Toxic Megacolon and Acute Ischemia of the Colon due to Sigmoid Stenosis Related to Diverticulitis
A 40-year-old man presented to the accident and emergency department with severe diffuse abdominal pain which had started 8 h earlier. He also reported abdominal bloating, diarrhea and nausea. In his past medical history he had two episodes of acute diverticulitis over the past 2 years. Ten years prior to this presentation he had been hospitalized for a ruptured diverticulum in the sigmoid colon. As he refused to have surgery he was treated conservatively at that time.\nOn physical examination his temperature was 38.8°C and his heart rate was 120 beats/min. Blood pressure and oxygen saturation (while breathing ambient air) were normal. He had abdominal distension and tenderness on deep palpation on the left lower quadrant without peritoneal signs. Rectal examination revealed no stool in the vault. Laboratory examination revealed: hemoglobin 15.9 g/dl, WBC 19.120 (NEUT 80.2%), CRP 270.6 mg/l, CPK 543 U/l, GLU 125 mg/dl, LDH 481 U/l, fibrinogen 4.4 g/l, Na 141 mEq/l, and K 5.2 mEq/l.\nAn abdominal CT scan showed located stenosis of the sigmoid colon and marked dilation of the descending (12 cm diameter), transverse (7.5 cm diameter) and ascending (12 cm diameter) colon and of the cecum (11 cm diameter) (fig. ). It is to be noted that in one of his prior admissions due to a crisis of acute diverticulitis 2 years earlier, CT scan had showed a stenotic lesion in the sigmoid colon with mechanical obstruction and prestenotic dilation of the colon. Before the latest admission he had experienced mild periodic discomfort in the abdomen but had not sought medical treatment.\nOver a period of 8 h the patient deteriorated with signs of sepsis, multiorgan failure, severe dyspnea and metabolic acidosis. A CT scan was performed which ruled out pulmonary embolism. He was then intubated because of respiratory muscle fatigue. Laboratory tests changed to the following values: CRP 318 mg/l, CPK 543 U/l, fibrinogen 6 g/l, creatinine 2.2 mg/dl, PT 28.20 s, INR 2.56, D-dimer 2,223.2 μg/l, Na 133 mEq/l, K 5.4 mmol/l, and P 5.4 mg%.\nThe above clinical and laboratory findings were compatible with toxic megacolon. A surgical assessment was performed and emergency laparotomy was decided. Surgery revealed extensive necrotic colon and total colectomy was implemented with protective loop ileostomy. After surgery the patient was transferred to the intensive care unit because of hemodynamic instability. He was extubated after 12 h and transferred to the ward where he stayed until his discharge 10 days later. Histological examination of the resected colon revealed resolving necrotic colon. The specimen was negative for malignancy. The loop ileostomy was reversed 3 months later. Today, 4 years later, the patient remains in good health.