ABSTRACT
Toxic megacolon is most commonly considered as a complication of inflammatory bowel disease, especially ulcerative colitis and colonic Crohn's disease to a lesser extent. It appears in the context of moderate-to-severe disease and often requires colectomy. Currently, after an inadequate response to conventional therapy with systemic corticosteroids, the use of cyclosporine or infliximab is considered as an alternative option, prior to surgical intervention. We present a case report of toxic megacolon in a patient with a severe refractory colonic Crohn's disease, where anti-tumor necrosis factor (anti-TNF) therapies were contraindicated. Consequently, we decided to use ustekinumab as a rescue therapy, despite insufficient evidence to provide recommendations for this indication.
Subject(s)
Colitis, Ulcerative , Crohn Disease , Megacolon, Toxic , Crohn Disease/complications , Crohn Disease/drug therapy , Humans , Infliximab , Megacolon, Toxic/drug therapy , Megacolon, Toxic/etiology , Megacolon, Toxic/surgery , Tumor Necrosis Factor Inhibitors , Ustekinumab/therapeutic useABSTRACT
Dilatation of the colon in severe and fulminating ulcerative colitis is a sign of toxic megacolon and emergency surgery is usually the favored treatment option. Here we describe our experience with three cases of ulcerative colitis with megacolon in which surgery was avoided by treating the patients with a continuous intravenous infusion of cyclosporine, with full cooperation of the surgeons. We recommend that continuous intravenous infusion of cyclosporine be considered as an effective option for the conservative management of severe, fulminating ulcerative colitis with megacolon.
Subject(s)
Colitis, Ulcerative/drug therapy , Cyclosporine/therapeutic use , Immunosuppressive Agents/therapeutic use , Megacolon, Toxic/drug therapy , Humans , Infusions, Intravenous , MegacolonABSTRACT
Clostridioides (formerly Clostridium) difficile infections (CDIs) are becoming more common and more serious. C. difficile is the etiologic agent of antibiotic-associated diarrhea, pseudomembranous enterocolitis, and toxic megacolon while CDIs recur in 7.9% of patients. About 42.9 CDI cases/10,000 patient-days are diagnosed each day in Europe, whereas in Poland 5.6 CDI cases/10,000 patient-days are reported; however, the median for European countries is 2.9 CDI cases/10,000 patient-days. Epidemiology of CDIs has changed in recent years and risk of developing the disease has doubled in the past decade that is largely determined by use of antibiotics. Studies show that rate of antibiotic consumption in the non-hospital sector in Poland is much higher than the European average (27 vs. 21.8 DDD/1,000 patient-days), and this value has increased in recent years. Antibiotic consumption has also increased in the hospital sector, especially in the intensive care units - 1,520 DDD/1,000 patient-days (ranging from 620 to 3,960 DDD/1,000 patient-days) - and was significantly higher than in Germany 1,305 (ranging from 463 to 2,216 DDD/1,000 patient-days) or in Sweden 1,147 (ranging from 605 to 2,134 DDD/1,000 patient-days). The recent rise in CDI incidence has prompted a search for alternative treatments. Great hope is placed in probiotics, bacteriocins, monoclonal antibodies, bacteriophages, and developing new vaccines.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Clostridioides difficile/drug effects , Enterocolitis, Pseudomembranous/drug therapy , Enterocolitis, Pseudomembranous/epidemiology , Megacolon, Toxic/drug therapy , Megacolon, Toxic/epidemiology , Bacterial Vaccines , Bacteriocins/therapeutic use , Enterocolitis, Pseudomembranous/microbiology , Humans , Megacolon, Toxic/microbiology , Phage Therapy/methods , Poland/epidemiology , Probiotics/therapeutic useABSTRACT
INTRODUCTION: Aspergillus is a rare cause of surgical site infection most often seen in immunocompromised patients undergoing cardiac, transplant, ophthalmologic, or burn operations; an unusual case following a colon resection is presented here. CASE REPORT: The authors report a case of an invasive Aspergillus fumigatus infection following a subtotal colectomy for toxic megacolon. The patient was on antibiotics following the operation and chronic immunosuppression with steroids and infliximab. This was an unusual cause of a postoperative wound infection. CONCLUSIONS: This case highlights the importance of early and accurate identification, debridement, and systemic antifungals to prevent widespread infection. With changes in antifungal care over recent years, engaging infectious disease physicians during treatment is recommended.
Subject(s)
Aspergillosis/microbiology , Aspergillus fumigatus/isolation & purification , Debridement/methods , Megacolon, Toxic/surgery , Postoperative Complications/microbiology , Surgical Wound Infection/microbiology , Adult , Antifungal Agents/therapeutic use , Aspergillosis/drug therapy , Colectomy , Female , Humans , Immunocompromised Host , Megacolon, Toxic/drug therapy , Postoperative Complications/drug therapy , Surgical Wound Infection/drug therapy , Treatment Outcome , Triazoles/therapeutic use , Voriconazole/therapeutic useABSTRACT
Clostridium difficile (C. difficile) is an anaerobic, Gram-positive, spore-forming, toxin-secreting bacillus. It is transmitted via a fecal-oral route and can be found in 1-3 % of the healthy population. Symptoms caused by C. difficile range from uncomplicated diarrhea to a toxic megacolon. The incidence, frequency of recurrence, and mortality rate of C. difficile infections (CDIs) have increased significantly over the past few decades. The most important risk factor is antibiotic treatment in elderly patients and patients with severe comorbidities. There is a screening test available to detect C. difficile-specific glutamate dehydrogenase (GDH), which is produced by both toxigenic and non-toxigenic strains. To confirm CDIs, it is necessary to test for toxins in a fresh, liquid stool sample via polymerase chain reaction or an enzyme-coupled immune adsorption test. If CDIs are diagnosed, then ongoing antibiotic treatment should be ended. Metronidazole is used to treat mild cases, and vancomycin is recommended for severe cases. Vancomycin or fidaxomicin should be used to treat recurrences (10-25 % of patients). In cases with several recurrences, a treatment option is fecal microbiome transfer (FMT). The cure rate following FMT is approximately 80 %. The treatment of severe and complicated CDI with a threatening toxic megacolon remains problematic. The degree of evidence of medicated treatment in this situation is low; the significance of metronidazole i. v. as an additional therapeutic measure is controversial. Tigecycline i. v. is an alternative option. Surgical treatment must be considered in patients with a toxic megacolon or an acute abdomen.
Subject(s)
Anti-Bacterial Agents/administration & dosage , Clostridioides difficile/isolation & purification , Enterocolitis, Pseudomembranous/diagnosis , Enterocolitis, Pseudomembranous/drug therapy , Megacolon, Toxic/diagnosis , Megacolon, Toxic/drug therapy , Aminoglycosides/administration & dosage , Diarrhea/diagnosis , Diarrhea/drug therapy , Diarrhea/microbiology , Enterocolitis, Pseudomembranous/microbiology , Evidence-Based Medicine , Fidaxomicin , Humans , Megacolon, Toxic/microbiology , Metronidazole/administration & dosage , Treatment Outcome , Vancomycin/administration & dosageABSTRACT
Toxic megacolon is an infrequent but life-threatening complication that occurs most commonly in patients with severe ulcerative colitis. Intravenous steroids are often recommended for patients with toxic megacolon secondary to ulcerative colitis. However, steroid dependency may mask the presence of intra-abdominal sepsis and is associated with refractoriness, during which cytomegalovirus reactivation may occur. In this report, we present two rare cases of megacolon accompanying pancolonic severe ulcerative colitis that were successfully treated with oral tacrolimus, including one steroid-naïve patient. In cases of ulcerative colitis with megacolon, treatment with oral tacrolimus is recommended, thereby avoiding steroid dependency and improving the long-term prognosis.
Subject(s)
Colitis, Ulcerative/complications , Immunosuppressive Agents/therapeutic use , Megacolon, Toxic/drug therapy , Tacrolimus/administration & dosage , Administration, Oral , Female , Humans , Male , Megacolon, Toxic/diagnosis , Megacolon, Toxic/etiology , Middle Aged , Prognosis , Treatment OutcomeSubject(s)
Abdominal Pain/etiology , Colitis, Ulcerative/complications , Megacolon, Toxic/complications , Acute Disease , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/therapeutic use , Child , Clostridioides difficile , Clostridium Infections/prevention & control , Colitis, Ulcerative/diagnostic imaging , Colitis, Ulcerative/drug therapy , Female , Glucocorticoids/therapeutic use , Humans , Infusions, Intravenous , Megacolon, Toxic/diagnostic imaging , Megacolon, Toxic/drug therapy , Prognosis , Radiography , Risk FactorsABSTRACT
Refractory medical treatment of Crohn disease-associated toxic megacolon usually requires surgery, which carries substantial morbidity and mortality. We report a case of a woman with steroid and antibiotic-refractory fulminant Crohn colitis and ileitis, complicated by a toxic megacolon, who was successfully treated with infliximab. Infliximab induced rapid clinical response and remission, thereby avoiding emergency (ileo) colectomy. This is the first report of treatment of Crohn disease-associated toxic megacolon with infliximab.
Subject(s)
Antibodies, Monoclonal/therapeutic use , Crohn Disease/drug therapy , Gastrointestinal Agents/therapeutic use , Megacolon, Toxic/drug therapy , Adult , Crohn Disease/complications , Female , Humans , Infliximab , Megacolon, Toxic/etiology , Treatment OutcomeABSTRACT
Clostridium difficile infection (CDI) in non-hospitalized patients has been reported with increased frequency, whereas an association between CDI and pregnancy has not been highlighted. We report a case of toxic megacolon complicating a severe CDI during the second trimester of pregnancy in a patient without traditional risk factors, such as antibiotic use, immunodeficiency, and prolonged and recent hospitalization.
Subject(s)
Clostridioides difficile , Enterocolitis, Pseudomembranous/complications , Megacolon, Toxic/complications , Pregnancy Complications, Infectious/microbiology , Adult , Anti-Bacterial Agents/therapeutic use , Enterocolitis, Pseudomembranous/drug therapy , Enterocolitis, Pseudomembranous/microbiology , Female , Humans , Megacolon, Toxic/drug therapy , Megacolon, Toxic/microbiology , Megacolon, Toxic/pathology , PregnancySubject(s)
Clostridioides difficile/isolation & purification , Colon/microbiology , Enterocolitis, Pseudomembranous/microbiology , Intestinal Mucosa/microbiology , Megacolon, Toxic/microbiology , Anti-Bacterial Agents/administration & dosage , Colon/diagnostic imaging , Drug Administration Schedule , Enterocolitis, Pseudomembranous/diagnostic imaging , Enterocolitis, Pseudomembranous/drug therapy , Humans , Intestinal Mucosa/diagnostic imaging , Male , Megacolon, Toxic/diagnostic imaging , Megacolon, Toxic/drug therapy , Middle Aged , Tomography, X-Ray Computed , Vancomycin/administration & dosageSubject(s)
Antibodies, Monoclonal/therapeutic use , Colitis, Ulcerative/complications , Colitis, Ulcerative/drug therapy , Megacolon, Toxic/complications , Megacolon, Toxic/drug therapy , Tumor Necrosis Factor-alpha , Humans , Infliximab , Male , Middle Aged , Remission Induction , Severity of Illness IndexABSTRACT
No disponible
Subject(s)
Male , Middle Aged , Humans , Megacolon, Toxic/complications , Colitis, Ulcerative/complications , Antibodies, Monoclonal/pharmacokinetics , Colectomy , Megacolon, Toxic/drug therapy , Colitis, Ulcerative/drug therapy , Tumor Necrosis Factor-alpha/antagonists & inhibitorsABSTRACT
Toxic megacolon is a gastrointestinal emergency requiring prompt management to avoid fatal outcome. Although a majority of patients respond to conservative treatment, those not responding have been treated with intravenous cyclosporine or emergency surgery. Infliximab has been tried in patients with severe steroid-refractory ulcerative colitis. We report the successful use of this drug in the management of toxic megacolon in a 48-year-old woman not responding to the routine measures and who refused surgery.
Subject(s)
Antibodies, Monoclonal/therapeutic use , Colitis, Ulcerative/complications , Colitis, Ulcerative/drug therapy , Megacolon, Toxic/complications , Megacolon, Toxic/drug therapy , Humans , Infliximab , Male , Middle AgedABSTRACT
BACKGROUND: Toxic megacolon is a life-threatening complication most commonly observed in patients with ulcerative colitis or Crohn's disease that is characterized by total or segmental nonobstructive colonic dilatation of at least 6 cm on plain abdominal films associated with systemic toxicity. CASE REPORT: We report an unusual case of fulminant steroid-refractory ulcerative colitis complicated by toxic megacolon treated successfully with the immunosuppressant tacrolimus. CONCLUSION: Tacrolimus administration induced clinical remission and bridged the time interval, until the standard immunosuppressant azathioprine could maintain clinical remission, thereby avoiding eminent emergency colectomy.
Subject(s)
Immunosuppressive Agents/therapeutic use , Megacolon, Toxic/drug therapy , Tacrolimus/therapeutic use , Adult , Anti-Inflammatory Agents/adverse effects , Female , Humans , Megacolon, Toxic/etiology , SteroidsSubject(s)
Humans , Inflammatory Bowel Diseases/complications , Inflammatory Bowel Diseases/physiopathology , Inflammatory Bowel Diseases/classification , Inflammatory Bowel Diseases/surgery , Inflammatory Bowel Diseases/diagnosis , Colitis/diagnosis , Colitis/surgery , Colitis/therapy , Colitis/complications , Megacolon, Toxic/diagnosis , Megacolon, Toxic/etiology , Megacolon, Toxic/surgery , Megacolon, Toxic/therapy , Megacolon, Toxic/drug therapy , Hemorrhage/epidemiology , Hemorrhage/surgery , Intestinal Perforation/epidemiology , Intestinal Perforation/diagnosis , Intestinal Perforation/surgery , Intestinal Perforation/mortality , Colectomy , Proctocolectomy, Restorative , Enterocolitis, Pseudomembranous , Anti-Bacterial Agents/therapeutic useSubject(s)
Humans , Colitis , Hemorrhage , Inflammatory Bowel Diseases , Megacolon, Toxic/surgery , Megacolon, Toxic/diagnosis , Megacolon, Toxic/etiology , Megacolon, Toxic/drug therapy , Megacolon, Toxic/therapy , Intestinal Perforation/surgery , Intestinal Perforation/diagnosis , Intestinal Perforation/epidemiology , Intestinal Perforation/mortality , Anti-Bacterial Agents/therapeutic use , Colectomy , Enterocolitis, Pseudomembranous , Proctocolectomy, RestorativeABSTRACT
BACKGROUND AND AIMS: It has been suggested that the analgesic effect of the somatostatin analogue octreotide in visceral pain involves peripheral mechanisms. We evaluated the effect of octreotide on responses to noxious colorectal distension in rats. METHODS: In a behavioural study, pressor and electromyographic responses to colorectal distension were evaluated before and after intravenous or intrathecal administration of octreotide. In pelvic nerve afferent fibre recordings, responses of mechanosensitive fibres innervating the colon to noxious colorectal distension (80 mm Hg, 30 seconds) were tested before and after octreotide. RESULTS: Octreotide was ineffective in attenuating responses to colorectal distension in either normal or acetic acid inflamed colon when administered intravenously but attenuated responses when given intrathecally. Administration of octreotide over a broad dose range (0.5 microg/kg to 2.4 mg/kg) did not alter responses of afferent fibres to noxious colorectal distension in untreated, or acetic acid or zymosan treated colons. CONCLUSIONS: In the rat, octreotide has no peripheral (pelvic nerve) modulatory action in visceral nociception. The antinociceptive effect of octreotide in this model of visceral nociception is mediated by an action at central sites.
Subject(s)
Gastrointestinal Agents/therapeutic use , Megacolon, Toxic/drug therapy , Octreotide/therapeutic use , Acetic Acid , Analysis of Variance , Animals , Dose-Response Relationship, Drug , Electromyography/drug effects , Injections, Intravenous , Injections, Spinal , Male , Nociceptors/drug effects , Pressoreceptors/drug effects , Rats , Rats, Sprague-Dawley , Statistics, Nonparametric , Treatment OutcomeABSTRACT
An 11-year-old boy with acute fulminant ulcerative colitis (UC) is presented. He had systemic deterioration with frequent diarrhea and lethargy. Acute fulminant UC associated with toxic megacolon was diagnosed by rectal endoscopy and biopsied specimen. He was treated with intensive intravenous administration of prednisolone and total parenteral nutrition. He recovered completely without any surgical intervention.
Subject(s)
Colitis, Ulcerative/complications , Megacolon, Toxic/complications , Acute Disease , Child , Colitis, Ulcerative/drug therapy , Colitis, Ulcerative/pathology , Glucocorticoids/therapeutic use , Humans , Male , Megacolon, Toxic/drug therapy , Megacolon, Toxic/pathology , Prednisolone/therapeutic useABSTRACT
The vast majority of patients with inflammatory bowel disease experience chronic symptoms punctuated by periodic exacerbations requiring adjustments in medical therapy or surgery. True emergencies are fortunately uncommon but have been associated with high rates of morbidity and mortality. Patients presenting with fulminant colitis, toxic megacolon, or perforation require prompt identification as well as intensive medical therapy and monitoring by physicians and surgeons experienced in the care of such patients. Recent advances in the evaluation and treatment of these complicated patients are reviewed.