Colo-Rectal
Last updated (26 October 2003)
Good Stuff
Spot Diagnosis
Colo-Rectal
Padding space Distended Colon
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Distended Colon Click on the image to download a larger version
The patients general condition has been deteriorating, the doctors looking after her have observed that the dose of inotropic drugs needed to maintain the target blood pressure has been increasing, and when the drugs are briefly discontinued there is a precipitous fall in blood pressure. The urinary output has fallen to 20 ml per hour and the base deficit is increasing. She has received 3 doses of broad spectrum antibiotics for an infiltrate noted on the CXR.
Would any further investigations be helpful?
Colonoscopy
Stools for Cl difficle toxin
CT scanning
Lactate levels

The answer

Furhter investigations will be mostly unhelpful. Enough infomation has been given to indicate that the patient has toxic colitis, if the patients downward spiral of deterioration is to be arrested, definitive treatment in the form of laparotomy and coloectomy needs to be performed. Stools should be checked for Cl difficle toxin but even if they are negative the patient should be treated empirically for Cl difficle colitis.

Small print

Colonoscopy may be helpful. However, if it is to be performed it would be best to bring the instrument to the intensive care rather than attempt to transfer the patient from the intensive care to the endoscopy suite. It may show the typical appearances of pseudomembranous colitis or ischaemic colitis, but there is the added risk that it will cause a perforation, in particular if the bowel is friable. If the clinicians feel that the patient has a toxic colitis then colonoscopy may not be necessary as it would not be therapeutic and would only subject the patient to additional risk. It would be more appropriate to perpare the patient for theatre. Colonoscopy may be appropriate if the clinicians are not convinced about the findings on the plain film and would prefer to avoid surgery.

Similarly CT scanning would give a nice picture it may show gas in the wall of the colon, but would not necessarily add to what is already known, the patient would have to be transferred to the radiology department, which may be hazardous. Again if the clinicians are not convinced about the clinical picture and the plain film findings a CT may help them make up their mind.

Lactate levels will be elevated, measuring them wont help the patient, however the test is simple and can be useful to monitor the patients progress.

Adrian P. Ireland