A 22-year-old woman with a severe flare of ulcerative colitis develops abdominal distension and fever on day 3 of admission. Abdominal radiograph shows a transverse colon diameter of 7 cm with loss of haustration. She is hypotensive with a pulse of 128/min. Intravenous steroids and broad-spectrum antibiotics are started with nasogastric decompression. Over the next 12 hours she deteriorates further with rising lactate. What is the next step in management?
- A Urgent subtotal colectomy with end ileostomy ✓
- B Add intravenous cyclosporine and reassess at 72 hours
- C Switch to oral mesalazine and continue monitoring
- D Perform urgent flexible sigmoidoscopy with decompression
Correct answer: A. Urgent subtotal colectomy with end ileostomy
Explanation
Toxic megacolon is defined as colonic dilatation more than 6 cm with systemic toxicity in acute severe colitis. Initial therapy is resuscitation, IV steroids, antibiotics and decompression, but failure to improve within 24 to 48 hours mandates emergency subtotal colectomy with end ileostomy, since delay risks perforation and mortality rises sharply. Adding cyclosporine is inappropriate once the patient is deteriorating with hypotension and rising lactate, and endoscopy risks perforation.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.