Opinion statement
Megacolon, defined as dilation of the abdominal colon, may occur acutely or in a chronic form. Acute megacolon that occurs in association with severe inflammation of the colon is known as toxic megacolon, whereas acute megacolon without obvious colonic disease is known as Ogilvie’s syndrome. The pathophysiology and management of toxic megacolon, Ogilvie’s syndrome, and chronic megacolon in adults differ significantly, and it is critically important to distinguish among these entities. Toxic megacolon is a medical emergency that requires coordinated intensive medical and surgical management. In addition to vigorous resuscitation with fluids, electrolytes, and blood products, medical treatment consists of parenteral corticosteroids, broad-spectrum antibiotics, and close monitoring of the patient. Surgical intervention is required if there is no improvement, or deterioration after 12 to 24 hours of intensive medical management, or if there is evidence of colon perforation. Ogilvie’s syndrome usually occurs in hospitalized patients with serious underlying medical or surgical illnesses. Management is directed at preventing ischemia and perforation of the distended colon. Supportive therapy includes nasogastric suction, correction of fluid and electrolyte imbalances, stopping potentially aggravating medications, and decompressing the colon with a rectal tube and positional changes. Intravenous neostigmine is the only pharmacologic agent of proven efficacy; colonoscopic decompression is an alternative in patients who do not respond to neostigmine or who have conditions that contraindicate its use. Daily oral administration of polyethylene glycol electrolyte solutions appears to decrease the relapse rate after initial decompression is achieved. Chronic megacolon in adults represents advanced colon failure that does not respond to pharmacologic stimulation. Goals of therapy are to cleanse the colon, prevent impaction, and minimize stool volume and gas buildup. For patients with disabling symptoms, surgical exclusion of the colon, decompression and antegrade enemas via cecostomy, or subtotal or segmental resection may be palliative.
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References and Recommended Reading
Swan NC, Geoghegan JG, O’Donoghue DP, et al.: Fulminant colitis in inflammatory bowel disease: detailed pathologic and clinical analysis. Dis Colon Rectum 1998, 41:1511–1515.
Caprilli R, Viscido A, Latella G: Current management of severe ulcerative colitis. Nat Clin Pract Gastroenterol Hepatol 2007, 4:92–101.
Meyers S, Janowitz HD: The place of steroids in the therapy of toxic megacolon. Gastroenterology 1978, 75:729–731.
Cottone M, Pietrosi G, Martorana G, et al.: Prevalence of cytomegalovirus infection in severe refractory ulcerative and Crohn’s colitis. Am J Gastroenterol 2001, 96:773–775.
Greenstein AJ, Sachar DB, Gibas A, et al.: Outcome of toxic dilatation in ulcerative and Crohn’s colitis. J Clin Gastroenterol 1985, 7:137–143.
Jakobovits SL, Travis SP: Management of acute severe colitis. Br Med Bull 2005, 75–76:131–144.
Hommes DW, Sterringa G, van Deventer SJ, et al.: The pathogenicity of cytomegalovirus in inflammatory bowel disease: a systematic review and evidence-based recommendations for future research. Inflamm Bowel Dis 2004, 10:245–250.
Maconi G, Colombo E, Zerbi P, et al.: Prevalence, detection rate and outcome of cytomegalovirus infection in ulcerative colitis patients requiring colonic resection. Dig Liver Dis 2005, 37:418–423.
Hanauer SB: Inflammatory bowel disease. N Engl J Med 1996, 334:841–848.
Lennard-Jones JE, Ritchie JK, Hilder W, Spicer CC: Assessment of severity in colitis: a preliminary study. Gut 1975, 16:579–584.
Gan SI, Beck PL: A new look at toxic megacolon: an update and review of incidence, etiology, pathogenesis, and management. Am J Gastroenterol 2003, 98:2363–2371.
Allez M, Lemann M, Bonnet J, et al.: Long term outcome of patients with active Crohn’s disease exhibiting extensive and deep ulcerations at colonoscopy. Am J Gastroenterol 2002, 97:947–953.
Almer S, Bodemar G, Franzen L, et al.: Plain X-ray films and air enema films reflect severe mucosal inflammation in acute ulcerative colitis. Digestion 1995, 56:528–533.
Caprilli R, Vernia P, Latella G, Torsoli A: Early recognition of toxic megacolon. J Clin Gastroenterol 1987, 9:160–164.
Hyde GM, Jewell DP: Review article: the management of severe ulcerative colitis. Aliment Pharmacol Ther 1997, 11:419–424.
Travis SP, Farrant JM, Ricketts C, et al.: Predicting outcome in severe ulcerative colitis. Gut 1996, 38:905–910.
Carbonnel F, Lavergne A, Lemann M, et al.: Colonoscopy of acute colitis. A safe and reliable tool for assessment of severity. Dig Dis Sci 1994, 39:1550–1557.
Buckell NA, Williams GT, Bartram CI, Lennard-Jones JE: Depth of ulceration in acute colitis: correlation with outcome and clinical and radiologic features. Gastroenterology 1980, 79:19–25.
Carbonnel F, Gargouri D, Lemann M, et al.: Predictive factors of outcome of intensive intravenous treatment for attacks of ulcerative colitis. Aliment Pharmacol Ther 2000, 14:273–279.
Kornbluth A, Sachar DB: Ulcerative colitis practice guidelines in adults (update): American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 2004, 99:1371–1385.
Carter MJ, Lobo AJ, Travis SP: Guidelines for the management of inflammatory bowel disease in adults. Gut 2004, 53(Suppl 5):V1–V16.
Present DH: The knee-elbow position relieves distension [comment]. Gut 1994, 35:1150; Author reply 1.
Turner D, Walsh CM, Steinhart AH, Griffiths AM: Response to corticosteroids in severe ulcerative colitis: a systematic review of the literature and a meta-regression. Clin Gastroenterol Hepatol 2007, 5:103–110.
Bossa F, Fiorella S, Caruso N, et al.: Continuous infusion versus bolus administration of steroids in severe attacks of ulcerative colitis: a randomized, double-blind trial. Am J Gastroenterol 2007, 102:601–608.
Truelove SC, Willoughby CP, Lee EG, Kettlewell MG: Further experience in the treatment of severe attacks of ulcerative colitis. Lancet 1978, 2:1086–1088.
Lichtiger S, Present DH, Kornbluth A, et al.: Cyclosporine in severe ulcerative colitis refractory to steroid therapy [see comment]. N Engl J Med 1994, 330:1841–1845.
Poritz LS, Rowe WA, Swenson BR, et al.: Intravenous cyclosporine for the treatment of severe steroid refractory ulcerative colitis: what is the cost? Dis Colon Rectum 2005, 48:1685–1690.
Odes HS, Fich A, Reif S, et al.: Effects of current cigarette smoking on clinical course of Crohn’s disease and ulcerative colitis. Dig Dis Sci 2001, 46:1717–1721.
Creed TJ, Probert CS: Review article: steroid resistance in inflammatory bowel disease — mechanisms and therapeutic strategies. Aliment Pharmacol Ther 2007, 25:111–122.
Lindgren SC, Flood LM, Kilander AF, et al.: Early predictors of glucocorticosteroid treatment failure in severe and moderately severe attacks of ulcerative colitis. Eur J Gastroenterol Hepatol 1998, 10:831–835.
D’Haens G, Lemmens L, Geboes K, et al.: Intravenous cyclosporine versus intravenous corticosteroids as single therapy for severe attacks of ulcerative colitis. Gastroenterology 2001, 120:1323–1329.
Pham CQ, Efros CB, Berardi RR: Cyclosporine for severe ulcerative colitis. Ann Pharmacother 2006, 40:96–101.
Kornbluth A, Present DH, Lichtiger S, Hanauer S: Cyclosporin for severe ulcerative colitis: a user’s guide. Am J Gastroenterol 1997, 92:1424–1428.
Rutgeerts P, Sandborn WJ, Feagan BG, et al.: Infliximab for induction and maintenance therapy for ulcerative colitis. N Engl J Med 2005, 353:2462–2476.
Faubion WA, Jr, Loftus EV, Jr, Harmsen WS, et al.: The natural history of corticosteroid therapy for inflammatory bowel disease: a population-based study. Gastroenterology 2001, 121:255–260.
Ho GT, Chiam P, Drummond H, et al.: The efficacy of corticosteroid therapy in inflammatory bowel disease: analysis of a 5-year UK inception cohort. Aliment Pharmacol Ther 2006, 24:319–330.
Tung J, Loftus EV, Jr, Freese DK, et al.: A population-based study of the frequency of corticosteroid resistance and dependence in pediatric patients with Crohn’s disease and ulcerative colitis. Inflamm Bowel Dis 2006, 12:1093–1100.
D’Amico C, Vitale A, Angriman I, et al.: Early surgery for the treatment of toxic megacolon. Digestion 2005, 72:146–149.
Cohen JL, Strong SA, Hyman NH, et al.: Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum 2005, 48:1997–2009.
Quigley EM: Colonic dysmotility. In: Clinical Gastroenterology and Hepatology. Edited by Weinstein WM, Hawley CJ, Bosch J. Philadelphia: Elsevier; 2005:473–478.
Saunders MD, Kimmey MB: Acute colonic pseudo-obstruction. Clin Perspect Gastroenterol 2000, May/June:156–162.
Hutchinson R, Griffiths C: Acute colonic pseudo-obstruction: a pharmacological approach. Ann R Coll Surg Engl 1992, 74:364–367.
Pronec RJ, Saunders MD, Kimmey MB: Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med 1999, 341:137–141.
Jetmore AB, Timmcke AE, Gathright JB, Jr, et al.: Ogilvie’s syndrome: colonic decompression and analysis of predisposing factors. Dis Colon Rectum 1992, 35:135–142.
Rex DK: Colonoscopy and acute colonic pseudo-obstruction. Gastrointest Endosc Clin N Am 1997, 7:499–508.
Sgouros SN, Vlachogiannakos J, Vassiliadis K, et al.: Effective use of polyethylene glycol electrolyte balanced solution on patients with acute colonic pseudo-obstruction after resolution of colonic dilation: a prospective, randomized, placebo-controlled trial. Gut 2006, 55:638–640.
Duh QY, Way LW: Diagnostic laparoscopy and laparoscopic cecostomy for colonic pseudo-obstruction. Dis Colon Rectum 1993, 36:65–70.
Wedel T, Spiegler J, Soellner S, et al.: Enteric nerves and interstitial cells of Cajal are concomitantly altered in patients with slow-transit constipation and megacolon. Gastroenterology 2002, 123:1459–1467.
Meier-Ruge WA, Muller-Lobeck H, Stoss F, Bruder E: The pathogenesis of idiopathic megacolon. Eur J Gastroenterol Hepatol 2006, 18:1209–1215.
Szarka LA, Pemberton JH: Treatment of megacolon and megarectum. Curr Treat Options Gastroenterol 2006, 9:343–350.
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Hanauer, S.B., Wald, A. Acute and chronic megacolon. Curr Treat Options Gastro 10, 237–247 (2007). https://doi.org/10.1007/s11938-007-0017-z
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DOI: https://doi.org/10.1007/s11938-007-0017-z