Toxic megacolon: a potentially lethal condition. Case report.

Toxic megacolon denotes an abrupt non-obstructive distension of the colon, accompanied by systemic signs of toxicity. Mortality rates can soar as high as 7.9%. While primarily linked with chronic bowel conditions, the incidence attributed to Clostridioides difficile has surged due to the indiscriminate use of broad-spectrum antibiotics. Surgical intervention becomes necessary in the majority of cases. Herein, we illustrate the case of a 50-year-old female presenting with episodic epigastric pain lasting 9 h, vomiting, and watery bowel movements, devoid of peritoneal irritation findings and lacking a history of chronic intestinal inflammation. Under certain circumstances, toxic megacolon may manifest atypically, underscoring the importance of conducting a comprehensive medical history and clinical assessment. Moreover, it is imperative to solicit pertinent paraclinical investigations to address the patient holistically and foster a favorable clinical outcome.

Megacolon tóxico: A propósito de un caso / Toxic Megacolon. Case Report

RESUMEN El megacolon tóxico es una enfermedad mortal, que se presenta, con mayor frecuencia, como una complicación de la inflamación intestinal, infecciones e isquemia intestinal. Se caracteriza por la presencia de diarrea sanguinolenta, distensión abdominal, signos de toxicidad sistémica y, en estudios de imagen, se observa dilatación colónica segmentaria. Para el diagnóstico, según los criterios de Jalan, se tiene en cuenta la dilatación colónica más de 6 cm, tres de los siguientes: fiebre, taquicardia, leucocitosis o anemia, y cualquiera de los siguientes criterios: hipotensión, hipovolemia, trastorno electrolítico y estado mental alterado. En este artículo, se presenta el caso de una paciente mujer que ingresa por cuadro de dolor abdominal y diarrea crónica con estudio de imagen, en la que se visualiza dilatación de todo el marco colónico. Se realizan los estudios correspondientes y se diagnostica megacolon tóxico por colitis ulcerativa, por lo que recibe tratamiento médico con evolución favorable. Es dado de alta y reingresa por shock séptico, se realizan estudios y se identifica infección por Clostridium difficile. Se inicia tratamiento antibiótico, pero presenta evolución desfavorable, lo que ocasionó el fallecimiento de la paciente. El presente caso representa la alta mortalidad de esta enfermedad.

ABSTRACT Toxic megacolon is a fatal disease, most commonly occurring as a complication of inflammatory bowel disease, infections, and intestinal ischemia. It is characterized by the presence of bloody diarrhea, abdominal distension, signs of systemic toxicity, and segmental colonic dilation is observed in imaging studies. For the diagnosis, according to the Jalan criteria, colonic dilation of more than 6 cm is taken into account, three of the following: fever, tachycardia, leukocytosis or anemia, and any of the following criteria: hypotension, hypovolemia, electrolyte disorder and altered mental status. This article presents the case of a female patient who was admitted with abdominal pain and chronic diarrhea with an imaging study showing dilation of the entire colonic framework. The corresponding studies were carried out which indicated that she had a toxic megacolon due to colitis. ulcerative, receives medical treatment with favorable evolution, is discharged and readmitted for septic shock, studies are performed and Clostridium difficile infection is identified, antibiotic treatment is started but the evolution is unfavorable, which caused the death of the patient. The present case represents the high mortality of this disease.

Megacolon tóxico: peritonitis fecaloidea por colitis amebiana. Reporte de un caso y revisión de literatura / Toxic megacolon: fecaloid peritonitis caused by amebic colitis. Report of a case and literature review

Introducción: La amebiasis es una enfermedad causada por el parásito Entamoeba histolytica, y condiciona importantes tasas de afectación a escala global. Una de las complicaciones de la colitis amebiana es el megacolon tóxico, el cual se caracteriza por la dilatación colónica y signos de toxicidad sistémica. Aunque poco frecuente, el megacolon tóxico es considerado letal.Caso clínico : se trata de paciente femenino de 26 años, quien consulta por presentar dolor abdominal generalizado, de fuerte intensidad, tipo cólico, acompañado de náuseas y múltiples episodios eméticos. Al examen físico se precisó hemodinámicamente estable, sin signos de irritación peritoneal, por lo que es ingresada con diagnóstico de colitis amebiana. Se instaura manejo médico y es egresada por mejoría clínica. Luego de 7 días, es readmitida por deterioro clínico y distensión abdominal, realizándose diagnóstico de megacolon tóxico. Mediante laparotomía de emergencia se observa peritonitis fecaloidea difusa y perforación del ciego, se realiza hemicolectomía derecha e ileostomía terminal. Posteriormente, presenta absceso intraabdominal que fue drenado por vía percutánea. Conclusión : el megacolon tóxico es una patología infrecuente que surge como complicación de entidades como la colitis amebiana. En la actualidad, a pesar de los avances tecnológicos que han desencadenado importantes progresos en el ámbito sanitario, el diagnóstico del megacolon tóxico continúa representando un desafío para el profesional médico, por lo que la sospecha clínica es ineludible y determinante en el diagnóstico acertado y oportuno, que permiten la instauración de la terapéutica apropiada y reducción de la morbilidad y mortalidad que de esta se derivan(AU)

Introduction: Amebiasis is a disease caused by the parasite Entamoeba histolytica, and causes significant rates of infection on a global scale. One of the complications of amoebic colitis is toxic megacolon, which is characterized by colonic dilation and signs of systemic toxicity. Although rare, toxic megacolon is considered lethal. Clinical case: this is a 26-year-old female patient, who consults due to generalized abdominal pain, of strong intensity, colic type, accompanied by nausea and multiple emetic episodes. On physical examination she was found to be hemodynamically stable, with no signs of peritoneal irritation, so she was admitted with a diagnosis of amoebic colitis. Medical management was established and she was discharged due to clinical improvement. After 7 days, she was readmitted due to clinical deterioration and abdominal distention, and a diagnosis of toxic megacolon was made. Through emergency laparotomy, diffuse fecaloid peritonitis and perforation of the cecum were observed; right hemicolectomy and terminal ileostomy were performed. Subsequently, she developed an intra-abdominal abscess that was drained percutaneously. Conclusion: toxic megacolon is a rare pathology that arises as a complication of entities such as amoebic colitis. Currently, despite the technological advances that have triggered important progress in the healthcare field, the diagnosis of toxic megacolon continues to represent a challenge for the medical professional, which is why clinical suspicion is unavoidable and decisive in an accurate and timely diagnosis, which allow the establishment of appropriate therapy and reduction of the morbidity and mortality that arise from it(AU)

Colitis ulcerosa en paciente con enfermedad celiaca silente

RESUMEN Se presenta caso de mujer con enfermedad celiaca que presentó colitis ulcerosa complicada con megacolon tóxico. El cuadro revirtió con inmunosupresores y tratamiento médico. Se sugiere a los médicos la búsqueda activa de enfermedades autoinmunes asociadas, además del diagnóstico precoz y tratamiento oportuno de la enfermedad celiaca para evitar complicaciones.

ABSTRACT We present case of a woman with celiac disease who presented ulcerative colitis complicated with toxic megacolon. The condition reversed with immunosuppressants and medical treatment. Physicians are advised to actively search for associated autoimmune diseases, as well as early diagnosis and timely treatment of celiac disease to avoid complications.

RESUMO Apresentamos o caso de uma mulher com doença celíaca que apresentou colite ulcerosa complicada com megacolo tóxico. A condição foi revertida com imunossupressores e tratamento médico. Os médicos são aconselhados a pesquisar ativamente as doenças autoimunes associadas, além do diagnóstico precoce e do tratamento oportuno da doença celíaca para evitar complicações.

Treatment of acute severe ulcerative colitis using accelerated infliximab regimen based on infliximab trough level: A case report.

BACKGROUND: Acute severe ulcerative colitis (ASUC) is a complication of ulcerative colitis associated with high levels of circulating tumor necrosis factor alpha, due to the intense inflammation and faster stool clearance of anti-tumor necrosis factor drugs. Dose-intensified infliximab treatment can be beneficial and is associated with lower rates of colectomy. The aim of the study was to present a case of a patient with ASUC and megacolon, treated with hydrocortisone and accelerated scheme of infliximab that was monitored by drug trough level. CASE SUMMARY: A 22-year-old female patient diagnosed with ulcerative colitis, presented with diarrhea, rectal bleeding, abdominal pain, vomiting, and distended abdomen. During investigation, a positive toxin for Clostridium difficile and colonic dilatation of 7 cm consistent with megacolon were observed. She was treated with oral vancomycin for pseudomembranous colitis and intravenous hydrocortisone for severe colitis, which led to the resolution of megacolon. Due to the persistent severe colitis symptoms, infliximab 5 mg/kg was prescribed, monitored by drug trough level (8.8 µg/mL) and fecal calprotectin of 921 µg/g (< 30 µg/g). Based on the low infliximab trough level after one week from the first infliximab dose, the patient received a second infusion at week 1, consistent with the accelerated regimen (infusions at weeks 0, 1, 2 and 6). We achieved a positive clinical and endoscopic response after 6 mo of therapy, without the need for a colectomy. CONCLUSION: Infliximab accelerated infusions can be beneficial in ASUC unresponsive to the treatment with intravenous corticosteroids. Longitudinal studies are necessary to define the best therapeutic drug monitoring and treatment regimen for these patients.

Megacolon tóxico en paciente con COVID-19 / Toxic megacolon in a patient with Covid-19

Introducción: La pandemia derivada de la enfermedad por el nuevo coronavirus 2019 (COVID-19) se ha convertido en una emergencia de salud pública mundial, debido a que puede desarrollar complicaciones que amenazan la vida. Si bien se sabe que el SARS-CoV-2 causa enfermedad pulmonar sustancial, se han observado muchas manifestaciones extrapulmonares, incluyendo el compromiso del sistema gastrointestinal. El megacolon tóxico es una complicación rara pero, potencialmente, mortal que se asocia más con la enfermedad inflamatoria intestinal. Sin embargo, cualquier afección que conduzca a la inflamación del colon puede conducir a una dilatación tóxica. Objetivo: Se presenta el caso de un paciente con un síndrome de dificultad respiratoria aguda secundario a una infección por SARS-COV-2. De manera concomitante presentó un cuadro de dilatación no obstructiva del colon, asociado con toxicidad sistémica. Caso clínico: El desarrollo de megacolon tóxico en un paciente con SARS-COV-2 puede estar justificado debido a que el virus infecta las células huésped a través del receptor de la enzima convertidora de angiotensina 2. Se cumplieron los criterios diagnósticos para megacolon tóxico. Conclusiones: Esta también se encuentra altamente expresada en las células epiteliales intestinales, por lo tanto, se debe considerar su diagnóstico oportuno para una intervención temprana, en aras de reducir la tasa de mortalidad tanto como sea posible(AU)

Introduction: The pandemic derived from the 2019 novel coronavirus disease (COVID-19) has become a global public health emergency, due to the fact that it can develop life-threatening complications. Although SARS-CoV-2 is known to cause substantial lung disease, many extra-pulmonary manifestations have been observed, including involvement of the gastrointestinal system. Toxic mega colon is a rare but life-threatening complication most associated with inflammatory bowel disease. However, any condition that leads to inflammation of the colon can lead to toxic dilation. Objective: To report the case of a patient with ARDS secondary to a SARS-COV-2 infection. Concomitantly, she had non-obstructive dilation of the colon, associated with systemic toxicity. Clinical case report: The development of toxic mega colon in a patient with SARS-COV-2 may be justified because the virus infects host cells through the angiotensin-converting enzyme 2 receptor. The diagnostic criteria for toxic megacolon were met. Conclusions: It is also highly expressed in intestinal epithelial cells, therefore, its timely diagnosis should be considered for early intervention, in order to reduce the mortality rate as much as possible(AU)

Megacolon tóxico de origen idiopático: reporte de caso / Megacolon toxic of idiophatic origin: case report

Resumen El megacolon tóxico (MT) es una patología con una tasa de mortalidad superior al 80% desencadenada por un proceso inflamatorio progresivo que compromete la pared del colon con dilatación secundaria de la luz intestinal debido a procesos inflamatorios o infecciosos. Su presentación clínica es infrecuente y los pilares básicos en su manejo son un diagnóstico oportuno, un manejo médico adecuado (antibiótico, reanimación hídrica y corrección metabólica) y, de ser necesario, un manejo quirúrgico eficaz que evite al máximo las complicaciones que empeoran el pronóstico de los pacientes. En este artículo se presenta un caso de una paciente con choque séptico secundario a MT, con desenlace fatal y con sospecha de un cuadro de colangitis grado III descartado por ecografía, lo cual generó distorsiones en su enfoque y manejo inicial. Por deterioro clínico y distensión abdominal, la paciente se llevó a laparoscopia diagnóstica en la que se evidenció un compromiso isquémico severo de todo el colon sin compromiso de intestino delgado, razón por la que se le realizó una colectomía total. El reporte de patología y la historia clínica descartan colitis ulcerativa o enfermedad de Crohn, lo que confirmó el MT. La paciente no presentaba factores de riesgo para el desarrollo de colitis pseudomembranosa. Se concluyó que fue la presentación de un caso de MT idiopático.

Abstract Toxic megacolon is a pathology whose mortality rate is over 80%. A progressive inflammatory process compromises the colon wall, and secondary dilation of the intestinal lumen occurs due to inflammatory or infectious processes. Its clinical presentation is bizarre. but the basic pillars for management are opportune diagnosis and adequate medical management with antibiotics, water resuscitation, and metabolic correction. If necessary, effective surgical management can prevent the development of complications that worsen the disease and the prognosis of a patient. In this article we present the case of a patient who died after developing septic shock secondary to toxic megacolon. Cholangitis grade III was suspected, but discarded after ultrasonography, and this resulted in generated distortions in approach and initial management. Due to clinical deterioration and abdominal distension, the patient underwent diagnostic laparoscopy which revealed severe ischemic compromise of the entire colon but without involvement of the small intestine. For this reason, a total colectomy was performed. The pathology report and clinical history ruled out ulcerative colitis or Crohn's disease which confirmed the diagnosis of toxic megacolon. The patient had no risk factors for the development of pseudomembranous colitis. We conclude that this was a case of idiopathic toxic megacolon.

Present and past perspectives on Clostridium difficile infection. / Perspectivas históricas y vigentes sobre la infección por Clostridium difficile.

Clostridium difficile is a Gram-positive bacillus that has become one of the main hospital-acquired human gastrointestinal infections in recent years. Its incidence is on the rise, involving more virulent strains, affecting new and previously uncontemplated groups of patients, and producing changes in clinical presentation and treatment response that influence disease outcome. Early diagnosis and disease stratification based on the severity of C.difficile infection are essential for therapeutic management and the implementation of containment measures. However, the speed at which new strains with greater pathogenicity are developing is surpassing that of the development of new drugs, making it necessary to validate other therapeutic options. The present article is a review of the epidemiologic, pathophysiologic, diagnostic, and therapeutic aspects of C.difficile infection, from its first isolation to the present date, that aims to contribute to the preparation of general physicians and specialists, so that patients with this infection receive opportune and quality medical attention.

Management of acute severe ulcerative colitis: a clinical update / Manejo da colite ulcerativa aguda grave: atualização terapêutica

ABSTRACT Introduction: Acute severe colitis is a potentially lethal medical emergency and, even today, its treatment remains a challenge for clinicians and surgeons. Intravenous corticoid therapy, which was introduced into the therapeutic arsenal in the 1950s, continues to be the first-line treatment and, for patients who are refractory to this, the rescue therapy may consist of clinical measures or emergency colectomy. Objective: To evaluate the indications for and results from drug rescue therapy (cyclosporine, infliximab and tacrolimus), and to suggest a practical guide for clinical approaches. Methods: The literature was reviewed using the Medline/PubMed, Cochrane library and SciELO databases, and additional information from institutional websites of interest, by cross-correlating the following keywords: acute severe colitis, fulminating colitis and treatment. Results: Treatments for acute severe colitis have avoided colectomy in 60-70% of the cases, provided that they have been started early on, with multidisciplinary follow-up. Despite the adverse effects of intravenous cyclosporine, this drug has been indicated in cases of greater severity with an imminent risk of colectomy, because of its fast action, short half-life and absence of increased risk of surgical complications. Therapy using infliximab has been reserved for less severe cases and those in which immunosuppressants are being or have been used (AZA/6-MP). Indication of biological agents has recently been favored because of their ease of therapeutic use, their good short and medium-term results, the possibility of maintenance therapy and also their action as a "bridge" for immunosuppressant action (AZA/6-MP). Colectomy has been reserved for cases in which there is still no response five to seven days after rescue therapy and in cases of complications (toxic megacolon, profuse hemorrhage and perforation). Conclusion: Patients with a good response to rescue therapy who do not undergo emergency operations should be considered for maintenance therapy using azathioprine. A surgical procedure is indicated for selected cases.

RESUMO Racional: A colite aguda grave é emergência médica, potencialmente letal e o seu tratamento permanece ainda nos dias de hoje um desafio para o clínico e cirurgião. A corticoterapia intravenosa introduzida no arsenal terapêutico na década de 50 permanece como primeira linha de tratamento, e nos pacientes refratários a tal medida, a terapia de resgate pode ser com medidas clínicas ou colectomia de urgência. Objetivo: Avaliar os resultados da terapia de resgate medicamentosa (ciclosporina, infliximabe e tracolimus), suas indicações e resultados, e sugerir um guia prático para abordagem clínica. Métodos: Foi realizada revisão na literatura utilizando as bases Medline/Pubmed, Cochrane Library, Scielo, e informações adicionais em sites institucionais de interesse cruzando os descritores: colite aguda grave, colite fulminante e tratamento. Resultados: O tratamento da colite aguda grave tem evitado a colectomia em 60- 70% dos casos, desde que iniciado precocemente e com acompanhamento multidisciplinar. A ciclosporina intravenosa apesar de seus efeitos adversos, tem sido indicada naqueles casos mais graves com risco iminente de colectomia, pela sua rapidez de ação, meia-vida curta, e não aumentar os riscos de complicações cirúrgicas. A terapia com infliximabe tem sido reservada para os casos menos graves e naqueles em uso ou já expostos a imunossupressores (AZA/6-MP). A facilidade terapêutica, seus bons resultados a curto e médio prazo, a possibilidade de terapia de manutenção e também por agir como "ponte" para ação de imunossupressores (AZA/6-MP) tem recentemente favorecido a indicação de biológicos. A colectomia fica reservada para casos que não apresentaram resposta a terapia de resgate após cinco a sete dias de tratamento e nas complicações (megacólon tóxico, hemorragia profusa e perfuração). Conclusõe s: Os pacientes com boa resposta à terapia de resgate e não submetidos à operações de urgência, deverão ser considerados para terapia de manutenção com azatioprina, sendo procedimento cirúrgico indicado para casos selecionados.

[Frequency, clinical evolution and prognosis of toxic megacolon]. / Frecuencia, evolución clínica y pronóstico del megacolon tóxico.

INTRODUCTION: Toxic megacolon (MT) is a potentially lethal complication of inflammatory, ischemic and infectious colitis. Usually it is related to ulcerative nonspecific colitis or Crohn disease. Recently it has been observed an increased in pseudomembranous colitis as cause of TM. The aim of this study is to describe the frequency, clinical evolution and prognosis of patients with TM. METHODS: Retrospective study, from January 2009 to January 2014 1500 patients were hospitalized in the Department of Coloproctology. We included 13 of 1500 patients with diagnosis of TM according to Jalan criteria and surgically corroborated. To determine the averages descriptive statistics was used. RESULTS: We studied 13 patients with TM (79.9% male and 20.1% female), the average age was 47.69±18.3 years. The most frequently associated diseases were: nonspecific ulcerative colitis (30.8%), pseudomembranous colitis (30.8%), neutropenic colitis (23.1%), Crohn Disease (7.7%) and ischemic colitis (7.7%). Subtotal colectomy plus terminal ileostomy was done in 84.6%, extended right hemicolectomy with ileostomy plus mucous fistula in 7.7% and extended right hemicolectomy with ileostomy plus Hartmann pouch in 7.7%. The mortality was 61.5%. The prevalence in the 5 years was 13 of 1500 (0.86%) patients. CONCLUSIONS: The prevalence of TM is low with a high mortality. A prompt diagnosis and treatment can improve the poor prognosis in these patients.

Introducción: el megacolon tóxico (MT) es una complicación potencialmente mortal de la colitis infl amatoria, isquémica e infecciosa. Usualmente se relaciona con la colitis ulcerosa inespecífica y la colitis de Crohn. Recientemente, se ha observado un repunte de la colitis pseudomembranosa como causa del MT. El objetivo fue describir la frecuencia, evolución clínica y pronóstico de los pacientes con MT.Métodos: estudio retrospectivo de enero de 2009 a enero de 2014 se hospitalizaron 1500 pacientes en el departamento de Coloproctología. De estos pacientes, se incluyeron a 13 de ellos con diagnóstico de MT de acuerdo a los criterios de Jalan y corroborados por cirugía. Se utilizó estadística descriptiva.Resultados: se estudiaron 13 pacientes con MT. Las enfermedades más frecuentemente asociadas al MT fueron: colitis ulcerosa inespecífica, colitis pseudomembranosa y colitis neutropénica, enfermedad de Crohn y colitis isquémica. En el 84.6 % se realizó colectomía subtotal más ileostomía terminal; hemicolectomía derecha extendida con ileostomía más fístula mucosa en el 7.7 %, y hemicolectomía derecha extendida con ileostomía más bolsa de Hartmann en el 7.7 %. La mortalidad fue del 61.5 %. La prevalencia en los 5 años fue de 13/1500 pacientes (0.86 %).Conclusiones: la prevalencia del MT es baja, con alta mortalidad. El diagnóstico y tratamiento oportunos puede mejorar el mal pronóstico de estos pacientes.