A 35-year-old Caucasian man is seen in the emergency department for the evaluation of fever, weakness, generalized abdominal pain, and bloody stools. He denies any vomiting but his appetite has been poor. He was diagnosed with ulcerative colitis six months ago and he has been on and off sulfasalazine treatment. His flare-up started four days ago, and rapidly progressed to his having multiple bloody bowel movements and severe abdominal pain. He is a current smoker, but he has been trying to quit. He has not been taking any antibiotics recently and he denies recent travel. His temperature is 100 F (37.8 C) , heart rate is 124/min, and blood pressure is 106/72 mmHg. His mucous membranes appear dry. Bowel sounds are hypoactive. There is generalized abdominal tenderness and distension without any rebound tenderness or guarding. The percussion note is tympanitic. Item 1 of 2
Which of the following is the best initial step for managing this patient?

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Quizplus · Accepted Answer

Explanation: This patient is clearly in the midst of a severe ulcerative colitis flare as evidenced by his multiple bloody bowel movements and severe abdominal pain, particularly given the history of only sporadic use of sulfasalazine. However, this patient has a somewhat toxic appearance, given his fever and tachycardia. The tympany to percussion elicited on physical exam may be secondary to bowel dilatation. This conglomeration of findings is concerning for possible toxic megacolon, and an abdominal x-ray should be performed to evaluate for colonic dilatation. Findings of peritonitis may be absent in toxic megacolon, so the lack of rebound tenderness or guarding on this patient's exam does not exclude the diagnosis. The transverse colon usually shows the most prominent dilatation among the colonic segments in cases of toxic megacolon, generally measuring at least 6 cm in diameter. Multiple air-fluid levels are commonly seen, along with loss of the normal haustral pattern and possibly mucosal ulcerations. Pneumoperitoneum may be present if the toxic megacolon has progressed to perforation. Patients with inflammatory bowel disease are most at risk of developing toxic megacolon early in the course of their disease, possibly even at initial presentation. (Choice A)Abdominal x-rays typically demonstrate bowel abnormalities better than ultrasound. Furthermore, x-rays tend to be more readily available and less operator-dependent. (Choice C)Full colonoscopy should be avoided in patients with toxic megacolon because there is a significant risk of perforation. (Choice D) Toxic megacolon can occur secondary to amebiasis or bacterial infections such as shigella, salmonella, or campylobacter. However, the patient's underlying inflammatory bowel disease would be the most likely cause of toxic megacolon here, and the results of stool studies would not be available readily enough to affect his acute management anyway. Educational objective: Toxic megacolon should be suspected in patients who have a history of severe colitis, particularly secondary to inflammatory bowel disease, who develop toxic signs and have a distended, tympanitic abdomen. Abdominal plain films are helpful for making the diagnosis. CT scan is best utilized for early detection of complications. References: Toxic megacolon in ulcerative colitis. Early diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/3091613) Toxic megacolon: role of CT in evaluation and detection of complications. (http://www.ncbi.nlm.nih.gov/pubmed/11682295) A new look at toxic megacolon: an update and review of incidence, etiology, pathogenesis, and management. (http://www.ncbi.nlm.nih.gov/pubmed/14638335)

A 35-Year-Old Caucasian Man Is Seen in the Emergency Department