A 25-year-old woman with known ulcerative colitis presents to the emergency room with a 24-hour history of abdominal pain, distention, and obstipation. Physical examination reveals a temperature of 38.6° C, abdominal distention

c. Total abdominal colectomy with formation of Hartmann pouch and end ileostomy

Acute toxic megacolon occurs in 6% to 13% of patients with ulcerative colitis. Initial treatment for toxic megacolon includes intravenous fluid and electrolyte resuscitation, nasogastric suctioning, broad spectrum antibiotics, and total parenteral nutrition. The therapeutic role of intravenous steroids in toxic megacolon is controversial. Most patients presenting with a severe attack of ulcerative colitis are already receiving steroid therapy and require stress doses of corticosteroids to prevent adrenal crisis. When symptomatology is progressive or when there is evidence of colonic perforation, emergency surgery is indicated. Postoperative complications including sepsis, wound infection, intraperitoneal abscess, fistula formation, and delayed wound healing are common and have been reported in up to 50% of patients. The presence of colonic perforation doubles operative risk. In the presence of toxic megacolon or colonic perforation, the operation should be definitive without being overly aggressive. Abdominal colectomy with ileostomy and Hartmann closure of the rectum is the procedure of choice. After recovery, delayed surgery for restoration of continence can be performed. Leaving the rectum intact allows its use for subsequent mucosal proctectomy and ileoanal anastomosis.