P3062 - Large Bowel Obstruction From Intraabdominal Mesh Masquerading as Toxic Megacolon

Rhea Fogla, MD¹, Aiya Aboubakr, MD², David Wan, BS, MD^3
1New York-Presbyterian/Weill Cornell, New York, NY; ²New York Presbyterian-Weill Cornell Medical Center, New York, NY; ³Weill Cornell Medicine, New York, NY

Introduction: Toxic megacolon (TM) is a rare and potentially fatal complication that is characterized by nonobstructive colonic dilatation (greater than 6 cm diameter on radiographic film) with signs of systemic toxicity. There is a broad differential for colonic dilatation, though typically signs of toxicity can help differentiate TM from other conditions.

Case Description/Methods: An 80-year-old female with history of aortic stenosis status post valve replacement, polymyalgia rheumatica, breast cancer status post mastectomy, incisional hernia status post mesh repair, and IgA nephropathy presented to the hospital with acute lower abdominal pain. Labs were notable for a white blood cell count 36 x 10³ µL, lactate 5.10 mmol/L and creatinine 3.34 mg/dL (baseline 1.7-2.0 mg/dL). Imaging revealed diffuse dilatation of the colon up to 8.5 cm and marked pericolonic inflammatory changes. Given concern for toxic megacolon, patient was initiated on broad spectrum antibiotics, including empiric C. difficile therapy. She underwent an exploratory laparotomy, which showed patchy necrosis throughout the ascending and transverse colon and a large bowel obstruction at the level of the intrabdominal mesh, resulting in subtotal colectomy with ileostomy. Stool sample tested negative for C. difficile. Post operatively, patient had increased pressor requirement despite resuscitation efforts. On exam, her ostomy site had a dusky appearance, which prompted an emergent exploratory laparotomy at bedside and resection of an ischemic end ileostomy. Surgical team planned to re-explore abdomen, however her family opted for comfort care and patient expired.

Discussion: Meeting diagnostic criteria for toxic megacolon is not definitive and does not preclude a patient from other etiologies of dilatation. As reflected in this case, large bowel obstructions can present with bowel necrosis and therefore lead to systemic toxicity, presenting in a similar fashion to TM. Identifying a patient’s clinical history and risk factors are critical, such as history of inflammatory bowel disease, clostridium difficile infection, and abdominal surgery. Given this patient’s significant clinical deterioration with worsening sepsis and end organ damage, surgical intervention was indicated regardless of etiology, as there is a high risk of bowel ischemia and perforation in both TM and bowel obstruction.



Disclosures:


Rhea Fogla, MD¹, Aiya Aboubakr, MD², David Wan, BS, MD³. P3062 - Large Bowel Obstruction From Intraabdominal Mesh Masquerading as Toxic Megacolon, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.