Published: 2022-01-28

Incidence, prevalence, pathogenesis, and manifestations of toxic megacolon

Hisham Abdullah Almottowa, Ahmed Eisa Alobaidi, Mohammed Hadi Assiri, Abdullah Abdulmohsen Almulhim, Elaf Mohammed Hameed Aljafri, Talal Mohammed Alharbi, Faisal Fahad Alrowaidan, Haya Abdulaziz Alkhamis, Mariam Hadi Alshammari, Yusra Fadhel Hasan, Khulud Yousef Qutub, Fayez Ali Alzahrani


Toxic megacolon is an inflammatory condition that affects the colon, leading to nonobstructive dilatation and serious morbidity. It can be found as total and segmental. In the present literature review, we have discussed the epidemiology, pathogenesis, and manifestations of toxic megacolon based on relevant data from studies in the literature. Unfortunately, reports regarding the prevalence and incidence of toxic megacolon are scarce. Therefore, it is difficult to draw a suitable conclusion in this context, and further studies are encouraged. Nevertheless, infection with Clostridium difficile might be the commonest etiology, and estimates indicate that this is a significant risk factor for developing the condition. In addition, colonic motility is usually inhibited by the significant presence of certain inflammatory mediators. Furthermore, the clinical manifestations of toxic megacolon are not very specific, and the diagnosis can be made through adequate history taking, together with clinical and radiological manifestations. Finally, prompt management of the condition is essential to intervene against the development of serious complications.


Toxic megacolon, Colon dilatation, Epidemiology, Prevalence, Incidence, Pathogenesis, Clinical manifestations, Diagnosis

Full Text:



Jalan KN, Sircus W, Card WI. An experience of ulcerative colitis. I. Toxic dilation in 55 cases. Gastroenterology. 1969;57(1):68-82.

Autenrieth DM, Baumgart DC. Toxic megacolon. Inflammatory Bowel Dis. 2012;18(3):584-91.

Ausch C, Madoff RD, Gnant M. Aetiology and surgical management of toxic megacolon. Colorectal Dis. 2006;8(3):195-201.

Andreyev HJ, Davidson SE, Gillespie C, Allum WH, Swarbrick E. Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer. Gut. 2012;61(2):179-92.

Pascu M, Müller AR, Wiedenmann B, Dignass AU. Rescue therapy with tacrolimus in a patient with toxic megacolon. Int J Colorectal Dis. 2003;18(3):271-5.

Norland CC, Kirsner JB. Toxic dilatation of colon (toxic megacolon): etiology, treatment and prognosis in 42 patients. Medicine (Baltimore). 1969;48(3):229-50.

Grieco MB, Bordan DL, Geiss AC, Beil AR, Jr. Toxic megacolon complicating Crohn's colitis. Ann Surg. 1980;191(1):75-80.

Kelly CP, LaMont JT. Clostridium difficile--more difficult than ever. The New England journal of medicine. 2008;359(18):1932-40.

Bagdasarian N, Rao K, Malani PN. Diagnosis and treatment of Clostridium difficile in adults: a systematic review. JAMA. 2015;313(4):398-408.

McDonald LC, Gerding DN, Johnson S. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infect Dis. 2018;66(7):e1-48.

Berman L, Carling T, Fitzgerald TN. Defining surgical therapy for pseudomembranous colitis with toxic megacolon. J Clin Gastroenterol. 2008;42(5):476-80.

Trudel JL, Deschênes M, Mayrand S, Barkun AN. Toxic megacolon complicating pseudomembranous enterocolitis. Diseases Colon Rectum. 1995;38(10):1033-8.

Hokama A, Ohira T, Kishimoto K, Kinjo F, Fujita J. Impending megacolon: small bowel distension as a predictor of toxic megacolon in ulcerative colitis. Internal Emergency Med. 2012;7(5):487-8.

Mansouri F. Toxic Megacolon with Colonic Ischemia Masquerading as Diabetic Ketoacidosis: A Case Report. Saudi J Med Pharmaceutical Sci. 2020;06:58-63.

Reddy SN, Bazzocchi G, Chan S. Colonic motility and transit in health and ulcerative colitis. Gastroenterology. 1991;101(5):1289-97.

Snape WJ Jr, Kao HW. Role of inflammatory mediators in colonic smooth muscle function in ulcerative colitis. Dig Dis Sci. 1988;33(3):65s-70.

Buckell NA, Williams GT, Bartram CI, Lennard-Jones JE. Depth of ulceration in acute colitis: correlation with outcome and clinical and radiologic features. Gastroenterology. 1980;79(1):19-25.

Boeckxstaens GE, Pelckmans PA, Herman AG, Van Maercke YM. Involvement of nitric oxide in the inhibitory innervation of the human isolated colon. Gastroenterology. 1993;104(3):690-7.

Lundberg S, Holst M, Hellström P. Expression of iNOS mRNA associated with suppression of colonic contraction in rat colitis. Acta Physiologica. 2006;187(4):489-94.

Mourelle M, Casellas F, Guarner F. Induction of nitric oxide synthase in colonic smooth muscle from patients with toxic megacolon. Gastroenterology. 1995;109(5):1497-502.

Palatka K, Serfozo Z, Veréb Z. Changes in the expression and distribution of the inducible and endothelial nitric oxide synthase in mucosal biopsy specimens of inflammatory bowel disease. Scand J Gastroenterol. 2005;40(6):670-80.

Mourelle M, Vilaseca J, Guarner F, Salas A, Malagelada JR. Toxic dilatation of colon in a rat model of colitis is linked to an inducible form of nitric oxide synthase. Am J Physiol. 1996;270(3 Pt 1):G425-430.

Cao W, Fiocchi C, Pricolo VE. Production of IL-1beta, hydrogen peroxide, and nitric oxide by colonic mucosa decreases sigmoid smooth muscle contractility in ulcerative colitis. Am J Physiol Cell Physiol. 2005;289(6):C1408-16.

Strong DS, Cornbrooks CF, Roberts JA, Hoffman JM, Sharkey KA, Mawe GM. Purinergic neuromuscular transmission is selectively attenuated in ulcerated regions of inflamed guinea pig distal colon. J Physiol. 2010;588(Pt 5):847-59.

Candiotto A, Pascoli I, Gritti A, Busato E, Dal Pozzo G. Toxic megacolon complicating a Clostridium difficile infection in a pregnant woman. J Med Microbiol. 2010;59(Pt 1):124-6.

Roys G, Kaplan MS, Juler GL. Surgical management of toxic megacolon. Am J Gastroenterol. 1977;68(2):161-6.

Greenstein AJ, Barth JA, Sachar DB, Aufses AH, Jr. Free colonic perforation without dilatation in ulcerative colitis. Am J Surg. 1986;152(3):272-5.

Greenstein AJ, Aufses AH, Jr. Differences in pathogenesis, incidence and outcome of perforation in inflammatory bowel disease. Surg Gynecol Obstetr. 1985;160(1):63-9.

Desai J, Elnaggar M, Hanfy AA, Doshi R. Toxic Megacolon: Background, Pathophysiology, Management Challenges and Solutions. Clin Experimental Eastroenterol. 2020;13:203-10.

Present DH. Toxic megacolon. Med Clin N Am. 1993;77(5):1129-48.

LaMont JT, Kandel GP. Toxic megacolon in ulcerative colitis. Early diagnosis and management. Hospital practice (Office ed). 1986;21(9):102A-102D, 102H, 102K-102M passim.

Fazio VW. 11 - Toxic Megacolon in Ulcerative Colitis and Crohn’s Colitis. Clin Gastroenterol. 1980;9(2):389-407.

Benchimol EI, Turner D, Mann EH. Toxic megacolon in children with inflammatory bowel disease: clinical and radiographic characteristics. Am J Gastroenterol. 2008;103(6):1524-31.

Turner D, Walsh CM, Benchimol EI. Severe paediatric ulcerative colitis: incidence, outcomes and optimal timing for second-line therapy. Gut. 2008;57(3):331-8.

Maconi G, Sampietro GM, Ardizzone S. Ultrasonographic detection of toxic megacolon in inflammatory bowel diseases. Dig Dis Sci. 2004;49(1):138-42.

Imbriaco M, Balthazar EJ. Toxic megacolon: role of CT in evaluation and detection of complications. Clin Imaging. 2001;25(5):349-54.