Aetiology and surgical management of 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.

A case of community-acquired Clostridioides difficile infection causing intussusception, severe pneumonia, and severe hypokalemia

BACKGROUND

Clostridioides difficile infection is associated with antibiotic use and manifests as diarrhea; however, emerging cases of fulminant diarrhea caused by binary toxin-producing C. difficile unrelated to prior antibiotic exposure have been reported. Although fulminant colitis caused by C. difficile has been documented, instances of intussusception remain scarce. Here, we present a case of adult intussusception with severe hypokalemia and pneumonia resulting from a community-acquired C. difficile infection in Japan.

CASE PRESENTATION

An 82-year-old male presented with dizziness, progressive weakness, and diarrhea. Initial vital signs indicated severe respiratory and circulatory distress, and laboratory findings revealed hypokalemia, pneumonia, and septic shock. Imaging confirmed intussusception of the ascending colon. Although colonoscopy suggested a potential tumor, no malignancy was found. The C. difficile rapid test result was positive, indicating community-acquired C. difficile infection. Treatment with vancomycin was initiated; however, intussusception relapsed. Surgical intervention was successful and led to clinical improvement. The patient's complex pathophysiology involved community-acquired C. difficile-induced severe diarrhea, hypokalemia, hypermetabolic alkalosis, and subsequent intussusception. Although adult intussusception is uncommon, this case was uniquely linked to binary toxin-producing C. difficile. The identified strain, SUH1, belonged to a novel sequence type (ST1105) and clade 3, suggesting a highly virulent clone. Resistome analysis aligned with phenotypic susceptibility to metronidazole and vancomycin, confirming their treatment efficacy.

CONCLUSION

This case report highlights a binary toxin-producing C. difficile that caused intussusception. The consideration of community-acquired C. difficile in the differential diagnosis of severe enteritis is necessary, even in Japan.

Surgical Emergencies in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) patients are at risk for undergoing emergency surgery for fulminant disease, toxic megacolon, bowel perforation, intestinal obstruction, or uncontrolled gastrointestinal hemorrhage. Unfortunately, medical advancements have failed to significantly decrease rates of emergency surgery for IBD. It is therefore important for all acute care and colorectal surgeons to understand the unique considerations owed to this often-challenging patient population.

Case Report: Ambergris coprolite and septicemia in a male sperm whale stranded in La Palma (Canary Islands)

On the 21st of May 2023, a dead adult male sperm whale (Physeter macrocephalus) of 13 m in length and estimated weight of around 18,000 kg was reportedly stranded at Playa Los Nogales, La Palma, Canary Islands, Spain. A necropsy was performed 48hpm. A 50 cm diameter and 9.5 kg coprolite was found obstructing the caudal colon-rectal lumen. Necro-hemorrhagic lesions were found in heart muscles and three different bacteria of intestinal origin were isolated and identified (Edwarsiella tarda, Hathewaya limosa and Clostridium perfringens). It is reported a lethal septicemia of intestinal origin associated with ambergris coprolite as cause of death in this sperm whale.

Clostridioides difficile infection leading to fulminant colitis with toxic megacolon

Clostridioidesdifficile infection (CDI) is the culprit of millions of nosocomial infections in the United States. Programs that successfully decrease its incidence, therefore, render cost savings for the healthcare system. Toxic megacolon and perforation are two of the most significant complications with increased mortality rates. We report a 23-year-old nursing home resident hospitalized for fever, cough, and green sputum. After 3 days of antibiotic therapy, he developed abdominal distension, diarrhea, and vomiting and underwent a total colectomy. The colon was dilated to a maximum of 11 cm with markedly edematous mucosa and yellow pseudomembranes. Qualitative PCR of the stool detected Clostridioides difficile toxin B gene. While there is no consensus for the required interval between antibiotic treatment and CDI, this presentation 3 days after starting the antibiotic therapy is earlier than most proposed ranges.

Campylobacter jejuni pancolitis complicated by toxic megacolon in an immunocompetent host

This is an unusual case of a middle-aged, immunocompetent man who developed toxic megacolon (TM) secondary to infection with a normally harmless bug, Campylobacter jejuni He presented with diarrhoea, fever and abdominal pain. Faecal cultures were positive for C. jejuni However, the patient did not show significant improvement after a trial of intravenous antibiotics. Bowel segment dilation on a CT scan combined with systemic signs (fever) led to the diagnosis of TM. A subtotal colectomy was planned but an unexpected positive response to conservative therapy deferred the surgery. Our case emphasises the crucial role that bowel rest and good nutritional support play in treating TM of infectious aetiology and how it can help avoid the need for a life-altering subtotal colectomy and ileostomy. For such presentations we also highlight how empirical steroid therapy or diagnostic sigmoidoscopy for suspected underlying ulcerative colitis can be detrimental to patient outcomes.

A contemporary series of surgical outcomes following subtotal colectomy and/or completion proctectomy for management of inflammatory bowel disease

BACKGROUND

The main indications for emergency subtotal colectomy (SC) include management of toxic colitis, refractory haemorrhage and/or perforation. Alternatively, elective surgery is performed for those refractory to medical therapy or with evidence of multifocal dysplasia. Overall, the annual incidence of SC has fallen since the introduction of biologic therapies and we aimed to review our current practices.

METHODS

A retrospective review of inflammatory bowel disease (IBD) patients undergoing subtotal colectomy between 2013 and 2020 was performed. Medical records, operative notes, discharge summaries, histopathology reports and other supporting documents were reviewed. Indication for surgery, management of the rectum (i.e. maintenance of rectal stump, progression to completion proctectomy or IPAA formation) associated morbidity (Clavien-Dindo classification) and length of hospital stay were examined.

RESULTS

Fifty-six IBD patients underwent a subtotal colectomy. Twenty-five patients (UC 14, Crohn's 11) had an elective procedure, and 31 patients (UC 19 Crohn's 12) had an emergency/semi-urgent procedure. Interestingly, 80% (n = 25) of the emergency cohort and 68% (n = 17) of the elective cohort had a laparoscopic resection. Major morbidity (Clavien-Dindo > 2) was higher among the emergency group (39% vs. 24%). Deep surgical site infection was the commonest morbidity (13%) in the emergency group, while superficial surgical site infection was commonest in the elective cohort (20%). Overall, there was no difference in surgical re-intervention rate (13% vs 12%), and there were no perioperative mortalities. Median post-operative length of stay was shorter in the elective cohort (9 versus 13 days).

CONCLUSION

A significant proportion of IBD patients still require semi-urgent/emergency colectomy, which is associated with considerable length of stay and morbidity. The results of our study provide real-world outcomes to help counsel patients on expected outcomes.

Spectrum of bowel wall thickening on ultrasound with pathological correlation in children

Applications for bowel US in children have been well described; however, less focus has been placed on patterns of bowel wall architectural change in specific disease states. This pictorial essay reviews normal bowel wall architecture and covers a variety of inflammatory, infectious, vascular and neoplastic disorders outside the neonatal period as seen on US, with illustrative pathological correlation. A thorough understanding of normal and abnormal bowel wall architecture can enrich sonographic interpretation and provide a valuable adjunct to appropriate clinical investigation.

WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting

BACKGROUND

Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons.

METHOD

A group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019.

CONCLUSIONS

Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate.

Communicating multiple tubular enteric duplication with toxic megacolon in an infant: A case report

RATIONALE

Gastrointestinal tract duplication is a rare congenial anomaly which can be found anywhere along the gastrointestinal tract. While many patients are incidentally diagnosed during operation, in some cases it can present with severe gastrointestinal symptoms. In this case report, the patient presented with signs of toxic megacolon leading to rapid aggravation of inflammatory shock.

PATIENT CONCERNS

A 49-day old male infant presented with fever, poor feeding, and severe abdominal distension.

DIAGNOSIS

Abdominal ultrasonography was done. During the examination, a foley catheter was inserted through the anus to evaluate bowel patency and enable rectal decompression. The tip of the foley catheter was located in a separate narrower tubular lumen adjacent to the distended rectum. These findings suggested possibility of a tubular duplication cyst of the rectum as the culprit for the bowel obstruction.

INTERVENTIONS

The patient underwent emergency laparotomy. Findings showed multiple tubular intestinal duplications involving the ileum, appendix, cecum, descending colon, sigmoid colon and rectum. The true lumen of the rectosigmoid colon was completely collapsed while the adjacent tubular cyst remained severely distended and stool passage was not possible. Decompression of the sigmoid colon was done with loop colostomy with both the wall of the true bowel and enteric cyst forming the colostomy orifice.

OUTCOMES

After 40 days of postoperative care, the patient was discharged with no immediate complications. Four months after the initial operation, colostomy take-down and transanal rectal common wall division was done. No complications were observed.

LESSONS

To our knowledge, this is the first case to be reported where a rare presentation of intestinal duplication resulted in an acute presentation toxic megacolon. Such emergency cases can be effectively treated with emergency surgical bowel decompression and elective common wall division.

Toxic Megacolon: Background, Pathophysiology, Management Challenges and Solutions

Toxic megacolon (TM) is one of the fatal complications of inflammatory bowel disease (IBD) or any infectious etiology of the colon that is characterized by total or partial nonobstructive colonic dilatation and systemic toxicity. It is associated with high morbidity and mortality, and surgical management is necessary for the majority of the cases. An accurate history and physical examination, plain radiographs of the abdomen, sigmoidoscopy, and, most important of all, awareness of the condition facilitate diagnosis in most cases. Operative intervention is warranted when massive hemorrhage, perforation, or peritonitis complicate the clinical scenario or medical therapy fails to control the disease. We sought to review the management challenges of TM and its possible management strategies in this article.

Campylobacter colitis leads to toxic megacolon and multiple organ failure

A 58-year-old woman presented to the emergency department in a district general hospital with severe abdominal pain and diarrhoea, after collapsing at home. She was admitted to the intensive care unit (ICU) in septic shock, and with acute kidney injury. An initial CT scan was suggestive of colitis. She was treated for suspected gastroenteritis and her microbiology results showed Campylobacter coli as the causative organism. She failed to respond to antibiotics, and underwent serial contrast CTs which showed no progression of colitis. Colonoscopy performed on day 10 of her admission, however, revealed fulminant colitis. After a multidisciplinary meeting among gastroenterologists, general surgeons and intensivists, the patient underwent total colectomy with ileostomy. She made a slow but steady recovery in ICU, and subsequently in the ward, and was discharged to a local community hospital for further rehabilitation.

New-onset ulcerative colitis in pregnancy associated to toxic megacolon and sudden fetal decompensation: Case report and literature review

Ulcerative colitis (UC) is a chronic inflammatory disease rarely arising during gestation. Because the available information is based on case reports or small retrospective studies, diagnosis may be difficult and treatment is still controversial. A case of toxic megacolon developing in late pregnancy associated to a sudden fetal decompensation is described. Diagnostic and clinical topics of acute UC onset in pregnancy are debated.A primipara, 34 years old, 33/0 weeks of gestation, was admitted with a diagnosis of preterm labor, associated to acute bloody diarrhea (up to 10 daily motions) and cramping abdominal pain. A diagnosis of new-onset early-stage UC was made by sigmoidoscopy. An intensive care regimen including hydrocortisone, antibiotics and parenteral nutrition was immediately started. Magnetic resonance imaging of maternal abdomen, fostered by the worsening patient conditions, evidenced dilatation of the entire colon and a severely hampered of fetal muscular tone.Toxic megacolon complicated by superimposed Clostridium difficile infection was associated to a sudden fetal decompensation diagnosed by chance during maternal abdominal magnetic resonance imaging. An emergency cesarean section was mandatory. According to a senior surgeon's decision, total colectomy was not immediately performed following cesarean section with reference to the absence of colonic perforation. We obtained a good short-term maternal outcome and an uncomplicated neonatal course. Counseling of those patients must be focused on timely and multidisciplinary intervention in order to improve the course of maternal disease and to prevent fetal distress.

Incidence, features, in-hospital outcomes and predictors of in-hospital mortality associated with toxic megacolon hospitalizations in the United States

Toxic megacolon (TM) is a potentially fatal condition characterized by non-obstructive colonic dilatation and systemic toxicity. It is most commonly caused by inflammatory bowel disease (IBD). Limited data for TM are available demonstrating incidence, in-hospital outcomes and predictors of mortality. We sought to investigate incidence, characteristics, mortality and predictors of mortality associated with it. Data were obtained from the Healthcare Cost and Utilization Project (HCUP)'s Nationwide Inpatient Sample (NIS) database from January 2010 through December 2014. An analysis was performed on SAS 9.4 (SAS Institute Inc., Cary, NC). Patients below 18 years were excluded. A mixed-effects logistic regression model was developed to analyze predictors of mortality. Thus, 8139 (weighted) cases of TM were diagnosed between 2010 and 2014. TM is more prevalent in women (56.4%) than in men (43.6%), with a mean age of onset at 62.4 years, affecting whites (79.7%) more than non-whites. The most common reason for hospital admission included IBD (51.6%) followed by septicemia (10.2%) and intestinal infections (4.1%). Mean length of stay was 9.5 days and overall in-hospital mortality was 7.9%. Other complications included surgical resection of the large intestine (11.5%) and bowel obstruction (10.9%). Higher age, neurological disorder, coagulopathy, chronic pulmonary disease, heart failure, and renal failure were associated with greater risk of in-hospital mortality. TM is a serious condition with high in-hospital mortality. Management of TM requires an inter-disciplinary team approach with close monitoring. Patients with positive predictors in our study require special attention to prevent excessive in-hospital mortality.

Early Surgical Intervention for Acute Ulcerative Colitis Is Associated with Improved Postoperative Outcomes

BACKGROUND

Timing of surgical intervention for acute ulcerative colitis has not been fully examined during the modern immunotherapy era. Although early surgical intervention is recommended, historical consensus for "early" ranges widely. The purpose of this study was to evaluate outcomes according to timing of urgent surgery for acute ulcerative colitis.

METHODS

All non-elective total colectomies in ulcerative colitis patients were identified in the National Inpatient Sample from 2002 to 2014. Procedures, comorbidities, diagnoses, and in-hospital outcomes were collected using International Classification of Disease, 9th Revision codes. An operation was defined as early if within 24 hours of admission. Results were compared between the early versus delayed surgery groups.

RESULTS

We found 69,936 patients that were admitted with ulcerative colitis, and 2650 patients that underwent non-elective total colectomy (3.8%). Early intervention was performed in 20.4% of patients who went to surgery. More early operations were performed laparoscopically (28.1% versus 23.3%, p = 0.021) and on more comorbid patients (Charlson Index, p = 0.008). Median total hospitalization costs were $20,948 with an early operation versus $33,666 with a delayed operation (p < 0.001). Delayed operation was an independent risk for a complication (OR = 1.46, p = 0.001). Increased hospitalization costs in the delayed surgery group were statistically significantly higher with a reported complication (OR = 3.00, p < 0.001) and lengths of stay (OR = 1.26, p < 0.001).

CONCLUSION

Delayed operations for acute ulcerative colitis are associated with increased postoperative complications, increased lengths of stay, and increased hospital costs. Further prospective studies could demonstrate that this association leads to improved outcomes with immediate surgical intervention for medically refractory ulcerative colitis.

Large Bowel Obstruction in the Emergency Department: Imaging Spectrum of Common and Uncommon Causes

Although large bowel obstruction (LBO) is less common than small bowel obstruction, it is associated with high morbidity and mortality due to delayed diagnosis and/or treatment. Plain radiographs are sufficient to diagnose LBO in a majority of patients. However, further evaluation with multidetector computed tomography (MDCT) has become the standard of care to identify the site, severity, and etiology of obstruction. In this comprehensive review, we illustrate the various causes of LBO emphasizing the role of MDCT in the initial diagnosis and detection of complications along with the tips to differentiate from disease which can mimic LBO.

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.

The Surgical Treatment of Toxic Megacolon in Hirschsprung Disease

OBJECTIVES

Enterocolitis remains the most significant cause of morbidity and mortality in Hirschsprung disease (HD). It could progress into toxic megacolon (TM)-acute dilatation of the colon as accompanying toxic complication of Hirschsprung enterocolitis. It is a devastating complication, especially in infants with so far undiagnosed HD.

METHODS

A retrospective analysis of medical records of 4 infants with TM was performed. The diagnosis TM was determined on the basis of clinical information (abdominal pain or tenderness, abdominal distension, diarrhea, bloody diarrhea, and constipation), plain x-rays of the abdomen (segmental or total colonic dilation), and the presence of such criteria (fever, high heart rate, increased white blood cell count, C reactive protein, anemia, dehydration, electrolyte disturbances, hypotension). Surgical management and outcome was evaluated by retrospective chart review.

RESULTS

The median duration of symptoms characteristic for TM was 3 days. Toxic megacolon was seen as the first manifestation of previously unknown HD in 3 patients; in 1 newborn, the contrast radiograph was suggestive of HD. In all patients, conservative treatment was failed. Three patients were treated with surgical decompression and ileostomy only. In all these cases, severe complications occurred, consequently 2 of them died. In 1 patient, a resection of the transverse dilated colon additionally was performed. This patient had no complications in postoperative period and survived.

CONCLUSIONS

Because of the high mortality in patients with TM that were treated medically or with colonic decompression, a resection of massively distended part of the colon should be performed.

Campylobacter colitis: Rare cause of toxic megacolon

INTRODUCTION

Campylobacter is the leading cause of bacterial diarrhoeal illness worldwide. Toxic megacolon is a rare but potentially devastating complication.

PRESENTATION OF CASE

A 55year old female with liver cirrhosis, alcoholism and hepatitis C, presented with severe colitis and stool specimen positive for Campylobacter. She developed septic shock, multi-organ dysfunction syndrome and toxic megacolon unresponsive to medical therapy, and underwent a subtotal colectomy with end ileostomy. Despite initial improvement, the patient died on postoperative day 4.

DISCUSSION

Early surgical consultation is essential as toxic megacolon may be complicated by perforation or uncontrolled bleeding; progressive colonic dilatation with clinical deterioration is also an important indication for surgery.

CONCLUSION

Toxic megacolon should be considered in a patient with Campylobacter colitis who becomes critically unwell. Despite treatment, toxic megacolon is associated with a significant risk of mortality.

Predictive factors associated with adverse events in patients with toxic colitis: an analysis of the National Surgical Quality Improvement Project

BACKGROUND

Toxic colitis (TC) is a potentially lethal complication of inflammatory bowel disease and infectious colitis.

METHODS

The National Surgical Quality Improvement Project dataset was queried to identify emergent colectomy for a primary diagnosis of TC using International Classification of Diseases, Ninth Revision codes. The study endpoints were 30-day mortality and 30-day morbidity. We performed multivariate logistic regression analyses to study factors associated with 30-day mortality.

RESULTS

Of the 189 TC patients, mortality for colectomy was 26.5%, 42.3% experienced pulmonary complications, 20.6% experienced sepsis complications, 17.5% experienced cardiovascular complications, 12.7% experienced renal complications, and 14.8% experienced wound complications. On multivariate analysis, independent factors associated with mortality were age 70 to 80 years (odds ratio [OR] 3.5), age greater than 80 (OR 22.2), female sex (OR 4.1), uremia blood urea nitrogen greater than 40 (OR 4.1), coagulopathy international normalized ratio greater than 2 (OR 7.7), preoperative respiratory failure (OR 2.73), and preoperative steroid use (OR 3.9).

CONCLUSIONS

Patients with TC are very ill. Poor outcome is associated with older age, female sex, preoperative azotemia, preoperative respiratory failure, and chronic steroid use. These factors will help acute care surgeons in preoperative risk assessment and could be an important addition to decision-making strategies.

Colorectal emergencies and related complications: a comprehensive imaging review--imaging of colitis and complications

OBJECTIVE

Colorectal emergencies are a common presentation in the emergency medicine setting and their timely diagnosis plays a crucial role in avoiding dreaded complications. The quintessential role of a radiologist lies in identifying the cause, narrowing the differential diagnosis according to imaging features, and, most importantly, identifying the associated complications.

CONCLUSION

This review focuses on imaging features of the spectrum of colitides and the complications related to colitides.

Damage control surgery for abdominal emergencies

BACKGROUND

Damage control surgery is a management sequence initiated to reduce the risk of death in severely injured patients presenting with physiological derangement. Damage control principles have emerged as an approach in non-trauma abdominal emergencies in order to reduce mortality compared with primary definitive surgery.

METHODS

A PubMed/MEDLINE literature review was conducted of data available over the past decade (up to August 2013) to gain information on current understanding of damage control surgery for abdominal surgical emergencies. Future directions for research are discussed.

RESULTS

Damage control surgery facilitates a strategy for life-saving intervention for critically ill patients by abbreviated laparotomy with subsequent reoperation for delayed definitive repair after physiological resuscitation. The six-phase strategy (including damage control resuscitation in phase 0) is similar to that for severely injured patients, although non-trauma indications include shock from uncontrolled haemorrhage or sepsis. Minimal evidence exists to validate the benefit of damage control surgery in general surgical abdominal emergencies. The collective published experience over the past decade is limited to 16 studies including a total of 455 (range 3-99) patients, of which the majority are retrospective case series. However, the concept has widespread acceptance by emergency surgeons, and appears a logical extension from pathophysiological principles in trauma to haemorrhage and sepsis. The benefits of this strategy depend on careful patient selection. Damage control surgery has been performed for a wide range of indications, but most frequently for uncontrolled bleeding during elective surgery, haemorrhage from complicated gastroduodenal ulcer disease, generalized peritonitis, acute mesenteric ischaemia and other sources of intra-abdominal sepsis.

CONCLUSION

Damage control surgery is employed in a wide range of abdominal emergencies and is an increasingly recognized life-saving tactic in emergency surgery performed on physiologically deranged patients.

Infliximab in Crohn's disease-associated toxic megacolon

Refractory medical treatment of Crohn disease-associated toxic megacolon usually requires surgery, which carries substantial morbidity and mortality. We report a case of a woman with steroid and antibiotic-refractory fulminant Crohn colitis and ileitis, complicated by a toxic megacolon, who was successfully treated with infliximab. Infliximab induced rapid clinical response and remission, thereby avoiding emergency (ileo) colectomy. This is the first report of treatment of Crohn disease-associated toxic megacolon with infliximab.

Toxic megacolon

Toxic megacolon represents a dreaded complication of mainly inflammatory or infectious conditions of the colon. It is most commonly associated with inflammatory bowel disease (IBD), i.e., ulcerative colitis or ileocolonic Crohn's disease. Lately, the epidemiology has shifted toward infectious causes, specifically due to an increase of Clostridium difficile-associated colitis possibly due to the extensive (ab)use of broad-spectrum antibiotics. Other important infectious etiologies include Salmonella, Shigella, Campylobacter, Cytomegalovirus (CMV), rotavirus, Aspergillus, and Entameba. Less frequently, toxic megacolon has been attributed to ischemic colitis, collagenous colitis, or obstructive colorectal cancer. Toxic colonic dilatation may also occur in hemolytic-uremic syndrome (HUS) caused by enterohemorrhagic or enteroaggregative Escherichia coli O157 (EHEC, EAEC, or EAHEC). The pathophysiological mechanisms leading to toxic colonic dilatation are incompletely understood. The main characteristics of toxic megacolon are signs of systemic toxicity and severe colonic distension. Diagnosis is made by clinical evaluation for systemic toxicity and imaging studies depicting colonic dilatation. Plain abdominal imaging is still the most established radiological instrument. However, computed tomography scanning and transabdominal intestinal ultrasound are promising alternatives that add additional information. Management of toxic megacolon is an interdisciplinary task that requires close interaction of gastroenterologists and surgeons from the very beginning. The optimal timing of surgery for toxic megacolon can be challenging. Here we review the latest data on the pathogenesis, clinical presentation, laboratory, and imaging modalities and provide algorithms for an evidence-based diagnostic and therapeutic approach.

Toxic megacolon associated Clostridium difficile colitis

Toxic megacolon is a severe complication of Clostridium difficile (C. difficile) colitis. As the prevalence of C. difficile colitis increases and treatments become more refractory, clinicians will encounter more patients with C. difficile associated toxic megacolon in the future. Here, we review a case of toxic megacolon secondary to C. difficile colitis and review the current literature on diagnosis and management. We identify both clinical and radiologic criteria for diagnosis and discuss both medical and surgical options for management. Ultimately, we recommend using the Jalen criteria in conjunction with daily abdominal radiographs to help establish the diagnosis of toxic megacolon and to make appropriate treatment recommendations. Aggressive medical management using supportive measures and antibiotics should remain the mainstay of treatment. Surgical intervention should be considered if the patient does not clinically improve within 2-3 d of initial treatment.

Toxic megacolon from hypervirulent Clostridium difficile infection (ribotype 027) following elective total knee replacement: an emerging challenge in modern health care

We present a rare case of community acquired (presenting in hospital on the day of admission or within 48 h of admission) Clostridium difficile infection (CDI) with the hypervirulent (ribotype 027) strain causing toxic megacolon in a patient, diagnosed on the third postoperative day following an elective total knee replacement. The patient did not have any of the commonly reported risk factors for CDI. The source of sepsis was initially presumed to be the operated prosthetic joint, and this caused a delay in the correct diagnosis and institution of appropriate antimicrobial treatment which may have contributed to a poorer outcome. This case highlights the risk of patients arriving from the community manifesting life threatening CDI in the hospital.

Operative management of Crohn's disease of the colon including anorectal disease

Evaluation and management of the patient who has Crohn's disease of the colon, rectum, and anus is challenging for even the most experienced provider. Because of its broad spectrum of presentation, recurrent nature, and potential for high morbidity, the surgeon needs to not only treat the acute situation but also keep in mind the potential long-term ramifications. Although there are exciting new medications and treatment modalities yielding promising results, surgery continues to remain at the forefront for the care of these patients. This article reviews various surgical options for the patient who has Crohn's disease of the colon, rectum, and perianal region with emphasis on symptomatic resolution and optimization of function.