Open Journal Systems

SURGICAL SPECIALITIES

Received: October 22^nd 2014

Accepted: March 6^th 2015

Frequency, clinical evolution and prognosis of toxic megacolon

Marcos Magallón-Tapia,^a Rodrigo Alberto Ceniceros,^a Jesús Arenas-Osuna,^b Cinthia Lizeth Juarez-Leal,^d Ana Lilia Peralta-Amaro^c

^aServicio de Coloproctología

^bDivisión de Educación en Salud

^cServicio de Medicina Interna

^dServicio de Ginecología del Hospital General de Zona 98, Estado de México

^a-cHospital de Especialidades, Centro Médico Nacional La Raza, Distrito Federal

Instituto Mexicano del Seguro Social, México

Communication with: Marcos Magallón-Tapia

Telephone: (55) 5724 5900, extensión: 23201

Email: c_os_mar10@hotmail.com

Background: 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.

Keywords: Colonic diseases; Ischemic colitis; Toxic megacolon.

---

Toxic megacolon (TM) is a potentially fatal complication of inflammatory, ischemic, and infectious colitis.^1,12,22 It was first described in 1930 as colonic dilatation associated with sepsis, but it was not until 1950 that Marshak defined it as total or segmental colonic distension greater than 6 cm, concomitant with acute colitis and systemic symptomatology.^1,2

Toxic megacolon is associated with nonspecific ulcerative colitis or Crohn's colitis, but any other inflammatory condition of the colon may predispose toxic dilation, among which are: inflammatory bowel disease, pseudomembranous colitis, Salmonella, Shigella, Campylobacter, Entamoeba, collagenous colitis, and ischemic colitis.^3-7,14,19 Association with the chronic use of proton-pump inhibitors was recently published.⁸ Cytomegalovirus is an opportunistic agent that can cause TM, especially in the course of a disseminated infection, such as in HIV-positive patients and patients with ulcerative colitis treated with steroids.^3,9

Grieco et al. report TM incidence in patients with ulcerative colitis between 1 and 2.5%.^10,11 For Crohn's disease it is 1 to 6%.¹⁰ Other studies report similar incidences to 1 to 5%, with 20% probability that Crohn's disease debuts with TM.¹³ The current incidence of TM secondary to antibiotic-induced pseudomembranous colitis is estimated at 0.4 to 3%.^1,15 The aim of our study was to describe the frequency, clinical course, and prognosis of TM at the Hospital de Especialidades Centro Médico Nacional La Raza.

Methods

Observational study that included 13 patients diagnosed with TM according to the criteria of Jalan.¹⁷ The study collected information from logs, surgical report sheets from the Servicio de Coloproctología, and records from clinical files of the Hospital de Especialidades Centro Médico Nacional La Raza, in the period from January 2009 to December 2014, for patients diagnosed with TM. Inclusion criteria were: patients with clinical and radiological diagnosis of TM established by the Servicio de Coloproctología, of both genders, and older than 16 years old. The following variables were analyzed: gender, age, height, weight, chronic nonspecific ulcerative colitis (CNUC), Crohn's disease, pseudomembranous colitis, neutropenic colitis, ischemic colitis, other infectious colitis, temperature, heart rate, white blood cells, hemoglobin, colon diameter, nutritional status, hypertension, diabetes mellitus, hemato-oncological diseases, use of immunosuppressants, use of antibiotics, days of hospital stay, surgical procedure, postoperative complications, and overall mortality.   

The analysis was performed using descriptive statistics calculating percentages, means, and medians. Relative risk and chi-squared for correlation of variables were calculated.

Results

13 patients were recruited, 79.9% (10 patients) were male and 23.1% (3 patients) were female. The average age was 47.69 ± 18.3 years, with a maximum of 82 years and a minimum of 19 years. The median for weight and height was 59 kg (40-71 kg) and 1.68 m (1.68-1.90 m) respectively. The median for BMI was 21 (15-26). Diseases most frequently causing TM are described in Table I.  

The average temperature was 38 °C, with figures from 36.5 to 39 °C. Median heart rate was 100 beats per minute, as for leukocytes the median was 8500/mm³. Median hemoglobin was 10.2 g/dl. Colon dilation was 15 cm on average (Figure 1) and the median of albumin was 2.5 g/dl. Of the 13 patients, only one patient had hypertension (7.7%) and one presented type 2 diabetes mellitus (7.7%).

Hemato-oncological diseases as the cause of TM accounted for 23.1%, finding only the following two conditions: acute myeloid leukemia in 15.4% and non-Hodgkins lymphoma in 7.7% (Table II).

The immunosuppressive drugs most frequently associated with TM were hydrocortisone with 15.4%, and cytarabine and idarubicin by the same percentage. Antibiotics administered prior to TM diagnosis in our patients were: metronidazole (61.5%), followed by imipenem (30.8%), ciprofloxacin (23.1%), cefotaxime (15.4%), meropenem (7.7%), linezolid (7.7%) and moxifloxacin (7.7%). The surgical procedure performed most in our patients was subtotal colectomy with end ileostomy in 84.6% (Table III).

Our postoperative complications were: surgical wound infection as the most common with 23.1%; ileus, abdominal collections, acute pancreatitis, necrosis of the ileostomy, and bleeding occurred in 7.7% each; 38.5% of patients had no postoperative complications.

The mortality rate was 61.5%, corresponding to 8 of 13 patients, and the most frequent cause of death was septic shock (46.2%), followed by acute respiratory failure in 7.7% and disseminated intravascular coagulation in 7.7%. Total colonic perforation was in 23.1%.

The average hospital stay was 21 days, with a maximum of 101 days and a minimum of 5 days. The average time from suspected TM to surgical treatment was 5 days, with 18 days maximum and 1 day minimum.

The prevalence over 5 years was 0.008% of total admissions to the Servicio de Coloproctología (1500 patients). We found 3 patients with colonic perforation, two of whom died (Table IV).

Discussion

TM is a potentially fatal complication of inflammatory, ischemic, and infectious colitis.^1,12,22 We observed that TM is more common in males at 79.9%, with a mean age of 47.69 ± 18.3 years; average albumin was 2.5 g/dl, which could indicate that the patient's nutritional status may influence the development of this pathology.

The diseases most often associated with TM is CNUC and Crohn's disease; according the national and international literature, Grieco et al. report TM incidence in patients with ulcerative colitis from 1% to 2.5%.^10,11 The incidence of Crohn's disease associated with TM is about 1 to 6%.¹⁰ Other studies report incidences similar to 1 to 5%, with 20% of Crohn's disease debuting with TM.¹³ For antibiotic-induced pseudomembranous colitis an incidence of 0.4 to 3% is estimated,^1,15 mainly associated with the following antibiotics: cephalosporins, clindamycin, and fluoroquinolones.^10,15,21

Our work indicated that CNUC is a major cause of TM; both CNUC and pseudomembranous colitis are presented as the underlying cause in 30.8% each, followed by neutropenic colitis in 23.1% and Crohn's disease in only 7.7%. In pseudomembranous colitis, the drugs are most often associated are imipenem in 30.8% and ciprofloxacin in 23.1%, followed by cefotaxime (15.4%), meropenem (7.7%), linezolid (7.7%) and moxifloxacin (7.7%). Our results regarding the pathology most associated with TM coincide with those published by Frasko, who reports the most frequent reason for TM as ulcerative colitis (36.8%, 7 patients), followed by pseudomembranous colitis (26.3%, 5 patients) and ischemic colitis (15.8%, 3 patients).²⁴ Autenrieth says to this that TM is most commonly associated with inflammatory bowel disease (IBD); however, lately, the epidemiology has shifted towards infectious causes, specifically due to an increase in colitis due to Clostridium difficile, possibly due to the widespread use of broad-spectrum antibiotics, with which we are in agreement.²⁵

Systemic arterial hypertension occurred in 7.7%, same as DM2, so we believe that these conditions are not related to TM. We found that hemato-oncological diseases trigger TM in 23.1%, the most important being: acute myeloid leukemia and non-Hodgkins lymphoma, secondary to the use of immunosuppressive drugs to treat these diseases.

Because it is a disease with very low incidence and prevalence, it is not thought of as an initial diagnosis, and usually when TM is suspected there is a delay in diagnosis of five days on average, which results in our study in all patients having surgery as first intention, without the opportunity for initial medical management as other authors report.²³ 84.6% underwent subtotal colectomy plus end ileostomy, same as Frasko,²⁴ with postoperative complications in 61.5%, with surgical wound infection as the most frequent. 

Our mortality rate was 61.5%. The mortality of our patients is higher than that reported in the literature, where Strauss, in a study of patients with TM, reported an overall mortality of 19%, higher in patients managed medically (27%) than in those who had early surgery (19.5%). The mortality rate rises to 41.5% with colonic perforation from 8.8% in those without evidence of perforation.^1,16,20 Emergency surgery has a mortality of 30%, compared to 5% if it is elective.^10,18 Surely our mortality is higher for the delay in diagnosis, resulting in emergency surgery in all our patients, which leads to colonic perforation in some of them (in 23.1%), with 66.6% mortality in these. The overall prevalence of TM at the Hospital de Especialidades Centro Médico Nacional La Raza over five years is 0.008% of total admissions to the Servicio de Coloproctología (1500 patients). The prevalence is lower than that reported in the world literature.^10,15,21

Conclusions

TM prevalence is very low compared to other diseases, but its mortality is high, and the clinical course and prognosis of these patients is bad, and for this reason we believe that early recognition, rational use of broad-spectrum antibiotics, proper treatment, and prompt surgical intervention are paramount.

References

1. Carrillo-Esper R, Calderón-Álvarez JL, Muciño-Bermejo J, Ramírez-Rosillo FJ. Megacolon tóxico. Med Int Mex. 2012;28(3):282-7.
2. González V, Pére JL, Marín I. Actitud ante un megacolon tóxico. Rev Esp Enferm Dig. 2003;95(6):415-21.
3. Graziano A, Ramírez Rojas P. Megacolon tóxico.
   Cirugía Digestiva, F. Galindo. 2009; III-354: pág. 1-13.
4. Thirunavuk B,
   Shanthi A, Jayakumar P, Poonam K. Unusual Complication of Toxic Megacolon in Typhoid Colitis. ndian J Pediatr. May 2014,81(5):504-6.
5. Bains S, Lloyd G.M, Sutton CD, West K, Miller AS. A case of toxic megacolon in a patient with collagenous colitis. Tech Coloproctol (2009) 13:165-6.
6. Arun-Babu T, Ananthakrishnan S, Jayakumar P, Kullu P. Unusual complication of toxic megacolon in typhoid colitis. Indian J Pediatr. 2014 May;81(5):504-6.
7. Brodrick R, Sagar J. Toxic megacolon from sexually transmitted Shigella sonnei infection. Int J Colorectal Dis. 2012 Mar;27(3):415.
8. Wade JW. Toxic megacolon after abdominoplasty: a case report. Ann Plast Surg. 2014 Jun; 72(6):S170-1.
9. Inoue K, Wakabayashi N, Fukumoto K, Yamada S, Bito N, Yoshida N, et al. Toxic megacolon associated with cytomegalovirus infection in a patient with steroid-naïve ulcerative colitis. Intern Med. 2012;51 (19):2739-43.
10. Wolff BG, Boller AM. Toxic megacolon. 2009 Springer Science Business Media, LLC. p. 827-32.
11. Grieco MB, Bordan DL, Geiss AC, Beil AR. Toxic megacolon complicating Crohn’s colitis. Ann Surg 1991:75-80.
12. Hokama A, Ohira T, Kishimoto K, Kinjo F, Fujita J. Impending megacolon: small bowel distension as a predictor of toxic megacolon in ulcerative colitis. Intern Emerg Med (2012) 7:487-8.
13. Hefaiedh R, Cheikh M, Ennaifer R, Gharbi L, Bel N. Toxic megacolon complicating a first course of Crohn’s disease: about two cases. Clinics and Practice 2013; volume 3:63-4.
14. García A, Abenamar J, Blas R, et al. Megacolon tóxico por colitis pseudomembranosa. ActA MédicA Grupo ÁnGeles., October-December 2011;Volumen 9(4):217-20.
15. Leena S, Darshan K, Robert J R. Toxic megacolon associated Clostridium difficile colitis. World J Gastrointest Endosc August 2010 16;2(8):293-7.
16. Strauss RJ, Flint GW, Platt N. The surgical management of toxic dilatation of the colon: A report of 28 cases and review of the literature. Ann Surg 1976; 184:682-8.
17. Jalan KN, Sircus W, Card WI, et al. (1969) An experience of ulcerative colitis. I. Toxic dilation in 55 cases. Gastroen- terology 57:68-82.
18. Greenstein AJ, Sachar DB, Gibas A, Heimann T, Janowitz HD, Aufses AH. Outcome of toxic dilatation in ulcerative and Crohn’s colitis. J Clin Gastroenterol 1985;7:137-43.
19. Wilbert P, Takeshi M. Colitis fulminante y megacolon toxico. Colon Recto y Ano. Editor DR Takeshi M. Vol 1: pag 260-4.
20. Miniello S, Marzaioli R, Balzanelli MG, Dantona C, Lippolis AS, et al. Toxic megacolon in ulcerative rectocolitis. Current trends in clinical evaluation, diagnosis and treatment. Ann Ital Chir. 2014;85:45-9.
21. Yu S, Abdelkarim A, Nawras A, Hinch BT, Mbaso C, Valavoor S, et al. Fecal Transplant for Treatment of Toxic Megacolon Associated With Clostridium Difficile Colitis in a Patient With Duchenne Muscular Dystrophy. Am J Ther. 2014 May 22.
22. Antonopoulos P, Almyroudi M, Kolonia V, Kouris S, Troumpoukis N, Economou N. Toxic Megacolon and Acute Ischemia of the Colon due to Sigmoid Stenosis Related to Diverticulitis. Case Rep Gastroenterol. 2013 Sep 11;7(3):409-13.
23. van-Geenen EJ, Sachar DB. Infliximab in Crohn’s disease-associated toxic megacolon. J Clin Gastroenterol. 2012 Apr;46(4):321-3.
24. Frasko R, Uchytil Z, Sváb J, Výborný J, Krska Z. Treatment outcomes in patients with toxic megacolon, Rozhl Chir. 2011 Jun;90(6):339-42.
25. Autenrieth DM, Baumgart DC. Toxic megacolon. Inflamm Bowel Dis. 2012 Mar;18(3):584-91.

Enlaces refback

• No hay ningún enlace refback.