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Difficulty: HardPediatric Gastrointestinal Disorders

A 14-year-old girl is hospitalized for an acute, severe exacerbation of newly diagnosed ulcerative colitis. Over the past 48 hours, she has been treated with intravenous fluids, methylprednisolone, and prophylactic low-molecular-weight heparin. The nursing staff urgently calls the physician to the bedside due to an abrupt deterioration in her clinical status. The patient reports continuous, excruciating abdominal pain that is no longer crampy. Her temperature is 39.4°C (102.9°F), blood pressure is 84/50 mmHg, heart rate is 142/min, and respiratory rate is 28/min. Physical examination demonstrates a markedly distended, tympanitic abdomen with diffuse rigidity, guarding, and rebound tenderness. Bowel sounds are absent. A portable supine abdominal radiograph reveals a transverse colon diameter of 7.5 cm, loss of normal haustral markings, and mucosal edema, with no free intraperitoneal air.

Which of the following is the most appropriate next step in management?

  1. Request an immediate surgical consultation for an emergency colectomyAnswer
  2. B
    Transport the patient to the radiology department for a contrast-enhanced abdominal computed tomography scan
  3. C
    Initiate intravenous infliximab therapy and continue intensive care observation
  4. D
    Administer oral loperamide to provide symptomatic relief and reduce colonic dilation
  5. E
    Discontinue corticosteroids and rely on empiric broad-spectrum intravenous antibiotics

Answer

Request an immediate surgical consultation for an emergency colectomy
The patient is presenting with toxic megacolon complicated by peritonitis and hemodynamic instability. Toxic megacolon is characterized by severe colonic dilation (typically >6 cm) accompanied by systemic toxicity. While initial management for uncomplicated toxic megacolon includes bowel rest, decompression, intravenous corticosteroids, and broad-spectrum antibiotics, the presence of a rigid surgical abdomen, rebound tenderness, and shock indicates impending or actual perforation. In such unstable patients with peritonitis, medical management is inadequate, and an immediate emergency surgical consultation for subtotal colectomy is required to prevent fatal outcomes.

Step-by-Step Solution

1
Identify the primary complication based on clinical and radiographic findings.
The patient has toxic megacolon, evidenced by severe systemic toxicity (fever, tachycardia) and colonic dilation >6 cm (7.5 cm in this case) on the radiograph.
Recognizing toxic megacolon is critical as it is a life-threatening complication of inflammatory bowel disease.
2
Assess the patient for signs of impending or actual perforation.
The presence of a rigid abdomen, rebound tenderness, absent bowel sounds, and hemodynamic shock (BP 84/50 mmHg) indicates peritonitis.
Peritonitis in the setting of toxic megacolon signals failure of medical therapy and an extremely high risk of imminent mortality.
3
Determine the most appropriate definitive intervention.
Emergency surgical consultation for subtotal colectomy is required.
While uncomplicated toxic megacolon can initially be treated medically, the development of peritonitis and shock mandates immediate surgical source control.

Key Concept

Surgical indications in toxic megacolon complicating pediatric ulcerative colitis
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Topics

Pediatric Gastrointestinal Disorders

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