Toxic megacolon in ulcerative rectocolitis. Current trends in clinical

Toxic megacolon in ulcerative rectocolitis.
Current trends in clinical evaluation,
diagnosis and treatment.
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Ann. Ital. Chir., 2014 85: 45-49
pii: S0003469X14019551
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Stefano Miniello, Rinaldo Marzaioli, Mario Giosué Balzanelli, Caterina Dantona,
Anna Stella Lippolis, Diana Barnabà, Michele Nacchiero
Department of Applications in Surgery of the Innovative Technologies, University of Bari Medical School, Bari, Italy
Toxic megacolon in ulcerative rectocolitis. Current trends in clinical evaluation, diagnosis, and treatment
Toxic megacolon is a clinical condition associated to high risk of colonic perforation, that significantly increases – even
triplicates – the megacolon-related mortality when causing diffuse peritonitis.
Abdominal and pelvic helical CT scan proved to be a fundamental diagnostic tool, in defining the colic dilatation and
perforation.
Conservative treatment is initially indicated in the event of toxic megacolon arising at the onset of a severe or toxic colitis. However it should be avoided when the toxic megacolon appears on corticosteroid therapy. Non operative management must not exceed 48 hours. The rationale of this strategy lies on the fact that early surgery is burdened by a mortality rate that, although moderate, is still higher than medical treatment. Nevertheless, successful conservative management does not exempt from surgery, which must be performed as soon as possible, in an elective setting, to prevent the
recurrence of toxic megacolon.
In emergency total colectomy and end ileostomy is the gold standard procedure. Bowel continuity will be restored, evaluating case by case, by performing an ileorectal anastomosis or proctectomy and ileoanal pouch anastomosis. Primary ileorectal anastomosis should be reserved to selected cases.
In the elective setting, after proper therapy and regression of toxic megacolon, proctocolectomy and ileoanal pouch anastomosis is indicated.
WORDS:
Surgery, Toxic megacolon, Treatment, Ulcerative colitis
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KEY
Introduction
Toxic megacolon is a life-threatening complication of the
acute severe or hyperacute-toxic ulcerative rectocolitis. It
is characterized by segmental or whole colon distention.
Pervenuto in Redazione Novembre 2012. Accettato per la pubblicazione Marzo 2012
Correspondence to: Stefano Miniello, MD, Section of Emergency and
Trauma Surgery, Department of Applications in Surgery of the Innovative
Technologies - University of Bari Medical School - Policlinico, P.zza
Giulio Cesare 11, 70124 Bari, Italy. (e-mail: stefanominiello@yahoo.it)
Colon diameter, in transverse tract, exceeds the measure
of 6 cm, with disappearance of the haustra and peristalsis.
In this work we report our experience with the intent
of highlighting the clinical signs to consider in monitoring the evolution of the disease, the available diagnostic methods and the surgical strategies to perform.
Materials and Methods
From January 1985 to December 2006, 1182 patients
with diagnosis of ulcerative rectocolitis were observed
(Tab. I); 192 cases with severe or toxic or complicated
Ann. Ital. Chir., 85, 1, 2014
45
S. Miniello, et al.
Patients
N.
Observed
Hospitalized
(severe or toxic or complicated ulcerative colitis)
urgent or emergency surgery
elective surgery (improved toxic megacolon)
non-operative treatment
1182
192
63
6
123
%
32.8
3.1
64.1
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TABLE II - Non-operative treatment.
my was performed in 59/63 (95.6%); emergency proctocolectomy and ileostomy was carried out in 4/63
(6.4%) who manifested a severe haemorrhage of the rectum.
All the patients affected by toxic megacolon underwent
total colectomy, with intraperitoneal rectal stump sinking and ileostomy. Twelve were operated in urgency; 6
underwent elective delayed surgery. In the latter the toxic megacolon appeared at the onset of the severe acute
or toxic ulcerative colitis; intensive care and proper pharmacological treatment allowed emergency procedure to
be avoided. These patients were submitted to an elective proctocolectomy, in order to prevent the high risk
of recurrence of the megacolon. 1
In the emergency surgery group (Tab. IV), the morbidity observed (42.85%) was due to: laparotomic wound
infection (N=8; 12.7%), pulmonary disease (N=6; 9.5%),
cystitis (N=5; 7.9%), central venous catheter infection
(N=4; 6.3%), infusion phlebitis (N=4; 6.3%). The mortality (6/63; 9.5%) referred to MOFS (Tab. V) following severe colitis (N=1), toxic megacolon (N=2) and
bowel perforation (N=3).
In the group of patients operated for toxic megacolon,
complications were observed only among the emergency
procedures (7/12; 58.3%): surgical wound infection
(N=3; 25%), bronchopneumonia (N=2; 16.66%), cystitis (N=1; 8.33%) and central venous catheter infection
(N=1; 8.33%). Two patients – both belonging to the
emergency surgery group – died of sepsis and MOFS.
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TABLE I - Ulcerative colitis. Case series 1985-2006.
Complication
N. of patients
Severe colitis
Severe haemorrhage
Toxic colitis
Total
95
16
12
123
(77.2%)
(13.0%)
(9.8%)
(100.0%)
ulcerative rectocolitis required hospitalization and intensive treatment; 63 patients (32.8%) underwent urgent or
emergency surgery; 6 (3.1%) were submitted to delayed
elective surgical treatment; in 123 (64.1%) patients, a
conservative management was successfully performed, as
they responded positively to intensive care and drug therapy (Tab. II).
The diagnosis in the 123 non-operatively treated cases
was severe colitis (N=95; 77.2%), hemorrhagic colitis
(N=16; 13%), and toxic colitis (N=12; 9.8%). The 63
patients who underwent urgent or emergency surgery
(Tab. III), were affected by severe or toxic colitis (N=36;
57.1%), toxic megacolon (N=12; 19.1%), bowel perforation (N=8; 12.7%) and severe haemorrhage (N=7;
11.1%). The 6 patients treated in elective surgery were
affected by toxic megacolon (Tab. I).
Thus toxic megacolon was diagnosed in 18 patients (10
males, 8 females), mean age 48.6 (range: 28-72 years).
Results
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In the patients who underwent emergency surgery (Tab.
III) a colectomy with rectal stump sinking and ileosto-
Discussion
Toxic megacolon may arise at the beginning of severe
acute or toxic ulcerative colitis, or, in most cases, during the worsening of its course.
Laboratory and radiographic monitoring of severe and
toxic ulcerative rectocolitis plays a fundamental role for
the clinician, to detect the early premonitory signs of
toxic megacolon.
In regards to the clinical parameters, the surgeon rarely
observes the onset of symptoms of patients affected by
ulcerative rectocolitis. They are frequently evaluated on
pharmacological – particularly corticosteroids – therapy,
TABLE III - Urgent or emergency surgery.
Indication to surgery
N. of Patients
Surgical procedure
Severe or toxic colitis
Toxic megacolon
Perforation
Severe haemorrhage
36
12
8
7
(57.1%)
(19.1%)
(12.7%)
(11.1%)
36
12
8
3
4
Colectomy, rectal
Colectomy, rectal
Colectomy, rectal
Colectomy, rectal
Proctocolectomy
Total
63
(100.0%)
59
4
Colectomy, rectal stump sinking, ileostomy
Proctocolectomy
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Ann. Ital. Chir., 85, 1, 2014
stump
stump
stump
stump
sinking,
sinking,
sinking,
sinking,
ileostomy
ileostomy
ileostomy
ileostomy
Toxic megacolon in ulcerative rectocolitis. Current trends in clinical evaluation, diagnosis and treatment
Postoperative complication
N. of patients
Surgical wound infection
Bronchopneumonia
Cystitis
Central venous catheter infection
Infusion phlebitis
Total
8/63
6/63
5/63
4/63
4/63
27/63
(12.69%)
(9.52%)
(7.93%)
(6.34%)
(6.34%)
(42.85%)
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TABLE V - Sepsis or Multiple Organ Failure Syndrome related postoperative mortality.
terized by gas distension of the whole colon or of a tract
– the transverse tract – exceeding 6 cm in diameter,
combined with haustra disappearance4.
Jejunum and ileum distension is a premonitory sign of
toxic megacolon1, predicting the failure of the conservative treatment in over 40% of cases5. This radiological
feature suggests incipient toxic megacolon6, when associated to the following hematochemical parameters: pH
≥ 7.5, albuminemy < 2.5 g/dL, serum chlorine <95
mEq/L, serum calcium <4.2 mEq/L and serum phosphorus < 1.5 mEq/L.
Finally, a plain abdominal X-Rays indicates the presence
of intraperitoneal air (free intra-abdominal gas) in the
event of colonic perforation. Toxic megacolon is associated with a high risk of perforation, and – when leads
to diffuse peritonitis – it significantly increases, even triplicating, the megacolon-related mortality7.
Perforation, on the other hand, may complicate the acute
severe colitis even in the absence of toxic megacolon,
and in this case too it represents a serious complication,
with a fourfold risk of mortality, compared to severe
acute colitis 8.
An ultrasound scan of abdomen and pelvis proved to be
useful in monitoring patients with ulcerative colitis 3. It
allows the evaluation of bowel dilatation degree, intraluminal content, intestinal wall thickness, presence of
ulcers and their deepening – predictive sign of perforation – by performing repeated and close controls, as well
as the presence of islands of normal mucosa.
Abdominal and pelvis CT scan – especially spiral CT –
proved to be the most effective imaging tool3,9,10, even
without contrast agents 11, in defining the colic dilatation and perforation, as well as the involvement of each
colic wall layer in the inflammatory process.
Several clinical predictive indices have been tested for
the monitoring of clinical course, intended to set proper timing of medical treatment and indication to
surgery 12-15.
We adopted the surveillance protocol proposed by Kumar
16,17 to perform an accurate monitoring of the patients
affected by ulcerative rectocolitis. This is aimed at providing an early diagnosis of complications, including toxic megacolon.
The protocol implies:
– physical examination twice a day, performed by the
surgical staff;
– monitoring cardiac frequency and body temperature;
number of defecations and characteristics of the stools
(consistency, presence of blood);
– abdominal pain and tenderness, characteristics of peristalsis;
– haemoglobin and electrolytes dosage once a day, erythrocyte sedimentation rate and C-reactive protein dosage
in alternate days;
– plain abdomen X-Rays daily.
In presence of toxic megacolon, when appearing at the
onset of an acute severe or toxic colitis, it is preferable
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TABLE IV - Postoperative complications.
Clinical feature
N. of patients
Toxic colitis
Toxic megacolon
Perforation
Total
1/63
2/63
3/63
6/63
(1.6%)
(3.1%)
(4.8%)
(9.5%)
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prescribed by a physician or a gastroenterologist.
Corticosteroid therapy may unfortunately hide the clinical evidence, interfering with fever and abdominal reactivity. Hence, in patients with severe ulcerative rectocolitis, abdominal pain must be carefully considered; the
abdominal examination has to be accurate, above all the
auscultation, where we may find decreased bowel peristalsis sounds, often distanced one from another by long
silent intervals.
An important clinical sign is the consistency of stools2.
This expresses the amount of water reabsorbed by the
colic mucosa, and consequently the magnitude of the
disease.
The most significant hematochemical parameters to monitor in severe acute or toxic ulcerative rectocolitis are:
haemochrome (WBC, Hb, HTC), haemogasanalysis, to
evaluate metabolic alkalosis, albuminemy, serum electrolytes (kaliemy, particularly), erythrocyte sedimentation
rate and C-reactive protein (CRP), showing the extension of the inflammatory process2. Indeed, CRP value is
low in case of proctitis or proctosigmoiditis, whereas it
increases over 2.8 mg/l in the presence of left colitis or
pancolitis.
Plain abdomen X-rays is an important diagnostic tool in
severe ulcerative rectocolitis3. It allows the evaluation of
colitis anatomical extent, revealing – among the most
significant signs – bowel wall thickening and mucosa
altered shape. Islands of normal mucosa bordered by surrounding ulcerations may be shown. Moreover, severe
colitis may be characterized by the so-called “empty right
colon”, due to the absence of gas and faeces in the
ascending colon.
Furthermore an emergent or actual complication of
severe or toxic ulcerative rectocolitis – toxic megacolon
- may be shown at abdominal radiogram. It is charac-
Ann. Ital. Chir., 85, 1, 2014
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S. Miniello, et al.
Conclusions
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Toxic megacolon is a severe and life-threatening complication of ulcerative rectocolitis, requiring intensive care
and proper treatment.
As regards diagnosis, we point out the importance of
clinical evaluation, often suffering the pitfalls of concealed signs and symptoms in patients on corticosteroid treatment, which may sometimes lead to misdiagnosis.
Emergency surgery is mandatory when the toxic megacolon appears on corticosteroid therapy or when a conservative treatment is not effective after 48 hours.
Elective surgery should be promptly performed in all cases of successful conservative management, taking advantage of the possibility of an adequate intestinal preoperative preparation.
In emergency total colectomy and end ileostomy and
rectal stump sinking is the gold standard; proctocolectomy and ileoanal pouch anastomosis are indicated in
elective settings.
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to not opt for immediate surgery; intensive care and
drug therapy will be performed for no longer than 48
hours18.
Indeed early surgery, though burdened by low mortality rate, is related to higher mortality with respect to
conservative management19, and longer duration of medical therapy before urgent colectomy correlates to major
surgical complications20.
When the pharmacological therapy is effective, the
patient in any case has to undergo elective surgery as
soon as possible, to prevent the high risk of a further
short term oncoming attack of complicated ulcerative
colitis1.
Emergency surgery is mandatory when the patient with
toxic megacolon appears to have had corticosteroid therapy. Indeed, in this case prolonged medical treatment is
associated with a high mortality rate21. The administration of high doses of corticosteroids may conceal abdominal signs and symptoms related to perforation. For this
reason it must be investigated by performing daily plain
X-rays of the abdomen.
Finally, more than half of the patients affected by severe
ulcerative rectocolitis, complicated by massive hemorrhage, develop a toxic megacolon22. Therefore, the coexistence of both complications must always be suspected.
The surgical option concerning the toxic megacolon is
well stated at present 18,23-30.
In emergency, it is advisable to avoid complex and
demolitive surgical procedures requiring a long operation
time. The resection of the colon – responsible for toxic and septic conditions – is mandatory31. The surgical
gold standard is total colectomy with ileostomy and rectal stump sinking; in emergency settings this procedure
supersedes proctocolectomy32,33, that shows a higher morbidity and mortality (6.1% vs. 14.7%)34. Furthermore,
total colectomy with ileostomy is followed by favourable
post-operative course. Nevertheless in case of massive
bleeding involving the rectum, unresponsive to drug therapy or relapsing, emergency proctocolectomy and ileostomy is indicated as high mortality risk is related to rectal re-bleeding.
We advise evaluating case by case the necessity of bowel continuity restoration – after 3 months in our experience35– by performing an ileorectal anastomosis or completing the surgical demolitive procedure by carrying out
a proctectomy and ileoanal pouch anastomosis. Indeed
primary ileorectal anastomosis following emergency colectomy is burdened by high risk of dehiscence36 and should
be reserved to selected cases, proving good local and systemic healing capacity of the anastomosis22. It is advisable, in such a case, to protect the ileorectal anastomosis with a loop ileostomy.
In the event of regression of conservatively treated toxic megacolon, elective surgery should be performed, consisting of proctocolectomy and ileoanal pouch anastomosis.
48
Ann. Ital. Chir., 85, 1, 2014
Riassunto
Il megacolon tossico è una condizione clinica che si associa al più alto rischio di perforazione del colon, che
accresce in modo significativo – fino a triplicarla – la
mortalità correlata al megacolon quando determina una
peritonite diffusa.
La TC spirale addomino-pelvica si è dimostrata una indagine diagnostica fondamentale nel definire la dilatazione
del colon e la sua perforazione.
Nel caso che il megacolon tossico tragga origine all’inizio
di una colite grave o tossica, inizialmente è indicato il
trattamento conservativo. Comunque dovrebbe essere evitato quando il megacolon tossico si manifesta in corso
di terapia cortisonica. Il trattamento non operatorio non
dovrebbe superare le 48 ore. Il razionale di questa strategia si basa sul fatto che la chirurgia precoce è gravata
da un’incidenza di mortalità che, sebbene modesta, è
comunque più elevata che nel caso del trattamento medico. Ciononostante, l’eventuale successo del trattamento
conservativo non esclude la chirurgia, che deve seguire
al più presto possibile ed in fase di elezione, per prevenire la recidiva del megacolon tossico.
In emergenza la colectomia totale con ileostomia terminale rappresenta la procedura più valida. La continuità
intestinale sarà restaurata caso per caso con una anastomosi ileo-rettale oppure con una proctocolectomia ed
un’anastomosi ileo-anale su pouch.
L’anastomosi ileo-rettale fin dall’inizio va riservata a casi
selezionati.
Nel caso della chirurgia di elezione, dopo adeguata terapia e regressione del megacolon tossico, c’è indicazione
per una la proctocolectomia seguita da anastomosi ileoanale su pouch.
Toxic megacolon in ulcerative rectocolitis. Current trends in clinical evaluation, diagnosis and treatment
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