El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
This is the case of a 53 year-old female, with Chronic Renal Insufficiency, was hospitalized due to acute abdomen in a the national hospital of social insurance (seguro social ISSS) in el Salvador, the abdominal ultrasound and the cat scan displayed colon dilation, patient underwent abdominal laparotomy, with no specified finding except thickening of the colon, one week after the surgery, patient initiates with lower gi bleeding, due to the colonoscopes that used in that hospital were under reparation a colonoscopy was performed in our office finding the characteristics here described.

Video Endoscopic Sequence 1 of 12.

 Toxic Dilatation of the Colon

 This is the case of a 53 year-old female, with Chronic Renal
 Insufficiency, was hospitalized due to acute abdomen in a
 national hospital of social insurance (seguro social ISSS) in
 el Salvador, the abdominal ultrasound and the cat scan
 displayed colon dilation, patient underwent abdominal
 laparotomy, with no specified finding except thickening of
 the walls of the colon, one week after the surgery, patient
 initiates with lower gi bleeding. Because of the
 colonoscopes that used in that hospital were under
 reparation a colonoscopy was performed in our office
 finding the characteristics here described.

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The colonoscopic finding are of that a hemorrhagic inflammatory polyposis with thickening of the colonic folders. Risk factors for the development of severe colitis in patients with C. difficile infection include malignancy, chronic obstructive pulmonary disease, immunosuppressive therapy, renal failure, or exposure to antiperistaltic medications or clindamycin. Toxic megacolon has been described in patients with recurrent C. difficile.

Video Endoscopic Sequence 2 of 12.

 The colonoscopic finding are of that a hemorrhagic colitis
 with inflammatory polyposis with difuse thickening of the
 colonic folders.

  Risk factors for the development of severe colitis in
 patients with C. difficile infection include malignancy,
 chronic obstructive pulmonary disease, immunosuppressive
 therapy, renal failure, or exposure to antiperistaltic
 medications or clindamycin. Toxic megacolon has been
 described in patients with recurrent C. difficile.
Toxic megacolon is often seen in the setting of ulcerative colitis. If severe enough, many other colitides can also precipitate a toxic megacolon. Crohn disease, antibiotic-induced pseudomembranous colitis, amebiasis, Salmonella enteritis and Campylobacter enteritis infection (particularly when antimotility agents are used), and ischemic colitis are all known causes of toxic megacolon.

Video Endoscopic Sequence 3 of 12.

 Toxic megacolon is often seen in the setting of ulcerative
 colitis. If severe enough, many other colitides can also
 precipitate a toxic megacolon. Crohn disease,
 antibiotic-induced pseudomembranous colitis, amebiasis,
 Salmonella enteritis and Campylobacter enteritis infection
 (particularly when antimotility agents are used), and
 ischemic colitis are all known causes of toxic megacolon.

 

 
Salmonella, Shigella, and Campylobacter colitis are very rarely complicated by toxic dilatation, and can usually be differentiated from IBD by histology and endoscopic biopsy. Toxic megacolon may also complicate hemorrhagic colitis and hemolytic?uremic syndrome secondary to infection with E. coli

Video Endoscopic Sequence 4 of 12.

 Salmonella, Shigella, and Campylobacter colitis are very
 rarely complicated by toxic dilatation, and can usually be
 differentiated from IBD by histology and endoscopic
 biopsy.
 Toxic megacolon may also complicate hemorrhagic colitis
 and hemolytic–uremic syndrome secondary to infection
 with E. coli.

 

Video Endoscopic Sequence 5 of 12.

Thickening of the colonic folders

 Superimposed pseudomembranous colitis involving the
 right colon.
Megacolon is considered present if the diameter of the colon is 5.5 cm or more, with apparent edema of the bowel wall on plain abdominal radiographs. Rarely, the toxic dilatation may extend to the terminal ileum. Colonic dilatation may be superimposed on an acute fulminant colitis in a patient with a history of inflammatory bowel disease. The dilatation may fluctuate or resolve completely, leaving the patient with toxic colitis. Clostridium difficile is the most common causative agent implicated in pseudomembranous colitis.

Video Endoscopic Sequence 6 of 12.

 Megacolon is considered present if the diameter of the
 colon is 5.5 cm or more, with apparent edema of the bowel
 wall on plain abdominal radiographs. Rarely, the toxic
 dilatation may extend to the terminal ileum. Colonic
 dilatation may be superimposed on an acute fulminant
 colitis in a patient with a history of inflammatory bowel
 disease. The dilatation may fluctuate or resolve
 completely, leaving the patient with toxic colitis.
 Clostridium difficile is the most common causative agent
 implicated in pseudomembranous colitis.

Toxic megacolon complicating pseudomembranous colitis. Toxic megacolon is associated with an acute transmural fulminant colitis with the neurogenic loss of motor tone. The result is the rapid development of colonic dilatation due to damage to the entire wall of the colon associated with neuromuscular degeneration. Histologic examination reveals extensive sloughing of the mucosa and frequent necrosis of the muscle layers of the bowel wall. Thinning of the muscle layer of the colon often occurs.

Video Endoscopic Sequence 7 of 12.

 Toxic megacolon complicating pseudomembranous colitis

 Toxic megacolon is associated with an acute transmural
 fulminant colitis with the neurogenic loss of motor tone.
 The result is the rapid development of colonic dilatation
 due to damage to the entire wall of the colon associated
 with neuromuscular degeneration. Histologic examination
 reveals extensive sloughing of the mucosa and frequent
 necrosis of the muscle layers of the bowel wall. Thinning of
 the muscle layer of the colon often occurs.

 

Video Endoscopic Sequence 8 of 12.

The Cecum.

This image and the video clip shows brilliant red blood.

Extension of the mucosal inflammation may also be important. In contrast to typical ulcerative colitis in which the inflammatory response is limited to the mucosa, toxic megacolon is characterized by severe inflammation of the smooth muscle layer which paralyzes the colonic smooth muscle, thereby leading to dilatation. The extent of dilatation appears to be correlated with the depth of inflammation and ulceration. Damage to the myenteric plexus of the colon is not a consistent finding.

Video Endoscopic Sequence 9 of 12.

 Extension of the mucosal inflammation may also be
 important. In contrast to typical ulcerative colitis in which
 the inflammatory response is limited to the mucosa, toxic
 megacolon is characterized by severe inflammation of the
 smooth muscle layer which paralyzes the colonic smooth
 muscle, thereby leading to dilatation. The extent of
 dilatation appears to be correlated with the depth of
 inflammation and ulceration. Damage to the myenteric
 plexus of the colon is not a consistent finding.

Video Endoscopic Sequence 10 of 12.

Acute transmural fulminant colitis.

 

Video Endoscopic Sequence 11 of 12.

 

Video Endoscopic Sequence 12 of 12.

 Due to the uncontrollable hemorrhage, patient
 underwent a colectomy (Restorative Procto-Colectomy).

 Download the video clip by clicking in the endoscopic
 image.

 
ToxicColon13

 
ToxicColon14

 
ToxicColon15

 

 
ToxicColon16

 
ToxicColon17