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| Year : 1984 | Volume
: 30
| Issue : 3 | Page : 191-2 |
Toxic megacolon : survival without colectomy (a case report).
Chaudhary AA, Jain SK, Gupta NM
How to cite this article:
Chaudhary A A, Jain S K, Gupta N M. Toxic megacolon : survival without colectomy (a case report). J Postgrad Med 1984;30:191 |
Toxic megacolon, an uncommon presentation of various types of acute colitis, is a potentially lethal complication. Surgery offers the only hope of survival in these patients of severe pancolitis. As discussed by Peskin and Davis,[3] three types of surgery are possible in such cases, namely total proctocolectomy with ileostomy; subtotal colostomy with ileostomy, sigmoid colostomy and loop ileostomy. The present communication concerns a patient of toxic megacolon, who was too moribund for any conventional surgical procedure; colonic decompresion was successfully achieved in him by the use of a flatus tube intra-operatively.
R.K., an 18 year old male, was admitted in the emergency services of the Institute Hospital in a state of shock. There was ten days' history of frequent loose motions mixed with mucus, and blood. There was no abdominal pain and no history of similar episodes in the past. Examination revealed a pale, moderately built adult. The pulse rate was 130/minute and blood pressure, 70 mm Hg-systolic. There was no jaundice. The abdomen was distended and soft. No lump could be palpated. There was no free fluid and liver dullness was preserved. Rectal examination was normal. Proctoscopy revealed congested rectal mucosa but no ulcers could be seen. Sigmoidoscopic examination of the rectum was unsatisfactory because of liquid fecal matter in the lumen.
Investigations revealed haemoglobin to be 8 gm/dl with polymorphonuclear leukocytosis (TLC 14,000 per cmm). Blood biochemistry was within normal limit. Blood urea was 68 mg% and serum creatinine 1.7 mg%. Stool for Entamoeba histolytica done thrice was positive for cysts once only. Chest X-ray was normal. Plain X-ray of the abdomen showed a huge distension of the transverse colon with loss of haustral pattern [Fig. 1].
The patient was started on metronidazole and after adequate resuscitation taken up for emergency laparotomy. The peritoneal cavity was completely occupied by the hugely distended transverse colon which was obscuring all other viscera. The serosal aspect of the colon looked congested though there was no perforation. There was no abscess in the liver. The patient's blood pressure dropped to 40 mm Hg during abdominal exploration despite energetic fluid and blood replacement. At this juncture, a flatus tube was passed from the anal opening and guided upto the splenic flexure. The colon was gently deflated manually. Lot of gas and liquid stools came out and the colon collapsed. The patient's general condition did not improve and in consultation with the attending anaesthetist it was decided to close the abdomen. The flatus tube was left in place and fixed to the anal verge by a skin stitch. Post-operatively, the patient showed a gradual improvement. The flatus tube was removed on the second postoperative day. Abdominal distension disappeared within 4 days. The patient was discharged two weeks after surgery in good health. Plain X-ray of the abdomen done at the time of discharge was normal. Amebic serology (J.H.A.) was strongly positive both at the time of admission and discharge (1 in 512 and l in 256 respectively).
The term "toxic megacolon" was coined by Roth et al,[4] and the condition was first reported in ulcerative colitis.[2] It is also seen in toxic phases of typhoid fever, acute bacillary dysentery, amebic colitis and cholera. The exact aetiology and pathogenesis of toxic megacolon continue to be obscure, but is currently believed to be due to transmural extension of the inflammatory process to all coats of the colonic wall.' The clinical and radiological features of this serious complication have been well established.[5],[7],[8]
The outlook in these cases is dismal, prognosis becoming worse once the distended colon perforates.[6] Thus there is no role of expectant medical treatment. Immediate surgery in the form of colectomy (total or subtotal) or simpler procedures like loop ileostomy or multiple colostomies have been advocated. In the ideal conditions, colectomy probably gives the best results since the diseased segment is removed. To the best of our knowledge, the technique of mechanical deflation of the distended transverse colon by the passage of a flatus-tube at surgery, has not been reported as a treatment modality in desperate cases of toxic megacolon. We feel that it is worth a trial in very moribund cases who do not tolerate surgery and anaesthesia well. Even partial decompression of a hugely distended colon is a help in handling the colon if colectomy is planned. The procedure should not be used if there is an impending or already existing colonic perforation. This mechanical deflation is certainly not a substitute for definitive procedure like colectomy and should be resorted to in desperate circumstances only.
| 1. | Jalan, K. N., Sircus, W., Cord, W. I., Falconer, C. W. A., Bruce, T., Crean, G. P., McManus, J. P. A., Small, W. P. and Smith, A. N.: An experience of ulcerative colitis; Toxic dilatation in 55 cases. Gastro-enterology, 57: 68,-82,1969.  |
| 2. | Marshak, R. H. and Luster, L. J.: Megacolon-a complication of ulcerative colitis. Gastro-enterology, 16: 768-772, 1950. |
| 3. | Peskin, G. W. and Davis, A. V.: Acute fulminating ulcerative colitis with colonic distension. Surg. Gynaec. & Obstet., 114: 269-276, 1960. |
| 4. | Roth, J. A., Valdes-Dapena, A., Stein, G. N. and Bockus, H. L.: Toxic megacolon in ulcerative colitis. Gastro-enterology, 37: 239-255, 1959. |
| 5. | Stein, D., Bank, S. and Louw, J. H.: Fulminating amoebic colitis. Surgery, 85: 349-352, 1979. |
| 6. | Strauss, R. J., Flint, G. W., Platt, N., Levin, L. and Wise, L.: The surgical management of toxic dilatation of the colon. A report of 28 cases and review of the literature. Ann. ,Surg., 184,: 682,-688, 1976. |
| 7. | Wig, J. D., Talwar, B. L. and Bushurmath, R.: Toxic dilatation complicating fulminant amoebic colitis. Brit. J. Surg., 68: 148-150. 1981. |
| 8. | Wruble, L. D., Duckworth, J. K., Duke, D. D. and Rothschild, J. A.: Toxic dilatation of the colon in a case of amoebiasis. New Engl. J. Med., 275: 926-928, 1966. |
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