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
Explanation: Toxic megacolon
This is toxic megacolon complicating acute severe ulcerative colitis — fever, tachycardia, abdominal distension, and colonic dilation are the red flags. Management requires admission, IV corticosteroids, bowel rest, and early surgical consultation, since failure to respond within 72 hours (or signs of perforation) mandates escalation to biologics (infliximab) or colectomy.
- A — inadequate for systemic toxicity/severe flare.
- B — oral steroids are insufficient; IV route is required in acute severe disease.
- D — too slow-acting (weeks) for an acute emergency.
- E — antibiotics alone don’t treat the underlying flare or prevent perforation; may be adjunctive, not primary.
