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Computerized tomographic demonstration of toxic megacolon: Report of a case
Computerized Radiol. Vol. I, No. 5, pp. 279-281, Printed in the U.S.A.All rightsreserved
0730-4862/83 $3.00+ 0.00 Copyrightc 1983PergamonPressLtd
1983
COMPUTERIZED TOMOGRAPHIC DEMONSTRATION OF TOXIC MEGACOLON: REPORT OF A CASE STEPHEN D. BRAWNER, JACK M. A. TISHLER, EVA RUBIN and RODRIGO F. LUNA Department of Diagnostic Radiology, The University of Alabama School of Medicine, 619 South 19th Street, Birmingham, AL 35233, U.S.A. (RYceirL’d 24 Srptemhrr
1982; received
for
publication
30 March
1983)
Abstract -Computerized tomography was performed on a patient with toxic megacolon. It is conceivable that a patient may be studied by CT prior to plain radiography, and the appearance of the colon described below should
alert the examiner
Toxic megacolon graphy
Inflammatory and toxic megacolon
to the possibility bowel disease
of toxic megacolon. Computerized
tomography
Computerized
tomo
INTRODUCTION Toxic megacolon is a poorly understood complication of the acute inflammatory colitides such as ulcerative colitis, Crohn’s disease. and infectious colitis. Despite advances in medical and surgical therapy, mortality remains high (30x), death usually being caused by colonic perforation [l]. Decreased mortality is directly related to early diagnosis and initiation of prompt medical or surgical therapy. Conventional radiography of the abdomen usually provides information which is diagnostic, revealing gaseous dilatation, particularly of the ascending and transverse colon (the least dependent portion of the colon in the supine position [Z]), loss of haustral markings. and sometimes nodular filling defects representing mucosal islands. The latter are highly suggestive of the diagnosis. Though attempts have been made to assign an upper limit of normal diameter to the transverse colon, a progression of dilatation on serial abdominal radiographs is probably of greater diagnostic value. The presence of mucosal islands militates toward prompt surgical intervention [3]. We present a case of toxic megacolon in which CT examination was performed. With the increasing use of CT in evaluation of abdominal conditions, it is conceivable that a patient may present for CT examination prior to preliminary studies. The findings described should alert the examiner to the possibility of toxic megacolon, and close clinical correlation is immediately indicated.
CASE
REPORT
One month prior to transfer to our hospital, this previously well 42-yr old white male was admitted to a community hospital with a 2-week history of bloody diarrhea (8 x qd), intermittent nausea and vomiting, weight loss, and fever. Barium enema and colonoscopy showed mucosal irregularity, nodular filling defects, skip areas, and rectal sparing, diagnostic of Crohn’s disease. An intensive medical regimen (including steroids) was instituted with some symptomatic improvement (defervescence, decrease in stools to l-4 qd). One week prior to transfer, low glade fever, nausea and vomiting returned and persisted. Upon transfer, the patient was in no real distress. He had a temperature of lOO”F, BP 130/80, pulse 136, and respirations of 16. The abdomen was moderately distended, but only slightly tender. Bowel sounds were present. Physical examination was otherwise unremarkable. WBC count was 7900 (10 lymphs, 2.5 monos, 27 segs, and 38 bands) and HCT was 27. Laboratory investigation was otherwise normal. Plain abdominal radiographs demonstrated colonic dilatation and large intraluminal polypoid filling defects: there was no evidence of perforation (Fig. 1). 279
280
STEPHEND. BRAWNEZR et al
Fig. 1. Left lateral
decubitus
shows colonic
dilatation.
Arrow
points
to characteristic
mucosal
islands.
An intensive medical regimen was continued and the patient improved clinically over the following 48 hr. However, abdominal radiographs demonstrated increasing diameter of the transverse colon. Because of clinical suspicion of intraabdominal abscesses, CT of the abdomen was carried out, and revealed dilatation of the transverse, distal ascending and proximal descending colon. In places where the haustra were effaced, the mucosa had an irregular, nodular appearance (Fig. 2). In tangential sections, the haustra were thickened (Fig. 3). On day three, the patient underwent an abdominal colectomy. The specimen contained a markedly dilated colon (in places up to 25 cm in diameter). Most of the mucosa was totally denuded. The distal small bowel was included in the sample and had a cobblestone appearance with multiple fissures and ulcerations. The patient’s postoperative course was complicated by multiple intraabdominal abscesses, sepsis and renal failure, and he expired 8 weeks after the colectomy. DISCUSSION Toxic megacolon is readily identifiable on plain radiographs patients.
Fig. 2. Effaced haustra
and an irregular
mucosal
of the abdomen in the majority of
pattern
(arrows)
CT demonstration
Fig. 3. Tangential
section
through
of toxic megacolon
the transverse
colon. Arrow depicts
281
thickened
haustra
In this case report, we are not suggesting that CT scanning is indicated in patients with toxic megacolon (in fact, the diagnosis was apparent on conventional radiographs in our case). However, when a patient with an acute abdomen presents for CT scan, and has the above findings, toxic megacolon should be strongly suspected. In such a case, we would expect the plain abdominal radiographs that followed to be dignostic as well. REFERENCES 1. T. J.. Muscroft, P. M., Warren, P. Asquith, R. D. Montgomery and G. S. Sokhi, Toxic megacolon in ulcerative colitis: a continuing challenge, Postgrad. Med. J. 57, 223-227 (198 I). 2. P. Kramer and J. Wittenberg. Colonic gas distribution in toxic megacolon, Gastroentrrology 80, 433-437 (1981). 3. S. C. Truelove and C. G. Marks, Toxic megacolon, Part I: Pathogenesis. diagnosis and treatment, Cli~l. Gastror,~rrrol. 10. 109-I 13 (1981). About the Author-STEPHEN
D. BRAWNER received his M.D. from the University of Alabama Medicine in 1977, when he was graduated magna cum laude. He is currently a resident in Diagnostic at University of Alabama in Birmingham.
School of Radiology
M. A. TISHLER received his M.D. in 1961 from McGill l_Jniversity. He trained in Radiology at the University of Michigan and was on the faculty of the University of Manitoba from 1966 to 1977. He is presently Professor of Radiology at the University of Alabama School of Medicine. and is the author of numerous publications. About the Author-JACK
About the Author-EvA
did an internship and training at New York St Vincent’s Hospital, Diagnostic Radiology Diagnostic Radiology
RUBIN received her M.D. in 1974 from the University of Alabama in Birmingham. two years of residency in radiology at the University of Toronto and completed her Hospital-Cornell Medical Center. She completed a fellowship in special procedures at New York City and returned to New York Hospital as Assistant Professor of in 1979. Since July 1980 she has been an Assistant Professor in the Department of at the University of Alabama in Birmingham.
F. LUNA graduated from the University of Chile in 1965, and interned Crawford Long Hospital in Atlanta. He trained in Diagnostic Radiology at the University of Alabama Birmingham from 1968 to 1971, where he is now Associate Professor of Radiology.
About the Author-Romao
at in
0730-4862/83 $3.00+ 0.00 Copyrightc 1983PergamonPressLtd
1983
COMPUTERIZED TOMOGRAPHIC DEMONSTRATION OF TOXIC MEGACOLON: REPORT OF A CASE STEPHEN D. BRAWNER, JACK M. A. TISHLER, EVA RUBIN and RODRIGO F. LUNA Department of Diagnostic Radiology, The University of Alabama School of Medicine, 619 South 19th Street, Birmingham, AL 35233, U.S.A. (RYceirL’d 24 Srptemhrr
1982; received
for
publication
30 March
1983)
Abstract -Computerized tomography was performed on a patient with toxic megacolon. It is conceivable that a patient may be studied by CT prior to plain radiography, and the appearance of the colon described below should
alert the examiner
Toxic megacolon graphy
Inflammatory and toxic megacolon
to the possibility bowel disease
of toxic megacolon. Computerized
tomography
Computerized
tomo
INTRODUCTION Toxic megacolon is a poorly understood complication of the acute inflammatory colitides such as ulcerative colitis, Crohn’s disease. and infectious colitis. Despite advances in medical and surgical therapy, mortality remains high (30x), death usually being caused by colonic perforation [l]. Decreased mortality is directly related to early diagnosis and initiation of prompt medical or surgical therapy. Conventional radiography of the abdomen usually provides information which is diagnostic, revealing gaseous dilatation, particularly of the ascending and transverse colon (the least dependent portion of the colon in the supine position [Z]), loss of haustral markings. and sometimes nodular filling defects representing mucosal islands. The latter are highly suggestive of the diagnosis. Though attempts have been made to assign an upper limit of normal diameter to the transverse colon, a progression of dilatation on serial abdominal radiographs is probably of greater diagnostic value. The presence of mucosal islands militates toward prompt surgical intervention [3]. We present a case of toxic megacolon in which CT examination was performed. With the increasing use of CT in evaluation of abdominal conditions, it is conceivable that a patient may present for CT examination prior to preliminary studies. The findings described should alert the examiner to the possibility of toxic megacolon, and close clinical correlation is immediately indicated.
CASE
REPORT
One month prior to transfer to our hospital, this previously well 42-yr old white male was admitted to a community hospital with a 2-week history of bloody diarrhea (8 x qd), intermittent nausea and vomiting, weight loss, and fever. Barium enema and colonoscopy showed mucosal irregularity, nodular filling defects, skip areas, and rectal sparing, diagnostic of Crohn’s disease. An intensive medical regimen (including steroids) was instituted with some symptomatic improvement (defervescence, decrease in stools to l-4 qd). One week prior to transfer, low glade fever, nausea and vomiting returned and persisted. Upon transfer, the patient was in no real distress. He had a temperature of lOO”F, BP 130/80, pulse 136, and respirations of 16. The abdomen was moderately distended, but only slightly tender. Bowel sounds were present. Physical examination was otherwise unremarkable. WBC count was 7900 (10 lymphs, 2.5 monos, 27 segs, and 38 bands) and HCT was 27. Laboratory investigation was otherwise normal. Plain abdominal radiographs demonstrated colonic dilatation and large intraluminal polypoid filling defects: there was no evidence of perforation (Fig. 1). 279
280
STEPHEND. BRAWNEZR et al
Fig. 1. Left lateral
decubitus
shows colonic
dilatation.
Arrow
points
to characteristic
mucosal
islands.
An intensive medical regimen was continued and the patient improved clinically over the following 48 hr. However, abdominal radiographs demonstrated increasing diameter of the transverse colon. Because of clinical suspicion of intraabdominal abscesses, CT of the abdomen was carried out, and revealed dilatation of the transverse, distal ascending and proximal descending colon. In places where the haustra were effaced, the mucosa had an irregular, nodular appearance (Fig. 2). In tangential sections, the haustra were thickened (Fig. 3). On day three, the patient underwent an abdominal colectomy. The specimen contained a markedly dilated colon (in places up to 25 cm in diameter). Most of the mucosa was totally denuded. The distal small bowel was included in the sample and had a cobblestone appearance with multiple fissures and ulcerations. The patient’s postoperative course was complicated by multiple intraabdominal abscesses, sepsis and renal failure, and he expired 8 weeks after the colectomy. DISCUSSION Toxic megacolon is readily identifiable on plain radiographs patients.
Fig. 2. Effaced haustra
and an irregular
mucosal
of the abdomen in the majority of
pattern
(arrows)
CT demonstration
Fig. 3. Tangential
section
through
of toxic megacolon
the transverse
colon. Arrow depicts
281
thickened
haustra
In this case report, we are not suggesting that CT scanning is indicated in patients with toxic megacolon (in fact, the diagnosis was apparent on conventional radiographs in our case). However, when a patient with an acute abdomen presents for CT scan, and has the above findings, toxic megacolon should be strongly suspected. In such a case, we would expect the plain abdominal radiographs that followed to be dignostic as well. REFERENCES 1. T. J.. Muscroft, P. M., Warren, P. Asquith, R. D. Montgomery and G. S. Sokhi, Toxic megacolon in ulcerative colitis: a continuing challenge, Postgrad. Med. J. 57, 223-227 (198 I). 2. P. Kramer and J. Wittenberg. Colonic gas distribution in toxic megacolon, Gastroentrrology 80, 433-437 (1981). 3. S. C. Truelove and C. G. Marks, Toxic megacolon, Part I: Pathogenesis. diagnosis and treatment, Cli~l. Gastror,~rrrol. 10. 109-I 13 (1981). About the Author-STEPHEN
D. BRAWNER received his M.D. from the University of Alabama Medicine in 1977, when he was graduated magna cum laude. He is currently a resident in Diagnostic at University of Alabama in Birmingham.
School of Radiology
M. A. TISHLER received his M.D. in 1961 from McGill l_Jniversity. He trained in Radiology at the University of Michigan and was on the faculty of the University of Manitoba from 1966 to 1977. He is presently Professor of Radiology at the University of Alabama School of Medicine. and is the author of numerous publications. About the Author-JACK
About the Author-EvA
did an internship and training at New York St Vincent’s Hospital, Diagnostic Radiology Diagnostic Radiology
RUBIN received her M.D. in 1974 from the University of Alabama in Birmingham. two years of residency in radiology at the University of Toronto and completed her Hospital-Cornell Medical Center. She completed a fellowship in special procedures at New York City and returned to New York Hospital as Assistant Professor of in 1979. Since July 1980 she has been an Assistant Professor in the Department of at the University of Alabama in Birmingham.
F. LUNA graduated from the University of Chile in 1965, and interned Crawford Long Hospital in Atlanta. He trained in Diagnostic Radiology at the University of Alabama Birmingham from 1968 to 1971, where he is now Associate Professor of Radiology.
About the Author-Romao
at in