Feb. 1, 1964, vol.


Canad. Med. Ass. 3.



E XTREME dilatation of the colon is now being recognized as one of the more severe complications of ulcerative colitis. Although Madison and Bargen1 drew attention to this condition in 1950, references to it have been found as early as 1933.2 It is only in the past decade, however, that studies of large numbers of patients have been undertaken to clarify the nature of the condition. For addition to the growing literature on this subject, we submit the following report of four cases seen by us in the last four years.

CAsE 1.-K.M., a 33-year-old white man, was admitted to hospital on March 31, 1959. He had had ulcerative colitis since 1955, two acute episodes requiring hospitalization for several weeks in 1955 and 1958. One month previous to the present admission he began having severe diarrhea, averaging 10 bloody bowel movements per day. The diarrhea gradually became worse. Fever and chills began one week before admission, with anorexia and vomiting. He fainted just prior to admission. On admission his temperature was 1040 F., his blood

pressure 90/76 mm. Hg; and his pulse rate 140/mm. He appeared moderately dehydrated, pale, weak and
confused. There was abdominal tenderness but no guarding, rebound tenderness or distension. The bowel sounds were normal. The hemoglobin was 10.8 g. %, the hematocrit was 32% and the erythrocyte sedimentation rate (ESR) was 78 mm. in one hour (Westergren). His white blood cell count was 13,600/c.mm. with 71% mature polymorphonuclear leukocytes and 10% band cells. The neutrophils showed toxic granulation. The serum sodium was 138 mEq./l., serum potassium 3.9 mEq./l. and chloride 93.3 mEq./l. Blood cultures were negative on two occasions. Stool cultures revealed E. coli and Pseudomonas aeruginosa. No acid-fast bacilli, ova or parasites were found. The patient was put on a regimen consisting of bland diet, codeine, appropriate intravenous electrolytes and vitamins, phenobarbital, intramuscular penicillin and streptomycin, with oral neomycin and azulfidine. When over the next few days his hemoglobin fell to 9.5 g. %, blood transfusions were given. Increasing abdominal distension was noted over the next few days, at which time oral feedings were discontinued and a gastric tube was passed. Scout films of the abdomen on April 8 showed the entire colon to be dilated, this dilatation being most marked in the transverse colon (11 cm. in diameter). The walls of the colon showed irregular scalloped margins, and a cobbling effect of the mucosa was noted. A small amount of gas was seen scattered throughout the small bowel. No evidence of free intraperitoneal air was found. Over the next week his temperature spiked daily from 1000 F. to 1040 F. His bowel sounds decreased in frequency and intensity. Increasing abdominal dis-

ABSTRACT Toxic dilatation of the colon is now a wellrecognized complication of ulcerative colitis. Our experience with four cases is preseuted. The clinical picture was characterized by severe ulcerative colitis with increasing abdominal distension, high swinging temperatures, obvious toxicity, and a moderate to high leukocytosis with a pronounced shift to younger forms. Accurate history and physical examination, plain radiographs of the abdomen, sigmoidoscopy and, most important of all, awareness of the condition facilitate diagnosis in most cases. The main indications. for surgical intervention are progressive abdominal distension and impending or actual perforation. Ileostomy and subtotal or total colectomy are the surgical procedures of choice. We feel that steroids play little part in the early management, but are of value in the early postoperative period. The three patients in our series treated surgically survived. One treated by medical means alone died of peritonitis.

7. %. and his pulse 80/min. CASE 3. the hemoglobin (after transfusion) was 10.5 mEq./l. Steroids were begun for the first time at the time of operation (100 mg. eosinophils and plasma cells. occasionally in the first postoperative week. The white blood cell count was 6700/c. He had had no bowel complaints till one month before admission when he began passing several stools each day. with 63% mature polymorphonuclear leukocytes and 17% band cells. Bloody diarrhea persisted despite therapy. hematocrit 36%.3 g./l. The inflammatory reaction extended to the submucosa. This dose was reduced by 25 mg. On admission.-A. Sigmoidoscopy revealed bleeding ulcerated lesions in the rectum. On October 27..A. with bland diet. the patient was placed on a regimen described above. chloride 92 mEq. and the total GO2. Gross examination of the resected intestine showed that the bowel varied in thickness from areas where it was almost translucent to the other extreme where the wall was thick. On admission his hemoglobin was 11. 90 was so distended and friable in places that merely touching it would cause a perforation to occur.mm./hr.Canad... muscular layers and subserosa. of hydrocortisone was given intramuscularly every 12 hours for the first two days. 1. 33 mEq. 1958.. %. The blood urea nitrogen (BUN) was 12 mg.7 g. potassium 3./hr. The mucosal surface showed large irregular areas of ulceration with intervening pseudopolyps.9 to 3./l. 1964. Vessels were engorged and often showed thromboplilebitic reaction. and because of the falling hemoglobin the patient was treated with blood transfusions. sometimes densely adherent. Ass. The ulcerating areas were granulating and for the most part covered by thick. Hg. Except for this. His abdomen was moderately distended.1 mEq. each day until it was discontinued 10 days postoperatively. fibrotic and edematous.mm. his blood pressure 100/60 mm. No ova or parasites were observed. with 32% mature polymorphonuclear leukocytes and 36% band cells. The patients temperature fell to normal immediately after the operation but spiked to 1010 F. and vitamins by parenteral feeding. the hematocnit 32% and the ESR 71 mm.S. There was no evidence of pentoneal irritation and the bowel sounds were normal. and chloride 92 mEq. antibiotics orally and parenterally. was admitted to hospital on October 8. Biopsy showed atrophic and ulcerated mucosa with microscopic abscesses and fibrosis. her recovery was uneventful./l. Feb.. supplemental fluid. with diffuse tenderness. He was unable to estimate the number of stools per day. vol./l. the serum sodium was 130 mEq. electrolytes. of hydrocortisone intravenously). On October 23. The albumin-globulin ratio was 2. The serum sodium was 131 mEq. The white blood cell count was 9200 per c. and ESR 88 mm. analgesics and sedatives. J. most marked in the right lower quadrant. On admission.. %. green necrotic debris.. Blood and stool cultures showed no pathogens. Med. a 63-yearold Indian from a Northern Canadian tribe. his temperature was 99*50 F. potassium 3. nor had he observed whether they contained blood. (previously reported) . He appeared moderately dehydrated but was fairly well orientated. Scout films of the abdomen on October 8 showed gas scattered throughout the small bowel and ascend- ./l. Postoperatively 100 mg. Microscopic examination revealed inflammatory infiltration of neutrophils.

1964. and 1020 F. This was increased to 200 mg.K. Three areas of perforation were evident in the central part of the transverse colon. On October 15. Because of the clinical and radiological evidence of increasing distension of the colon./.mm.. Med.0 mEq. INCIDENCE Acute dilatation of the colon occurs during an attack of fulminant ulcerative colitis.-Mrs. 1961. measuring up to 1. The whole colon had a markedly congested serosa. Hg. 1. 3. 90 SILVERBEIIG AIM) ROGERS: ULCERATIVE CoLrrls 359 ing and transverse colon. in diameter). in diameter. The hemoglobin on admission was 12. At operation. Several ulcerations were also noted in the stomach. The hemoglobin fell to 9. CAsE 4. the mucosa showed a cobblestone appearance. with no evidence of intraperitoneal air. F. The actual incidence of the condition is not clearly known.. the abdomen was opened and an abundance of fecal-stained purulent material was noted throughout the peritoneal cavity./l. with rebound tenderness. Over the next three weeks her diarrhea became steadily worse. one had had the condition for 23 years. There was no evidence of free perforation.. . and two for about one month. His clinical condition and abdominal distension remained unchanged until November 19 when he developed coffee-ground emesis and severe abdominal pain. The mucosa showed edematous and hemorrhagic pseudopolyps with intervening areas showing deep ulceration with granulation tissue. her temperature was 1000 F. The whole colon mucosa had a markedly mottled (cobblestone) appearance and scalloped margins. An inflammatory reaction spread through the whole wall was characterized by plasma cells and lymphocytes. then discontinued. At autopsy. the sodium to 131 mEq. Multiple dilated small-bowel lo9ps were noted but there was no evidence of free intraperitoneal air. The serum potassium fell to 3. A bland low-residue diet was given until signs of increasing distension were noted. The ESR was 21 mm. There was complete absence of haustral markings.. and her pulse rate 120/min.1 g. % and the ESR rose to 104 mm. She had generalized abdominal tenderness but no guarding or rebound tenderness. and the colonic wall revealed the characteristic scalloped margins. showed evidence of increasing distension. with 5% mature polymorphonuclear leukocytes and 72% band cells. or who had a temperature greater than 1020 F. her blood pressure 110/50 mm. Surgical intervention was not deemed advisable because of the difficulties that would be encountered by the patient in caring for an ileal stoma in a home without plumbing facilities.. Microscopic examination showed extreme congestion of blood vessels in the bowel wall./l. The serum sodium was 139 mEq. 3. 29 mEq. Gross and microscopic findings were similar to those decribed in the previous cases. in diameter). The temperature which had been 1020 F. and 1030 F. Ass. when it was discontinued and gastric suction was initiated. %. immediately after operation and on heavy antibiotic coverage returned to normal over two weeks. omentum being plastered down to it in a spotty fashion. Stool cultures were negative. per hour. 1961. There was poor evacuation of the barium. Most commonly it occurs during an acute exacerbation in patients with the chronic intermittent type of ulcerative colitis. the transverse colon now having a diameter of 10 cm. Hg. vol.mm./l. Polymorphonuclear leukocytes were present in areas of acute inflammation.. The neutrophils showed toxic granulation. prompting her admission to hospital. His blood pressure was 60/45 mm. and no ova or parasites were observed. and temperature 960 F. preoperatively fell to 990 F. was admitted to hospital on March 14. barium enema examination showed a slightly dilated colon (7 cm. At the time of operation the patient was placed on antibiotics and cortisone (100 mg./l. On admission she was placed on a regimen similar to that described in Case 1. Subtotal colectomy and ileostomy were performed. pulse 90/mm. Her abdomen became tympanitic and her bowel sounds decreased in frequency and intensity. but instead fluctuated between 98 F. in diameter). She had no previous history of ulcerative colitis. and GO2. intravenously). but Mclnerney et al.2 mEq. Feb. Throughout the illness the temperature rarely rose over 1000 F. Barium enema examination on March 19 showed a moderate degree of dilatation of the colon. except that an antispasmodic (Belladenal) was administered for five days. 1961. The wall itself was thickened up to 1 cm. The leukocyte count rose to 16. She appeared slightly dehydrated but well orientated. The subserosal layer was thickened.3 g.5 cm. most marked in the transverse colon (9 cm. but it can also occur during the first attack of the disease or in the chronic continuous type. She appeared slightly distended but her bowel sounds were normal. The ulcerations extended from the anus to the cecum. His condition deteriorated rapidly and he died within 12 hours. Scout films on March 20 and 21./l. but tenderness remained diffuse with no rebound. There was extreme abdominal tenderness and guarding. and the GO2 to 27 mEq. the chloride to 98 mEq. and 10O. an operation was performed on March 22. with 13% mature leukocytes and 53% band cells. Three weeks before admission she was delivered of her first baby./day for the first two postoperative days and then was gradually reduced and finally discontinued 10 days after the operation.100 per c. Five days after delivery she began to have diarrhea with 5-10 bowel movements per day each containing mucus and bright red blood. potassium.000/c. with young connective tissue infiltrated with inflammatory cells. a 26-year-old white woman. Bowel sounds were absent.Canad. The leukocyte count was 15. the entire colon was markedly distended and quite inflamed. chloride 99 mEq./l. Of the four cases presented herein. per hour (Westergren). During this period she became progressively more distended. She complained of severe abdominal pain. Over the next week her temperature began spiking between 990 F. On examination.. The hematocrit was 30%. The transverse colon was slightly distended (7 cm.5% of 1230 patients hospitalized with ulcerative colitis and in 8% of 379 patients who were ill enough to require blood transfusion. No free intraperitoneal air was seen... Scout films of the abdomen showed the transverse colon dilated to 9 cm. another for four years.4 found it in 2. and later between 1000 F. A./l.

4'6 That this may play a secondary role in aggravating the damaged bowel seems possible. This is an unfortunate term. the position of the transverse colon. and putrefaction of colonic contents have been considered as etiologic agents. They produced no change in the clinical picture. or at least as aggravating factors in this condition. Diffusion of Gas Excessive diffusion of gas from the blood vessels into the colon through the raw mucosal surfaces may be responsible for some of the dilatation. out distension may show similar muscle destruction. Damage to the Myenteric Plexus Because of the severe damage to the myenteric plexus in several cases. most workers now deny its significance in the pathogenesis of acute bowel dilatation in patients with ulcerative colitis. producing enough hypoxia to destroy whatever intestinal tone is left.5' . Certainly there is no striking response to the administration of potassium. Most authorities are agreed4'6"0 that such steroids have no effect on the production of this condition. but this has not been proved. gas should tend to collect there on a mechanical basis alone. That the condition can occur without their use has been shown by Smith and by others. J. since such damage is not found in all cases. Others6 have noted that the colon distal to the dilated bowel showed a "relative stenosis" which they consider may be an etiological factor. None of our four patients had steroids before or during the period of acute dilatation. Antibiotic Therapy No constant relationship has been found between the use of antibiotics and the production of this condition.5 In our cases serum potassium values never fell below 3 mEq. some7 have called this condition "toxic aganglionic megacolon". Aerophagia Though aerophagia may occur. antibiotics. The Position of the Transverse Colon Since the transverse colon is the most mobile portion of the colon and. 1964. . Narcotics Smith et al. three had barium enema examinations prior to severe colonic dilatation.'0 have also suggested that opiates may precipitate the condition by inhibiting the propulsive movements of the colon (although they may increase its nonpropulsive activity). control surgical specimens of ulcerative colitis with-./l. The entrance of barium into the colon under the usual pressure of 90 cm. We noted no dramatic deterioration while our patients were receiving codeine or meperidine (Demerol).4-7 In such a damaged bowel. Some8 have noted that the area distal to the dilatation has the greatest plexus damage. aerophagia. Of our four cases. Antispasmodics were administered to only one of our patients (Case 4) and then only for five days. Gas in the stomach and small bowel is certainly a frequent accompaniment of colonic dilatation and it seems probable that it may contribute to the distension.5 Anticholinergics Smith et al. Med. The pathology would suggest that the diffuse inflammation of the muscle and nerve elements of the colon is the most important factor in the pathogenesis of this condition.6 Also. The third remained unchanged but his colon perforated and he died four weeks later. and it may be found in areas of bowel that are not distended. Such factors as hypokalemia. worsening of the clinical picture and increasing dilatation prompted operation within four days. many secondary factors which would ordinarily have little effect on the bowel may aggravate an already bad situation. of water may reduce the already compensated circulation. is uppermost. In two of these thee. its exact role is uncertain. 1. and have suggested a mechanism similar to that in Hirschsprung's disease to explain the condition. barium enema. anticholinergics. Barium Enema The possibility of a relationship between the administration of a barium enema and the onset of acute dilatation has been suggested by some workers4' 10 who noted worsening of the clinical state in some patients following tLiis procedure. This has been shown during operative manipulation. vol. narcotics. in the supine position.360 SILVERBERG AND ROGERS: ULcEIwrIvE Couns Canad.10 have suggested that the administration of anticholinergic drugs may precipitate acute dilatation of the colon by inhibiting the peristaltic waves that remain. ABS. excessive gaseous diffusion though the mucosa into the bowel. Corticosteroicis This condition is known to have been present before corticosteroids were developed. Severe Muscle Destruction Although this undoubtedly contributes to the dilatation of the colon. 90 ETIOLOGY The essential cause of dilatation of the colon is unknown. Hypokalemia Though some9 once considered hypokalemia to be an important factor. The mechanical disturbance produced by the procedure may liberate more bacteria into the circulation. steroids. similar or more severe muscle changes have been found in neighbouring parts of the colon which are not dilated. Feb.

These pseudopolyps and ulcers are also responsible for the irregnlar scalloped margins. around 16. In most cases. 1. These findings are most marked in the transverse colon. and occasionally dilatation may involve the whole colon. In the vast majority of cases.. periarteritis nodosa).g. Varying degrees of dehydration will occur./hour (Westergren). Hypoalbuminemia often occurs and globulin values may be normal or elevated.4 PATHOLOGICAL FINDINGS A wide variety of other conditions have been mentioned in the literature as being important in the differential diagnosis. be quite variable. Recent reports4' 10 suggest the possibility that a barium enema may change an acute fulminating colitis into an acute dilatation. Free air may be seen in the erect or lateral decubitus position if perforation has occurred. but the pain may be steady. Depending upon the degree of toxemia." repeated abdominal scout films will bring the diagnosis to light and eliminate the need for a barium enema. 90 SILvElu3ERG . Other parts of the colon are less commonly dilated. high swinging temperatures. Although others question its contribution to the condition. Parts of the colon are dilated and extensive areas of thinning are found. The condition may develop within a day to weeks after the onset of the acute fulminating colitis. Hirschsprung's disease. Very often there is a marked shift to immature forms of neutrophils. Med. J. or may hasten the onset of perforation of the colon. including guarding and rebound tenderness. 1964. although occasionally low values have been found. In many cases. parts of the colon which are least affected may be the most dilated. The erytbrocyte sedimentation rate is always increased. obstructing lesions (cancer of the colon or severe acute diverticulitis). averaging about 75 mm. In contrast to the findings in cases of mechanical obstruction. The prothrombin time may be increased. It should be noted that there is a poor correlation between the site of maximal dilatation of the colon and the site of the severest colitis as determined by barium enema. Fecal discharges may be grossly bloody. amebic and bacillary dysentery. apathy or coma. ROENTGENOLOGICAL FI. Gas is often present in the small bowel and stomach and there may be signs of small-bowel obstruction.Canad. however. may be found. Bowel sounds are usually weak and may be absent. owing either to edema of its wall or to the presence of peritoneal fluid between the loops of bowel. it confirms the findings noted on the abdominal scout film and also shows the inability of the colon to contract normally because of the loss of its tone.mm. The bowel wall often appears thick.4 Crampy abdominal pain is often present. no marked redundancy and overlapping of the large bowel shadows are seen.D Ro. This is due to the presence of pseudopolyps which stand out in contrast to the deep mucosal ulcers. Haustral sacculations may be entirely absent. although in some patients the distension may be less marked despite huge enlargement of the colon.rUREs Putrefaction of Colonic Contents Putrefaction produces gas which may contribute to the dilatation. obstruction of the mesenteric arteries or veins. vol. The degree of abdominal distension is variable.s: ULcERATIVE Cou¶rls 361 cholera. The clinical picture is marked by gradually increasing abdominal distension.). The colonic mucosa on scout film has a mottled or cobblestone appearance. and acute dilatation of the stomach. The severe diarrhea which was present before the dilatation occurred may continue unchanged. The abdomen is usually diffusely tender. CLINICAL Pic'ruiu. the mental state of the patient may vary from confusion to agitation. The serum electrolytes may remain normal but hyponatremia and hypochloremia often occur. DIFFERENTIAL DIAGNOSIS The most common and most impressive finding is marked colonic dilatation.'2 The mucosa shows vascular congestion with many hemorrhagic . The hemoglobin tends to fall as the condition progresses. sigmoidoscopy and abdominal scout films should allow the diagnoses to be made. and bromsulphalein (BSP) retention of significant degree may occur. collagen diseases (e. As Roth et at. LABORATORY INvESTIGATIONS The white blood cell count has been reported as being very high in some cases6 but usually is only moderately elevated. The temperature is characteristically spiking in type and may reach extremely high levels. Ass. In most the abdomen is protuberant. The average dilatation is 9-10 cm. obvious toxicity and a moderate to marked leukocytosis with a pronounced shift to younger forms. the high incidence of spontaneous perforations would seem to indicate that barium enema is a rather formidable procedure in such cases. Anorexia.000 cells/c. Feb. worsen or become less severe with the onset of dilatation.'1 The transverse colon is involved in almost 100% of cases and may be as much as 20 cm. surgery or necropsy. Tachycardia and hypotension are common. in diameter6 (normal: 5-6 cm. observed:6 if one is conscious of the condition the diagnosis is usually not difficult. nausea and vomiting often occur.. and toxic granulation may be seen. The serum potassium is usually normal. and signs of peritoneal irritation. These include infectious diseases (typhoid. Stool cultures are usually normal and blood cultures occasionally grow enteric organisms. detailed history. and miliary tuberculosis). If a barium enema is performed. The clinical course can.

4' 6. These patients are critically ill and should be followed closely by both an internist and a surgeon. Many workers are not impressed with their effectiveness in decreasing the distension and in inducing a remission. thrombophlebitis with pulmonary embolism. is not present in all cases of dilated colon. As soon as the condition is recognized. Smith et al.6 Varying degrees of interstitial edema are seen. Anticholinergics to control diarrhea are probably not useful and. Leukocytic inifitration of the serosa and subserosal connective tissue may occur. and evidence of perforation are generally accepted as indications for operative intervention. They include bowel hemorrhage. we agree with Ferguson that these patients may be too sick not to be operated upon. we have restricted the use of steroids to the time of operation and the early postoperative period. Tins Rou. When the clinical state worsens. Fluids. however. Others'0 have also pointed out tl. nor is it always found in the most severely dilated parts of the Opiates are used in a cautious manner to control diarrhea. Feb. sepsis and surgery.4-6. and liver disease. and others. 'Culture and sensitivity studies of stool and blood will aid in the choice of chemotherapeutic agents. A stomach tube and possibly a long intestinal tube should be passed. and in some areas the muscle fibres are degenerated or necrosed.362 SILVERBERG AND RoGElls: ULCERATIVE COLITIS Canad. however. vol. OF SURGERY At one time controversy existed over the type of operation to perform in these critically ill patients. Appropriate antibiotics should be administered parenterally. 10. The one patient in our study whose colon perforated died from this cause. as evidenced by increasing distension. Some consider this to be specffic for this condition. Advocates of . Deep colonic ulcerations or evidence of perforation are considered contraindications to the use of steroids because of the possibility that they may increase the friability of the bowel and thus the chance of future perforations.4' 10. he should undergo operation. that patients on steroids do The major complication of acute dilatation of the colon is bowel perforation with peritonitis. as long as there is no clinical deterioration. Free perforation of the colon may be found. This. 1. potassium and chlorides) and vitamins should be given intravenously. 8. Ass. Microscopic examination may reveal that the inner and outer muscle layers are involved by the inflammatory process. Some feel'4' '.'0 and still others up to two weeks. as has been previously mentioned. Some'3 have noted intense inflammatory necrosis of the blood vessel walls.25%. In the case of the patient whose dilatation is non-progressive there is disagreement as to how long to delay before operating.5'6'8 Some studies have shown. The other complications associated with this condition are not specific and can be found in patients with ulcerative colitis without dilatation. some advocating ileostomy. 14 colon. The myenteric plexuses are often infiltrated with inflammatory cells and may be edematous and distorted. Others have set the time limit of observation as five days.'0 consider that the primary role of these drugs is not to induce a remission but to correct the relative or absolute adrenal insufficiency produced by the severe stress of tissue trauma.iis remarkable tolerance to surgery in patients who were placed on steroids at or near the time of operation. In many places omentum may be plastered to the bowel wall. these patients can be managed conservatively.8 In our opinion. colectomy or subtotal colectomy with ileostomy. to 30%8 but has averaged in the neighbourhood of 2O. COMPLICATIONS Where the patient has been on long-term steroids prior to the onset of dilatation. that as soon as the metabolic requirements of the patient have been met. at this time emergency surgery is mandatory. these should be continued to prevent adrenal cortical failure.8 PROGNOSIS not perforate any more readily than those in whom steroids have been withheld.'0 TREATMENT The principle of the medical therapy in this condition is to attempt to control the overwhelming infection while doing as little as possible local damage to the bowel by therapeutic and diagnostic procedures.4' 8 It has also been found in severe ulcerative colitis in which no dilatation occurred. Sedation should be used to control anxiety. progressive abdominal distension. however. all oral intake should cease. Med. however. INDICATIONS FOR OPERATION The overall mortality of medical and surgical treatment has varied from O%'. Areas of severe ulceration and pseudopolyposis are found. Anemia should be treated by whole blood transfusions. Our experience has been that their use has reduced the morbidity that these severely ill patients experience after extensive surgical procedures.4'6'8' 12 This finding. may precipitate the condition. 14-17 In our own cases. 1964. 3. hemorrhage.4 Capillary dilatation with hemorrhages may be seen.'0 Severe unremitting bowel hemorrhage. 90 areas. Their possible role in worsening the dilatation should be balanced against the amount of pain the patient is having. is an infrequent finding. or evidence of perforation. Emotional support to these seriously sick patients should be given by the attending physician. electrolytes (including sodium. associated with vascular occlusion. Corticosteroids are of limited value in the treatment of the condition.

G. 43: 182. J. 2: 96. 1962. and a hard. et al: Ibid.. 1962. J. on account of their deep-seated and tough-walled character. L. Med. 15. AND DAVIS. electrolyte imbalance and anemia.: Gaetroenterology. as the most appropriate treatment of acute dilatation.-H. Ass. 37: 239. J. AND BARGEN. nor does scratching injure the lesions much. 1964. 1955. Burg. F. Bocxus. McCoNNxLL. 1958.: Burgery. shrinks into the skin. KIRsNER.. T. 17. forestall perforation and perhaps permit more secure walling-off of a perforation which is only poorly sealed. L. Butterworth & Co. begins with the eruption and continues for a few days thereafter. AND RAMSAY. 1. Case records of the Massachusetts General Hospital. CATTELL R B AND CoLcocK..: Proc. M.. 26: 21. KLEIN. mild prod. not alone by scratching. 1958. if there be any at all. follows closely on the appearance of the eruption.: 21. 40: 138.: Ann. J. 29: 375. 8. however. A large group of workers. L. Case 19023: New Bag. W. 5.s: ULcERATivE COLITIS 363 ileostomy19 pointed to the high incidence of perforation of the friable bowel during extensive surgery in patients with this condition.4-0'8' 10. particularly of the palms and soles. PAGES OUT OF THE PAST: FROM ThE JOURNAL OF FIFTY YEARS AGO CLINICAL CHARACTERISTICS OF SMALLPOX In smallpox the worst systemic disturbance and suffering are often found during the prodromes.: Gastroeatero fogy.7. The incidence. 17: 114. In chicken-pox the practical absence of prodromes means that the first appreciable systemic disturbance. Early diagnosis and active supportive therapy.. TRUELOVE. Mayo Olin. if not begun before toxic megacolon becomes apparent. Ga8troenterology. pathology. 1962. G. 12. S. F. LENNARD-JONES. AND Wii'rs. signs of clinical improvement may occur even at time of perforation. 14. V. They admit that in severely ill patients perforation of the colon can occur without physical signs and. including the treatment of infection.. are important. they feel that resection of the colon is necessary in order to control the pentoneal infection. et al. 1960.. opaque. E. . 4: 125. 42: 244.. Burg. 2.. AND STEVENs. 42: 233. brown. S. 30: 950. AND DOWNEY.: Brit. J. et aL: Ibid. Severe prodromes may be followed by either mild or severe eruption. REFERENCES 1.: Quart. however. A. 1959.: Brit. H. 1960. Klein et al. 2nd series. 2: 1041.7. B. 155: Dr. SUMMARY Four additional cases of patients with ulcerative colitis who developed toxic megacolon have been reported. C. . 18. L. LuMs. Med. 0. Rogers: 394 Graham Ave. RooERs.. Path. 1951. J. etiology. 20. Jones. AND ROBINSON. The major controversy in the recent literature concerns the choice of cecostomy. there would seem to be an advantage in removing an area of bowel so grossly infected.. J.: Ibid.: Ga. M.. 13. In mild and abortive smallpox and in varioloid similar caps are at times found on the body. B. B. L. P. 19. GOLDORABER. In chicken-pox itching is highly characteristic. vol. S. Arnold G. A.. ante mortem and post mortem records as used in weekly clinical-pathologic exercises. and the bowel may be perforated at the time of surgery. C. L. should be withheld until the time of operation. dehydration. In smallpox itching during the early stages of the eruption is not usually a marked symptom. WILLIAMs. . A. In chicken-pox the vesicle. FERGUSON. Surgery is indicated when there is appreciable clinical or radiologic evidence of deterioration. PssxIN. 3. clinical features. J. 7. 1960. B. K.. Winnipeg 1.. The toxemia and septicemia produced by the products absorbed from the damaged colon prolong the period of convalescence. H. if only temporary. 110: 269. no matter how minimal the procedure. shrinks by evaporation to a brittle. if the patient is on steroids. 1948. Although subtotal or total colectomy in this condition is difficult. they suggested. the pustule. S. 33: 434. Hill: Caned. 9. 11: 640. 1957.: Radiiology. 208: 94. 17 Diverting the stream for the ileum into the large bowel does nothing to relieve the distension and the threat of perforation that already exists in the large bowel.20 and others4'5'21 advocate cecostomy as a safe and simple means of deflating and draining the distended colon in order to decrease toxic absorption. if not wiped off or collapsed early. the operative risk notwithstanding. Ileostomy. COPIT. AND ROBBINS. or subtotal (or total) colectomy with ileostomy. both ileostomy and cecostomy are fraught with the danger of rupture of the bowel due to manipulation. edited by F.. I.: Po8tgrad. Ass. 90 SILVERBERG AND RoG. Man. H. The extent of the eruption on the face is a fair index of the general severity of the attack.m. G. Med. very tenacious scab is often formed. et al.. J. very easily broken off or dislodged. 47: 339. et al. WARREN. W. B.: Ia: Modern trends in gastroenterology.. and improvement.7. 14. L. H.: Amer. W. 1961.. Med. 4. W. AND VIVIAN. G. but still somewhat elevated cap. in shrinking. London..955. 1955. AND TUMEN. 11. E. .* Feb. on the other. Med. 38: 165. W.Canad. This feature is in itself of very strong diagnostic imporL In smallpox the thick walls of the pustule permit comparatively little evaporation. This is especially true of the lesions of the extremities. on the one hand. BEBCHUK W. 1914. Ltd. p.. 1949.stroeaterology. H. SMITH. 71: 674. 25: 10. R. 6. HANELIN. 1956.. 1960. P. and since the relatively superficial and thin-walled lesions are very fragile they are easily destroyed. diverted the fecal stream without causing any trauma to the large bowel. et aL: Ibid. prognosis and treatment of this condition are reviewed. R. 16. Another criticism of this method of treatment is that. S. Gyaec. . A. J. Med.: Ibid. AND SOMMERS. B. A. Obatet. AND PALMER. MADIsON. For these reasons many surgeons prefer subtotal or total colectomy with ileostomy in the treatment of acute dilatation of the colon. L. are opposed to the use of ileostomy. G. et al. MCINERNEY. MARsHAK. J. RoTH. 1933.. L. usually by mild eruption. laboratory findings. We feel that steroid therapy. 233. M. J. PROTHEROS.: Burg. 1960. S. L. CoHN. A. W. G. 657. 296. C. and then tapered off postoperatively over the next 10 to 14 days. but by every form of contact. RANKIN. When obvious perforation occurs.

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