Approach

Patients diagnosed with toxic colitis/toxic megacolon (TC/TM) often present with septic shock; if septic shock is suspected, the patient should be urgently reviewed by intensive care. Sepsis treatment guidelines produced by the Surviving Sepsis Campaign remain the most widely accepted standards globally.[28] Regional guidelines include those from the UK Academy of Medical Royal Colleges (AOMRC).[29] Local protocols for management of suspected sepsis should be followed; these may include guideline-based care bundles to ensure key interventions are carried out in a timely way as appropriate for the individual patient.

A multidisciplinary team (including a gastroenterologist, a surgical critical care specialist, and a surgeon) should be involved at the earliest opportunity. The main goals of treatment are mitigating complications of colitis and preventing associated morbidity and mortality. High index of suspicion and surgical intervention at the appropriate time are critical in preventing mortality.

Medical management

The patient should be monitored by both medical and surgical teams. Frequent physical examinations should be performed, evaluating for haemodynamic instability, fever, abdominal tenderness, rebound tenderness, and abdominal distension. Daily laboratory studies are advised including full blood count with differential, serum chemistries, albumin, and lactic acid levels.

The patient should be adequately resuscitated with intravenous fluid and electrolytes to correct abnormalities (especially potassium and magnesium), transfused if significantly anaemic, and made nil by mouth to avoid worsening the bowel dilation. Nasogastric decompression is a helpful adjunct to decrease upper gastrointestinal tract gaseous distension, if present. Parenteral nutrition is of little value in this setting because it does not reduce the likelihood for colectomy or morbidity associated with the procedure; however, bowel rest is usually indicated in the setting of symptomatic colonic atony.[7]

Antidiarrhoeals, anticholinergics, and opioid analgesics should be avoided to prevent worsening ileus.[7][30] Patients should be started on prophylaxis for gastric stress ulceration, and for deep vein thrombosis.[5][7][31]

All patients with TC/TM secondary to inflammatory bowel disease (IBD) should receive intravenous corticosteroids.[5] Corticosteroids have no role in toxic megacolon associated with infective colitis. Sulfasalazine or other aminosalicylates should be avoided in toxic megacolon as they may have triggered the episode. These drugs can be considered for treating underlying IBD once toxic megacolon has resolved. 

Although the usefulness of antibiotics has not been proved for toxic megacolon, given the risk of perforation and systemic bacteraemia, broad-spectrum antibiotics should be considered in all patients.[7]

In patients with a presumptive diagnosis of toxic megacolon due to Clostridium difficile colitis, antimicrobial medication that could have precipitated the infection should be stopped.[32] Local protocols for managing C difficile colitis should be followed. For detailed recommendations including drug regimens, see our topic Clostridium difficile-associated disease.

Patients in whom medical management fails

In the absence of free perforation or peritonitis, intensive medical management should be aggressively pursued. If there is no improvement after 24-72 hours, or if the patient deteriorates at any point, urgent surgical management is needed.[31] Indications for urgent surgical intervention are free perforation, haemorrhage requiring increasing transfusions, increased signs of toxicity, and worsening colonic distension.[4][33][34] In patients with IBD, the signs and symptoms of impending perforation may be masked by the effects of the immunosuppressive medications.[35] Prompt surgery is indicated for patients with IBD. Delays to surgery increase the rate of perforation; mortality rates increase with increasing time between perforation and surgical intervention.[31][35] In patients with HIV/AIDS, failure of medical management must be recognised promptly. In this population, emergency laparotomy with abdominal colectomy and ileostomy is required (if the patient can tolerate surgery).[14]

Nasogastric tube insertion animated demonstration
Nasogastric tube insertion animated demonstration

How to insert a fine bore nasogastric tube for feeding.

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