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.

Clostridioides difficile-related toxic megacolon after Cryptococcus neoformans cellulitis: A complex of two rare infections in an immunocompromised host.

A 76-year-old Japanese woman was admitted due to uncontrolled cellulitis of the right lower leg. She had deep vein thrombosis on the right limb. Moreover, she had a long history of rheumatoid arthritis treated with corticosteroids. Skin biopsy and lumbar puncture were performed to diagnose disseminated cryptococcosis. She was administered antifungal agents (liposomal amphotericin B and 5-fluorocytosine). On treatment day 14, debridement was performed, and cryptococcosis was controlled. However, she developed toxic megacolon due to Clostridioides difficile infection (CDI). On day 32, she was transferred to the intensive care unit due to severe acidosis and acute kidney injury secondary to CDI-related toxic megacolon. Vancomycin, metronidazole, and tigecycline were administered for treatment of CDI. After several weeks of intensive care, toxic megacolon was improved, but renal replacement therapy was discontinued according to the patient's will. On day 73, she died of renal failure. We experienced a complex of rare diseases, Cryptococcus neoformans cellulitis and Clostridioides difficile-related toxic megacolon. Both diseases were presumed to be the result of corticosteroid and methotrexate use. Hence, careful monitoring is required when treating immunocompromised hosts to reduce the risk of developing complications.

[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.

An unexpected complication following uterine artery embolisation.

A 35-year-old nulliparous woman underwent uterine artery embolisation (UAE) for heavy menstrual bleeding and anaemia due to fibroids, refractive to medical and surgical treatment.Bilateral UAE was performed after cephazolin prophylaxis and analgesia. Postoperatively, pain and abdominal bloating were prominent. Symptoms were initially treated as postembolisation syndrome, and analgesia was escalated. By the third day, pain was worsening and the woman developed marked tachypnoea and tachycardia, with raised inflammatory markers and lactate. An abdominal X-ray and CT showed dilated colon. A colonoscopy demonstrated severe mucosal ulceration down to the muscular layer.A subtotal colectomy and end ileostomy formation was performed with intraoperative findings of toxic megacolon with near perforation. The cause of the toxic megacolon, in the absence of previous bowel pathology, was attributed to pseudomembranous colitis as a consequence of single dose prophylactic antibiotic.

Fecal Transplant for Treatment of Toxic Megacolon Associated With Clostridium Difficile Colitis in a Patient With Duchenne Muscular Dystrophy.

Clostridium difficile (C diff) colitis infection is the most common cause of nosocomial infectious diarrhea and the prevalence is increasing worldwide. Toxic megacolon is a severe complication of C diff colitis associated with high mortality. Gastrointestinal (GI) comorbidity and impaired smooth muscle contraction are risk factors for the development of C diff-associated toxic megacolon. We present a case of fulminant C diff colitis with toxic megacolon in a patient with Duchenne muscular dystrophy (DMD) in the intensive care unit. C diff colitis was diagnosed by clinical presentation and positive C diff DNA amplification test (polymerase chain reaction). The impairment of GI tract due to DMD predisposes these patients to severe C diff infection and toxic megacolon, as observed in this case report. For the same reason, the recovery of GI function in these patients can be prolonged. While surgery was conducted for relieving the pressure from toxic megacolon, fecal microbiota transplantation through colonoscopy resulted in successful resolution of the C diff symptoms, although the recovery is prolonged due to DMD.

[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.

A case of toxic megacolon caused by clostridium difficile infection and treated with fecal microbiota transplantation.

Clostridium difficile infection. The mortality rate of fulminant C. difficile infection is reported to be as high as 50%. Fecal microbiota transplantation is a highly effective treatment in patients with recurrent or refractory C. difficile infection. However, there are few published articles on the use of such transplantation for fulminant C. difficile infection. Here, we report on a patient with toxic megacolon complicated by C. difficile infection who was treated successfully with fecal mi-crobiota transplantation. (Gut Liver, 2015;9:247-250).

[Toxic megacolon complicated by ulcerative colitis in six patients: a case report and literature review].

OBJECTIVE: To summarize the clinical features of ulcerative colitis (UC) complicated by toxic megacolon for early diagnosis and proper treatment. METHODS: Six cases of toxic megacolon in the patients suffered from UC in Peking Union Medical College Hospital from 1983 to 2010 were analyzed, and related literature was searched and reviewed. RESULTS: The incidence of the toxic megacolon in the patients with UC in our center was 0.7%(6/824), which was lower than those reported in the literature. There were always risk factors triggering the disease. The prognosis of the patients was poor, even after medical care and surgery intervention. Evaluation of the patients and making right timing to perform the surgery would improve the prognosis of the patients in foreign literature. CONCLUSION: It's crucial to make early diagnosis of the toxic megacolon in the patients suffered from UC. The right choice and timing to perform urgent surgery or selective surgery may improve their prognosis.

[Treatment of inflammatory bowel disease in intensive care medicine]. / Behandlung chronisch entzündlicher Darmerkrankungen in der Intensivmedizin.

In patients with inflammatory bowel disease (IBD) complications of both IBD and immunosuppressive therapy may be life-threatening conditions requiring intensive care therapy. These patients oftentimes present themselves with severe bloody diarrhoea, and infectious colitis, pseudomembranous colitis or intestinal ischemia must be included in the differential diagnosis. Steroids, immunosuppressants such as azathioprine, 6-mercaptopurine, methotraxate or ciclosporine, as well as biologicals, which act as TNF-alpha antagonists, are commonly used for maintenance therapy and treatment of acute exacerbations of IBD. Due to immunosuppressive therapy potentially life-threatening infections and reactivations of latent infections like tuberculosis or cytomegalovirus (CMV) can occur. Fistulas, abscesses, perforations and intestinal obstructions are typical complications of Crohn's disease in the intensive care setting, whereas clinical presentation in ulcerative colitis is characterised by its acute exacerbation and the toxic dilatation of the colon, potentially resulting in toxic megacolon with high risk of perforation or severe bleeding. Most important for an effective therapy in the critically ill patient with inflammatory bowel disease are the control of the underlying disease, the empiric antibiotic therapy in case of infectious complications, transcutaneous drainage of abscesses, bowel decompression in toxic megacolon and the early interdisciplinary assessment of the abdomen.

[Current management of toxic megacolon]. / Management des toxischen Megakolons.

Toxic megacolon is a rare and life-threatening complication of severe colitis, defined as a dilatation of the colon > 6 cm in the absence of distal obstruction in combination with signs of systemic toxicity (major criteria: fever, tachycardia, leukocytosis, anaemia). Various triggers are known and the most common causes are underlying ulcerative colitis and Clostridium difficile. Diagnosis can easily be made by clinical examination, routine laboratory parameters and a plain X-ray of the abdomen. Much more difficult is to decide between non-surgical treatment including intensive care treatment or surgery (mostly subtotal colectomy with terminal ileostomy). Non-surgical therapy includes balancing of electrolytes and fluid volumes, broad-spectrum antibiotics including metronidazole, positioning of patients and probably careful intermittent decompression. In case of ulcerative colitis immunosuppression should be started with corticosteroids and potentially with calcineurin inhibitors. In pseudomembranous colitis vancomycin should be given orally and metronidazole should be given intravenously. As far as possible the patient should be treated in a centre with experience in the field.

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.

A case of toxic megacolon in a patient with collagenous colitis.

Collagenous colitis is an uncommon inflammatory bowel disease, the aetiology of which is unknown. We report a case of toxic megacolon in a patient with collagenous colitis, a previously unreported complication.

The identification and treatment of toxic megacolon secondary to pseudomembranous colitis.

Toxic megacolon is an infrequently occurring, potentially life-threatening complication of pseudomembranous colitis. Although toxic megacolon may be considered rare, incidence is expected to increase because of the rapidly increased prevalence of pseudomembranous colitis. This article discusses the pathophysiology, clinical manifestation, diagnosis, treatment, and prognosis for toxic megacolon secondary to pseudomembranous colitis. Critical care nurses should be aware of the disease to intervene early and increase the chance of the patient's survival.

Toxic megacolon in children with inflammatory bowel disease: clinical and radiographic characteristics.

BACKGROUND: Toxic megacolon (TMC) denotes a rare clinical syndrome accompanied by colonic dilatation, and is a serious complication of inflammatory bowel disease (IBD). This study assessed the clinical and radiologic characteristics of TMC in children with IBD. METHODS: A systematic search identified patients with IBD-associated TMC and matched them by age to controls with ulcerative colitis without evidence of TMC. Clinical characteristics and outcomes were compared with conditional logistic regression. Abdominal X-rays were interpreted by two blinded radiologists and findings were compared with controls. RESULTS: Ten children with TMC (median age 12.6 [7.3-15.5] yr) were matched with 20 controls (median age 12.8 [6.8-15.2] yr). Altered level of consciousness and hypotension were rare in children with TMC. Fever (P= 0.005), tachycardia (P= 0.0001), dehydration (P= 0.01), and electrolyte abnormalities (P= 0.0002) were more common in children with TMC than controls. Air-fluid levels (P= 0.005), intestinal thickening (P= 0.006), and abnormal colonic haustra (P= 0.012) were more commonly seen on X-rays of TMC cases. Transverse colon luminal diameter >or=56 mm was strongly suggestive of TMC (sensitivity 90%, specificity 90%, area under the ROC curve 0.91). No child with TMC died and 70% required colectomy during admission. Two of the three with intact colons at discharge required second-line therapy during the subsequent year. CONCLUSIONS: Colonic dilatation >or=56 mm in children with IBD strongly suggests TMC, if clinical signs are present. Mental alteration and hypotension may be less common in children than in adults. TMC in children with IBD is associated with poor outcome, with a high rate of corticosteroid failure.