[Toxic Megacolon: A rare complication of chronic constipation. Three Pediatric Cases]. / Megacolon Tóxico: Complicación infrecuente de la constipación crónica. A propósito de 3 casos pediátricos.

INTRODUCTION: Chronic constipation is a frequent pathology in the pediatric age that affects the quality of life of pa tients and their families. Its management is usually complex and long associated with poor adheren ce. Toxic megacolon is a serious, potentially lethal disease when chronic constipation is left untreated or poor adherence to treatment. OBJECTIVE: To report 3 pediatric cases of toxic megacolon as a com plication of poorly managed chronic constipation. CLINICAL CASES: Three males patients, aged 6 to 13 years, with a history of chronic constipation and poor adherence to treatment are discussed. They were admitted to the emergency department with clinical findings of toxic megacolon (intestinal dilation and signs of systemic toxicity). Given their condition, all patients required management in the critical patient unit (CPU) and early surgical intervention, undergoing ostomy. All presented fa vorable outcome, performing stoma reversal surgery between 8-24 months later. In all cases, organic cause of the constipation was ruled out. CONCLUSIONS: Toxic megacolon is an infrequent but highly morbid and potentially lethal disease. It requires a high index of suspicion as well as multidisciplinary medical-surgical management.

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.

Acute primary abdominal compartment syndrome due to Clostridium difficile induced toxic megacolon: a case report and review of the literature.

BACKGROUND: Without timely diagnosis, acute primary abdominal compartment syndrome (ACS) is a potentially fatal syndrome and often goes unrecognized until severe symptoms appear. Early diagnosis may significantly improve the prognosis of these patients. CASE PRESENTATION: We present the case of a 54-year-old man, successfully treated for acute myeloid leukemia with cytosine arabinoside, admitted to the intensive care unit with severe shock, refractory to standard therapy with antibiotics, fluid resuscitation, and vasopressors. Early diagnosis of acute primary abdominal syndrome was made based on an intra-abdominal pressure of 20 mm Hg (3 kPa) with new onset organ failure, after which decompressive laparotomy was performed. Stool cultures grew Clostridium difficile. Despite abdominal decompression, the abdominal compartment syndrome persisted with the development of toxic megacolon and a total colectomy was performed with favorable evolution. METHODS: A systematic review of published case reports was performed describing a primary ACS due to C. difficile toxic megacolon. A PubMed database search was performed with the following search terms, single or in combination: 'clostridium difficile', 'toxic megacolon', 'abdominal compartment syndrome', and 'CDI'. The latest search was performed for March 2019; only case reports after 1998 were included. RESULTS: We found a total of 19 case reports with C. difficile toxic megacolon (including the present case). The male/female ratio was 12/7, and there were 3 children. The mean age was 48.7 ± 23.5 years. The reason for admission was sepsis in 6, trauma in 2, postoperative in 4, enterocolitis in 5, pregnancy in 1 and abdominal complaints after topical antibiotics in 1. Three patients did not develop diarrhea. Five patients presented with diarrhea on average 5.8 ± 5.1 (median 4, 1-14) days prior to hospital admission while 7 patients developed diarrhea on average after 10 ± 19.6 (median 3, 0-54) days during admission. The intra-abdominal pressure (measured in 6 patients, including ours) was 29.2 ± 11 (20-50) mm Hg (3-7 kPa). Treatment consisted of (a combination of) vancomycin (orally or via rectal enemas), metronidazole (orally or intravenously), and surgical intervention (with decompressive laparotomy). Three patients died (15.8%). CONCLUSIONS: Monitoring of intra-abdominal pressure allows early detection of abdominal compartment syndrome and is warranted in patients with C. difficile infection and/or toxic megacolon. Early decompression can lead to improved outcomes in patients with severe shock and organ failure.

[Inflammatory bowel disease: cardinal signs and their diagnostics]. / Chronisch entzündliche Darmerkrankungen: Leitsymptome und Diagnostik.

Inflammatory bowel diseases, including Crohn's disease and ulcerative colitis, often occur early in life. Therefore, they affect our patient's individual path of life, their ability to work and the quality of life tremendously, which calls for close and comprehensive medical care. This article features 5 cardinal signs and their diagnostics.

Shigellosis and toxic megacolon secondary to Shigella flexneri serotype 3a: The challenges of laboratory diagnosis.

We present a rare case of Shigella flexneri bacteraemia and toxic megacolon, and discuss the challenges of conventional laboratory techniques versus molecular PCR platforms in differentiating between Shigella species and Escherichia coli.

[Clostridium difficile infection : What is currently available for treatment?] / Clostridium-difficile-Infektion : Was ist gesichert in der Therapie?

Clostridium difficile (C. difficile) is an anaerobic, Gram-positive, spore-forming, toxin-secreting bacillus. It is transmitted via a fecal-oral route and can be found in 1-3 % of the healthy population. Symptoms caused by C. difficile range from uncomplicated diarrhea to a toxic megacolon. The incidence, frequency of recurrence, and mortality rate of C. difficile infections (CDIs) have increased significantly over the past few decades. The most important risk factor is antibiotic treatment in elderly patients and patients with severe comorbidities. There is a screening test available to detect C. difficile-specific glutamate dehydrogenase (GDH), which is produced by both toxigenic and non-toxigenic strains. To confirm CDIs, it is necessary to test for toxins in a fresh, liquid stool sample via polymerase chain reaction or an enzyme-coupled immune adsorption test. If CDIs are diagnosed, then ongoing antibiotic treatment should be ended. Metronidazole is used to treat mild cases, and vancomycin is recommended for severe cases. Vancomycin or fidaxomicin should be used to treat recurrences (10-25 % of patients). In cases with several recurrences, a treatment option is fecal microbiome transfer (FMT). The cure rate following FMT is approximately 80 %. The treatment of severe and complicated CDI with a threatening toxic megacolon remains problematic. The degree of evidence of medicated treatment in this situation is low; the significance of metronidazole i. v. as an additional therapeutic measure is controversial. Tigecycline i. v. is an alternative option. Surgical treatment must be considered in patients with a toxic megacolon or an acute abdomen.

Self-Administered Home Series Fecal "Minitransplants" for Recurrent Clostridium difficile Infection on a Rectal Remnant.

A fecal microbiota transplant has proved to be an extremely effective method for patients with recurrent infections with Clostridium difficile. We present the case of a 65-year-old female patient with multiple Clostridium difficile infection (CDI) relapses on the rectal remnant, post-colectomy for a CDI-related toxic megacolon. The patient also evidenced associated symptomatic Clostridium difficile vaginal infection. She was successfully treated with serial fecal "minitransplants" (self-administered at home) and metronidazole ovules.

[Toxic megacolon]. / Das toxische Megakolon.

BACKGROUND: Toxic megacolon constitutes a feared, life-threatening complication of severe intestinal inflammation and is a challenge for interdisciplinary medical care. OBJECTIVES: Specific aspects of conservative treatment based on current scientific evidence derived from guidelines, qualified reviews, and scientific studies are presented, which provide a rational approach and maximize therapeutic success. MATERIALS AND METHODS: This work is based on a selective literature review and the authors' experience of many years in gastroenterology and intensive care. RESULTS: Toxic megacolon requires a rapid interdisciplinary assessment. Depending on the underlying etiology, an individual treatment concept needs to be developed. If an infectious or inflammatory cause is probable, a conservative approach can reduce perioperative morbidity and mortality. A step-wise approach with controlled reevaluations of the response to therapy after 72 h and 7 days avoids uncontrolled delay of surgical options further ensuring patient safety. CONCLUSION: Despite a decreasing incidence of toxic megacolon, it remains an interdisciplinary therapeutic challenge.

Fulminant ulcerative colitis in a healthy pregnant woman.

This case report concerns a 25-year-old patient with 6-7 bloody stools/d, abdominal pain, tachycardia, and weight loss occurring during the third trimester of pregnancy. Severe ulcerative colitis complicated by toxic megacolon and gravidic sepsis was diagnosed by clinical evaluation, colonoscopy, and rectal biopsy that were performed safely without risk for the mother or baby. The patient underwent a cesarean section at 28+6 wk gestation. The baby was transferred to the neonatal intensive care unit of our hospital and survived without complications. Fulminant colitis was managed conservatively by combined colonoscopic decompression and medical treatment. Although current European guidelines describe toxic megacolon as an indication for emergency surgery for both pregnant and non-pregnant women, thanks to careful monitoring, endoscopic decompression, and intensive medical therapy with nutritional support, we prevented the woman from having to undergo emergency pancolectomy. Our report seems to suggest that conservative management may be a helpful tool in preventing pancolectomy if the patient's condition improves quickly. Otherwise, surgery is mandatory.

[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.

Toxic megacolon and human Cytomegalovirus in a series of severe ulcerative colitis patients.

BACKGROUND: Human Cytomegalovirus (HCMV) infection has been reported to be a cause of refractory ulcerative colitis (UC). Toxic megacolon (TM) is a rare but severe complication of an acute attack of UC. OBJECTIVES: Aim of this study is to evaluate in a case-control study the association between HCMV and TM. STUDY DESIGN: All patients who were admitted at Medicine Department of V. Cervello Hospital in Palermo (tertiary referral center) for a severe UC flare-up complicated by the onset of TM (diameter of the transverse colon>6 cm) between January 1990 and November 2011 were identified through the electronic database. A total of 24 consecutive patients (16 male/8 female) with TM were identified. Each case of TM were individually matched by sex, age, extent of the underlying disease to 24 severe UC controls who did not develop TM. A further non matched control population of 48 severe UC was included. Haematoxilin and eosin stain, immunohistochemical procedure and nested polymerase chain reaction were performed to detect HCMV genes and proteins on rectal biopsies or surgical specimens. Pp65 antigenemia was performed in order to diagnose any possible systemic infection. HCMV frequency was compared between patients with and without TM during follow-up, using Fisher's Exact test. RESULTS AND CONCLUSIONS: HCMV was detected in histological specimens of 11 patients (46%) with TM compared to 2 (9%) severe UC matched controls (P = 0.0078) and 7 (14%) unmatched controls (p = 0,003). In severe colitis the presence of HCMV is more frequently associated with TM.

A young leukemic patient with unusual catastrophic intestinal complication.

A 14-year-old child with acute lymphoblastic leukemia who had completed induction chemotherapy presented with fever and diffuse musculoskeletal pains which was thought to be a constellation of myositis, arthralgias and arthritis. Investigations revealed initially showed normal peripheral blood counts but had pancytopenia and pre-terminally blasts were seen in the peripheral blood smear. He had bone marrow necrosis. Disseminated intravascular coagulation was suspected with a positive fungal serology. At autopsy, he had evidence of disease relapsed in lymph nodes, liver, spleen, testes and kidneys. There was extensive pseudomembranous colitis and appendicitis with changes of toxic megacolon.

Oral tacrolimus for megacolon in patients with severe ulcerative colitis.

Toxic megacolon is an infrequent but life-threatening complication that occurs most commonly in patients with severe ulcerative colitis. Intravenous steroids are often recommended for patients with toxic megacolon secondary to ulcerative colitis. However, steroid dependency may mask the presence of intra-abdominal sepsis and is associated with refractoriness, during which cytomegalovirus reactivation may occur. In this report, we present two rare cases of megacolon accompanying pancolonic severe ulcerative colitis that were successfully treated with oral tacrolimus, including one steroid-naïve patient. In cases of ulcerative colitis with megacolon, treatment with oral tacrolimus is recommended, thereby avoiding steroid dependency and improving the long-term prognosis.

Toxic megacolon in ulcerative rectocolitis. Current trends in clinical evaluation, diagnosis and treatment.

Toxic megacolon is a clinical condition associated to high risk of colonic perforation, that significantly increases--even triplicates--the megacolon-related mortality when causing diffuse peritonitis. Abdominal and pelvic helical CT scan proved to be a fundamental diagnostic tool, in defining the colic dilatation and perforation. Conservative treatment is initially indicated in the event of toxic megacolon arising at the onset of a severe or toxic colitis. However it should be avoided when the toxic megacolon appears on corticosteroid therapy. Non operative management must not exceed 48 hours. The rationale of this strategy lies on the fact that early surgery is burdened by a mortality rate that, although moderate, is still higher than medical treatment. Nevertheless, successful conservative management does not exempt from surgery, which must be performed as soon as possible, in an elective setting, to prevent the recurrence of toxic megacolon. In emergency total colectomy and end ileostomy is the gold standard procedure. Bowel continuity will be restored, evaluating case by case, by performing an ileorectal anastomosis or proctectomy and ileoanal pouch anastomosis. Primary ileorectal anastomosis should be reserved to selected cases. In the elective setting, after proper therapy and regression of toxic megacolon, proctocolectomy and ileoanal pouch anastomosis is indicated.

Surgical Management of Toxic Megacolon.

BACKGROUND/AIMS: Toxic megacolon carries still a substantial mortality and the decision when to per form emergent colectomy needs precise predictors outcome. METHODOLOGY: Thirty-two patients with toxic megacolon were identified from a computer database, and their clinical variables were analysed both univariate and multivariate analysis. RESULTS: 30-day mortality was 16%, being 17% for the patients with Clostridium difficile colitis and 13% for the patients with inflammatory bowel diseases. Diabetes, MPI class II, ASA classes 4-5, increase serum creatinine level, fever over 39 degrees, renal failure, gangrenous bowel and vasopressor requirement significantly associated with in univariate analysis, but only MPI class II and ASA classes 4-5 were independent predictors of mortality. Major complications occurred in 53% of the patients and they associated with respiratory failure, development of shock and vasopressor requirement. Surgical intensive care was needed by the patients who developed respiratory failure, shock or anaemia the hospital treatment was longer in patients with Clostridium difficile colitis. CONCLUSION: Development of signs of organ failures or shock are associated with poorer outcome in patients with toxic megacolon and the patients should be urgently operated, when these signs occur.