CE Article #3

Feline Idiopathic Megacolon

Christopher G. Byers, DVM*
Christopher S. Leasure, DVM
Nancy A. Sanders, DVM, DACVIM, DACVECC*
VCA Veterinary Referral Associates, Inc.
Gaithersburg, Maryland

ABSTRACT: Feline idiopathic megacolon is a relatively common colonic disorder characterized by

severe distention of the colon. A thorough diagnostic investigation is needed to eliminate other
potential causes from the list of diagnostic differentials. Medical management consisting of dietary
modification and administration of laxatives, enemas, and/or promotility agents may be effective.
Patients refractory to medical therapy should be further evaluated to determine whether they are
candidates for subtotal colectomy.

F
eline idiopathic megacolon is characterized
by generalized colonic dysfunction mani-
festing as severe colonic dilation and fecal
impaction. Clinical signs commonly include
anorexia, weight loss, vomiting, and dyschezia;
physical examination classically reveals a large
amount of very firm feces palpable within the
colon. Diagnostic investigation is aimed at rul-
ing out underlying problems that could cause
colonic stricture and/or obstruction (see box on
page 659). Once this has been done, medical
management with dietary modification and
administration of laxatives, enemas, and/or pro-
motility agents may be effective. Patients refrac-
tory to medical therapy may benefit from
surgical intervention via subtotal colectomy.
PATHOPHYSIOLOGY
Feline idiopathic megacolon has traditionally
been attributed to primary
Send comments/questions via email to neurogenic and degenerative
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or fax 800-556-3288. *Drs. Byers and Sanders are cur-
rently collaborating with and are
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full-text articles, CE testing, and CE Clinical Investigation, LLC,
test answers. Bethesda, MD.
neuromuscular disorders. Previous investigations
by Washabau et al1,2 using in vitro isometric
stress measurements of colonic smooth muscle
segments revealed that cats with idiopathic di-
lated megacolon developed less isometric stress
in circular and longitudinal smooth muscle in
response to neurotransmitters, membrane depo-
larization, and electrical field stimulation com-
pared with healthy controls. These findings were
associated with decreased myosin light-chain
phosphorylation, suggesting a disturbance of
intracellular calcium mobilization2 and signify-
ing that feline idiopathic megacolon is a general-
ized dysfunction of colonic smooth muscle.
Thus colonic motility may be augmented with
therapeutic intervention designed to stimulate
colonic smooth muscle.
DIAGNOSIS
Constipation is defined as “a condition in
which bowel movements are infrequent or
incomplete”; severe constipation is often
referred to as obstipation.3 Obstipation implies
permanent loss of colonic motility, and when
obstipation results in dilation or hypertrophy of
the colon, the condition is called megacolon.3

COMPENDIUM 658 September 2006


Differential Diagnosis for Feline
Constipation or Obstipation
• Idiopathic
• Pelvic deformity
• Foreign bodies
• Neoplasia (extraluminal vs intraluminal)
• Nonneoplastic strictures
• Hypokalemia
• Hypercalcemia
• Hypothyroidism
• Sacral spinal cord deformities (Manx pedigree)
• Lumbosacral disease
• Cauda equina syndrome
• Ileus
• Dysautonomia
• Aganglionosis
• Nutritional secondary hyperparathyroidism
• Administration of:
— Opioid agonists
— Cholinergic antagonists
— Phenothiazines
• Hospitalization
• Dehydration
• Renal failure
Hypertrophic megacolon may result from pelvic fracture
malunion, pelvic canal stenosis, or luminal obstruction.4
Conversely, dilated megacolon is considered the end
stage of feline idiopathic megacolon.4
Domestic cats of any pedigree, age, or sex may develop
constipation or obstipation and/or megacolon.1,5,6 Most
cases involve middle-aged male cats; Domestic Shorthair,
Domestic Longhair, and Siamese cats are overrepre-
sented.1,6 Owners often describe affected cats as having
reduced, absent, and/or painful defecation for a variable
period of time.5,6 Large, hardened, desiccated feces are
commonly observed, but chronically constipated cats may
have intermittent episodes of hematochezia or diarrhea
from the irritant effect of fecal concretions on the colonic
mucosa. Systemic signs, most notably vomiting, anorexia,
and weight loss, may be observed in patients with pro-
longed difficulty defecating.5–7
Profound colonic impaction is a consistent physical
examination finding in cats with idiopathic mega-
colon.5–7 In addition, dehydration, abdominal pain, and
mild to moderate mesenteric lymphadenomegaly may
occur in severely affected cats. Cats with constipation
due to dysautonomia may have other signs of autonomic
nervous system failure, including mydriasis with de-
pressed direct and consensual pupillary light reflexes,
September 2006
Feline Idiopathic Megacolon CE 659
Figure 1. Right lateral abdominal radiograph of a cat
with idiopathic megacolon. Note the severe distention of the
colon, particularly the descending segment.
dysuria with a distended urinary bladder, dry mucous
membranes, prolapsed nictitans, and/or dysphagia.8,9 In
all cats with suspected idiopathic megacolon, clinicians
should carefully perform a digital rectal examination
with patients sedated or anesthetized. Rectal examina-
tion may identify less frequent causes of constipation,
including foreign bodies, rectal diverticula, stricture(s),
and/or rectal masses.7 Pelvic fracture malunion and/or
pelvic canal stenosis may also be detected in cats with
historical or current pelvic trauma. 4 Furthermore,
chronic tenesmus may be associated with perineal herni-
ation.4–6 A complete neurologic examination should be
performed to identify potential neurologic causes of
constipation.
To diagnose feline idiopathic megacolon, the following
must be eliminated from the list of diagnostic differen-
tials: systemic disturbances, mechanical obstructions, and
obvious functional abnormalities. Metabolic causes of
constipation, including dehydration, hypokalemia, and
hypercalcemia, may be detected in some cats. Therefore,
a thorough evaluation should include a complete blood
count, serum biochemical profile, and urinalysis. Because
iatrogenic hypothyroidism may be associated with con-
stipation, measurement of basal serum thyroxine concen-
tration is recommended in cats with recurrent
constipation after treatment of hyperthyroidism.10
Abdominal radiography is essential to help character-
ize the severity of colonic impaction and to identify pre-
disposing factors, including foreign object(s), mass
lesions, pelvic fractures, colonic strictures, and spinal
column abnormalities (Figure 1). However, in idiopathic
cases, radiographic findings with colonic impaction can-
COMPENDIUM
660 CE Feline Idiopathic Megacolon
Recommended Suppositories
• Glycerin
• Bisacodyl (Dulcolax, Boehringer Ingelheim)
• Dioctyl sodium sulfosuccinate (Colace, Mead
Johnson)
not be used to distinguish constipation, obstipation, and
megacolon.11
Abdominal ultrasonography may be used to more
extensively evaluate extraluminal mass lesions, and
ultrasound-guided biopsy may help obtain a definitive
histopathologic diagnosis. Colonoscopy after evacuation
of impacted feces may be indicated to inspect intralumi-
nal structural abnormalities, and contrast radiography
may be used if colonoscopy is not appropriate. Patients
with evidence of neurologic impairment may benefit
from cerebrospinal fluid analysis, myelography, and/or
electrophysiologic studies to definitively characterize the
malady.
MEDICAL MANAGEMENT
A first bout of constipation often resolves without
therapy, but mild to moderate or recurrent episodes of
constipation usually require some form of medical inter-
To diagnose feline idiopathic megacolon, the following must be eliminated from the list of diagnostic
differentials: systemic disturbances, mechanical obstructions, and obvious functional abnormalities.
vention. Often, a combination of dietary modification,
laxatives, enemas, and/or colonic prokinetic agents is
effective therapy. Studies12,13 have shown that dietary
supplementation with short-chain fatty acids improves
colonic smooth muscle contraction in both cats and
dogs. Hospitalization for intravenous fluid therapy to
correct dehydration and electrolyte derangements as
well as to evacuate impacted feces is typically required in
cases of obstipation and megacolon.
Rectal suppositories (see box above) are available to
manage mild constipation, but their use requires an
amenable pet and compliant pet owner. Suppositories
may be used alone or in conjunction with oral laxative
therapy. Mild to moderate or recurrent episodes of con-
stipation may require administration of enemas and/or
manual extraction of impacted feces. Several types of
enema solutions (see box at top right) are available;
COMPENDIUM
Recommended Enemas
• Warm water
• Warm 0.9% saline
• A 50:50 ratio of water or saline with a water-based
lubricant (Surgilube, E. Fougera)
• Dioctyl sodium sulfosuccinate (Colace, Mead
Johnson)
• Dioctyl calcium sulfosuccinate (Surfax, Hoechst)
• Mineral oil
• Lactulose (Duphalac, Reid Rowell)
these solutions should be administered slowly with a
well-lubricated red rubber catheter. Because enema
solutions containing sodium phosphate may cause
severe electrolyte disturbances in cats, these solutions
should never be used in this species.
Manual extraction of impacted feces is required in
patients in which enemas and laxative therapy have not
successfully facilitated defecation. Cats should be ade-
quately rehydrated, and anesthesia should be maintained
with an endotracheal tube in place to prevent aspiration
in case colonic manipulation induces vomiting via stim-
ulation of colonic stretch receptors. We recommend
perianesthetic administration of metronidazole (Flagyl,
Pharmacia and Searle; 7.5 to 15 mg IV bid) because of
potential anaerobic bacterial translocation with colonic
handling during digital extraction. Warm water or 0.9%
saline mixed in a 50:50 combination with a water-based,
sterile bacteriostatic surgical lubricant may be infused
into the colon while the fecal mass is manually reduced
via abdominal palpation. Laxative and/or prokinetic
therapy may be instituted once the fecal mass has been
adequately removed.
Lactulose is a hyperosmotic laxative and is perhaps
the most frequently used medication in treating idio-
pathic megacolon (see box on page 661). The organic
acids produced from lactulose fermentation stimulate
colonic fluid secretion and propulsive motility. 14
Another example of a hyperosmotic laxative is polyeth-
ylene glycol, and some researchers report 15 anecdotal
success with the use of this medication. Bulk-forming
September 2006

laxatives are typically minimally digestible polysaccha-
rides and celluloses, and constipated cats may respond to
dietary supplementation with one of these products.
Dietary fiber is preferable because it is well tolerated,
more effective, and more physiologic compared with
other laxatives.14 Fiber induces vigorous colonic contrac-
tion via colonic stretching in large-bowel segments
capable of effectively contracting; thus fiber supplemen-
tation may be effective in early stages of idiopathic
megacolon when the colon may still have some ability to
contract. In addition, fiber supplementation in late
stages of idiopathic megacolon may exacerbate colonic
distention and subsequent clinical signs; thus a low-
residue diet may be more beneficial in affected patients.
Emollient laxatives enhance lipid absorption and impair
water absorption by altering the miscibility of water and
lipid in ingesta. Animals should be well hydrated before
receiving bulk-forming, hyperosmotic, and/or emollient
laxatives. Lubricant laxatives impede colonic water
absorption while facilitating ease of defecation and are
typically beneficial with mild cases of constipation.
White petrolatum and mineral oil are the most common
examples of lubricant laxatives, but we do not recom-
mend oral administration of mineral oil because of the
risk for aspiration. Bisacodyl is a laxative that stimulates
colonic propulsive motility. This stimulant laxative may
be given individually or in combination with fiber sup-
plementation, but daily administration should be
avoided because of potential injury to myenteric neurons
with long-term use.16
Serotonergic 5-hydroxytryptamine (5-HT)–receptor
activation may cause colonic contraction, and 5-HT4
Clinicians should carefully perform a digital rectal examination using
sedation or anesthesia in all cats with suspected idiopathic megacolon.
agonists may stimulate both colonic and cardiac 5-HT4
receptors.17–21 Cisapride (from compounding pharma-
cies) is a substituted piperidinyl benzamide serotonin
receptor agonist,22 and in vitro studies23,24 showed that
this medication stimulates feline colonic smooth muscle
5-HT receptors to promote propulsive motility. This
medication has also been shown to cause prolongation
of the QT interval and slowing of cardiac repolarization
via blockade of the rapid component of the delayed rec-
tifier potassium channel in humans, 18–20 and these
September 2006
Feline Idiopathic Megacolon CE 661
Recommended Laxatives
• Hyperosmotic
—Lactulose
• Bulk-forming
—Canned pumpkin
—Psyllium
• Emollient
—Dioctyl sodium sulfosuccinate (Colace, Mead
Johnson)
—Dioctyl calcium sulfosuccinate (Surfax, Hoechst)
• Lubricating
—White petrolatum
—Mineral oil
• Stimulating
—Bisacodyl
changes may cause the fatal dysrhythmia torsades de
pointes. Similar in vitro effects have been characterized
in canine cardiac Purkinje fibers, but in vivo effects have
not been reported in dogs and cats.25 Although cisapride
has been removed from most pharmaceutical markets,
this medication may still be purchased from many com-
pounding pharmacies. The histamine (H2) antagonists
ranitidine (Zantac, GlaxoSmithKline) and nizatidine
(Axid, Eli Lilly) stimulate in vitro feline colonic smooth
muscle contraction via inhibition of tissue acetyl-
cholinesterase, but in vivo studies still need to be con-
ducted to determine whether these medications should
be considered a standard component of therapy for idio-
pathic megacolon.26
Tegaserod (Zelnorm, Novartis) is a partial non-benza-
mide agonist at 5-HT4 receptors and a weak pure ago-
nist at 5-HT 1D receptors on enteric cholinergic
neurons.14 Tegaserod has definite prokinetic effects in
the canine colon, but the mechanisms responsible for
tegaserod-induced canine colonic propulsion are
unknown.27 Effects of tegaserod have not been reported
in cats, and further studies are needed before the drug
should be considered in the medical treatment of feline
idiopathic megacolon.
Prucalopride (R093877, Janssen, LP) is a partial benz-
amide agonist at 5-HT4 receptors but has no effect at
COMPENDIUM
662 CE Feline Idiopathic Megacolon
Procedure for Subtotal Colectomy38,39
• Position the patient in dorsal recumbency.
• In a routine manner, shave and drape the ventral
abdomen for aseptic surgery.
• Monitor the patient’s cardiovascular status (i.e.,
temperature, heart rate and rhythm, respiratory rate,
blood pressure, end-tidal carbon dioxide)
continuously during the entire anesthetic period.
• Provide appropriate intraoperative fluids (typically,
isotonic crystalloid administered at 5–10 ml/kg/hr).
• Create a ventral midline celiotomy from cranial to
the umbilicus to the pubis.
• Thoroughly explore the abdomen.
• Harvest appropriate samples (tissue biopsy
specimens, fluids) from other abdominal organs
before incising the gastrointestinal tract.
• Isolate and pack off the colon with laparotomy pads
moistened with sterile 0.9% sodium chloride.
• From the surgical site, digitally manipulate fecal
material within the colonic lumen.
• Occlude the colonic lumen using noncrushing
clamps (Doyen forceps).
• Double-ligate only the short vasa recta vessels
supplying the segment to be resected, helping to
ensure that the caudal mesenteric, cranial rectal, left,
middle, and right colic vessels are intact to maximize
blood supply to the anastomosis site.
• Transect the distal colon 2–4 cm cranial to the
pubis.
• 3-0 or 4-0 absorbable suture is preferred for
colectomy; however, if the patient is
immunocompromised and/or hypoalbuminemic,
a nonabsorbable suture should be used.
Surgical area on a cat before subtotal colectomy.
Note the profound colonic distention.
COMPENDIUM
other 5-HT receptors.14 Prucalopride stimulates giant
migrating contractions in dogs, frequently causing defe-
cation within the first hour after administration.28,29 This
medication also increased defecation within a similar
time period in healthy cats with no alteration of fecal
consistency. 29 To date, prucalopride has not been
approved for use in the United States.
Misoprostol (Cytotec, Searle) is a prostaglandin E1
analogue shown to reduce the incidence of NSAID-
induced gastric injury. 30,31 An in vitro study revealed
that misoprostol stimulates feline colonic smooth mus-
cle contraction.32 However, to our knowledge, in vivo
studies have not been conducted.32 Erythromycin has
been shown to decrease in vitro canine colonic transit
time33; however, this medication has no effect on feline
colonic smooth muscle and thus is not indicated to
treat feline constipation or obstipation and/or mega-
colon.34 Metoclopramide HCl (Reglan, Wyeth-Ayerst)
and domperidone (Motilium, Janssen, LP) are
dopaminergic (D) antagonists with peripheral proki-
netic effects and central antiemetic effects at D2 recep-
tors.14 Metoclopramide antagonizes enteric cholinergic
neurons via 5-HT3 receptors and is also a 5-HT4 ago-
nist, whereas domperidone has antagonistic activity at
α2- and β2-adrenergic receptors.35 Although these med-
ications enhance gastric motility, they have a negligible
effect on colonic transit time, which minimalizes their
use in treating constipation or obstipation and/or
megacolon.14,30
SURGICAL MANAGEMENT
Cats with a history of chronic constipation refractory
to appropriate medical therapies may require surgical
intervention. Many surgical techniques for the manage-
ment of feline idiopathic megacolon have been
described, including coloplasty and partial or subtotal
colectomy.36 Partial colectomy involves removal of only
the dilated and atonic segment of colon at the time of
surgical exploration 37; grossly normal tissue is not
resected. Partial colectomy has fallen out of favor
because differentiation between normal and abnormal
tissue based on gross appearance at the time of surgery
is impossible. A study36 demonstrated that the entire
colon is likely histologically affected and any amount of
colon remaining following subtotal colectomy may con-
tinue to dilate, potentially resulting in recurrence of
clinical signs. Thus failure to resect a significant length
of grossly normal-appearing colon may result in thera-
peutic failure.36
September 2006

The current gold-standard surgical treatment of feline
idiopathic megacolon is subtotal colectomy37–39 (see box
on page 662 and Figure 2). This procedure involves
removal of 90% to 95% of the colon regardless of gross
appearance; only a short distal colonic segment is spared
to allow anastomosis. Controversy still exists as to
whether to preserve the ileocolic junction during the
colectomy procedure because the ileocolic valve allows
passage of the small intestinal contents into the colon
and prevents reflux of colonic contents into the ileum.
The removal of the ileocolic valve is thought to cause
reflux of colonic microorganisms into the small intes-
tine, resulting in small intestinal bacterial overgrowth
and diarrhea.40,41 In a study by Sweet et al,40 the ileocolic
junction was preserved in 14 cats and resected in eight
cats during subtotal colectomy. There was no difference
in the overall recurrence of constipation in either
group. 41 However, patients that underwent ileocolic
junction resection had significantly looser feces than
those in which the ileocolic junction was preserved.
The use of cleansing enemas is not recommended
before colonic surgery in veterinary medicine because
preoperative enemas may change firm, dry feces into a
bacteria-rich liquid capable of contaminating the surgi-
cal field. The patient should be fed a low-residue diet
until 12 hours before induction of general anesthesia, at
which time food should be withheld. Free access to
water should be allowed until anesthetic induction. Peri-
operative, broad-spectrum parenteral antimicrobial ther-
apy is recommended to reduce the risk for postoperative
infection. We prefer ampicillin–sulbactam sodium
(Unasyn, Pfizer) at a dose of 22 mg/kg IV administered
at induction; a second dose should be administered if
surgery lasts longer than 2 hours.
Potential postoperative complications include colonic
leakage, colotomy and/or ventral abdominal incisional
dehiscence, peritonitis, ischemic necrosis, stricture,
and/or abscess formation.38 Hydration should be main-
tained using intravenous fluids for 1 to 3 days after sur-
gery. Appropriate analgesics should be used as necessary
during the perioperative period. The patient may be fed
within 24 hours following surgery, although it is not
uncommon for the patient to initially have a poor
appetite. Appetite stimulants such as cyproheptadine
(Periactin, Corepharma, Inc.; 2 mg/cat PO bid) or
diazepam (Valium, Hospira, Inc.; 0.5 mg/cat IV) may
be necessary.22 The long-term prognosis for cats with
idiopathic megacolon that undergo subtotal colectomy
is fair to good.
September 2006
Feline Idiopathic Megacolon CE 663
Figure 2. Intraoperative image of the descending colon
of a cat with idiopathic megacolon.
CONCLUSION
Feline idiopathic megacolon is a relatively common
disease characterized by generalized colonic dysfunc-
tion. Common clinical signs include dyschezia,
anorexia, weight loss, and/or vomiting, and physical
examination typically identifies profoundly firm fecal
material within the colonic lumen. A thorough diagnos-
tic investigation must be conducted to rule out predis-
posing problems before establishing a diagnosis of
idiopathic disease. Medical management with dietary
modification and administration of laxatives, enemas,
and/or promotility agents may be successful. However,
subtotal colectomy should be considered for patients
refractory to medical therapy.
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664 CE Feline Idiopathic Megacolon

12. Rondeau MP, Meltzer K, Michel KE, et al: Short chain fatty acids stimulate
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ARTICLE #3 CE TEST
This article qualifies for 2 contact hours of continuing CE
education credit from the Auburn University College of
Veterinary Medicine. Paid subscribers may purchase
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CompendiumVet.com.Test answers are available online
free to paid subscribers as well.
1. Which pedigree is not overrepresented for hav-
ing feline idiopathic megacolon?
a. Domestic Shorthair
b. Maine coon
c. Domestic Longhair
d. Siamese
2. Which condition does not cause hypertrophic
megacolon?
a. pelvic fracture malunion
b. hypokalemia
c. pelvic canal stenosis
d. luminal obstruction
3. _____________ laxatives enhance lipid absorption
and impair colonic water absorption by altering
miscibility of water and lipid in ingesta.
a. Hyperosmotic
b. Bulk-forming
c. Emollient
d. Lubricant
4. ___________________ is a potentially adverse car-
diac side effect of cisapride.
a. Ventricular tachycardia
b. Prolongation of the QT interval
c. Atrial standstill
d. Left anterior fascicular block

COMPENDIUM September 2006

 Feline Idiopathic Megacolon CE 665

5. H2 antagonists stimulate in vitro feline colonic 8. Which may not be used as an enema?
muscle stimulation via a. a 50:50 ratio of water or saline plus a water-based
a. suppression of parietal cell activity. lubricant
b. inhibition of tissue acetylcholinesterase. b. dioctyl sodium sulfosuccinate
c. stimulation of enterochromaffin cells. c. glycerin
d. direct stimulation of myenteric plexi. d. lactulose

6. The preferred surgical treatment of idiopathic 9. During deobstipation, stimulation of the colonic
megacolon is afferent nerves may stimulate
a. coloplasty. a. extensor rigidity.
b. subtotal colectomy. b. vomiting.
c. partial colectomy. c. dysuria.
d. total colectomy. d. panniculus reflex.

7. Which is not a reported metabolic cause of 10. The preferred administration route for lubricant
colonic dysfunction? laxatives is
a. hyperphosphatemia a. oral.
b. hypokalemia b. intravenous.
c. hypercalcemia c. per rectum.
d. dehydration d. subcutaneous.

September 2006 COMPENDIUM