Trudel J L, Deschênes M, Mayrand S, Barkun A N
Department of Surgery, McGill University, Montreal, Quebec, Canada.
Dis Colon Rectum. 1995 Oct;38(10):1033-8. doi: 10.1007/BF02133974.
Toxic megacolon is a rare complication of pseudomembranous enterocolitis. We reviewed our recent experience with this complication.
The first five patients of the series were studied retrospectively, and six others were followed prospectively.
Between June 1992 and May 1994, 11 patients (8 male, 3 female) developed toxic megacolon secondary to pseudomembranous enterocolitis. Mean age was 60.7 +/- 11.8 (range, 40-79) years. Presenting symptoms and signs included diarrhea, 100 percent; malaise, 91 percent; abdominal pain, 82 percent; abdominal distention, 82 percent; abdominal tenderness, 72 percent; anemia less than 12 gm, 72 percent; albumin less than 3 gm, 64 percent; tachycardia greater than 100, 55 percent; fever greater than 38.5 degrees celsius, 45 percent; shock or hypotension, 45 percent. Predisposing factors included antibiotics, 64 percent; immunosuppressants or chemotherapy, 36 percent; antidiarrheals, 27 percent; and barium enema in one patient. Five patients (45 percent) had more than one predisposing factor. X-rays showed transverse colon dilation and loss of haustrations in eight patients (72 percent), with a mean diameter of 9.9 +/- 3.4 cm. Flexible proctosigmoidoscopy showed pseudomembranes in all scoped patients, and toxin assay for Clostridium difficile was positive in all patients. One patient had emergency surgery. Ten patients were initially treated medically with nasogastric suction and intravenous resuscitation (90 percent) and antibiotics (100 percent), usually in the intensive care unit (80 percent). Four patients did not respond and underwent surgery; two others improved, then deteriorated, and also underwent surgery. Altogether, 7 of 11 patients (64 percent) underwent surgery. Three patients (27 percent) responded well to medical treatment. One patient was deemed too ill to undergo surgery and died. Mean delay to surgery was 3.0 +/- 1.3 days. No sealed or overt perforation was found at laparotomy. All patients who underwent surgery had a subtotal colectomy, with either a Hartmann's stump (71 percent) or a mucous fistula (29 percent). Eventually, five of seven patients who were operated on and two of four medically treated patients died (overall mortality, 64 percent). Only one patient underwent closure of ileostomy and anastomosis.
Toxic megacolon complicating pseudomembranous enterocolitis is a serious problem that carries a high morbidity and mortality rate, regardless of treatment.
中毒性巨结肠是伪膜性小肠结肠炎的一种罕见并发症。我们回顾了近期处理该并发症的经验。
对该系列的前5例患者进行回顾性研究，另外6例进行前瞻性随访。
1992年6月至1994年5月，11例患者（8例男性，3例女性）发生了继发于伪膜性小肠结肠炎的中毒性巨结肠。平均年龄为60.7±11.8岁（范围40 - 79岁）。出现的症状和体征包括腹泻，100%；不适，91%；腹痛，82%；腹胀，82%；腹部压痛，72%；血红蛋白低于12克，72%；白蛋白低于3克，64%；心率大于100次/分，55%；发热高于38.5摄氏度，45%；休克或低血压，45%。诱发因素包括抗生素，64%；免疫抑制剂或化疗，36%；止泻药，27%；还有1例患者为钡剂灌肠。5例患者（45%）有不止一个诱发因素。X线显示8例患者（72%）横结肠扩张和结肠袋消失，平均直径为9.9±3.4厘米。所有接受乙状结肠镜检查的患者均可见伪膜，所有患者艰难梭菌毒素检测均为阳性。1例患者接受了急诊手术。10例患者最初接受内科治疗，包括鼻胃管吸引和静脉复苏（90%）以及抗生素治疗（100%），通常在重症监护病房（80%）。4例患者治疗无效接受了手术；另外2例患者病情改善后又恶化，也接受了手术。总共11例患者中有7例（64%）接受了手术。3例患者（27%）内科治疗反应良好。1例患者病情过重无法手术，死亡。平均手术延迟时间为3.0±1.3天。剖腹手术未发现封闭或明显穿孔。所有接受手术的患者均行了结肠次全切除术，采用Hartmann残端吻合术（71%）或黏液瘘（29%）。最终，接受手术的7例患者中有5例以及内科治疗的4例患者中有2例死亡（总死亡率64%）。只有1例患者行了回肠造口关闭和吻合术。
并发伪膜性小肠结肠炎的中毒性巨结肠是一个严重问题，无论采用何种治疗方法，其发病率和死亡率都很高。
