Toxic Dilatation of the Colon
Toxic Dilatation of the Colon Superimposed pseudomembranous colitis

Video Endoscopic Sequence 1 of 17.

Toxic Dilatation of the Colon Superimposed pseudomembranous colitis involving the right colon.

This is the case of a 53 year-old female, with Chronic Renal Insufficiency, was hospitalized due to acute abdomen in a national hospital of social insurance (seguro social ISSS) in El Salvador, the abdominal ultrasound and the cat scan displayed colon dilation, patient underwent abdominal laparotomy, with no specified finding except thickening of the walls of the colon, one week after the surgery, patient initiates with lower gi bleeding. Because of the colonoscopes that used in that hospital were under reparation a colonoscopy was performed in our office finding the characteristics here described.

 

pseudomembranous colitis

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Superimposed pseudomembranous colitis involving the

Video Endoscopic Sequence 2 of 17.

The colonoscopic finding are of that a hemorrhagic colitis with inflammatory polyposis with difuse thickening of the colonic folders.

Risk factors for the development of severe colitis in patients with C. difficile infection include malignancy, chronic obstructive pulmonary disease, immunosuppressive therapy, renal failure, or exposure to antiperistaltic medications or clindamycin. Toxic megacolon has been described in patients with recurrent C. difficile.

 

 

 

Superimposed pseudomembranous colitis involving the

Video Endoscopic Sequence 3 of 17.

Toxic megacolon is often seen in the setting of ulcerative colitis. If severe enough, many other colitides can also precipitate a toxic megacolon. Crohn disease, antibiotic-induced pseudomembranous colitis, amebiasis, Salmonella enteritis and Campylobacter enteritis infection (particularly when antimotility agents are used), and ischemic colitis are all known causes of toxic megacolon.

Superimposed pseudomembranous colitis involving the

Video Endoscopic Sequence 4 of 17.

Salmonella, Shigella, and Campylobacter colitis are very rarely complicated by toxic dilatation, and can usually be differentiated from IBD by histology and endoscopic biopsy.

Toxic megacolon may also complicate hemorrhagic colitis and hemolytic–uremic syndrome secondary to infection with E. coli.

 

Superimposed pseudomembranous colitis involving the

Video Endoscopic Sequence 5 of 17.

Thickening of the colonic folders with

Superimposed pseudomembranous colitis involving the right colon.

Toxic megacolon is the clinical term for an acute toxic colitis with dilatation of the colon. The dilatation can be either total or segmental. A more contemporary term for toxic megacolon is simply toxic colitis, because patients may develop toxicity without megacolon.

The hallmarks of toxic megacolon (toxic colitis), a potentially lethal condition, are nonobstructive colonic dilatation larger than 6 cm and signs of systemic toxicity. Toxic megacolon (toxic colitis) was recognized by Marshak and Lester in 1950.

 

Superimposed pseudomembranous colitis involving the

Video Endoscopic Sequence 6 of 17.

Megacolon is considered present if the diameter of the colon is 5.5 cm or more, with apparent edema of the bowel wall on plain abdominal radiographs. Rarely, the toxic dilatation may extend to the terminal ileum. Colonic dilatation may be superimposed on an acute fulminant colitis in a patient with a history of inflammatory bowel disease. The dilatation may fluctuate or resolve completely, leaving the patient with toxic colitis. Clostridium difficile is the most common causative agent implicated in pseudomembranous colitis.

 


 

Toxic megacolon complicating pseudomembranous colitis

Video Endoscopic Sequence 7 of 17.

Toxic megacolon complicating pseudomembranous colitis

Toxic megacolon is associated with an acute transmural fulminant colitis with the neurogenic loss of motor tone. The result is the rapid development of colonic dilatation due to damage to the entire wall of the colon associated with neuromuscular degeneration. Histologic examination reveals extensive sloughing of the mucosa and frequent necrosis of the muscle layers of the bowel wall. Thinning of the muscle layer of the colon often occurs.

 

Toxic megacolon complicating pseudomembranous colitis

Video Endoscopic Sequence 8 of 17.

The Cecum.

This image and the video clip shows brilliant red blood.

Jalan et al described the diagnostic criteria. The first criterion is radiographic evidence of colonic dilatation. The second criterion is any 3 of the following: fever (>101.5°F), tachycardia (>120 beats/min), leukocytosis (>10.5 103/ľL), or anemia. The third criterion is any 1 of the following: dehydration, altered mental status, electrolyte abnormality, or hypotension.

 

Toxic megacolon complicating pseudomembranous colitis

Video Endoscopic Sequence 9 of 17.

Extension of the mucosal inflammation may also be important. In contrast to typical ulcerative colitis in which the inflammatory response is limited to the mucosa, toxic megacolon is characterized by severe inflammation of the smooth muscle layer which paralyzes the colonic smooth muscle, thereby leading to dilatation. The extent of dilatation appears to be correlated with the depth of inflammation and ulceration. Damage to the myenteric plexus of the colon is not a consistent finding.

 

Toxic megacolon complicating pseudomembranous colitis

Video Endoscopic Sequence 10 of 17.

Acute transmural fulminant colitis.

Toxic megacolon (toxic colitis) was first thought to be a complication of ulcerative colitis. In fact, toxic megacolon (toxic colitis) may complicate any number of colitides, including inflammatory, ischemic, infectious, radiation, and pseudomembranous.

Video Endoscopic Sequence 11 of 17.

The classic etiologies of toxic megacolon (toxic colitis)
include the following inflammatory causes:

Ulcerative colitis

Crohn colitis

Pseudomembranous colitis

The many causes of infectious colitis, including the
following, may lead to toxic megacolon (toxic colitis):

Salmonella species

Shigella species

Campylobacter species

Yersinia species

Clostridium difficile

Entamoeba histolytica

Cytomegalovirus

Video Endoscopic Sequence 12 of 17.

Due to the uncontrollable hemorrhage, patient
underwent a colectomy (Restorative Procto-Colectomy).

Download the video clip by clicking in the endoscopic
image.

 

Video Endoscopic Sequence 13 of 17.

Toxic megacolon (toxic colitis) may also be caused by the
following:

Radiation colitis

Ischemic colitis

Nonspecific colitis secondary to chemotherapy

Rarely as a complication of collagenous colitis

 

Video Endoscopic Sequence 14 of 17.

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Video Endoscopic Sequence 16 of 17.

Video Endoscopic Sequence 17 of 17.

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