Colitis

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Colitis Microchapters

Overview

Classification

Allergic colitis
Infectious colitis
Ischemic colitis
Drug-induced colitis
Chemical colitis
Radiation colitis

Differential Diagnosis

Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: M.Umer Tariq [2]; Maham Khan [3]; Ogheneochuko Ajari, MB.BS, MS [4]; Rim Halaby, M.D. [5]; Qasim Salau, M.B.B.S., FMCPaed [6]; Mohamed Riad, M.D.[7]

Synonyms and keywords: Colitis, Proctocolitis, Proctitis, Enterocolitis.

Overview

Colitis is the inflammation of the colon, that can be either acute or chronic. Colitis may be caused by microorganisms such as Chlamydia trachomatis, Neisseria gonorrhoeae, Shigella dysenteriae, HSV, allergy (food protein-induced allergic proctocolitis), drugs (NSAIDs) and radiation. Colitis may co-exist with enteritis (inflammation of the small bowel), proctitis (inflammation of the rectum) or both. The symptoms of colitis such as diarrhea especially bloody diarrhea and abdominal pain (which may be mild) are seen in all forms of colitis. Colitis may be fulminant with a rapid downhill clinical course. In addition to the diarrhea, fever, and anemia may be reported. The patient with fulminant colitis has severe abdominal pain and presents a clinical picture similar to that of septicemia, where shock is present. Treatment of colitis depends on the etiology. It may include the elimination of cows-milk protein or other food allergens from the diet, administration of antibiotics and general anti-inflammatory medications such as mesalamine or its derivatives, steroids, or one of a number of other drugs that ameliorate inflammation. The mainstay of therapy for infectious colitis is antimicrobial therapy. A common antibiotic regimen in treatment of patients with colitis is a combination of ceftriaxone and doxycycline. Supportive therapies such as correction of dehydration and anemia, and reducing the intake of carbohydrates, lactose products, soft drinks, and caffeine is often done for most patients with colitis. Irritable bowel syndrome (spastic colitis or spastic colon) has been called colitis, causing confusion despite colitis not being a feature of the disease. Immune mediated colitis is the experimental name in animal studies of ulcerative colitis. It is a synonym of ulcerative colitis, but it should not be used as a synonym when referring to ulcerative colitis.

Classification

There is no established classification system for colitis. However, it may be classified based on etiology, age and duration of symptom.

Classification by etiology

Classes of Colitis Disorders
Autoimmune
Allergic
Infectious colitis
Idiopathic
Iatrogenic
Vascular
Drug induced
Unclassifiable

Classification by Anatomy

Colitis may co-exist with inflammation involving other parts of the gastrointestinal tract. It can be classified based on anatomy into:

Schematic of Anatomical Classification of Colitis

Affected anatomical areas: By Edelhart Kempeneers - Gray's Anatomy, Public Domain, https://commons.wikimedia.org/w/index.php?curid=534843[3]
*Regions 4 to 6: Enterocolitis
*Region 6: Colitis
*Regions 6 to 8: Proctocolitis
*Regions 7 to 8:Proctitis

Classification by Age

  • Infantile (first six months of life)[4][5][6]
  • Adult

Classification by duration of symptoms

  • Acute: Less than three months.[7]
  • Chronic: Longer than three months. Often months to years.[7]

Differential Diagnosis

The differential diagnosis of colitis can be classified into two categories according to age group. A work up for colitis must include the following differentials:

Differential diagnosis in Infants

Differential diagnosis in Adults

Differentiating Between Different Types of Colitis

The symptoms of colitis such as diarrhea especially bloody diarrhea and abdominal pain are seen are seen in all forms of colitis. The table below differentiates among the common causes of colitis:[8][9]

Diseases History and Symptoms Physical Examination Laboratory findings
Diarrhea Rectal bleeding Abdominal pain Atopy Dehydration Fever Hypotension Malnutrition Blood in stool (frank or occult) Microorganism in stool Pseudomembranes on endoscopy
Allergic Colitis + ++ + ++ ++
Chemical colitis + ++ ++ + + ++ +
Infectious colitis ++ ++ ++ +++ +++ ++ + ++ ++ +
Radiation colitis + ++ + + + ++
Ischemic colitis + + ++ + + + + ++
Drug-induced colitis + + ++ + ++ +

Causes

Common Causes

Common causes of proctocolitis include infectious agents such as Chlamydia trachomatis (which causes lymphogranuloma venereum), Neisseria gonorrhoeae, HSV, Shigella dysenteriae and Campylobacter species. It can also be allergic (e.g. food protein-induced proctocolitis), idiopathic (e.g. microscopic colitis), vascular (e.g. ischemic colitis), or autoimmune (e.g. inflammatory bowel disease).

Causes by Organ System

Cardiovascular EVAR, vasculitis
Chemical / poisoning Chemical colitis from Glutaraldehyde, Coffee enema, Hydrogen peroxide, lanthanum
Dental Dental braces
Dermatologic Albinism, Behcet disease, scleroderma, vasculitis
Drug Side Effect Alosetron, ampicillin Oral, auranofin, azithromycin, aztreonam Injection, cefaclor, cefadroxil, cefamandole Nafate Injection, cefazolin Sodium Injection, cefepime Injection, cefepime, cefoperazone Sodium Injection, cefotaxime Sodium Injection, cefotetan Disodium Injection, cefoxitin Sodium Injection, cefpodoxime, ceftazidime Injection, ceftazidime, ceftizoxime Sodium Injection, ceftriaxone Sodium Injection, cefuroxime Sodium Injection, cephalexin, cephalosporin, cephradine Oral, cidofovir, cilansetron, clindamycin, co-amoxiclav, corticosteroid, darifenacin, desogestrel and ethinyl estradiol, dicloxacillin, dirithromycin, enoxacin, ertapenem, erythromycin and Sulfisoxazole, flucytosine, glycopyrrolate, hyoscyamine, idelalisib, imipenem and Cilastatin Sodium Injection, ipilimumab, ixabepilone, levofloxacin Oral, lincomycin hydrochloride, linezolid, lomefloxacin, loracarbef, methotrexate, miconazole Injection, moxifloxacin, nafcillin Sodium Injection, nivolumab, norfloxacin, ofloxacin injection, oxacillin Sodium Injection, oxcarbazepine, oxybutynin, peginterferon alfa-2a, penicillin, pergolide, piperacillin sodium injection, pramipexole, prednisolone, procyclidine, propantheline, pseudoephedrine, quinolone, ramosetron, reserpine, solifenacin, sparfloxacin, tegaserod
Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic Aganglionic megacolon, alpha 1-antitrypsin deficiency, autistic enterocolitis, bacterial gastroenteritis, cap polyposis, chemical colitis, colitis ulcerosa, collagenous colitis, colonic ischemia, Crohn's disease, diversion colitis, diverticulosis, Gerson diet, infectious colitis, inflammatory bowel disease, intestinal ischemia, irritable bowel syndrome, ischemic colitis, lymphocytic colitis, microscopic colitis, multiple organ dysfunction syndrome, primary sclerosing cholangitis, protein losing enteropathy, pseudomembranous colitis, radiation colitis, radiation proctitis, solitary rectal ulcer syndrome, toxic megacolon, typhlitis, ulcerative colitis
Genetic Albinism, alpha 1-antitrypsin deficiency
Hematologic No underlying causes
Iatrogenic Diversion colitis, EVAR, radiation colitis, radiation proctitis
Infectious Disease Bacillary dysentery, bacterial gastroenteritis, balantidium coli, campylobacter jejuni, chlamydia trachomatis, clostridium difficile, cryptosporidiosis, cytomegalovirus, entamoeba histolytica, escherichia coli O157:H7, giardiasis, infectious colitis, isosporiasis, neisseria gonorrhoeae, neonatal necrotizing enterocolitis, pigbel, salmonella, schistosoma, sepsis, shigella, strongyloides stercoralis, syphilis, treponema pallidum, yersinia enterocolitica
Musculoskeletal / Ortho Ankylosing Spondylitis
Neurologic No underlying causes
Nutritional / Metabolic Gerson diet, lysinuric protein intolerance, milk allergy, pigbel, soy protein
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Opthalmologic No underlying causes
Overdose / Toxicity No underlying causes
Psychiatric Autistic enterocolitis
Pulmonary Multiple organ dysfunction syndrome
Renal / Electrolyte Multiple organ dysfunction syndrome
Rheum / Immune / Allergy Ankylosing spondylitis, Behcet disease, common variable immunodeficiency, allergic colitis (Food protein-induced colitis), scleroderma, vasculitis, Ulcerative colitis
Sexual Typical STI such as Chlamydia trachomatis, Neisseria gonorrheae, Treponema pallidum, HSV, CMV, Unusual STI Shigella dysenteriae. Proctitis is more common among individuals who have receptive anal exposures (oral-anal, digital-anal, or genital-anal). Genital HSV and Chlamydia proctitis occur predominantly in individuals with HIV infection. Neisseria meningitidis causes proctitis among men who have sex with men and individuals with HIV infection.[10][10]
Trauma No underlying causes
Urologic No underlying causes
Miscellaneous Microscopic colitis

Causes in Alphabetical Order

Life Threatening Causes

Example include toxic megacolon, ischemic colitis, infectious colitis such as escherichia coli O157:H7 and shigella.

Screening

There is insufficient evidence to recommend routine screening of sexual partners of patients with sexually transmitted enteric pathogens.

Diagnosis

History and Symptoms

Laboratory Findings

Laboratory findings consistent with the diagnosis of proctitis include:

Other Imaging Findings

Colonoscopy

Anoscopy or sigmoidoscopy may be helpful in the diagnosis of proctocolitis. Findings on an sigmoidoscopy suggestive of proctocolitis include inflammation of the colonic mucosa extending to 12 cm above the anus and rectal ulcers.

Treatment

Medical Therapy

Acute proctocolitis among individuals with receptive anal exposure is often sexually-transmitted. Empiric antibiotic treatment should be started while awaiting for the results of laboratory tests for

patients presenting with anorectal exudate on anoscopy or positive Gram-stained smear of anorectal exudate or secretions polymorphonuclear leukocytes or if anoscopy or Gram stain is not available.[13]

Recommended Regimen for Acute Proctitis

Ceftriaxone 500 mg IM in a single dose

plus

Doxycycline 100 mg orally 2 times/day for 7 days

Surgery

Surgical intervention is not recommended for the management of proctocolitis.

Primary Prevention

As proctocolitis can be a sexually transmitted disease, effective measures for the primary prevention of proctocolitis include:

  • Counseling on safe sex practices
  • Avoiding contact with feces during sexual intercourse
  • Hand washing after handing objects or materials that have been in contact with the anal area (i.e., sex toys or barriers) and after touching the anal area.

Secondary Prevention

Effective measures for the secondary prevention of proctocolitis include:

  • Abstinence from sexual activity until the patient and their partners are successfully treated (i.e., completion of a 7-day regimen and resolution of symptoms)
  • Sexual partners with individuals treated for chlamydia or gonorrhea <60 days before the onset of symptoms should receive evaluation and empiric treatment of the causative infection
  • Testing for other sexually-transmitted diseases
  • In case of proctocolitis caused by chlamydia or Neisseria gonorrhea, retesting for the causative organism is recommended 3 months after completion of treatment.

References

  1. ↑ 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control and Prevention (2015).http://www.cdc.gov/std/tg2015/proctitis.htm Accessed on August 29, 2016
  2. ↑ Hamlyn E, Taylor C (2006). "Sexually transmitted proctitis". Postgrad Med J. 82 (973): 733–6. doi:10.1136/pmj.2006.048488. PMC 2660501. PMID 17099092.
  3. ↑ WikiMedia Commons https://commons.wikimedia.org/wiki/File:Gastro-intestinal_tract.png. Accessed on September 09, 2016
  4. ↑ Nowak-Węgrzyn A (2015). "Food protein-induced enterocolitis syndrome and allergic proctocolitis". Allergy Asthma Proc. 36 (3): 172–84. doi:10.2500/aap.2015.36.3811. PMC 4405595. PMID 25976434.
  5. ↑ Pumberger W, Pomberger G, Geissler W (2001). "Proctocolitis in breast fed infants: a contribution to differential diagnosis of haematochezia in early childhood". Postgrad Med J. 77 (906): 252–4. PMC 1741985. PMID 11264489.
  6. ↑ Alfadda AA, Storr MA, Shaffer EA (2011). "Eosinophilic colitis: epidemiology, clinical features, and current management". Therap Adv Gastroenterol. 4 (5): 301–9. doi:10.1177/1756283X10392443. PMC 3165205. PMID 21922029.
  7. ↑ 7.0 7.1 Hauer-Jensen M, Denham JW, Andreyev HJ (2014). "Radiation enteropathy--pathogenesis, treatment and prevention". Nat Rev Gastroenterol Hepatol. 11 (8): 470–9. doi:10.1038/nrgastro.2014.46. PMC 4346191. PMID 24686268.
  8. ↑ Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.
  9. ↑ Khan AM, Faruque AS, Hossain MS, Sattar S, Fuchs GJ, Salam MA (2004). "Plesiomonas shigelloides-associated diarrhoea in Bangladeshi children: a hospital-based surveillance study". J Trop Pediatr. 50 (6): 354–6. doi:10.1093/tropej/50.6.354. PMID 15537721.
  10. ↑ 10.0 10.1 {{cite journal| author=Gutierrez-Fernandez J, Medina V, Hidalgo-Tenorio C, Abad R| title=Two Cases of Neisseria meningitidis Proctitis in HIV-Positive Men Who Have Sex with Men.<ref name="pmid24687130">Pallawela SN, Sullivan AK, Macdonald N, French P, White J, Dean G; et al. (2014). "Clinical predictors of rectal lymphogranuloma venereum infection: results from a multicentre case-control study in the U.K." Sex Transm Infect. 90 (4): 269–74. doi:10.1136/sextrans-2013-051401. PMC 4033117. PMID 24687130.
  11. ↑ Mohan P, Ramakrishnan MK, Revathy S, Jayanthi V (2011). "Granulomatous colitis in oculocutaneous albinism". Dig Liver Dis. 43 (1): e1. doi:10.1016/j.dld.2009.09.006. PMID 19833565.
  12. ↑ Gié O, Clerc D, Giulieri S, Demartines N (2014). "[Clostridial colitis: diagnosis and strategies for management]". Rev Med Suisse. 10 (434): 1309–13. PMID 25073304.
  13. ↑ Bissessor M, Fairley CK, Read T, Denham I, Bradshaw C, Chen M (2013). "The etiology of infectious proctitis in men who have sex with men differs according to HIV status". Sex Transm Dis. 40 (10): 768–70. doi:10.1097/OLQ.0000000000000022. PMID 24275725.
  14. ↑ Mohrmann G, Noah C, Sabranski M, Sahly H, Stellbrink HJ (2014). "Ongoing epidemic of lymphogranuloma venereum in HIV-positive men who have sex with men: how symptoms should guide treatment". J Int AIDS Soc. 17 (4 Suppl 3): 19657. doi:10.7448/IAS.17.4.19657. PMC 4225278. PMID 25394161.

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