A 26-year-old woman with extensive ulcerative colitis presents with fever, tachycardia, marked abdominal distension and tenderness. Abdominal radiograph shows a transverse colon diameter of 8.5 cm with no free air. Alongside intravenous fluids and serial imaging, what is the most appropriate initial management?
- A Intravenous hydrocortisone, broad-spectrum antibiotics, bowel rest and nasogastric decompression ✓
- B Urgent subtotal colectomy for all such patients regardless of response
- C Oral mesalamine dose escalation with discharge and outpatient review
- D Loperamide to reduce stool frequency and colonic distension
Correct answer: A. Intravenous hydrocortisone, broad-spectrum antibiotics, bowel rest and nasogastric decompression
Explanation
Toxic megacolon, defined as colonic dilatation beyond 6 cm with systemic toxicity, is managed initially with intravenous corticosteroids, broad-spectrum antibiotics, nil per os, nasogastric decompression and correction of electrolytes. Surgery is reserved for perforation, peritonitis, uncontrolled haemorrhage or deterioration despite therapy, making option B premature. Antimotility agents such as loperamide are contraindicated because they precipitate perforation.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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