Schein's Common Sense Emergency Abdominal Surgery, 4th Edition by Moshe Schein Paul N. Rogers Ari Leppäniemi

Author:Moshe Schein,Paul N. Rogers,Ari Leppäniemi
Language: eng
Format: epub, pdf
Tags: Critical Care
Publisher: TFM Publishing Ltd

When to operate? Severe colitis, fulminant colitis, and toxic colitis-megacolon

Patients with severe or fulminant colitis often do not appear overtly ‘septic’; however, close watching of these patients is essential as they can ‘look well’ for long periods of time (days, even weeks) but can deteriorate suddenly and progress onto toxic colitis.

Patients with severe colitis require urgent colectomy, but waiting to perform the operation in daylight hours is acceptable. On the other hand, when patients progress to toxic colitis, surgical intervention becomes an emergency.

When dealing with acute colitis there is really no difference in either the surgical or medical management of ulcerative colitis, Crohn’s colitis, or indeterminate colitis; but when using the terms ‘severe colitis’ or ‘fulminant colitis’, most individuals are speaking about ulcerative colitis.

To identify when and who to operate on with colitis, we need first to provide some definitions:

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Severe colitis: >5 bloody bowel movements a day, cramps, fever, heart rate >90, anemia, raised ESR (≥30mm/hour).

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Fulminant colitis: >9 bloody bowel movements a day, continuous bleeding, pain, signs of toxic symptoms (anorexia, fever, tachycardia).

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Toxic colitis-megacolon: a patient with fulminant colitis and radiographic evidence of distension of the colon; transverse colon >6cm in diameter or cecum >9cm in diameter. Only 1-5% of patients with inflammatory bowel disease ever develop toxic megacolon. (Clostridium difficile colitis on the other hand can result in toxic colitis — manifesting with a massive colonic edema on CT rather than a megacolon — in up to 3% and the incidence is rising. Other causes of toxic megacolon are CMV colitis, Salmonella, Shigella, Campylobacter, Entamoeba, and ischemic colitis. These are all rare.)

Truelove and Witts (Br Med J 1955; 2: 1041-8) developed an ulcerative colitis severity index which classifies the acute episode as mild, moderate or severe (Google it up....). In Table 26.1, we bring our simplified version which is a helpful way of thinking about these patients.

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