommended an interval of 6 mo to a year, 50% recommended yearly surveillance 10% recommended 2 yearly surveillance and the remaining 30% recommended risk stratification of patients and different screening intervals based on this. All studies agreed surveillance should be carried out via endoscopy and biopsy. Increased vigilance is needed in endoscopy in these patients. Literature review revealed a number of options for surgical management of the remnant rectum.

CONCLUSION

The retained rectal stump needs to be surveyed endoscopically according to risk stratification. Great care must be taken to avoid rectal perforation and pelvic sepsis at time of endoscopy. If completion proctectomy is indicated the authors favour removal of the anal canal using an intersphincteric dissection technique.

Clinical Outcomes After Ileal Pouch-Anal Anastomosis in Pediatric Patients

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) is the standard surgical reconstruction for patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) who undergo total proctocolectomy (TPC). Although patients receive the same reconstruction, their postoperative complications can differ. We hypothesize that indication for TPC and other preoperative clinical factors are associated with differences in postoperative outcomes following IPAA.

METHODS

A retrospective cohort of pediatric patients who underwent proctocolectomy with IPAA from 1996 to 2016 was identified. Preoperative, operative, and postoperative clinical variables were collected. Univariate analyses were performed to evaluate for relevant postoperative clinical differences.

RESULTS

Seventy-nine patients, 17 with FAP and 62 with UC, were identified. FAP patients spent a mean of 1125 ± 1011 d between initial diagnosis and first surgery compared to 585 ± 706 d by UC patients (P = 0.038). FAP patients took a mean of 57 ± 38 d to complete TPC with IPAA compared to UC patients at 177 ± 121 d (P < 0.001). FAP and UC patients did not differ in mean number of bowel movements at their 6-mo postoperative visit (4.7 ± 2.1 versus 5.6 ± 1.9, respectively [P = 0.134]). FAP patients were less likely to experience pouchitis (P = 0.009), pouch failure (P < 0.001), and psychiatric symptoms (P = 0.019) but more likely to experience bowel obstruction (P = 0.002).

CONCLUSIONS

IPAA is a safe, restorative treatment for FAP and UC patients after TPC. Based on diagnosis and preoperative course, there are differences in morbidity in IPAA patients. Clinical data such as these will allow surgeons to help families anticipate their child's preoperative and postoperative courses and to maximize successful postoperative outcomes.

Blowhole Colostomy for Clostridium difficile-Associated Toxic Megacolon

We present the case of a 58-year-old man who underwent urgent blowhole colostomy for toxic megacolon (TM) secondary to Clostridium difficile infection (CDI). This infection occurred under antibiotic coverage with amoxicillin-clavulanic acid, four days after laparoscopic sigmoidectomy in our hospital. Although prospective clinical research regarding the surgical management of TM is lacking, decompressive procedures like blowhole colostomy are reported to carry a high risk of postoperative morbidity and mortality and are widely regarded as obsolete. Subtotal or total colectomy with end ileostomy is currently considered the procedure of choice. After presenting our case, we discuss the literature available on the subject to argue that the scarce evidence on the optimal surgical treatment for TM is primarily based on TM associated with inflammatory bowel diseases (IBD) and that there might be a rationale for considering minimally invasive procedures like blowhole colostomy for CDI-associated TM.

A Case of Severe Ulcerative Colitis with Colonic Dilatation caused by Renal Mucinous Tubular and Spindle Cell Carcinoma

We present a case of ulcerative colitis (UC) in a patient during the first severe relapse with colonic dilatation and coexisting of giant renal tumor. Kidney tumor was constricting on colon and imitating toxic megacolon (TM). The patient with severe acute colitis (SAC) was admitted to the Department of Gastroenterology and Hepatology with inflammatory bowel disease (IBD) diagnosed in the previous month, based on clinical symptoms, endoscopy, and histopathology results. Computed tomography (CT) revealed a giant left kidney tumor without evidence of infiltration, a dilatation of the transverse colon up to 6 cm, and narrow light of the descending colon. There were no signs of intestinal obstruction or perforation. The control X-rays revealed maintaining megacolon, with dilatation of splenic flexure projection up to 6.5 to 7.5 cm. The patient was treated conservatively with no apparent improvement and finally operated on. Intraoperatively, a large tumor of the kidney (12 cm) constricting intestine was revealed. Left-sided nephrectomy and partial resection of the colon with the emergence of a colostomy was performed. The histopathology exam revealed renal mucinous tubular and spindle cell carcinoma (RMTSCC), a very rare malignant kidney tumor of low malignant potential and relative good prognosis. It was identified in the past 20 years. To date, approximately 100 such cases of cancer have been described.

How to cite this article

Kukulska M, Smola I, Halon A, Paradowski L, Poniewierka E, Kempinski R, Annabhani A. A Case of Severe Ulcerative Colitis with Colonic Dilatation caused by Renal Mucinous Tubular and Spindle Cell Carcinoma. Euroasian J Hepato-Gastroenterol 2016;6(2):190-193.