2. A 71-year-old woman was admitted with abdominal pain and diarrhoea. She had a cadaveric renal transplant 3 years earlier for ESRD secondary to unknown aetiology. She has a history of recurrent urinary tract infections treated as an outpatient with multiple courses of ciprofloxacin and nitrofurantoin. Initial stool tested positive for C. difficile toxin. The patient was treated with hydration and oral metronidazole. The immunosuppressive regimen included cyclosporine. Initial WBC count was 16,500/μL rose to 19,900/μL after 48 hours of therapy. The abdomen was mildly distended tender but no rebound tenderness. A plain abdominal radiograph (left) demonstrated an 8.9cm transverse colon. CT scan of the abdomen (right) revealed diffuse colonic thickening with scanty ascites.
- What is your management plan?
Dear All
This is a real case. I operated on this patient after resuscitation for a few hours. I have found 7 perforations in his colon. Do you think there is room for medical treatment?
No. this scenario requires urgent surgical intervention as already 48 hours of medical therapy have elapsed without any improvement.
This patient is surgical emergency
She is immunocompromised patient with no response to medical therapy
Her counts are increasing in spite of antibiotics and there is abdominal tenderness
The inflammatory response is anyways less in immunocompromised patients
So, we should have low threshold for exploration
Is it always better to have negative exploration than miss a positive finding.
But sir I have a doubt, did her Xray or CT scan show gas under diagram or in peritoneum.
No, this is a surgical case….
according to the updated IDSA guideline 2019 the predictor clinical and laboratory feature:
1-Age more than 70 years old
2-prior CDI.
3-profound leucocytosis of more than 18,000.
4- heamodymenic instability.
5- use of anti-peristaltic medication.
6-increasing abdominal pain, distension, and diarrhea.
delay surgery in this severe fulminant colitis increase likelihood of adverse outcome.
reference
1-Khanna S, Baddour LM, Dibaise JK, Pardi DS. Appendectomy is not associated with adverse outcomes in clostridium difficile infection: a population-based study. Am J Gastroenterol. 2013;108:626–7.
Absolutely no, this is an emergent case of surgery.
Dear All
Many of you provided a narrative review of the management, but it is not clear to me what are you going to do.
Will you carry on medical treatment or call the surgeon?
Treatment of the current case
EXCELLENT
Call surgery.
EXCELLENT
EXCELLENT
call the surgeon
I would call the surgeon,
Call the surgeon urgently
The above patient is a known case of CKD Status post renal transplant with recurrent history of UTI which was treated as out patient with ciprofloxacin and nitrofurantoin…She is presumed to have normal graft function….
Recurrent antibiotic exposure predisposes to pseudomembranous colitis which is caused by C.difficile. The current patient has fever, abdomen pain and diarrhoea.. It is charecterized by diarrhoea, abdomen pain and leucocytosis with fever.. The treatment is with good hydration and oral metronidazole which the patient is already on
The dreaded complication of pseudomembranous colitis is toxic megacolon – which is an emergency life threatening condition as a result of infection and inflammatory colitis…Other reasons for toxic megacolon include inflammatory bowel diseases..It is charecterized by non occlusive segemental bowel dilation with sepsis
Urgent total colectomy is described if there is increased abdomen pain and distension, increasing counts, increasing CRP and Procalcitonin, increasing colonic dilatation evidenced by X ray >6cm …..
The above surgery can reduce the overall mortality rate else it is very dangerous
The current patient has worsening sepsis sign with increase in diameter of the transverse colon warranting surgery….
In addition to above patients needs IV fluids, stopping MMF and reducing the dose of CNI due to sepsis, IV metronidazole, IV antibiotics to cover for translocation of bacterial sepsis…Decompression through flatus tube is not recommended due to risk of perforation but NG tube aspiration can be tried initially
Toxic mega colon due to c.difficile infection after antibiotic regimen
This urgent surgical case which needs immediate intervention for urgent total colectomy with prior resussscitation and stop cellcept ,decompression is contraindicated
This is toxic mega-colon which need surgical opinion and most likely intervention
1) NBM
2) Adjust immunosuppressant to IV steroid.
3) IV drip for hydration.
4) IV antibiotic as per local guidelines。
5) Analgesia
5) Refer surgeon for surgical intervention.
The most likely diagnosis in the above scenario is Pseudomembranous colitis which is the common cause of health care associated diarrhea.It occurs because of immunosuppression and intake of antibiotics for recurrent uti at multiple times.Diagnosis is made on the basis of hiatory followed by stool analysis and culture and sample for c.difficile toxin.Xray andomen as mentioned above aslo gives a clue[loss of haustrations,colonic dilatation more than 6 cm].,This is medical emergency and if this is not treated timely then devastating consequences of septic shock and death can occur.Patient should be admitted in surgical ITC and cardiac monitoring should be done along with maintaining adequate urine output with IV fluids..IV antibiotics should be started inmediately I.e.,oral vancomycin in a dose of 125-250 mg 4 times per day or metronidazole 500 mg 3 times per day.NG tube should be passed and gut decompressed.Monitoring of renal function and immunosuppression steroid should be increased and rest immunosuppression I.e.,ciclosporin decreased and mmf stopped.Other options which can be considered index combination of vancomycin and Metronidazole or use of fecal microbial transplantation..In refractory cases,colectomy and ileostomy can be done.
REFERENCE:
Calogero A, Gallo M, Sica A, Peluso G, Scotti A, Tammaro V, Carrano R, Federico S, Lionetti R, Amato M, Carlomagno N, Dodaro CA, Sagnelli C, Santangelo M. Gastroenterological complications in kidney transplant patients
Toxic mega-colon
Toxic Mega-colon is a severe complication of C.difficile colitis .
Its incidence about 3%.
Risk factors for development of toxic megacolon include concurrent malignancy , severe COPD,organ transplantation,diabetes mellitus and immunosuppression.
Management plan
1.Medical management : Oral vancomycin and IV metronidazole.
2.Decompression of the dilated colon with nasogastric tube and frequent repositioning of the patient.
3.Surgical intervention may be necessary in up to 80% of patients
Indication of surgical treatment:
Perforation,progressive dilatation of the colon,lack of clinical improvement over the first 48 to 72 h and uncontrolled bleeding.
The surgical procedure of choice is total or partial colectomy with preservaion of rectum and diverting ileostomy.
Sayedy L, Kothari D, Richards RJ. Toxic megacolon associated Clostridium difficile colitis. World J Gastrointest Endosc. 2010 Aug 16;2(8):293-7.
This patient need urgent surgical intervention
This case needs urgent exploration in view of progression of clinical disease, rise in TLC, non response to medical management and assumption of blunted response in view of triple drug immunosuppression.MMF needs to be stopped
Ø Repeated antibiotic courses ended by C. difficile colonization which is complicated by toxic mega colon.
Ø Now the patient has rising WBC count despite management, septic and distended abdomen. Management plan is:
1. GI surgery call immediately
2. NPO + NG tube
3. Vancomycin solution or rectal
4. Good hydration
5. Adjustment of immunosuppressant with: hold MMF if in the regimen, steroid minimize and IV
71y old female, renal transplant recipient, presented with diarrhea secondary to clostridium difficle, no responding to medical treatment, rising WBC, x-ray and CT abdomen showing distended bowel loops and diffuse colonic thickening—à> urgent surgical consultation is mandatory.
Keep Nil per mouth.
NGT to rest the bowel.
If hemodynamically stable and cleared by anaesthesia , she may need colectomy and ileostomy creation.
Post operative care in the ITU.
Stop MMF
Give IV hydrocortisone 100 mg TDS in day 0 then 50 mg tds.
This is a case of Toxic mega colon due to pseudomembranous colitis caused by C.D. overgrowth.
The condition failed medical treatment after 2 days of hydration and oral metronidazole as the patient inflammatory markers increase. So she need urgent surgical intervention for total colectomy and illeostomy with proper preparation by good fluid and electrolyte balance, N G T for decompression, stop antimetabolite drugs , and decrease the dose of CNIs , give stress dose of I.V HC 100 mg before operation and one day after till shifting to oral prednisone. If the patient left without surgical intervention this is associated with poor outcome.
This a toxic megacolon secondary to c.difficile infection it require urgent surgical intervention as long the medical treatment was tried without improvement
The patient had recurrent UTI with repeated antibiotics treatment
CT scan shows picture of toxic megacolon, with colonic dilation of transverse colon 8.9 cm,
leukocytosis( despite immunosuppression)
that increased within 48 h with no response to treatment.
He needs urgent surgical intervention before perforation occurs
Good hydration and corrections of electrolyte imbalance
Correction of electrolyte imbalance
NBO
with nasogatric tube
Stop MMF
Switch oral steroids to stress dose steroids
and CNI
Immunosuppression to iv with reduction of dose the lowest accepted level
Follow up of graft function and inflammatory markers after surgery until the patient is stabilized
This is a case of toxic mega-colon. Radiologic presentation includes severe dilatation of transverse colon (at least 6 cm). In this case, it was secondary to infectious colitis (due to C. difficile colitis). Patients are usually systemically ill with diarrhea. It’s a life-threatening condition with sepsis, shock and dehydration which needs immediate treatment as:
1. Correction of fluid and electrolyte disturbances.
2. Starting hydrocortisone 100 mg IV Q8h. It could be replaced by prednisolone after toleration of oral feeding.
3. Stop MMF because of sepsis.
4. Decrease tacrolimus level.
5. Urgent surgical intervention (total colectomy with ileostomy)
ICU admission.
71 yrs old, past history of recurrent UTI treated with ciprofloxacin. admitted with abdominal pain and diarrhoea. stool positive for C. difficile toxin. abdominal X-ray dilated colon and no air-fluid level. Ct scan shows a distended colon with a thick wall. treated for 2 days with antibiotics with no improvement.
surgical call is urgently indicated at this level, otherwise, the patient might be deteriorated and will not be fit for surgical intervention.
NOP
IV antibiotic (vancomycin + metronidazole)
ICU admission post-surgery
stop cellcept if not already done.
IV hydrocortisone
lowest prograft dose keep level around 3
correct any electrolytes disturbance
good hydration
Toxic mega component from C.difficile infection
Risk factors
Severe COPD , DM, immunosuppressive medications .
Treatment of the current case
This an emergency need urgent surgical intervention
ICU admission
Fluid therapy and avoid electrolytes imbalance
For immunosuppressive:
Hydrocortisone instead of prednisolone
Stop cellcept in view of sepsis
the diagnosis of this patient is pseudomembranous colitis complicated by toxic megacolon is clear in x-ray and the patient in spite of medical treatment(metronidazole) for 48 hours still not improving and wbcs is increasing so the plan of management of his condition:
1- total colectomy with ileostomy.
2-postsurgery ICU admission.
3-hydrocortizone100mg every 8 hours on day one and resume oral prednisolone on day two.
4-fluid and electrolytes management.
5- hold MMF and decrease TAC to maintain an acceptable low trough level.
6- thromboprophylaxis.
7- decompression is contraindicated either by rectal tube or endoscopy.
delay surgical intervention results in a worse adverse outcome
CT scan early stage of pseudomembranous colitis oedematous mucosa and thickness and intraabdominal free fluid is seen in more than 70% of cases
references
UpToDate
The patient has toxic megacolon, presence of radiologic evidence of colonic dilatation >6 cm and leukocytosis.
Fluid therapy
Correction of electrolyte imbalance
Bowel rest and nasogastric decompression to decrease air and fluid in GI tract.
Immunosuppression, IV hydrocortisone (stress dose), IV cyclosporine, antimetabolite should be stopped till control of sepsis.
Medical and surgical teams should comanage the patient
The condition didn’t improve after two days of medical management so surgical intervention is needed.
Early surgical intervention before colonic perforation is associated with lower mortality rate than colectomy after perforation.
Desai J, Elnaggar M, Hanfy AA, Doshi R. Toxic megacolon: background, pathophysiology, management challenges and solutions. Clinical and experimental gastroenterology. 2020;13:203.
This is a case of fulminant clostridium difficile complicated by pseudomembranous. colitis and toxic megacolon .
Radiologically ;
THIS X RAY showed dilatation of 8.9 cm in the transverse colon which is a typical radiological finding in toxic megacolon
the treatment of this case is mainly surgical parallel with medical treatment withholding of MMF AND REDUCE the Tac to the minimum accepted level
Mortality rates associated with toxic megacolon related to C. difficile colitis are high and range from 38% to 80%
Urgent surgical intervention as surgical indications are :
Progressive colonic dilatation (dilated colon 8.5 cm )
Lack of clinical improvement throughout the first 48 to 72 hours ( rising TLC after 48 hrs of metronidazole therapy )
in addition to if there is a perforation or uncontrolled bleeding
The surgical procedure of choice for toxic megacolon :
Total colectomy with preservation of rectum and diverting ileostomy
partial colectomy may be performed with worse outcomes as residual diseased bowel may be left in place.
reference
uptodate
This patient has toxic megacolon as a complication of severe C D infection
He has severe sepsis with high inflammatory marker ,in such case medical treatment a lone is not sufficient and may elapse at any time
this patient need surgical intervension urgently with decompression of his colon ,then will start IV metronidazole till total colectomy with illiostomy after that he may start oral vancomycin
In terms of immunosuppression medications:
MMF should be hold immediatly till resolvation of infection
tacrolimus should be reduced to the lowest possible dose
can continue with predinsolon after first 48 hr of iv hydrocortison as stress dose
Definitely this patient needs surgical intervention rather then medical.
This patient has a toxic megacolon secondary to a Fulminant disease of severe C difficile infection.
It should be treated with vancomycin 500 mg orally or through a nasogastric (NG) tube in addition to metronidazole 500 mg IV every 8 hours. If ileus is present, rectal vancomycin is recommended.
Patients who have fulminant colitis that fails to respond to initial medical treatment should be considered for surgery.
Indications for surgical intervention in patients with severe C difficile colitis include the following:
· Colon perforation
· Colon-wall full-thickness ischemia
· Necrosis
· Increased intra-abdominal pressure or abdominal compartment syndrome
· Signs of peritonitis
· End-organ failure
If surgical management is necessary for severely ill patients, perform subtotal colectomy with preservation of the rectum. Another option is a diverting loop ileostomy with colonic lavage, which has been associated with lower morbidity and mortality.
I think this patient has to have urgent surgery as he has already a severely dilated transverse colon, with diffuse colonic thickening on CT.
Reference: Medscape. Toxic Megacolon Treatment & Management: Approach Considerations, Medical Care, Surgical Care (medscape.com)
Clostridium difficile is a gram-positive colonizer of the gastrointestinal tract. Colonization may be asymptomatic, but the disease could be severe enough to cause graft loss or patient death.
Maintenance immunosuppressive treatments as well as antibiotics for both prophylaxis and treatment and frequent exposure to hospital facilities all raise the risk of severe CDI in KTR.
In our clinical scenario, the medical treatment was not optimal, as oral vancomycin and fidaxomycin are the treatment of choice.
However the patient’s condition is deteriorating with features of toxic megacolon and possible intestinal perforation. Hence, surgical intervention should not be delayed and patient should be transferred to surgical block for laparatomy and total colectomy.
Urgent call surgery, no chance of medical mangment .
the medical mangment can be after surgery by dcrese the dose of cellcept and good hydration with good cover by abx
A surgical consult is the first step in management.
Modification of immunosupression is immediately needed in view of ongoing sepsis and deteriorating clinical condition which may warrant a surgical intervention.
We can stop cell cept
start Iv hydrocortisone
ciclosporin can be switched to IV or withheld depending upon clinical condition
Clostridium difficile is a Gram-positive bacteria that colonizes the intestinal tract.
Colonization may be asymptomatic, and disease is caused by the proliferation of toxigenic strains.
The reported incidence of C. difficile infections in KTR varies greatly from less than 1% to 8%. Immunosuppressive regimens required posttransplant to prevent rejection, antibiotics for both prophylaxis and treatment, and frequent exposure to healthcare settings all position KTR to be at increased risk for severe CDI.
Regarding this case, the patient’s condition is deteriorating despite medical treatment ( raising WBC count, distended abdomen, thick colon), so surgery should be done.
References:
This patient has sepsis from toxic megacolon, So need urgent call to surgeon for colectomy and temporary colostomy and admitted to ICU and stabilize patient with intravenous fluid and intravenous hydrocortisone, hold cellcept and continuous prograf , good antibiotic
The diagnosis is most likely toxic megacolon.
The management plan is as follows:
· To continue antibiotic and supportive therapy in the ICU.
· MDT including GI surgery.
· The patient should undergo surgical resection of the toxic bowel.
· Prednisolone can be shifted to IV hydrocortisone +/- withdrawal or reduction of the MMF dose, till sepsis subsides.
Clostridium difficile infection risk factors are immunosuppressive therapy and frequent antibiotic use leading to dysbiosis.
This patient had distended abdomen without rebound rigidity ,investigation refer to toxic megacolon which can lead to perforation of the colon, sepsis or multi-organ failure
Surgical intervention is needed urgently either subtotal colectomy or total colectomy with ileostomy along with rehydration and correction of electrolyte imbalance as well as IV steroids is needed in antistress doses to avoid septic shock
A multidisciplinary team including surgeon gastroenterologist, nephrologist , critical care specialist) in treatment planning is mandatory
Bowel rest is important
MMF need to be suspended
Antibiotic coverage with vancomycin ,Fidaxomicin,
Bezlotoxumab in resistant cases
Prevention of recurrence is also crucial
-Reference
Dudzicz-Gojowy, S.;Wi ˛ecek, A.; Adamczak, M.
Clostridioides difficile Infection in Patients after OrganTransplantation—A Narrative
Overview. J. Clin. Med. 2022, 11, 4365.
It is a patient who needs emergency surgery. Contact the surgical team and prepare the operating room immediately, while the team prepares:
– Do intravenous hydrocortisone to decrease the inflammatory process
– Discontinue mycophenolate
– vigorous hydration
– hydroelectrolytic control
– pass an indwelling urinary catheter to monitor urinary output
– Perform ileostomy with colectomy of the compromised segment
– further treatment of Clostridioidis difficile with vancomycin, metronidazole, or fidomoxacin, all oral
– metabolic control
– prioritize regimens without mycophenolate (azathioprine, tacrolimus, and prednisone)
a case of toxic megacolon caused by CL.D infection in an immunocompromised patient
medical treatment includes
decrease immunosuppression
surgical treatment is indicated if
surgical correction includes total or partial colectomy with ileostomy
post-operative care includes good hydration, good antibiotics coverage, stopping MMF and stress dose steroids and tac targeting lower trough level around 5ng/dl
What is your management plan?
C.difficle fulminant infection with toxic megacolon with septicemia, since he had from the beginning WBC > 15,000 cells and increasing in spite of medical treatment it is considered severe fulminant CDC colitis, so I’ll ask for surgical consultation as soon as possible, as the timing to surgery may improve survival in such cases.
I would start medical treatment as soon as possible by IV metronidazole and iv vancomycin, and aggressive fluid resuscitation with serum electrolytes management.
I would give stress dose steroid, stop mycophenolate and keep the CNI at the lower acceptable level.
Indications for surgery are:
1. Colonic perforation or full-thickness ischemia.
2. Abdominal compartment syndrome or intra-abdominal hypertension.
3. Cardiopulmonary deterioration with ongoing or escalating need for vasopressor support despite adequate fluid resuscitation. 1. Using hemodynamics as trigger to surgery associated with higher mortality so should operate on this patient as soon as the diagnosis is there.
4. Respiratory failure requiring intubation and mechanical ventilation.
5. Worsening end organ failure, most notably acute renal failure.
6. Clinical signs of peritonitis or worsening abdominal exam despite adequate medical treatment.
7. Relative indications for surgery are (WBC) count >50,000 cells/mL, and Serum lactate levels >5 mmol/L.
References :
UpToDtae -Clostridioides difficile infection in adults: Treatment and prevention
UpToDate-Surgical management of Clostridioides difficile colitis in adults
This appears to be subacute intestinal obstruction with ‘ without perforation and needs urgent surgical intervention.
‘In our setup surgeons will go for exploratory laparotomy and then plan rest on table.
The Diagnosis is :
Clostridium difficile colitis Toxic megacolon
Clinically:
Abdominal pain and diarrhoea.
Hx of Antibiotic therapy: ciprofloxacin
Laboratory:
Initial stool tested positive for C. difficile toxin
WBC count was 16,500/μL rose to 19,900/μL
Radiologically :
A plain abdominal radiograph (left) demonstrated an 8.9cm transverse colon.
CT scan of the abdomen (right) revealed diffuse colonic thickening with scanty ascites
NB:
Radiological evidence of colonic dilatation, mainly affecting the ascending or transverse colon, is necessary for the diagnosis of toxic megacolon and use a cut-off of > 5-6 cm for colonic dilatation.
What is your management plan?
Mortality rates associated with toxic megacolon related to C. difficile colitis are high and range from 38% to 80%
Urgent surgical intervention as surgical indications are :
Progressive colonic dilatation (dilated colon 8.5 cm )
Lack of clinical improvement throughout the first 48 to 72 hours ( rising TLC after 48 hrs of metronidazole therapy )
in addition to if there is perforation or uncontrolled bleeding
The surgical procedure of choice for toxic megacolon :
Total colectomy with preservation of rectum and diverting ileostomy
partial colectomy may be performed with worse outcomes as residual diseased bowel may be left in place.
Pathogenesis:
toxins A and B produced by Clostridium difficile will severely damage the mucosa and lead to the development of pseudomembranes.
The most typical antibiotics linked to C. difficile infection include clindamycin, cephalosporins, and fluoroquinolones.
Risk factors for the development of toxic megacolon :
inflammatory bowel disease
ischemic colitis, or infectious colitis
Concurrent cancer
severe chronic obstructive lung disease
organ transplantation
cardiothoracic operations
diabetes mellitus
immunosuppression
renal failure
Medical Management :
oral vancomycin + IV metronidazole
bowel rest
bowel decompression
replacement of fluids and electrolytes
Colonic decompression with nasogastric suction and frequent repositioning of the patient
ReferencesGerding DN, Muto CA, Owens RC Jr. Treatment of Clostridium difficile infection. Clin Infect Dis. 2008;46 Suppl 1:S32–S42
Earhart MM. The identification and treatment of toxic megacolon secondary to pseudomembranous colitis. Dimens Crit Care Nurs. 2008;27:249–254
Bouza E, Muñoz P, Alonso R. Clinical manifestations, treatment and control of infections caused by Clostridium difficile. Clin Microbiol Infect. 2005;11 Suppl 4:57–64.
Will you carry on medical treatment or call the surgeon?
What do you mean by bowel decompression?
This is the case of toxic mega colon due to C. difficile infection
patient requires emergency total colectomy with end ileostomy
the colon should be sent for pathological examination which might show colonic dilatation with pseudomonas
patient should be managed in intensive care ward
the prednisolone should be changed to IV hydrocortisone
antimetabolites, MMF should be withheld during infections/ sepsis
oral vancomycin and IV metronidazole should be given
the cyclosporine level should be at lower level or change to single dose advagraf aiming at around through level 5
CTU should be done to rule out other cause of recurrent UTI, apart from IS as a causative agent, which lead to antibiotics usages
Will you carry on medical treatment or call the surgeon?
call the surgeon immediately
call the surgeon immediately
·What is your management plan?
CDC is the most common infectious cause of healthcare associated diarrhea.
Risk factors include:
1. Antibiotic use (this index case received multiple courses of antibiotics for recurrent UTIs)
2. High severity of illness (the severity in this index case is clearly evident by the need of hospital admission)
3. Hospitalized or nursing home patients, especially in elderly hospitalized patients
4. Immunosuppression
5. SOT &HCT recipients are particularly vulnerable
6. Old age
This index case has fulminant CDC (FCDC) 3 years after kidney transplantation.
Management plan
The treatment of FCDC is surgical:
·Total abdominal colectomy & ileostomy can be life saving
·If operated on after vasopressors are needed, the mortality rate increases significantly.
·So, early recognition of FCDC is needed for optimal & timely intervention:
-Altiparmak et al reported 2 patients who developed FCDC; both died without surgical intervention.
-One patient survived after surgery for FCDC (Mistry et al).
-Metronidazole is a very effective therapy for CDC & it can be combined with oral vancomycin.
References
1. Erik R.Dubberke et al. Epidemiology and Outcomes of Clostridium difficile Infection in Allogeneic Hematopoietic Cell and Lung Transplant Recipients. Transpl Infect Dis. 2018 April ; 20(2): e12855. doi:10.1111/tid.12855.
2. K.Keven et al. Clostridium difficile colitis in patients after kidney and pancreas-kidney transplantation. Transpl Infect Dis 2004: 6: 10-14
Excellent
See my answer above.
This is a case of Toxic megacolon for emergency surgery repair.
Absolute indications for surgery at any time include:
●Frank intraperitoneal perforation.
●Life-threatening hemorrhage or increasing transfusion requirements.
●Worsening systemic toxicity.
●Worsening colonic dilatation.
in addition, white blood cell count >50,000 cell/mL and serum lactate level of >5 mmol/L
are relative indications for surgery.
diverting loop ileostomy/colonic lavage is recommended .
Patients are given with blood products, intravenous fluids, and electrolytes (eg,
potassium).
References:
1- Sunil G. Sheth, Toxic Megacolon .Uptodate.Sep 26, 2022.
immunosuppression drugs ,reduce Cyclosporine dose and monitor level. IV
hydrocortisone suppressive dose during surgery.
71-year-old woman, renal transplant on immunosuppressant.Hx of recurrent UTIs, treated with multiple courses of antibiotics, C. difficile toxin in stool, treated, high WBC count, abdomen was mildly distended tender.
Toxic megacolon isa complications of any infectious etiology of the colon that is characterized by total or partial nonobstructive colonic dilatation and systemic toxicity.
Treatment: Both medical and surgical teams should co-manage patients on admission with daily evaluation.
*The main objective for the treatment is to reduce the inflammation, improve the motility of the colon, and to prevent free perforation.
– fluid replacement and intravenous steroid therapy is recommended
– along with addressing electrolyte derangements aggressively.
– Bowel rest, nasogastric/rectal tube can also help
-Serial labs, including CBC and Electrolytes, along with clinical abdominal x-ray
– Encouraging patients to walk around, using knee-elbow maneuver in the prone position
-Medical therapy with Glucocorticoids,Infliximab or Cyclosporine
-surgical management is necessary for the majority of the cases.Surgery is indicated in patients with colonic perforation, necrosis, or full-thickness ischemia, intra-abdominal hypertension or abdominal exam compartment syndrome, clinical signs of peritonitis, or worsening abdominal despite adequate medical therapy, and end-organ failure. Besides, white blood cell count >50,000 cell/mL and serum lactate level of >5 mmol/L are relative indications for surgical intervention.
30. Roys G, Kaplan MS, Juler GL. Surgical management of toxic megacolon. Am J
Gastroenterol. 1977;68(2):161–166. [PubMed] [Google Scholar]
31. Trudel JL, Deschenes M, Mayrand S, Barkun AN. Toxic megacolon complicating pseudomembranous enterocolitis. Dis Colon Rectum. 1995;38(10):1033–1038. doi: 10.1007/BF02133974 [PubMed] [CrossRef] [Google Scholar]
32. Greenstein AJ, Aufses AH. Differences in pathogenesis, incidence and outcome of
Jiten Desai, Mohamed Elnaggar, […], and Rajkumar Doshi
Additional article information
35. Dickinson RJ, Ashton MG, Axon AT, Smith RC, Yeung CK, Hill GL. Controlled trial of intravenous hyperalimentation and total bowel rest as an adjunct to the routine therapy of acute colitis. Gastroenterology. 1980;79(6):1199–1204. doi: 10.1016/0016-5085(80)90913-0 [PubMed] [CrossRef] [Google Scholar]
Thankyou what about the IS plan
Toxic megacolon should be suspected in patients with abdominal distension and diarrhea.
The most widely used criteria are:
●Radiographic evidence of colonic dilation (diameter >6 cm), PLUS at least three of the following:
•Fever >38ºC
•Heart rate >120 beats/min
•Neutrophilic leukocytosis >10,500/microL
•Anemia
PLUS at least one of the following:
•Dehydration
•Altered sensorium
•Electrolyte disturbances
•Hypotension
Imaging studies
· Plain abdominal radiographs, typical features:
1. The degree of dilatation is usually the greatest in the transverse or right colon, followed by the descending colon, the sigmoid colon, and the rectum
2. The diameter of the transverse and right colon is frequently greater than 6 cm and occasionally up to 15 cm on supine films
3. The normal colonic haustral pattern is either absent or severely disturbed
4. Multiple air-fluid levels can be seen in the colon
· Abdominal CT is more reliable in evaluating both the length and severity of colitis and the presence of colonic dilatation than plain abdominal radiographs
· CT may even be able to distinguish toxic megacolon from severe acute colitis
· CT feasures of severe acute colitis: diffuse colonic wall thickening, submucosal edema, pericolonic fat stranding, and ascites
· CT can also identify complications of megacolon, such as perforation or vascular compromise, and is helpful for excluding other causes of colonic distension, such as mechanical obstruction
Limited endoscopy for selected patients
· complete colonoscopy should generally be avoided in patients with toxic megacolon because it can cause colonic perforation
· A limited endoscopic examination without bowel preparation is safer and can be used to diagnose C. difficile colitis in the rectum or sigmoid colon
· while a proctoscopic finding of pseudomembrane may allow rapid diagnosis of C. difficile colitis, the rectum may be spared in up to 40 percent of patients with C. difficile colitis
TREATMENT of Toxic megacolon
· Supportive therapy: May need ICU due to systemic toxicity
– laboratory tests and abdominal radiographs are checked twice a day until the patient is stabilized, then continued daily
–replete blood products, IV fluids, and electrolytes
–nasogastric tube decompression may be required
–TPN could be necessary for patients who cannot tolerate enteral nutrition
–Broad-spectrum antibiotics and, in case of colonic perforation, histamine-2 blockers or proton pump inhibitors for ulcer prophylaxis and venous thromboembolism prophylaxis
–Intermittent rolling maneuvers or the knee-elbow position may help redistribute and expel gas in the colon
· Etiology-specific therapy: C. difficile colitis
– The inciting antibiotics should be stopped and Steroids are not used for infectious colitis
– Nonfulminant disease: Initial episode (nonsevere or severe disease):
Fidaxomicin 200 mg orally twice daily for 10 days
Vancomycin 125 mg orally 4 times daily for 10 days
For nonsevere disease, alternative regimen if above agents are unavailable:
Metronidazole◊ 500 mg orally 3 times daily for 10 to 14 days
– Recurrent episode
1. First recurrence
Fidaxomicin
200 mg orally twice daily for 10 days, OR
200 mg orally twice daily for 5 days, followed by once every other day for 20 days
VancomycinΔ in a tapered and pulsed regimen, for example:
125 mg orally 4 times daily for 10 to 14 days, then
125 mg orally 2 times daily for 7 days, then
125 mg orally once daily for 7 days, then
125 mg orally every 2 to 3 days for 2 to 8 weeks
Vancomycin 125 mg orally 4 times daily for 10 days
Adjunctive treatment: Bezlotoxumab 10 mg/kg intravenously, given once during administration of standard antibiotic regimen.
2. Second or subsequent recurrence
Fidaxomicin
200 mg orally twice daily for 10 days, OR
200 mg orally twice daily for 5 days, followed by once every other day for 20 days
Vancomycin in a tapered and pulsed regimen (example as above)
Vancomycin followed by rifaximin:
Vancomycin 125 mg orally 4 times daily by mouth for 10 days, then
Rifaximin 400 mg orally 3 times daily for 20 days
Adjunctive treatment: Bezlotoxumab 10 mg/kg intravenously, given once during administration of standard antibiotic regimen.
– Fulminant disease
Absence of ileus: Enteric vancomycin plus parenteral metronidazole:
Vancomycin 500 mg orally or via nasogastric tube 4 times daily, AND
Metronidazole 500 mg intravenously every 8 hours
If ileus is present, additional considerations include:
FMT (administered rectally) OR
Rectal vancomycin (administered as a retention enema 500 mg in 100 mL normal saline per rectum; retained for as long as possible and readministered every 6 hours)
– Surgery is indicated for colonic perforation, necrosis, or full-thickness ischemia, intra-abdominal hypertension or abdominal compartment syndrome, clinical signs of peritonitis or worsening abdominal examination despite adequate medical therapy, and end-organ failure
– Relative indications for surgery: white blood cell count >50,000 cell/mL and serum lactate level of >5 mmol/L
Rubin MS, Bodenstein LE, Kent KC. Severe Clostridium difficile colitis. Dis Colon Rectum 1995; 38:350.
Trudel JL, Deschênes M, Mayrand S, Barkun AN. Toxic megacolon complicating pseudomembranous enterocolitis. Dis Colon Rectum 1995; 38:1033.
Berman L, Carling T, Fitzgerald TN, et al. Defining surgical therapy for pseudomembranous colitis with toxic megacolon. J Clin Gastroenterol 2008; 42:476.
Louie TJ. Treatment of first recurrences of Clostridium difficile-associated disease: waiting for new treatment options. Clin Infect Dis 2006; 42:765.
Fischer M, Sipe BW, Rogers NA, et al. Faecal microbiota transplantation plus selected use of vancomycin for severe-complicated Clostridium difficile infection: description of a protocol with high success rate. Aliment Pharmacol Ther 2015; 42:470.
Gweon TG, Lee KJ, Kang DH, et al. A case of toxic megacolon caused by clostridium difficile infection and treated with fecal microbiota transplantation. Gut Liver 2015; 9:247.
Hocquart M, Lagier JC, Cassir N, et al. Early Fecal Microbiota Transplantation Improves Survival in Severe Clostridium difficile Infections. Clin Infect Dis 2018; 66:645.
Ahmed N, Kuo YH. Early Colectomy Saves Lives in Toxic Megacolon Due to Clostridium difficile Infection. South Med J 2020; 113:345.
Thankyou Hussam but the RELATIVE indications for surgical intervention are risky as IS can mask signs and symptoms.You have a rising WBC count and a very strong radiology finding ,usually you find unexpected complications during surgery.
what about IS medications how will you manage that.
Will you carry on medical treatment or call the surgeon?
In this patient with toxic megacolon, I could not see the fluid-air levels, but as Prof. Ahmed did, this case needed surgical exploration because the supportive care wand anti-biotherapy was not enough. Not sure, but I think the ct is with rectal contrast (not oral or iv ??)
*This case by history had: Abdominal pain and distension, massive colonic distension and thickening diameter 8.9cm transverse colon , recurrent attacks of UTIs treated with prolonged antibiotics that; causes bacterial proliferation , stool culture demonstrated: c.difficile , so; from the previous data this is a case of Toxic megacolon.
Treatment : must be started early unless perforation and even death can occur with ICU admission under G.surgery speciality.
Stabilize the patient vital signs firstly,fix NGT to relieve distended bowel , good hydration to avoid septic ATN ,start antibiotics ( Oral metronidazole 500 mg q 8hrs per day for mild-to-moderate cases if failed ; then start oral vancomycin 125-250mg q 6 hrs for up to 14 days)
*Regarding immuno-suppression medications: Half the dose of MMF or even stop it , lower dose of CNI , continue on stress dose of corticosteroids.
If , no improvement then exploration is a must with possible hemi-colectomy and colostomy can be followed with later on re-anastomosis accordingly.
N.B: Eye on KFT, inflammatory markers to follow-up improvement.
References:
Gallo M, Sica A, Peluso G, Lionetti R, etal.: Gastroenterological complications in kidney transplant patients. Open Med 2020;15(1):623-634.
Thankyou
DINA This is a real case. I have operated on this patient. I have found 7 perforations in his colon. Do you think there is a room for medical treatment?
From the information given and the radiology result shown, the likely diagnosis is pseudomembranous colitis by toxic megacolon caused by C. difficile infection due to the overuse of antibiotics used in the treatment of urinary tract infection that causes a proliferation of bacteria. Also, the patient is on immunosuppressive medications.
The diagnosis of this pathology is based on the following:
1) Clinical history based on what was presented about the prolonged use of antibiotics
2) Physical examination that shows abdominal distention and pain.
3) Radiology studies that show colonic dilatation more significant than 6 cm.
4) Other details that can help in the diagnosis are fever, signs of sepsis, septic shock, etc
Complications of megacolon are:
1) Perforation if not diagnosed on time the patient can lead to toxic shock and even death
Treatment:
1) It is an emergency and as such ICU and general surgery must be informed
2) Admit to ICU
3) Ensure proper hydration and chart input and output
4) Monitor vitals
5) Monitor electrolytes and correct the same
6) Suspend via oral
7) Pass NG tube
8) Start antibiotics: vancomycin via oral at a dose of about 125-250 mg 4 times per day and or metronidazole 500 mg 3 times per day
9) Can consider fecal microbial transplantation
10) Do stool culture and blood culture
11) Renal function tests so the kidney functions may not worsen or prevent it from worsening.
12) Adjust immunosuppressive medications: hold MMF, continue steroids, lower the CNI dose, and monitor levels
13) If the patient’s condition is not improving, then the next step is to op to surgery.
References:
Website: http://www.mayoclinic.org/diseases-conditions/pseudomembranous-colitis/symptoms-causes/syc-20351434
Salen, P., S., NCBI: Pseudomenbranous Colitis. Available at: www.ncbi.nlm.nih.gov/books/NBK470319/
Thankyou well done
This is a real case. I have operated on this patient. I have found 7 perforations in his colon. Do you think there is room for medical treatment?
The index patient is a transplant recipient with history of multiple episodes of antibiotic intake, now presenting with diarrhea and pain abdomen and a positive stool C. difficle toxin. There is leukocytosis and the imaging and clinical picture are suggestive of toxic megacolon (systemic toxicity and severe colonic distension) in this transplant recipient (1).
Diagnosis of toxic megacolon involves detailed history including recent use of antibiotics, recent travel, the use of immunosuppressives (2). Patient will have fever, abdominal pain with constipation, obstipation, abdominal tenderness and reduced bowel sounds. There may be dehydration and hypotension on examination. Laboratory tests will include a complete blood count (may show anemia, leukocytosis), CRP and ESR (elevated), blood culture, and stool sample for C. difficle toxin. Imaging will include plain abdominal x ray (colonic dilatation more than 6 cm, disturbed or loss of colonic haustrations, air-fluid levels, and small bowel distension) or CT abdomen (colonic wall thickening, pericolic stranding, ‘target sign’, complications like abscesses, perforation and ascending pyelophlebitis). An ultrasound abdomen can also pick these findings (2).
Treatment of toxic megacolon includes admitting the patient in intensive care unit, stopping the offending antibiotic, fluid resuscitation – management of dehydration as well as electrolyte correction, antibiotics (to reduce septic complications due to perforation, if it occurs), decompression (using nasogastric or long tube suction) and surgical consultation for intervention (3).
The patient needs to be kept nil per orally. Intravenous hydrocortisone and cyclosporine should be given to maintain immunosuppression.
Failed medical therapy after 24 to 72 hours (worsening clinical picture, increasing leukocytosis, progressive dilatation or perforation) will require urgent surgical intervention – hemicolectomy, as in this case.
Later-on, she should be evaluated for cause of recurrent UTI.
References:
1) Calogero A, Gallo M, Sica A, Peluso G, Scotti A, Tammaro V, Carrano R, Federico S, Lionetti R, Amato M, Carlomagno N, Dodaro CA, Sagnelli C, Santangelo M. Gastroenterological complications in kidney transplant patients. Open Med (Wars). 2020 Jul 11;15(1):623-634. doi: 10.1515/med-2020-0130. PMID: 33336019; PMCID: PMC7712021.
2) Autenrieth DM, Baumgart DC. Toxic megacolon. Inflamm Bowel Dis. 2012 Mar;18(3):584-91. doi: 10.1002/ibd.21847. PMID: 22009735.
3) Woodhouse E. Toxic Megacolon: A Review for Emergency Department Clinicians. J Emerg Nurs. 2016 Nov;42(6):481-486. doi: 10.1016/j.jen.2016.04.007. Epub 2016 May 13. PMID: 27185628.
Thankyou Amit WBC count is already on the rise !would still conserve for the next 24,72 hours?
No. this scenario requires urgent surgical intervention as already 48 hours of medical therapy have elapsed without any improvement.
This is a real case. I have operated on this patient. I have found 7 perforations in his colon. Do you think there is room for medical treatment?
No. this scenario requires urgent surgical intervention as already 48 hours of medical therapy have elapsed without any improvement.
_ The current case has toxic megacolon (dialted colon with diameter more than 6 cm and thickened wall) complicating pseudomembranous colitis (stole culture revealed Cl .difficile) , the predisposing factors in such elderly patient with repeated courses of antibiotics as ciprofloxacin.
_Mangement includes:
_ICU admission, nasogastric tube upper GIT decompression and rectal tube decompression.
_ starting oral vancomycin.
_good hydration to avoid graft hypoperfusion and ATN.
_Reduce dose of MMF or even stop it to minimize its GIT adverse effect.
_ continue CNI with caution as diarrhea can increase its level (in addition to the prerenal effect due to fluid losses, so close follow up of trough level and creatinine).
_consult surgery about need for exploration and partial colectomy with temporary colostomy then re-anastmosis.
In this septicemia state dealing with IS should be more strict ,depend on steroids mainly.
This is a real case. I have operated on this patient. I have found 7 perforations in his colon. Do you think there is room for medical treatment?
What is your management plan?
Thankyou
Excellent
The patient has pseudomembranous colitis complicated by toxic megacolon, secondary to C. difficile infection. likely due to frequent exposures to antimicrobials, and immunosuppressants.
C. Difficile in SOT:
– The incidence in SOT recipients is highest in the 3 months post Tx,
– Late-onset CDI occurs months to years after the transplant.
Clinical manifestations of C. difficile colonization
– Range from asymptomatic colonization, non-specific watery diarrhea, pseudomembranous colitis, to toxic megacolon
– Radiologic features consistent with CDI include thickened colonic wall, ascites, or marked colonic dilatation consistent with toxic megacolon
– Fulminant colitis (previously referred to as severe, complicated CDI) may be characterized by hypotension or shock, ileus, or megacolon, develops in up to 13% of SOT recipients with CDI.
Diagnosis:
Toxic megacolon should be suspected in patients with abdominal distension, diarrhea with severe systemic toxicity together with radiographic evidence of large bowel dilatation.
The most widely used criteria are:
-Radiographic evidence of colonic dilation (diameter >6 cm)
-PLUS at least three of the following:
Fever >38ºC
Heart rate >120 beats/min
Neutrophilic leukocytosis >10,500/microL
Anemia
-PLUS at least one of the following:
•Dehydration
•Altered sensorium
•Electrolyte disturbances
•Hypotension
Risk Factors:
– SOT recipients have unique risk factors that might contribute to more severe CDI.
– Exposure to multiple antimicrobials and/or broad spectrum/ extended courses is the most significant risk factor for development of CDI in the healthcare setting
– Prolonged hospitalization( healthcare setting)
– Female gender.
– Treatment for rejection intensified immunosuppression
– Intra-abdominal graft placement.
– Advance age.
– Use of PPI.
Megacolon may be complicated by bowel perforation; manifestations include abdominal rigidity, involuntary guarding, diminished bowel sounds, rebound tenderness, and severe localized tenderness in the left or right lower quadrants; abdominal radiographs may demonstrate free abdominal air.
Management:
Supportive management:
–Typically requires ICU because of systemic toxicity.
-careful monitoring of laboratory tests and abdominal radiographs
– Patients are repleted with blood products, intravenous fluids, and electrolytes (eg, potassium).
– Complete bowel rest (NPO) , and NGT decompression
– Enteral feeding, which hastens mucosal healing and stimulates normal motility, can be started as soon as the patient’s condition improves.
-Broad-spectrum antibiotics to treat sepsis
-venous thromboembolism prophylaxis.
-All medications that can impede colonic motility (eg, opiates, anticholinergics) should be stopped.
– Decrease of the immune suppression to the lowest effective dose with monitoring for rejection. Hold MMF, keep CNI lowest possible does ,and start steroids
Medical management;
-Oral metronidazole (500 mg 3 times daily) for mild-to-moderate disease.
-Oral vancomycin (125 to 250 mg 4 times daily) should be used for severe disease or if metronidazole fails.
-Fidaxomicin is a relatively new oral agent, less likely to permit recurrence of infection.
– IV metronidazole along with oral vancomycin in patients with severe gastrointestinal dysmotility or ileus, oral agents may not reach the colonic mucosa and.
-Fecal microbiota transplantation is a new therapy, which may have utility in preventing recurrent disease.
Early surgical consultation is warranted.
Indications for surgery
Absolute indications:
-Colonic perforation or full-thickness ischemia.
-Abdominal compartment syndrome or intra-abdominal hypertension.
-Cardiopulmonary deterioration with hemodynamic instability
-Respiratory failure requiring intubation and MV.
-Worsening end organ failure, most notably acute renal failure.
-Clinical signs of peritonitis
Relative indications for surgery;
-WBC count >50,000 cells/mL
-Serum lactate levels >5 mmol/L, which may be an indication of colonic ischemia
Surgical management options perform either a total abdominal colectomy with end ileostomy or a diverting loop ileostomy/colonic lavage
References:
– Sarah E. Ward, Clostridium difficile Infection in Solid Organ Transplant Patients– Calogero A., Gallo M., Sica A., Peluso G., Scotti A., et al. Gastroenterological complications in kidney transplant patients. Open Med., 2020; 15: 623-624.
– UpToDate.
Thankyou ,Exellent but how can WBC>50000 be a relative indication ,also Lactate >5mm/L this is an advanced septicemia with lactic acidosis.!
This is a real case. I have operated on this patient. I have found 7 perforations in his colon. Do you think there is room for medical treatment?
This patient had toxic megacolon secondary to C. difficile infection not improved after medical treatment over 48hrs, so he need urgent surgical consultation about surgical treatment
References:
Thankyou ,well done
As a Tx. Physician how will you deal with the IS drugs.
The recipient is >12 months post transplant & if graft function is stable is better to reduce the dose of MMF with close monitoring of graft function.
Excellent
Thank you sir
What is your management plan?
This patient developed toxic megacolon secondary to severe pseudomembraneous cololitis (C. difficele infection)
Presentation in immunosuppressed patient is atypical and a high suspicion is mandatory
Risk factors in this patient are:
1. Immunosuppressin
2. Recent antibiotic exposure (ciprofloxacin)
Criteria to diagnose toxic megacolon (three of the following four criteria):
1. fever > 101.5 F
2. HR > 120 beats/min
3. WBC > 10 500/mm^3
4. anemia with hemoglobin or hematocrit level less than 60% of normal
In addition, the patient must have any one of the following four clinical findings: dehydration, electrolyte disturbance, hypotension or changes in mental status
Severity of pseudomembraneous colitis (any one):
1. WBC > 15 × 109/L
2. Rise in serum creatinine level (≥ 133 μM/L or ≥ 1.5 times premorbid level)
3. > 38.5 °C
4. Albumin < 2.5 g/dL
Management of pseudomembraneous colitis
Oral metronidazole should be limited to the treatment of an initial episode of mild-moderate CDI
Oral vancomycin or fidaxomicin are recommended for treatment of patients with mild-moderate disease who do not respond to metronidazole (enema if cannot tolerate oral, but not intraveneous)
Repeated or prolonged courses of metronidazole should be avoided due to risk of cumulative and potentially irreversible neurotoxicity
Management of risk factors
Stop ciprofloxacin and MMF (MMF/MPA colitis is the most common post-transplant colitis, affecting 42.1% of patients with positive colonoscopy)
Supportive care
Intensive care unit
Intravenous fluid resuscitation, albumin supplementation, and electrolyte replacement, should be provided to all patients with severe C. difficile infection
In severe CDI, antibiotics should be discontinued, if possible. If they required for treatment of the primary infection, antimicrobial therapy with agents that are less associated with CDI (parenteral aminoglycosides, sulfonamides, macrolides, vancomycin, or tetracycline/tigecycline)
Surgical management
Early diagnosis and treatment is important to reduce the mortality associated with fulminant colitis
Patients with fulminant colitis who progress to systemic toxicity require surgical intervention (the index case)
Indications for surgery include: perforation, progressive dilation of the colon, lack of clinical improvement over the first 48-72 h and uncontrolled bleeding
Total colectomy with end ileostomy is the procedure of choice
Diverting loop ileostomy with antegrade colonic lavage may be a colon-preserving alternative to total colectomy
Patients with fulminant colitis should be treated with high dose vancomycin (500 mg, 6 hourly), oral and/or by enema, in combination with intravenous metronidazole (500 mg, 8 hourly)
References
1. Sayedy L, Kothari D, Richards RJ. Toxic megacolon associated Clostridium difficile colitis. World J Gastrointest Endosc. 2010 Aug 16;2(8):293-7. doi: 10.4253/wjge.v2.i8.293. PMID: 21160629; PMCID: PMC2999149.
2. Sartelli, M., Di Bella, S., McFarland, L.V. et al. 2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients. World J Emerg Surg 14, 8 (2019). https://doi.org/10.1186/s13017-019-0228-3
3. Sayedy L, Kothari D, Richards RJ. Toxic megacolon associated Clostridium difficile colitis. World J Gastrointest Endosc. 2010 Aug 16;2(8):293-7. doi: 10.4253/wjge.v2.i8.293. PMID: 21160629; PMCID: PMC2999149.
4. Gioco R, Puzzo L, Patanè M, Corona D, Trama G, Veroux P, Veroux M. Post-transplant colitis after kidney transplantation: clinical, endoscopic and histological features. Aging (Albany NY). 2020 Dec 22; 12:24709-24720. https://doi.org/10.18632/aging.202345
Thankyou the criteria you mentioned are those of TOXEMIA so l hope you considered the symptoms and the radiology.
HOw are you going to deal with the IS medications in this toxic state?
This is a real case. I have operated on this patient. I have found 7 perforations in his colon. Do you think there is room for medical treatment?
This is the case of infectious toxic megacolon due to antibiotic exposure, aggravated by immunosuppressant medication, CyA.
Toxic megacolon , although rare but it may cause deadly complication of the colonic complication, it define as non-obstructive dilatation of the colon.
Classification;
Inflammatory;
Infectious causes;
Ischemia.
Management;
General measures;
Specific;
Surgical management;
Refferences;
Jalan KN, Sircus W, Card WI, Falconer CW, Bruce CB, Crean GP, McManus JP, Small WP, Smith AN. An experience of ulcerative colitis. I. Toxic dilation in 55 cases. Gastroenterology. 1969 Jul;57(1):68-82. [PubMed]
2.
Autenrieth DM, Baumgart DC. Toxic megacolon. Inflamm Bowel Dis. 2012 Mar;18(3):584-91. [PubMed]
3.
Ausch C, Madoff RD, Gnant M, Rosen HR, Garcia-Aguilar J, Hölbling N, Herbst F, Buxhofer V, Holzer B, Rothenberger DA, Schiessel R. Aetiology and surgical management of toxic megacolon. Colorectal Dis. 2006 Mar;8(3):195-201. [PubMed]
4.
Hommes DW, Sterringa G, van Deventer SJ, Tytgat GN, Weel J. The pathogenicity of cytomegalovirus in inflammatory bowel disease: a systematic review and evidence-based recommendations for future research. Inflamm Bowel Dis. 2004 May;10(3):245-50. [PubMed]
5.
Norland CC, Kirsner JB. Toxic dilatation of colon (toxic megacolon): etiology, treatment and prognosis in 42 patients. Medicine (Baltimore). 1969 May;48(3):229-50
Thank you, Kamal
Yes, he needs surgery as you suggested. Well done
Thank you Prof.
——————————————————————————————————————-
Toxic megacolon
The criteria to diagnose toxic megacolon include:
What is your management plan?
-Otherwise, treatment for toxic megacolon will typically begin with:
Surgery
—————————————————————————————————————–
Reference
Thank you, Mohmoud
What are you going to do for this patient?
You provided a narrative review of the management, but it is not clear to me what are you going to do.
Will you carry on medical treatment or call the surgeon?
Thanks alot our Prof.Halawa
.
Supportive management:-
Will you carry on medical treatment or call the surgeon?
Yes of course call the surgeon.(Hemicolectomy)
This patient has Clostridium difficile colitis secondary to multiple antibiotics due to recurrent UTIs. She also has a toxic megacolon which is a complication of the C.difficile infection. Kidney transplant have the highest rate of UTIs among the solid organ transplants with an incidence of 7.3%.
Her management will include the following:
She will also need to be investigated for the recurrent urinary tract infections as this is what has led to her C.difficile infection. She will need a graft ultrasound with postvoid residual volume. We will also need the urine culture and sensitivity to make sure that we use the appropriate antibiotics and clear the infection
If she is getting recurrent infections, she will require prophylactic antibiotics for at least six months. She will also need to be advised to increase her fluid intake, maintain good hygiene (cleaning the perineum from front to back).
The use of cranberry supplements to reduce recurrent UTIs is controversial and there is no evidence that it works
N.Chacon-Mora et al. Enfarm Infect Microbiol Clin. 2017;35(4):255–259
Thank you, Hussein
Of course, needs surgery. What kind of surgery this patient needs?
Thank you Professor Halawa
The patient will require a hemicolectomy