[Toxic megacolon--surgical point of view]

Toxic megacolon is an infrequent, but potentially fatal complication of a fulminant colitis. Toxic colonic dilatation, also caused by ischaemic or infectious inflammation like pseudomembranous colitis, mostly occur in patients with inflammatory bowel disease. Toxic mega-colon is defined as segmental or total colonic distension of >6 cm with the presence of clinical signs of acute colitis and systemic toxicity. Because of the associated high morbidity and mortality the early diagnosis and the management play an important role. The free perforation means a fourfold increase in the mortalitiy of the acute colitis. Recognition of toxic megacolon is underlaying by x-ray of the abdomen with colonic distension and a lack of haustral pattern. Accompanying distension of the small bowel can predict the development of the disease. CT scanning shows a diffuse wall thickening, pericolic inflammation and abnormal haustral pattern and can also detect subclinical perforation or abscesses. The management of toxic megacolon should be with intravenous parenteral nutrition, adaequate supplementation of intravenous fluids and correction of electrolytes abnormalities and the therapy of colitis with corticosteroids. Antibiotics are indicated in infectious disease or bacteriemia and also in colonic perforation. Surgical intervention is indicated by the onset of signs of progression of the disease and complications as perforation, uncontrollable bleeding or distension. The surgical procedure of choice is colectomy and ileostomy. The mortality and morbidity was decreased by avoiding rectal excision. The rectum is closed as a Hartmann's procedure or a mucous fistula is created. A secondary ileoanal pouch can be created at a later date. The interdisciplinary approach with optimal timing of surgical intervention can decrease the morbidity and mortality of toxic megacolon.