Clinical Scenario:
A 13-year-old boy with known ulcerative colitis, on oral mesalamine, presents with worsening bloody diarrhea (8–10 times/day), fever (38.6°C), tachycardia, and a distended, tender abdomen. Abdominal X-ray shows transverse colon dilation of 6.5 cm.
What is the most appropriate next step in management?
A. Increase oral mesalamine dose
B. Start oral corticosteroids
C. Admit for IV corticosteroids and surgical consult
D. Start azathioprine
E. Start empiric antibiotics only
Correct answer & Explanation:
Correct Answer: C. Admit for IV corticosteroids and surgical consult
Explanation: Toxic Megacolon | Ulcerative Colitis
This 13-year-old boy has acute severe ulcerative colitis complicated by toxic megacolon.
The key clue is the transverse colon diameter of 6.5 cm (65 mm) together with systemic toxicity—fever and tachycardia. In children, transverse-colon dilatation >56 mm with systemic toxicity is diagnostic of toxic megacolon.
Acute severe colitis is a pediatric gastrointestinal emergency. Children with severe UC should be hospitalized for intensive monitoring and intravenous corticosteroid therapy.
Because toxic megacolon carries a risk of perforation and deterioration, early surgical consultation is essential, even when medical treatment is initially attempted. The pediatric ECCO/ESPGHAN guideline recommends prompt surgical evaluation; conservative management is appropriate only in carefully selected, clinically stable patients under close specialist monitoring.
Initial supportive management of toxic megacolon also includes IV fluids, bowel rest, correction of electrolyte abnormalities, and broad-spectrum IV antibiotics, in addition to IV corticosteroids.
Why the other options are incorrect
A. Increase oral mesalamine dose — Incorrect: Oral mesalamine is inadequate for acute severe UC with systemic toxicity and colonic dilatation.
B. Start oral corticosteroids — Incorrect: Severe disease requires IV corticosteroids and inpatient monitoring.
D. Start azathioprine — Incorrect: Azathioprine has a delayed onset and is not appropriate for acute induction of remission in this emergency.
E. Start empiric antibiotics only — Incorrect: Antibiotics alone do not treat the underlying severe UC. Antibiotics are part of supportive management of toxic megacolon but must not replace IV corticosteroids and surgical assessment.
High-Yield Exam Pearl for Pediatric Board
Child with UC + systemic toxicity + transverse-colon diameter >56 mm = toxic megacolon → urgent hospital management, IV corticosteroids, supportive therapy, and early surgical consultation.
Referenc
Assa A, Aloi M, Van Biervliet S, et al. Management of paediatric ulcerative colitis, part 2: acute severe colitis—an updated evidence-based consensus guideline from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition and the European Crohn’s and Colitis Organization. J Pediatr Gastroenterol Nutr. 2025;81(3):816-851. doi:10.1002/jpn3.70096.
You can also practice another scenario based MCQ on Diarrhea and Pain Abdomen.
