Rectal endometriosis presenting as toxic megacolon

Background The bowel is the most common site of extragenital endometriosis, with involvement of the locoregional sigmoid colon and anterior rectum seen most often. The clinical presentation varies depending on how soon patients seek medical care, thus requiring changes in management strategies. Endometriosis can cause a life-threatening surgical emergency with progressive obliteration of the bowel lumen leading to obstruction and late complications including toxic megacolon and transmural necrosis. Case presentation We report the case of a 41-year-old woman presenting with an acute abdomen and complete large bowel obstruction complicated by sepsis and toxic megacolon. The patient underwent emergency total colectomy with ileostomy. Medical history was significant for chronic, vague, and episodic lower abdominal pain self-medicated with herbal tea and laxatives. Pathologic examination demonstrated colonic endometriosis within the bowel wall as the cause of obstruction, ischemia, and transmural necrosis. Conclusions Although a rare clinical entity, this case highlights two important points. First, it demonstrates the value of performing proper and complete clinical work up to rule out or in all possible causes of colonic obstruction, including intestinal endometriosis. Second, it suggests a potential benefit of a formalized multidisciplinary approach, including surgery, in the management of medically unresponsive endometriosis. In conclusion, this case shows that endometriosis can cause life-threatening colonic obstruction in women of childbearing age. Prompt early intervention is warranted, particularly when obstruction is only partial and ischemia has not supervened, to conceivably prevent the development of a toxic megacolon requiring colectomy and avoid late complications.

Colitis ulcerativa fulminante complicada con megacolon tóxico / Fulminant ulcerative colitis complicated with toxic megacolon

Presentamos un caso de abdomen agudo secundario a megacolon tóxico perforado como debut de colitis ulcerativa que requirió múltiples intervenciones quirúrgicas y estancia prolongada en la unidad de cuidados intensivos. El megacolon tóxico es una complicación infrecuente y potencialmente fatal de la colitis ulcerativa, siendo más raro aún como debut en un paciente sin antecedentes y con solo un factor de riesgo identificado, considerándolo una oportunidad para compartir su estudio y abordaje. El diagnóstico de megacolon tóxico se configura de acuerdo con los criterios propuestos por Jalan. Aunque el tratamiento inicial es médico con corticoterapia endovenosa, un porcentaje importante de pacientes precisará abordaje quirúrgico.

We present a case of acute abdomen secondary to perforated toxic megacolon in a patient with new-onset ulcerative colitis (UC) that required multiple surgical interventions and prolonged intensive care unit stay. Toxic megacolon is a rare but potentially fatal complication of UC, being even rarer in new-onset UC in a patient with no history and only one risk factor identified, considering this an opportunity to share its study and approach. The diagnosis of toxic megacolon is based on the criteria proposed by Jalan. Although the initial treatment is medical therapy with intravenous corticosteroids, surgical management is necessary for a significant majority of patients.

Megacolon tóxico en paciente con COVID-19 / Toxic megacolon in a patient with Covid-19

Introducción: La pandemia derivada de la enfermedad por el nuevo coronavirus 2019 (COVID-19) se ha convertido en una emergencia de salud pública mundial, debido a que puede desarrollar complicaciones que amenazan la vida. Si bien se sabe que el SARS-CoV-2 causa enfermedad pulmonar sustancial, se han observado muchas manifestaciones extrapulmonares, incluyendo el compromiso del sistema gastrointestinal. El megacolon tóxico es una complicación rara pero, potencialmente, mortal que se asocia más con la enfermedad inflamatoria intestinal. Sin embargo, cualquier afección que conduzca a la inflamación del colon puede conducir a una dilatación tóxica. Objetivo: Se presenta el caso de un paciente con un síndrome de dificultad respiratoria aguda secundario a una infección por SARS-COV-2. De manera concomitante presentó un cuadro de dilatación no obstructiva del colon, asociado con toxicidad sistémica. Caso clínico: El desarrollo de megacolon tóxico en un paciente con SARS-COV-2 puede estar justificado debido a que el virus infecta las células huésped a través del receptor de la enzima convertidora de angiotensina 2. Se cumplieron los criterios diagnósticos para megacolon tóxico. Conclusiones: Esta también se encuentra altamente expresada en las células epiteliales intestinales, por lo tanto, se debe considerar su diagnóstico oportuno para una intervención temprana, en aras de reducir la tasa de mortalidad tanto como sea posible(AU)

Introduction: The pandemic derived from the 2019 novel coronavirus disease (COVID-19) has become a global public health emergency, due to the fact that it can develop life-threatening complications. Although SARS-CoV-2 is known to cause substantial lung disease, many extra-pulmonary manifestations have been observed, including involvement of the gastrointestinal system. Toxic mega colon is a rare but life-threatening complication most associated with inflammatory bowel disease. However, any condition that leads to inflammation of the colon can lead to toxic dilation. Objective: To report the case of a patient with ARDS secondary to a SARS-COV-2 infection. Concomitantly, she had non-obstructive dilation of the colon, associated with systemic toxicity. Clinical case report: The development of toxic mega colon in a patient with SARS-COV-2 may be justified because the virus infects host cells through the angiotensin-converting enzyme 2 receptor. The diagnostic criteria for toxic megacolon were met. Conclusions: It is also highly expressed in intestinal epithelial cells, therefore, its timely diagnosis should be considered for early intervention, in order to reduce the mortality rate as much as possible(AU)

Management of inflammatory bowel diseases in urgent and emergency scenario / Manejo das doenças inflamatórias intestinais na urgência e emergência

Abstract Objective To review the main acute complications of inflammatory bowel disease in order to present the state of the art of their respective diagnosis and treatment. Methods A bibliographic search was conducted in Medline database using the following keywords: "inflammatory bowel disease", "Colitis Ulcerative", "Crohn Disease", "emergency" among others that had their variation evaluated by the MESH. Articles from the last 10 years conducted with humans, written in Portuguese or English, and published in journals with impact factor greater than 1 were selected. Results After carrying out the search phrase and selecting the filters, 20 articles were selected to be included in the research. The most common acute complications were evaluated, focusing on their current propaedeutic and management aspects. Conclusion Most emergencies related to inflammatory bowel disease should be treated non-operatively firstly, prioritizing patient hemodynamic state. In selected cases of life-threatening complications emergent operative treatment are mandatory. The timing of procedure is the most important aspect. As general rule, in Crohn's Disease, operative treatment should be postponed as much as possible and the resection as small as possible. In case of ulcerative rectocolitis, if the hemodynamic state of the patient allows, proctocolectomy should be expedited with curative intention.

Resumo Objetivo Revisar as principais complicações agudas das doenças inflamatórias intestinais, a fim de apresentar o estado da arte de seus respectivos diagnósticos e tratamentos. Métodos Foi realizada uma pesquisa bibliográfica no banco de dados Medline, utilizando as seguintes palavras-chave: "doença inflamatória intestinal", "Colite Ulcerativa", "Doença de Crohn", "emergência" entre outras que tiveram sua variação avaliada pelo MESH. Artigos dos últimos 10 anos realizados com seres humanos, escritos em português ou inglês, e publicados em periódicos com fator de impacto maior que um foram selecionados. Resultados Após a construção da frase de pesquisa e seleção dos filtros, 20 artigos foram selecionados para inclusão no estudo. As complicações agudas mais comuns foram avaliadas, enfocando seus atuais aspectos propedêuticos. Conclusão A maioria das emergências relacionadas à doença inflamatória intestinal deve ser tratada primariamente de forma não cirúrgica, priorizando a hemodinâmica do paciente. Em casos selecionados de complicações potencialmente fatais, tratamento cirúrgico de emergência é mandatório. O momento do procedimento é o aspecto mais importante. Como regra geral, na Doença de Crohn, o tratamento cirúrgico deve ser adiado ao máximo com ressecção menor possível. No caso de retocolite ulcerativa, se o estado hemodinâmico do paciente permitir, a proctocolectomia deve ser realizada com intenção curativa.

Megacolon tóxico de origen idiopático: reporte de caso / Megacolon toxic of idiophatic origin: case report

Resumen El megacolon tóxico (MT) es una patología con una tasa de mortalidad superior al 80% desencadenada por un proceso inflamatorio progresivo que compromete la pared del colon con dilatación secundaria de la luz intestinal debido a procesos inflamatorios o infecciosos. Su presentación clínica es infrecuente y los pilares básicos en su manejo son un diagnóstico oportuno, un manejo médico adecuado (antibiótico, reanimación hídrica y corrección metabólica) y, de ser necesario, un manejo quirúrgico eficaz que evite al máximo las complicaciones que empeoran el pronóstico de los pacientes. En este artículo se presenta un caso de una paciente con choque séptico secundario a MT, con desenlace fatal y con sospecha de un cuadro de colangitis grado III descartado por ecografía, lo cual generó distorsiones en su enfoque y manejo inicial. Por deterioro clínico y distensión abdominal, la paciente se llevó a laparoscopia diagnóstica en la que se evidenció un compromiso isquémico severo de todo el colon sin compromiso de intestino delgado, razón por la que se le realizó una colectomía total. El reporte de patología y la historia clínica descartan colitis ulcerativa o enfermedad de Crohn, lo que confirmó el MT. La paciente no presentaba factores de riesgo para el desarrollo de colitis pseudomembranosa. Se concluyó que fue la presentación de un caso de MT idiopático.

Abstract Toxic megacolon is a pathology whose mortality rate is over 80%. A progressive inflammatory process compromises the colon wall, and secondary dilation of the intestinal lumen occurs due to inflammatory or infectious processes. Its clinical presentation is bizarre. but the basic pillars for management are opportune diagnosis and adequate medical management with antibiotics, water resuscitation, and metabolic correction. If necessary, effective surgical management can prevent the development of complications that worsen the disease and the prognosis of a patient. In this article we present the case of a patient who died after developing septic shock secondary to toxic megacolon. Cholangitis grade III was suspected, but discarded after ultrasonography, and this resulted in generated distortions in approach and initial management. Due to clinical deterioration and abdominal distension, the patient underwent diagnostic laparoscopy which revealed severe ischemic compromise of the entire colon but without involvement of the small intestine. For this reason, a total colectomy was performed. The pathology report and clinical history ruled out ulcerative colitis or Crohn's disease which confirmed the diagnosis of toxic megacolon. The patient had no risk factors for the development of pseudomembranous colitis. We conclude that this was a case of idiopathic toxic megacolon.

Cardiac Arrest in a Patient with a Severely Distended Colon

Toxic megacolon is a devastating complication of colitis, which is commonly caused by inflammatory bowel disease. Frequently reported complications of toxic megacolon are bleeding, sepsis, colon perforation, and shock. Herein, we report a rare case of cardiac arrest that was likely caused by toxic megacolon in a 49-year-old male, who experienced 3 months of intermittent dyspnea and abdominal distension that abruptly worsened before presentation. Our case suggests that severe colon dilation complicated by toxic megacolon, especially accompanied by cardiopulmonary symptoms and signs, has the potential to progress to an abdominal compartment syndrome, which is a rare but life-threatening complication.

Toxic megacolon and interstitial pneumonia caused by cytomegalovirus infection in a pediatric patient with acute lymphoblastic leukemia receiving chemotherapy

No abstract available.

A Case of Toxic Megacolon Caused by Clostridium difficile Infection and Treated with Fecal Microbiota Transplantation

Toxic megacolon is a rare clinical complication of fulminant 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 microbiota transplantation.

Toxic Megacolon Associated with Secondary Amyloidosis: An Unusual Complication of Clostridium difficile Colitis / 이화의대지

Amyloidosis is characterized by extracellular deposition of protein fibrils in one or multiple organs. AA amyloidosis is secondarily occurred to be related with chronic infections or inflammatory diseases. We report a 67-year-old man suffered from secondary AA amyloidosis related with chronic Clostridium difficile colitis after repeated total hip replacement surgery. Infection control is the most important treatment of AA amyloidosis secondary to chronic infection. However, the patient's C. difficile colitis was not controlled well, eventually toxic megacolon with sepsis was developed. Consequently, he had to take total colectomy, but he expired with multi-organ failures. We suggested that early surgical procedure might be one option for intractable C. difficile colitis complicated with secondary amyloidosis.

Cytomegalovirus Colitis Causing Cecal Perforation and Massive Lower Gastrointestinal Bleeding / 대한소화기내시경학회지

Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality in immunocompromised patients. It may cause serious illness including bleeding, ulceration and perforation of the gastrointestinal tract. However, bowel perforation, toxic megacolon, and massive lower gastrointestinal bleeding caused by CMV in one patient is not common. In this report, we present a case of CMV colitis causing cecal perforation and massive lower gastrointestinal bleeding in a patient with lupus nephritis. In our case, severe lower gastrointestinal bleeding developed during successful treatment of CMV infection with ganciclovir. Even though the outcome of CMV colitis has improved since ganciclovir has been available for immunocompromised patients, reductions in gastrointestinal bleeding from colonic ulcers of CMV colitis may be possible during successful treatment with ganciclovir. This case suggests the possibility of lower gastrointestinal bleeding from a colon ulcer of CMV colitis should be considered during successful treatment with ganciclovir in immunocompromised patients.

A Case of a Cytomegalovirus Colitis Related Rectal Stricture Treated by Endoscopic Balloon Dilation / 대한소화기내시경학회지

Cytomegalovirus (CMV) colitis is a common opportunistic infection in immunocompromised patients. Affected individuals present with abdominal pain, diarrhea, or hematochezia. Complications of CMV colitis can include massive bleeding, toxic megacolon, bowel perforation and, rarely, colon stricture. A 69-year-old woman who had no specific past history was admitted to the orthopedic department for pelvic bone fracture with right iliac artery rupture caused by a traffic accident. She was successfully managed with emergency transarterial coil embolization. After 2 weeks, she developed hematochezia and recurrent abdominal pain. Colonoscopy showed a huge, deep ulcer in the rectosigmoid colon. Biopsy and immunohistochemical staining revealed giant cells with intracellular inclusion bodies that were positive for CMV antigen. She received antiviral treatment after which her symptoms improved. On follow-up colonoscopy 3 months later, we found a tight luminal narrowing in the rectum. We did a repeat endoscopic balloon dilation in this patient and she experienced improvement.

A Case of Transverse Colon Perforation after Colonoscopy in a Patient withEnterocolitis Caused by Non-typhoidal Group D Salmonella / 대한소화기내시경학회지

Clinical manifestations of Salmonella infection are variable such as enterocolitis, bacteremia, enteric fever, focal infection and asymptomatic carrier status. Among these presentations, enterocolitis is the most common clinical manifestation and can be diagnosed by the use of fecal specimens. Patients with severe infectious colitis are at increased risk of developing a colon perforation after colonoscopy due to colon trauma. We report a case of a 31-year-old woman with transverse colon perforation after colonoscopy that was diagnosed with enterocolitis caused by infection with non-typhoidal group D Salmonella.

A Case of Toxic Megacolon Associated with Fulminant Pseudomembranous Colitis / 대한소화기내시경학회지

The clinical presentation of Clostridium difficile infection ranges from asymptomatic carriage, colitis with or without pseudomembranes, to fulminant colitis. Although not common, fulminant Clostridium difficile colitis can result in bowel perforation and peritonitis with a high mortality rate. We report a case of toxic megacolon associated with fulminant pseudomembranous colitis. We experienced a case of a 65-year-old male patient who presented with abdominal distension and pain for three days during treatment of pneumonia. We were able to diagnose the case as a toxic megacolon associated with fulminant pseudomembranous colitis. In spite of oral metronidazole treatment and conservative treatment, the clinical course worsened and the patient went into septic shock. The patient underwent a total colectomy but the clinical situation did not improve and the patient died.

A Case of Benign Colonic Stricture Treated by Therapeutic Balloon Dilatation in Ulcerative Colitis / 대한소화기내시경학회지

Ulcerative colitis produces repeated improvements and relapses of chronic colonic inflammation. Complications of the disease can include bleeding, toxic megacolon, colon cancer, or colon stricture. While colonic strictures are common in Crohn's disease, this complication rarely appears in ulcerative colitis cases. Unlike in Crohn's disease, where strictures are commonly treated by endoscopic balloon dilatation, surgical management is the basis for treatment of strictures in ulcerative colitis because malignant strictures are common and because the stricture region is generally wide. We report the case of a patient who presented with decreased stool caliber while undergoing treatment for ulcerative colitis. We performed therapeutic balloon dilatation in this patient with a benign stricture caused by ulcerative colitis and experienced improvement of symptoms.

Un caso de megacolon tóxico por salmonella / Case report of a toxic megacolon due to salmonella infection

Se presenta el caso de un paciente masculino de 59 años de edad, con antecedentes de colitis ulcerosa, que luego de la ingesta de agua no potable se internó por diarrea de una semana de evolución con más de veinte deposiciones acuosas diarias. Al momento de la internación se realizó rectosigmoidoscopía que no reveló actividad de su enfermedad intestinal de base. Se solicitaron estudios para descartar diversas etiologías infecciosas, obteniéndose en coprocultivo desarrollo de Salmonella species por lo que se indicó tratamiento antibiótico con ciprofloxacina.

Un caso de megacolon tóxico por Salmonella / Toxic megacolon by salmonella infection. Case report

Se presenta el caso de un paciente masculino de 59 años de edad, con antecedentes de colitis ulcerosa, que luego de la ingesta de agua no potable se internó por diarrea de una semana de evolución con más de veinte deposiciones acuosas diarias...Presentó como complicación del cuadro infeccioso, deshidratación e insuficiencia renal con requerimiento de hemodiálisis y apoyo hemodinámico con inotrópicos, evolucionando luego con toxicidad sistémica, peritonismo y dilatación de colon transverso evidenciada por radiografía de abdomen