A53-03 Vasopressor-Refractory Shock Secondary to Stercoral Colitis and Toxic Megacolon: A Critical Care Challenge

Abstract Introduction Toxic megacolon is a rare, life-threatening complication of colonic inflammation typically associated with established Ulcerative Colitis, Crohn’s Disease or severe infectious colitis, and is conventionally diagnosed when colonic dilation 6 cm is demonstrated on imaging concomitant with systemic toxicity. However, recognition of this entity may be delayed when classic imaging features are absent and there is no prior inflammatory bowel disease (IBD) history, potentially resulting in catastrophic outcomes. We report a unique fatal case of refractory shock due to presumed toxic megacolon physiology in a patient without IBD history and lacking imaging evidence of colonic dilation. Case report A 54-year-old male with no history of IBD presented with abdominal distension and fever. Imaging showed stercoral colitis, and he was admitted for medical management. His condition rapidly deteriorated with rising lactate and hypotension, prompting emergent surgery with partial colectomy. Postoperatively, he required escalating vasopressors including norepinephrine, vasopressin, and epinephrine despite aggressive fluid resuscitation, broad-spectrum antibiotics, and transfusion support (packed red blood cells, platelets, FFP, and cryoprecipitate). Additional therapies with methylene blue and intravenous immunoglobulin were initiated for refractory vasoplegia. Despite maximal support, he remained hypotensive. A second emergent subtotal colectomy and subsequent bedside exploratory laparotomy were performed for ongoing bleeding and distension. Despite these interventions, he developed multiorgan failure and died within 24 hours of presentation. Discussion This case highlights several important learning points: (1) toxic megacolon may present with a fulminant hemodynamic phenotype (i.e., refractory shock) in the absence of classic radiographic colonic dilation; (2) absence of prior IBD history should not preclude consideration of this diagnosis in critically ill patients with unexplained shock and abdominal features; (3) pathophysiologic mechanisms, such as mucosal ischemia, translocation, cytokine-mediated vasoplegia and microvascular failure, may precede overt colonic dilation visible on imaging, delaying diagnosis; (4) early recognition and prompt surgical consultation may be critical even when imaging is non-confirmatory. To our knowledge, few reports describe fatal toxic-megacolon-type presentations characterized by refractory shock without radiographic evidence of colonic dilation or underlying IBD. This case expands the clinical spectrum of toxic megacolon and emphasizes the need for heightened clinical suspicion in patients with severe colitis and shock physiology unresponsive to standard resuscitative measures.Stercoral colitis can precipitate toxic megacolon physiology and vasopressor-refractory shock with fatal outcomes despite aggressive management. Early recognition, multidisciplinary coordination, and proactive surgical intervention are vital. Intensivists should consider vasoplegic physiology early and discuss prognosis when shock persists despite maximal support. This abstract is funded by: None