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Case 11

Crohn's colitis with toxic megacolon

An elderly man with acute abdominal pain

This 75 year old man presented to the Emergency Department with acute abdominal pain and bloody diarhoea. What does the plain abdominal film show?

Findings

There is loss of the normal mucosal outline to the large bowel, with an irregular margin and no visible haustral markings, indicating mucosal inflammation and oedema. There is marked dilatation of the large bowel, from the caecum on the right to a loop of sigmoid seen centrally in the pelvis. The appearances and the extent thus indicate a pancolitis. The transverse colon measures more than 5.5cm across, which in the presence of colitis indicates a toxic megacolon, with the risk of imminent perforation.

Diagnosis

Crohn's colitis with toxic megacolon

Discussion

Toxic megacolon is a complication of inflammatory bowel disease. It is due to transmural inflammation with loss of neuromuscular function leading to dilatation and eventually perforation. It constitutes a surgical emergency.

The causes are:

• Ulcerative colitis
• Crohn disease
• Amoebiasis
• Pseudomembranous colitis
• Ischaemic colitis

The commonest cause is ulcerative colitis, but in a gentleman of this age ischaemic colitis should be considered. In fact he underwent emergency colectomy and a histological diagnosis of Crohn's colitis was made; unusual given that he had never previously had any bowel symptoms.

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