Imaging studies show the presence of colonic dilatation with some air-fluid levels. There is no pneumoperitoneum. Initial evaluation shows:
Stool studies are negative for C. difficile toxin. At this point, the patient is most likely to benefit from which of the following?

Question

Imaging studies show the presence of colonic dilatation with some air-fluid levels.  There is no pneumoperitoneum.  Initial evaluation shows:
 Stool studies are negative for C.  difficile toxin.  At this point, the patient is most likely to benefit from which of the following?

Quizplus · Accepted Answer

Explanation: This patient's elevated WBC count along with the presence of a dilated colon with air-fluid levels on x-ray confirms the diagnosis of toxic megacolon. Surgical consultation is recommended upon admission, though surgery can be avoided in up to 50% of patients with aggressive medical management. Therefore nonsurgical treatment is usually attempted first in the absence of perforation. The patient should have a nasogastric tube placed after being put on bowel rest, and should be admitted to the ICU for close monitoring. Any medications that could decrease peristalsis (e.g., anticholinergics, opiates) should be held. The best step at this point would be to start the patient on glucocorticoids to decrease the severity of the underlying inflammatory bowel disease. Note that management depends on the underlying cause of the toxic megacolon, and that glucocorticoids should be avoided in patients with toxic megacolon secondary to C. difficile or other infections. The patient should also receive aggressive fluid resuscitation as he is likely volume depleted given his tachycardia, and any electrolyte abnormalities should be corrected. (Choice A) 5-aminosalicylic acid compounds, such as sulfasalazine, should not be used acutely in patients with inflammatory bowel disease complicated by toxic megacolon, as they can precipitate attacks. Sulfasalazine could be restarted at a later time after the patient's condition has improved with the glucocorticoids. (Choice B) Broad-spectrum antibiotics are started in many patients with toxic megacolon given the concern that perforation could eventually develop. However, opioids should definitely be avoided since they decrease bowel motility and may worsen colonic dilatation. (Choice C) Medical management should be the first-line treatment for patients with toxic megacolon unless perforation has already occurred. Surgery may be needed if the patient does not improve with medical therapies, although surgery should not be prolonged too much because the prognosis is worse if perforation has already occurred. (Choice E)TNF-alpha receptor antagonists may play a role in the chronic management of patients with ulcerative colitis, but are not used in the acute management of toxic megacolon. Educational objective: The first-line treatment for toxic megacolon is medical management to lessen the degree of colitis, with glucocorticoids used for patients with underlying inflammatory bowel disease and appropriate antibiotics used for patients with infectious colitis. 5-ASA compounds and opioids should be avoided in patients with toxic megacolon. References: A new look at toxic megacolon: an update and review of incidence, etiology, pathogenesis, and management. (http://www.ncbi.nlm.nih.gov/pubmed/14638335)

Imaging Studies Show the Presence of Colonic Dilatation with Some