A 37-year-old woman is evaluated in the emergency department for the acute onset of
pain after 2 weeks of bloody diarrhea. The diarrhea has escalated to 15 times per
day. She has ulcerative colitis that was diagnosed 2 years ago. She currently takes
On physical examination, she appears ill. Following aggressive fluid resuscitation,
temperature is 38.9 °C (102.0 °F), blood pressure is 70/40 mm Hg, pulse
rate is 148/min, and respiration rate is 35/min. Abdominal examination discloses absent
bowel sounds, distention, and diffuse marked tenderness with mild palpation.
Laboratory studies reveal a leukocyte count of 16,800/µL (16.8 × 109/L). Abdominal radiograph is shown:
Which of the following is the most appropriate management?
A. CT scan
B. Immediate surgery
C. Start infliximab
D. Start intravenous hydrocortisone
B. Immediate surgery
Toxic megacolon is the most severe complication associated with ulcerative colitis;
progressive abdominal distention and tenderness with hemodynamic instability are indications
for immediate surgery.
Manage toxic megacolon in a patient with ulcerative colitis.
The most appropriate management is immediate surgery. Most patients with toxic megacolon
related to ulcerative colitis have at least 1 week of bloody diarrhea symptoms that
are unresponsive to medical therapy. On examination, patients have tachycardia, fever,
hypotension, decreased or absent bowel sounds, and lower abdominal distention and
tenderness, often with peritoneal signs. On plain film radiography, the transverse
colon is most affected, with dilatation exceeding 6 cm. This patient has toxic megacolon
based on the clinical history, examination findings, and imaging studies. Toxic megacolon
is the most severe complication associated with ulcerative colitis; it is associated
with a 40% mortality rate in patients undergoing emergency colectomy after a perforation
has occurred (compared with 2% without a perforation). About 50% of patients with
toxic megacolon may improve with medical therapy (bowel rest, intravenous corticosteroids,
antibiotics, and fluids); however, progressive abdominal distention and tenderness
with hemodynamic instability are indications for immediate surgery.
A CT scan could further identify the extent of colonic dilatation and wall thickening
as well as possible abscess formation or microperforation, but this would not change
the required management of this patient.
Infliximab is a good treatment for flares of ulcerative colitis, but it is not an
effective therapy for toxic megacolon and would not be indicated in this patient.
Intravenous hydrocortisone would be a good choice for an ulcerative colitis flare
or possibly toxic megacolon, but only if the patient was clinically stable.
Gan SI, Beck PL. A new look at toxic megacolon: an update and review of incidence,
etiology, pathogenesis, and management. Am J Gastroenterol. 2003;98(11):2363-2371. PMID: 14638335
This question was derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.
A 38-year-old man is evaluated in follow-up after a diagnosis of ulcerative colitis. Ten days ago he was started on prednisone, 60 mg/d, but his symptoms have not improved. He has six to nine bloody bowel movements per day and moderate abdominal pain. He has decreased his oral intake because eating exacerbates his pain and diarrhea.
On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 110/56 mm Hg, and pulse rate is 96/min. He is pale but in no distress. The abdomen is diffusely tender without distention, guarding, or rebound.
Laboratory studies reveal a hemoglobin level of 9.7 g/dL (97 g/L) and a leukocyte count of 6300/µL (6.3 × 109/L).
Stool culture and Clostridium difficile assay are negative.
Which of the following is the most appropriate treatment?
A. Increase prednisone to 80 mg/d
B. Initiate adalimumab
C. Initiate ciprofloxacin and metronidazole
D. Initiate mesalamine
E. Initiate sulfasalazine
B. Initiate adalimumab
Patients with moderate to severe ulcerative colitis whose disease does not respond to oral glucocorticoids should be treated with either intravenous glucocorticoids or an anti–tumor necrosis factor agent.
Treat refractory ulcerative colitis with an anti–tumor necrosis factor agent.
The most appropriate treatment is to initiate an anti–tumor necrosis factor (anti-TNF) agent such as adalimumab. This patient has moderate to severe ulcerative colitis that is not responding to 60 mg/d of prednisone. Moderate to severe ulcerative colitis is often treated with oral glucocorticoids such as prednisone, 40 to 60 mg/d. Patients whose disease does not respond to oral glucocorticoids should be hospitalized and given intravenous glucocorticoids or should be treated with an anti-TNF agent. Randomized controlled clinical trials have shown three anti-TNF antibodies (infliximab, adalimumab, and golimumab) to be effective for inducing and maintaining remission in patients such as this with ulcerative colitis. Indications for hospital admission include dehydration, inability to tolerate oral intake, fever, significant abdominal tenderness, and abdominal distention.
A meta-analysis of clinical trials showed that using doses of prednisone above 60 mg/d provides little if any additional efficacy and produces more side effects.
Ciprofloxacin and metronidazole should be used in patients with severe colitis associated with high fever, significant leukocytosis, peritoneal signs, or toxic megacolon. However, antibiotics are not indicated in a patient such as this with colitis without signs of systemic toxicity.
Patients with mild to moderate ulcerative colitis respond well to 5-aminosalicylate agents. Patients with proctitis or left-sided colitis should receive topical therapy with a 5-aminosalicylate or hydrocortisone suppositories or enemas. If patients require repeated courses of glucocorticoids or become glucocorticoid dependent, thiopurines (6-mercaptopurine or azathioprine) or an anti-TNF agent should be initiated (methotrexate has not been shown to be effective in ulcerative colitis). Anti-TNF agents should be used in patients who do not maintain remission with thiopurines or patients whose disease is refractory to glucocorticoids. It is unlikely that 5-aminosalicylates would be beneficial in this patient with more severe disease that is refractory to prednisone.
Talley NJ, Abreu MT, Achkar JP, et al; American College of Gastroenterology IBD Task Force. An evidence-based systematic review on medical therapies for inflammatory bowel disease. Am J Gastroenterol. 2011 Apr;106 Suppl 1:S2-25; quiz S26. PMID: 21472012
This question was derived from MKSAP® 17, the Medical Knowledge Self-Assessment Program.