Chapter 93 - Part B: Megacolon Is a Neurologic Problem, Not a Stool Problem

In this BoardsCast episode, we continue Tobias Chapter 93 — Colon by deleting the most dangerous mental model in constipation medicine:

megacolon is not a plumbing problem.

If you treat it like a clog—more laxatives, more enemas, more fiber—you can waste critical time while the colon is literally losing the ability to contract. This episode reframes megacolon correctly: a neuromuscular failure where the “container” is broken, not just the “content.” 

You’ll learn:

• Why treating megacolon like a stool problem is dangerous (symptom treatment while the organ fails) 
• The difference between constipation vs obstipation — and why obstipation implies loss of function 
• The colon’s three jobs (storage, absorption, propulsion) — and which one dies in megacolon 
• The progression from hypertrophic to dilated megacolon (compensation → irreversible failure) 
• The failure loop: distension → reduced contractility → more distension → “dead organ” 
• The board-critical timeline: changes are usually considered irreversible after ~6 months of dilation 
• Primary (idiopathic) vs secondary megacolon (pelvic fractures, neurologic causes like Manx syndrome) 
• Why cisapride, lactulose, and fiber can fail—or worsen the loop—in true megacolon 
• Why subtotal colectomy works: removing a nonfunctional reservoir (not “unclogging”) + the ICJ tradeoff 

This episode teaches the shift the boards expect: stop fighting the poop—start evaluating propulsion.

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