Toxic Megacolon with Perforation: A Complication of Salmonella Colitis in the U.S.

Abstract

FigureFigurePurpose: Intestinal perforation as a life-threatening complication of toxic megacolon following non-typhoid Salmonella infection has not been reported in the United States according to current literature reviews. The disease is rapidly progressive, and death may ensue due to septicemia and/or perforation. Methods: A 48-year-old gentleman presented to the ER with bloody, watery stools every hour associated with a crampy abdominal pain that progressively worsened with eating. A week prior, the patient presented to an outlying facility where he was prescribed Dicyclomine and Imodium which did not improve his condition. On this presentation, CT scan revealed multiple air-fluid levels and follow up colonoscopy showed necrotic areas throughout the colon with thick white discharge and ulcers. The patient was started on steroids and Flagyl. The stool was negative for Clostridium Difficile and later grew Salmonella group D isolate found to be susceptible to Ciprofloxacin which was then started. The patient's abdominal distention, pain and discomfort began to resolve. He was started on a clear liquid diet and then discharged on treatment. Results: Two days later, the patient again presented to the ER with worsening abdominal pain. Plain films showed severe colonic distention with free air under the diaphragm which suggested toxic megacolon with perforation. The patient then underwent a total colectomy with ileostomy. Conclusion: Dicyclomine and Loperamide should not be used in cases of dysentery as it may predispose to toxic megacolon. Identification of patients with toxic megacolon associated with non-typhi Salmonella infections is important as they are at risk for further intestinal perforation. Early effective fluid resuscitation, antibiotics, steroids and rectal tube insertion may be helpful to prevent the occurrence of intestinal perforation.[figure1][figure2]