He met the clinical criteria of toxic megacolon 1, 2. There was colonic distension of the transverse colon measuring 8.5cm. He was febrile at 38ºC, tachycardia at HR >148 and anaemic at Hb 105 g/L. He also had hypotension of SBP 92 and severe electrolytes disturbances with serum magnesium of 0.51mmol/L and phosphate 0.44 mol/L on admission.
He had an emergency operation.
A flexible sigmoidoscopy was performed first. It demonstrated diffuse severe inflammation in the descending colon (Figure 1 and 2). The colitis was associated with ulcerations and pustules. It endoscopically resembled pseudomembranous colitis. Large amount of gas and diarrhoea was evacuated from the colon to facilitate laparoscopic surgery.
He then proceeded to have a laparoscopic hand assisted total colectomy and ileostomy. Findings included a very distended upper rectum measuring 14cm.