Well, if patient with toxic megacolon who failed to respond to therapy with infliximab/cyclosporine in 72 hours, it's recommended to discus colectomy.

For more detailed information check this:

http://www.uptodate.com/contents/management-of-severe-ulcerative-colitis

First dose of inlfiximab is given and expecting response with in 72 hours . If pt does not response  within 72 hours so cyclosporin can be tried ? Anybody has experience about this . One study showed that a group of pt who did not respond to infliximab ,   33 % responded to cyclosporin . Group of pts who did not respond to cyclosporin 40% of them responded to infliximab...

In cases of non-response to Infiximab or Cyclosporin,  switching to either therapy is associated with signifcant  morbidity and mortality and is not recommended. There are low threshold of surgery in cases of non-response toxic megacolon to medical therapy within 48 h. This intervention is recommended as a option to decrease the morbidity and mortality of this condition. 

I agree with dr Yankov statemtents

If the megacolon has resulted from ulcerative colitis, steroids IV can be given for 5 days awaiting a response. Modern biologics like infliximab or cyclosporine can be tried awaiting response for 48 - 72 hours. However there is no evidence that patient not responding to infliximab will do so to cyclosporine. Side effects of both the drugs are severe and can be fatal. The waiting time for response also depends on the patient condition. Colectomy is life saving for such patients and biologics can worsen the preoperative status making her unfit for surgery. The decision about when to operate or to continue with biologics should be jointly taken with a gastrosurgeon.

I think the patient needs urgent colectomy.

What is the pt clinical condition?

If he has SIRS and abd is distended/tender and progressively deteriorating, then you don't have much time and colectomy will be life saving.

If he is overall stable and not ill, and all you have is a distended colon per imaging, you can wait longer for a response to medicine.  Other option is colon decompression with colonoscopy, preferably by someone with experience performing those.

dera Dr Arshad

i think the patient condition is the most important factor for your decide the next step, if the condition deteriorates you should not waste the golden time for surgery.

dear Colleague,

I agree with colleagues who recommand not to wait too long with surgical decision. Therapeitcs are also deletere for colon wall and decompression colonoscopy is dangerous; Whatever etiology (infectious or congenital), surgeryseems to be  a valid treatment.

Can you tell us thet decision you have taken and what issue of the case? Thank you

In this scenario I would first do a good counselling to the bystanders regarding possibility of colectomy.

A stool routine is vital to r/o infective causes

An emergency CT scan and if possible a limited view of the colon after switching off air would be helpful to know the state of the colonic mucosa although slightly risky.

If the patient does not respond with standard line of treatment, I would certainly resort to cyclosporine or infliximab. if patient responds it would be great else it would be subtotal colectomy.

I would keep my surgeon in confidence regarding this case.

I am not sure from what described the clinical diagnosis for the toxic megacolon. Have you excluded infectious causes before starting him on inlfiximab?