Overview
Definition:
Subtotal colectomy is a surgical procedure involving the removal of most of the colon, leaving the rectum in place, often as an emergency or semi-elective procedure for severe, life-threatening colitis
Fulminant colitis is a severe, rapid progression of colonic inflammation that can lead to toxic megacolon, perforation, or sepsis.
Epidemiology:
Fulminant colitis is a rare but serious complication of inflammatory bowel disease (IBD), primarily ulcerative colitis (UC) and less commonly Crohn's disease
It occurs in approximately 5-10% of patients with severe UC
Incidence is higher in younger adults.
Clinical Significance:
Fulminant colitis represents a surgical emergency with high morbidity and mortality if not managed promptly
Subtotal colectomy is a life-saving procedure that debulks the inflamed bowel, reduces systemic toxicity, and facilitates patient stabilization, often paving the way for eventual proctectomy or restorative proctocolectomy.
Clinical Presentation
Symptoms:
Severe abdominal pain
Profuse, bloody diarrhea, often exceeding 10-15 stools per day
Fever and chills
Nausea and vomiting
Abdominal distension and tenderness
Tachycardia and hypotension in advanced cases.
Signs:
Generalized abdominal tenderness, often with peritoneal signs in cases of impending perforation
Marked abdominal distension
Rectal examination may reveal blood or purulent discharge
Signs of systemic inflammatory response syndrome (SIRS) or sepsis.
Diagnostic Criteria:
Clinical diagnosis of fulminant colitis is based on severe symptoms and signs of systemic toxicity
Radiographic evidence of colonic dilation (toxic megacolon) is a key criterion, typically defined by a colonic diameter > 6 cm on plain radiography or CT, with evidence of inflammation.
Diagnostic Approach
History Taking:
Detailed history of IBD duration and severity
Previous medical and surgical treatments for colitis
Recent exacerbation of symptoms
Fever, abdominal pain, and stool characteristics are crucial
Rule out infectious causes of colitis.
Physical Examination:
Assess vital signs for stability (BP, HR, RR, Temp)
Perform a thorough abdominal examination, noting distension, tenderness, guarding, and rebound tenderness
Assess for signs of dehydration and shock
Rectal examination is essential.
Investigations:
Complete blood count (CBC) revealing leukocytosis and anemia
Electrolytes and renal function tests to assess hydration and organ function
Liver function tests
Inflammatory markers (ESR, CRP)
Blood cultures if sepsis is suspected
Plain abdominal X-rays to assess colonic dilation and rule out perforation (free air)
CT abdomen/pelvis for better assessment of colonic wall thickening, mural necrosis, free air, and abscess formation
Stool studies to rule out C
difficile infection or other pathogens.
Differential Diagnosis:
Ischemic colitis
Infectious colitis (e.g., C
difficile, Shigella, Salmonella)
Diverticulitis with perforation
Appendicitis with perforation
Perforated peptic ulcer disease
Mesenteric ischemia.
Management
Initial Management:
Aggressive resuscitation with intravenous fluids
Broad-spectrum antibiotics to cover gram-negative and anaerobic organisms
Bowel rest and nasogastric tube decompression
Correction of electrolyte imbalances
Transfusion of blood products if anemic or bleeding
Steroids and immunosuppressants if IBD is the underlying cause, but decision for surgery often supersedes medical management in fulminant cases.
Medical Management:
While surgery is definitive, initial medical management focuses on stabilization
IV corticosteroids (e.g., methylprednisolone 60-100 mg/day) are often initiated, but their efficacy in established fulminant disease is debated
Close monitoring for signs of deterioration is paramount.
Surgical Management:
Subtotal colectomy is indicated in patients with fulminant colitis who fail to improve with maximal medical therapy within 24-72 hours, or those with evidence of perforation, significant bleeding, or toxic megacolon with signs of systemic toxicity
The procedure involves excising the entire colon proximal to the rectum, creating a mucous fistula in the left lower quadrant and an ileal pouch or performing an ileostomy
Immediate proctectomy and ileal pouch-anal anastomosis (IPAA) may be considered in select, stable patients, but often a staged approach is preferred.
Supportive Care:
Intensive monitoring in an ICU setting
Frequent fluid and electrolyte balance assessment
Nutritional support, often with parenteral nutrition
Pain management
Close observation for signs of intra-abdominal sepsis or anastomotic leak if a primary anastomosis is performed.
Complications
Early Complications:
Sepsis and septic shock
Intra-abdominal abscess
Anastomotic leak (if primary anastomosis performed)
Bleeding
Ileus
Retained rectal stump inflammation
Incisional hernia.
Late Complications:
Stomal complications (stenosis, retraction, prolapse)
Small bowel obstruction
Malnutrition
Infertility (especially in women undergoing pelvic dissection)
Pelvic abscess
Adhesions
Rectal stumpitis or proctitis
Development of pouchitis if IPAA is performed.
Prevention Strategies:
Judicious patient selection for surgery
Meticulous surgical technique
Adequate antibiotic coverage
Careful fluid and electrolyte management
Early recognition and management of complications
Staged approach for reconstruction when indicated.
Prognosis
Factors Affecting Prognosis:
Presence of toxic megacolon
Degree of colonic necrosis
Sepsis
Comorbidities
Time to surgical intervention
Skill of the surgical team
Underlying cause of colitis (UC vs
Crohn's).
Outcomes:
Mortality rates for fulminant colitis requiring emergent colectomy can range from 5-15%
With prompt surgical intervention and intensive supportive care, many patients recover and can undergo subsequent reconstructive surgery
Long-term outcomes depend on the underlying disease and whether a restorative procedure is achieved.
Follow Up:
Regular follow-up with a gastroenterologist and surgeon is essential
This includes monitoring for recurrence of IBD, managing stomas, assessing for complications of restorative procedures (e.g., pouchitis), and monitoring nutritional status
Long-term surveillance for colorectal cancer is recommended, especially in patients with a history of IBD.
Key Points
Exam Focus:
Subtotal colectomy is for fulminant colitis/toxic megacolon unresponsive to medical therapy or with signs of peritonitis/sepsis
The procedure involves colon removal, leaving the rectum
Staged approach (mucous fistula/ileostomy first) is common
High risk of sepsis and anastomotic leak.
Clinical Pearls:
Suspect fulminant colitis in any patient with severe IBD exacerbation and systemic toxicity
Aggressive resuscitation and broad-spectrum antibiotics are crucial pre-operatively
Do not hesitate to operate if medical management fails
delay increases mortality
Consider CT abdomen for better assessment of colonic wall, perforation, and abscesses.
Common Mistakes:
Delaying surgery in the face of deteriorating patient condition
Underestimating the systemic effects of fulminant colitis
Performing primary anastomosis in severely ill patients
Inadequate antibiotic coverage
Failure to rule out infectious causes like C
difficile.