Treatment of Toxic Megacolon in Acute Severe Ulcerative Colitis with More Than Six Bloody Stools per Day
This protocol covers the management of toxic megacolon arising in acute severe ulcerative colitis — a presentation defined by high bloody stool frequency combined with systemic signs of toxicity.
Clinical Scenario
Acute severe ulcerative colitis presents with more than six bloody stools per day accompanied by at least one systemic sign of toxicity: tachycardia, fever, anemia (hemoglobin below 10.5 g/dL), or markedly elevated inflammatory markers (ESR greater than 30 mm/h or CRP greater than 30 mg/L).
Treatment Approach
Surgical intervention is the indicated management in this setting — a colectomy-based procedure is the operation of choice, with specific alternative surgical options available for patients in select clinical circumstances.
References
- Acute severe ulcerative colitis (ASUC), historically referred to as "fulminant" or "toxic" colitis, represents a severe form of acute colitis involving more than six bloody stools per day accompanied by at least one systemic sign of toxicity including tachycardia, fever, anemia (hemoglobin <10.5 g/dL), or elevated erythrocyte sedimentation rate (ESR) greater than 30 mm/h.
- Patients with severe medically refractory ASUC, TM, massive hemorrhage, or colonic perforation should undergo surgical therapy.
- The operation of choice continues to be subtotal abdominal colectomy with end ileostomy.
- To prevent rectal stump dehiscence and leak, most surgeons elect to leave a transanally placed rectal tube for decompression.
- While decompressive procedures alone carry a significant morbidity when compared with subtotal colectomy and end ileostomy, a Turnbull blowhole colostomy can be considered in patients with prohibitive comorbidities, a hostile abdomen, or a pregnant patient with acute severe colitis.
DOI: 10.1186/s13017-021-00362-3
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