Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – resuscitation and monitoring

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ACUTE
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all patients
1st line – 

resuscitation and monitoring

The patient should be made nothing by mouth and adequately resuscitated with intravenous fluids immediately.

The intravenous rate should be tailored to the patient based on signs of volume depletion, specifically urine output.

Electrolyte abnormalities, especially hypokalemia and hypomagnesemia, should be corrected. The patient should be transfused if significantly anemic.

The patient should be monitored by both medical and surgical teams to assess for signs of improvement or deterioration. Frequent physical exams should be performed, evaluating for hemodynamic instability, fevers, abdominal tenderness, rebound tenderness, and abdominal distention.

Daily laboratory studies are advised, including complete blood count with differential, serum chemistries, serum albumin, and serum lactic acid. Serum CRP, serum erythrocyte sedimentation rate, and blood culture may be helpful. Any signs of hemodynamic instability or worsening abdominal examination are indications for surgical intervention.

Patients diagnosed with toxic colitis/toxic megacolon (TC/TM) often present with septic shock; if septic shock is suspected, the patient should urgently be reviewed by intensive care. Sepsis treatment guidelines produced by the Surviving Sepsis Campaign remain the most widely accepted standards globally.[31] Regional guidelines include those from the UK Academy of Medical Royal Colleges (AOMRC).[32] 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.

Plus – consider broad-spectrum antibiotics

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ACUTE
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all patients
Plus – 

consider broad-spectrum antibiotics

Treatment recommended for ALL patients in selected patient group

Toxic megacolon causes impairment of the colonic mucosa defense mechanism, which increases bacteria translocation into the bloodstream, resulting in systemic bacteremia. Therefore, broad-spectrum antibiotics should be considered for all patients diagnosed with toxic megacolon. Imipenem/cilastatin, meropenem, or piperacillin/tazobactam can be used as single-agent therapy. Cefepime, ceftazidime, ciprofloxacin, or levofloxacin in combination with metronidazole may also be prescribed. Antibiotic choice may depend in part on formulary availability and the local pathogen profile at individual institutions.

Treatment course: 7 to 10 days.

Primary options

imipenem/cilastatin: 500 mg intravenously every 6 hours, or 1000 mg intravenously every 8 hours

OR

meropenem: 1 g intravenously every 8 hours

OR

piperacillin/tazobactam: 3.375 g intravenously every 6 hours

More

OR

metronidazole: 15 mg/kg intravenously as a loading dose, followed by 7.5 mg/kg every 6 hours

-- AND --

cefepime: 2 g intravenously every 8-12 hours

or

ceftazidime sodium: 2 g intravenously every 8 hours

or

ciprofloxacin: 400 mg intravenously every 12 hours

or

levofloxacin: 750 mg intravenously every 24 hours

Plus – supportive care

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ACUTE
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all patients
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Prophylaxis should be started for gastric stress ulceration, and for deep vein thrombosis.[5][7][33]

Medications for symptomatic relief including antidiarrheals, anticholinergics, and opioid analgesics should be avoided to prevent worsening colonic dilation.[7]

Consider – nasogastric decompression

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ACUTE
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all patients
Consider – 

nasogastric decompression

Treatment recommended for SOME patients in selected patient group

Nasogastric decompression is a helpful adjunct to decrease worsening upper gastrointestinal tract gaseous distention.

Plus – antibiotic therapy

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ACUTE
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all patients
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with presumed or confirmed severe Clostridium difficile colitis
Plus – 

antibiotic therapy

Treatment recommended for ALL patients in selected patient group

In patients with a presumptive diagnosis of TC/TM due to Clostridium difficile colitis, antimicrobial medication that could have precipitated the infection should be stopped.[34] Local protocols for managing C difficile colitis should be followed. For detailed recommendations including drug regimens, see our topic Clostridium difficile-associated disease.

Consider – intravenous corticosteroid

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ACUTE
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all patients
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with inflammatory colitis
Consider – 

intravenous corticosteroid

Treatment recommended for SOME patients in selected patient group

Patients with ulcerative colitis or Crohn colitis are often treated with corticosteroids to suppress the active inflammatory process.

Corticosteroid use has not been found to increase the rate of colonic perforation; however, it may mask the symptoms of a perforation.

Corticosteroids should be tapered after definitive management of toxic megacolon.[5]

Avoid sulfasalazine (and other aminosalicylates) during the acute episode.

Corticosteroids have no role in toxic megacolon associated with infective colitis.

In patients with inflammatory bowel disease (IBD), the signs and symptoms of impending perforation may be masked by the effects of the immunosuppressive medications.[37] 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.[33][37]

Primary options

hydrocortisone sodium succinate: 100 mg intravenously every 6-8 hours

OR

methylprednisolone sodium succinate: 12-15 mg intravenously every 6 hours initially, higher doses may be required in some patients, consult specialist for guidance on dose

Plus – surgery

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ACUTE
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all patients
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no improvement with medical management after 72 hours
Plus – 

surgery

Treatment recommended for ALL patients in selected patient group

No improvement after 72 hours with medical management in a confirmed diagnosis of TC/TM is an indication for surgical intervention. There are limited data regarding the exact timing of surgical intervention, and thus timing must be individualized to the patient. Free perforation, hemorrhage requiring increasing transfusions, increased signs of toxicity, and worsening colonic distention are indications for urgent surgical intervention.[4][7][35][36]

Abdominal colectomy with end-ileostomy is the procedure of choice for urgent surgeries (regardless of etiology) because it is associated with less morbidity and mortality than total proctocolectomy.[4][35][36][40] Creation of an anastomosis is typically avoided in the acute setting.

Some centers have had good success in Clostridium difficile colitis without megacolon with creation of a loop ileostomy and polyethylene glycol colonic irrigation followed by postoperative infusion of vancomycin into the colon through the efferent limb of the loop ileostomy.[41] The effectiveness of this approach in megacolon is uncertain.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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