Fulminant Toxic Megacolon Without Identifiable Underlying Cause Requiring Emergent Total Colectomy: A Case Report

TL;DR

A 71-year-old man with no prior colonic disease developed severe toxic megacolon due to ischemic colitis and required emergency surgery for survival.

Contribution

Highlights ischemic colitis as an underrecognized cause of toxic megacolon in elderly patients without prior colonic disease.

Findings

Toxic megacolon occurred in a patient without identifiable inflammatory or infectious colitis.

Extreme cecal dilation (14 cm) was a critical indicator for urgent surgical intervention.

Histopathology confirmed ischemic colitis as the underlying cause, not inflammatory bowel disease.

Abstract

Toxic megacolon is a life-threatening condition characterized by acute colonic dilation and systemic toxicity, most commonly associated with inflammatory or infectious colitis. However, ischemic colitis represents an important and underrecognized etiology in elderly patients with significant vascular comorbidities. We report the case of a 71-year-old male with a history of long-standing hypertension, type 2 diabetes mellitus, and chronic kidney disease, receiving losartan, nifedipine, and insulin therapy, who presented with five days of progressive diffuse abdominal pain, severe distension, obstipation, and systemic deterioration. On admission, he was febrile, tachycardic, metabolically acidotic, and demonstrated leukocytosis, elevated inflammatory markers, hyperlactatemia, and renal dysfunction. Initial management included aggressive intravenous fluid resuscitation, broad-spectrum antibiotics, electrolyte correction, and bowel rest. Computed tomography without intravenous contrast revealed severe diffuse colonic dilation with a maximal cecal diameter of 14 cm, without mechanical obstruction or perforation. Given the extreme dilation, systemic toxicity, and early organ dysfunction, urgent surgical intervention was performed within hours of admission. Exploratory laparotomy demonstrated diffuse colonic dilation with mural thinning and serosal inflammatory changes, and total colectomy with end ileostomy was undertaken. Histopathological examination confirmed extensive ischemic colitis with mucosal and submucosal necrosis, without evidence of inflammatory bowel disease or pseudomembranous colitis. The patient required short-term vasopressor support postoperatively but recovered without major complications and was discharged on postoperative day 12. This case emphasizes that toxic megacolon may occur in elderly patients without prior colonic disease and highlights extreme cecal dilation as a critical indicator for early surgical management to improve survival.

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