A 34-year-old man with acute severe ulcerative colitis fails 72 hours of intensive intravenous corticosteroids. He remains febrile and tachycardic, abdominal radiograph shows a transverse colon diameter of 7 cm, and serial imaging over 24 hours shows progressive dilatation despite medical therapy. What is the most appropriate management?

• A Add ciclosporin and reassess after another 72 hours
• B Subtotal colectomy with end ileostomy ✓
• C Total proctocolectomy with ileal pouch-anal anastomosis
• D Percutaneous decompressive cecostomy

Explanation

Toxic megacolon complicating acute severe colitis, defined as colonic dilatation over 6 cm with systemic toxicity, that fails to improve on maximal medical therapy mandates emergency subtotal colectomy with end ileostomy and mucous fistula or Hartmann closure of the rectal stump. Restorative pouch surgery is deferred because it carries unacceptable leak risk in sepsis and steroid-treated tissues. Continued drug escalation risks perforation.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.