A 22-year-old woman with a first attack of extensive ulcerative colitis presents with fever (38.9 C), pulse 122/min, abdominal distension, and tenderness over the transverse colon. Abdominal radiograph shows a transverse colon diameter of 7.5 cm with no free air. Stool studies are negative for Clostridioides difficile and ova-parasites. What is the most appropriate next step in management?

• A Immediate subtotal colectomy with end ileostomy
• B Urgent colonoscopy with mucosal biopsy to grade inflammation
• C Oral mesalazine 4 g/day and outpatient follow-up in one week
• D Intravenous corticosteroids, bowel rest, nasogastric decompression, and serial abdominal radiographs ✓

Explanation

Toxic megacolon is defined as colonic dilation more than 6 cm with systemic toxicity in severe colitis. In the absence of perforation, initial management is conservative: intravenous steroids, bowel rest, nasogastric decompression, correction of electrolytes, and serial radiographs. Surgery is reserved for perforation, worsening dilation, or failure to improve in 24 to 72 hours. Colonoscopy is contraindicated because insufflation risks perforation.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.