Colitis

WikiDoc Resources for Colitis
Articles
Most recent articles on Colitis Most cited articles on Colitis Review articles on Colitis Articles on Colitis in N Eng J Med, Lancet, BMJ
Media
Powerpoint slides on Colitis Images of Colitis Photos of Colitis Podcasts & MP3s on Colitis Videos on Colitis
Evidence Based Medicine
Cochrane Collaboration on Colitis Bandolier on Colitis TRIP on Colitis
Clinical Trials
Ongoing Trials on Colitis at Clinical Trials.gov Trial results on Colitis Clinical Trials on Colitis at Google
Guidelines / Policies / Govt
US National Guidelines Clearinghouse on Colitis NICE Guidance on Colitis NHS PRODIGY Guidance FDA on Colitis CDC on Colitis
Books
Books on Colitis
News
Colitis in the news Be alerted to news on Colitis News trends on Colitis
Commentary
Blogs on Colitis
Definitions
Definitions of Colitis
Patient Resources / Community
Patient resources on Colitis Discussion groups on Colitis Patient Handouts on Colitis Directions to Hospitals Treating Colitis Risk calculators and risk factors for Colitis
Healthcare Provider Resources
Symptoms of Colitis Causes & Risk Factors for Colitis Diagnostic studies for Colitis Treatment of Colitis
Continuing Medical Education (CME)
CME Programs on Colitis
International
Colitis en Espanol Colitis en Francais
Business
Colitis in the Marketplace Patents on Colitis
Experimental / Informatics
List of terms related to Colitis

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]

Synonyms and keywords: Proctocolitis, Proctitis, Enterocolitis.

Overview

Colitis is the inflammation of the colon, that can be either acute or chronic. Causes of colitis include infectious causes such as Chlamydia trachomatis, Neisseria gonorrhoeae, Shigella dysenteriae, HSV, allergic cause( food potein-induced proctocolitis) and radiation. Colitis may co-exist with enteritis (inflammation of the small bowel), proctitis (inflammation of the rectum) or both. The mainstay of therapy for infectious proctocolitis is antimicrobial therapy. The preferred regimen is a combination of Ceftriaxone and Doxycycline.

Classification

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

Classification by etiology

Classes of Colitis	Disorders
Autoimmune	Ulcerative colitis Crohn's colitis
Allergic	Food protein-induced proctocolitis (FPIP)
Infectious colitis	Pseudomembranous colitis (Clostridium difficile) Enterohemorrhagic colitis (Shigella dysenteriae or Shigatoxigenic group of Escherichia coli (STEC)) Protozoan (Entamoeba histolytica) Chlamydia proctocolitis
Idiopathic	Lymphocytic colitis Collagenous colitis
Iatrogenic	Diversion colitis Chemical colitis Radiation colitis
Vascular	Ischemic colitis
Drug induced	NSAIDs proctocolitis
Unclassifiable	Indeterminate colitis (features of both Crohn's disease and ulcerative colitis) Atypical colitis

Classification by Anatomy

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

• Proctitis when it involves the rectum
• Colitis when it involves the inflammation is limited to the colon
• Proctocolitis when it involves the rectum and colon (usually the distal part of the colon 12cm to 15cm above the anus (sigmoid colon)
• Enterocolitis when it involves the small intestine in addition to the colon

Classification by Age

• Infantile: More common in early infancy (first six months).
• Adults

Classification by duration of symptoms

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

Notes:

• Fulminant colitis is any colitis with a rapid downhill clinical course; in addition to the diarrhea, fever, and anemia seen in colitis, the patient has severe abdominal pain and presents a clinical picture similar to that of septicemia, where shock is present.
• Irritable bowel syndrome, a separate disease, has been called spastic colitis or spastic colon. This name causes confusion, since colitis is not a feature of irritable bowel syndrome.
• 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.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

• Crohn's disease
• Inflammatory bowel disease
• Ischemic colitis
• Pseudomembranous colitis
• Ulcerative colitis

Causes by Organ System

Cardiovascular	EVAR, vasculitis
Chemical / poisoning	Chemical colitis, 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, milk allergy, scleroderma, vasculitis
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	No underlying causes
Miscellaneous	Multiple organ dysfunction syndrome

Causes in Alphabetical Order

The unnamed parameter 2= is no longer supported. Please see the documentation for {{columns-list}}.

3

Diagnosis

Symptoms

• Diarrhea
• Abdominal pain
• Rectal bleeding

Physical Examination

• Abdominal tenderness
• Fever
• Hypotension
• Tachycardia

Diagnostic Tests

Colitis is associated with the following findings:

• Swelling of the colon tissue
• Bleeding
• Erythema (redness) of the surface of the colon
• Ulcerations of the colon

Common tests which reveal these signs include:

• X-rays of the colon
• Testing the stool for blood and pus
• Sigmoidoscopy
• Colonoscopy

Additional tests include stool cultures and blood tests, including blood chemistry tests. A high erythrocyte sedimentation rate (ESR) is one typical finding in acute exacerbations of colitis.

Treatment

Medical Therapy

Treatment of colitis may include the 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.

Changes in diet can be effective at treating the symptoms of colitis and easing the side effects. These can include reducing the intake of carbohydrates, lactose products, soft drinks, and caffeine. This approach has been championed by Elaine Gottschall.

Hygienic and naturopathic doctors have taken the diet approach further, attributing bowel inflammation to toxemia stemming from high-protein, fatty diets and other dietary irritants. Changing to a low-fat, minimally-processed, whole-foods diet per the Natural Hygiene self-healing system has been effective in eliminating symptoms and rebuilding health. Dr. Zarin Azar, MD,, is one advocate of this healing system.

Infliximab (or REMICADE) - a drug originally produced to treat Rheumatoid Arthritis - has recently been approved for the treatment of Colitis where traditional treatments have failed. REMICADE is a biologic therapy that recognizes, attaches to, and blocks the action of a protein in your body called tumor necrosis factor alpha (TNF-alpha). TNF-alpha is made by certain blood cells in your body. It is administered through a series of infusions.

Surgery

Approximately half of patients with fulminant colitis require surgery. Surgery usually entails removing the colon and bowel and creating a "pouch" with portions of the small intestine.

Pathophysiology

The pathophysiology of proctocolitis depends on the cause. Some pathogenetic mechanisms are not clearly understood.

Pathogenesis

Hypothesis regarding pathogenesis of Allergic proctocolitis

• It is a non IgE immunological reaction against food protein antigens which is thought to be T cell mediated.
  • T cell (CD8 and TH-2) results in release of proinflammatory cytokines, such as TNF, attracting Eosinophils mainly and other polymorphonuclear cells (PMN) to the intestinal tract and subsequent inflammation.
  • Genetic influence may have a role to play, may be seen in families.

• Could also be an autoimmune disease. Atypical p antineutrophil cytoplasmic antibodies (a-pANCA) have been seen in some infants with intestinal infiltration by Neutrophils.

Pathogenesis of Infectious proctocolitis

• Acquired commonly as a sexually transmitted infection (STI) among individuals who practice unsafe anal sex.
• The pathogens are transmitted directly through overt abrasions or microabrasions in the rectal mucosa or indirectly during oral-anal contact..
• In children, enteric organisms that cause proctocolitis can be acquired through faeco-oral contamination. As few as 100 bacterial cells can be enough to cause an infection.
• May also occur following antibiotic use, especially broad spectrum antibiotics.

Chlamydia trachomatis

• • Inoculation and replication of Chlamydia trachomatis serovars L1, L2, or L3 depends on alternation between two forms of the bacterium: the infectious elementary body (EB) and noninfectious, replicating reticulate body (RB).
  • The EB form is responsible for inoculation with C. trachomatis.
  • The C. trachomatis EB enters the body during sexual intercourse or by crossing epithelial cells of mucous membranes.
  • Once inside the host cell, EBs immediately start differentiating into reticulate bodies (RBs) that undergo replication.
  • The process of endocytosis and accumulation of RBs within host epithelial cells causes host cell destruction (necrosis) which leads to the formation of a papule at the site of inoculation which may ulcerate, depending on the extent of infection and number or EBs transmitted.

Shigella specie

• • Shigella first invades the epithelial cells of the large intestine (the rectosigmoid mucosa) by using M cells as entry ports for transcytosis. Shigella then invades macrophages and induces cellular apoptosis, which results in inflammation, generation of proinflammatory cytokines, and recruitment of polymorphonuclear neutrophils (PMNs).

Campylobacter

• • Regarding Campylobacter jejuni proctocolitis the exact pathogenesis by which it causes proctocolitis after transmission is not fully understood.
  • However, it is hypothesized that requirement for C. jejuni virulence include (1) motility, (2) drug resistance, (3) host cell adherence, (4) host cell invasion, (5) alteration of the host cell signaling pathways, (6) induction of host cell death, (7) evasion of the host immune system defenses, and (9) acquisition of iron which serves as a micronutrient for growth and works as a catalyst for hydroxyl radical formation.
  • C. jejuni is known to also secrete proteins that may contribute to the ability of the bacterium to invade the host epithelial cells.

Entameoba histolytica

• • Following transmission of Entameoba histolytica, the trophozoites undergo excystation in the small intestine, after which it migrates to the large intestine using pseudopods.
  • In the large intestine, the trophozoites invades the intestinal mucosa into the bloodstream. Simultaneously, they form resistant cysts in the large intestines that are then excreted in human stools.
  • E. histolytica trophozoites secrete proteases, which induce the release of mucin from goblet cells, resulting in glandular hyperplasia.
  • E. histolytica is also said to contain glycosidases that cleave glycsolyated mucin molecules, resulting in mucin degradation.

Pseudomembranous colitis

• • Under normal condition, there is usually a balance in the normal intestinal commensals.
  • Following broad spectrum systemic antibiotics use, especially penicillin-based antibiotic such as amoxicillin, cephalosporins, fluoroquinolones and macrolides this balance is affected with killing susceptible bacteria and allowing for proliferation of the remaining non-susceptible bacteria.
  • Clostridium difficile, an obligate anaerobic gram positive spore forming bacillus tends to proliferate under such conditions and is the usual cause (almost 99 percent of cases) pseudomembranous colitis.
  • Clostridium difficile, produces toxin A (enterotoxin), toxin B (cytotoxin), and binary toxin. These toxins are required for it to colonize the gut, intestinal cell disruption, attract inflammatory cells and cause disease.
  • Other reported causes of pseudomembranous colitis include infections such as Staphylococcus aureus, Yersinia specie, Salmonella specie, Shigella specie, NSAIDs such as indomethacin, chemotherapeutic drugs like - cisplatin and inflammatory bowel disease.

Pathogenesis of radiation proctocolitis

• Occur following radiation treatment for pelvic tumors.
• More common with radiation doses higher than 45Gy.
• The DNA is the main site of damage. May also affect RNA, proteins and cell membranes.
  • Injury occurs few hours to days, up to three months after irradiation in acute radiation proctocolitis. It affects rapidly dividing cells of the epithelium and mucosa.
  • This leads to cell death, recruitment and activation of polymorphonuclear (PMN) inflammatory cells, mucosal edema and damage to small blood vessels.
  • Usually self limiting.
  • In chronic radiation proctocolitis, mesenchymal tissue is involved.
  • The damage is progressive with atrophy of the mucosa, fibrosis of the intestinal wall, obliteration of small arteries, chronic ischemia, ulcers, and fistula formation.
  • This occurs usually after three months to years.

Pathogenesis of ischemic proctocolitis

• Rare cause of proctocolitis, due to rich collateral vascular supply to the rectum.
• Seen in the elderly with compromised cardiovascular status.
• The exact pathogenesis remains unclear. It is characterized by polymorphonuclear (PMN) cells infiltration, extensive mucosal necrosis and bleeding, submucosa edema and absence of lymphocytes and plasma cells in the deeper aspect of the lamina propria.

Hypotheses related to the pathogenesis of ulcerative proctocolitis

• Exact pathogenesis not fully clear.
• It is a chronic inflammatory disease affecting the innermost part of the lamina propria.
• An interplay between hyper-reactive immune system, gut microbiota, Impaired gut mucosa barrier, genetic factors, and environmental factors.
• Cytotoxic T cells and autoantibodies (IgG and IgE) against the colon, cytoskeleton and bowel smooth muscles are seen.
• The balance in gut microbes is shifted toward pathogenic microorganism, including colonic sulphate reducing bacteria.
• About 160 genetic loci have been identified for inflammatory bowel disease (IBD) with newer potential loci being identified. Some of these loci are associated with impaired mucosal barrier function.

Other pathogenetic mechanisms of proctocolitis=

• NSAIDS can also cause proctocolitis. The mechanism is not completely understood.
  • Inhibits cyclooxygenase and thus prostaglandin production. Prostaglandin helps maintain mucosal integrity.
  • NSAIDS also impair oxidative phosphorylation, increasing risk of oxidative injury to the gut.
  • Direct damage to the intestinal mucosa has been suggested in NSAID related injury since the rectum is often spared.
  • It is also hypothesized that there is increased intestinal permeability with to antigenic materials following NSAID use, causing activation of the immune system and subsequent inflammation.

• Glutaraldehyde, a disinfectant used in cleaning endoscopes is an uncommon cause of proctocolitis.
  • Proctocolitis results from direct mucosa contact with the chemical.
  • Improper cleaning of the endoscopes allows the glutaraldehyde disinfectant to remain, subsequently causing a chemical proctocolitis.
  • The primary mucosa toxin in glutaraldehyde is not fully known. However, it may be related to the aldehyde.

Genetics

There is no specific genetic cause for proctocolitis. However, genetic predisposition may play a role in some causes.

Associated conditions

• Human Immunodeficiency Virus (HIV)/ AIDS
• Arterosclerosis
• Artificial infant feeding

Gross pathology

• Gross pathological findings are often limited to the rectosigmoid region and show evidence of acute or chronic inflammation with or without necrosis, ulcers and hemorrhage. In addition, specific changes based on the cause may be seen.
  • Food protein-induced proctocolitis (FPIP) shows patchy or diffuse erythematous and friable mucosa. Characteristic circumscribed nodular hyperplasia with central pit-like erosions and ulcers may also be seen.
  • Pseudomembranous colitis. The gross pathologic finding is presence of diffuse, small, 2 to 10mm, raised yellowish (or whitish) lesions. Mucosa in between lesions may appear normal. Lesions may merge giving rise to a characteristic "pseudomembrane" layer over the mucosa.
  • Ulcerative colitis. On gross pathology, the inflammation is seen in the innermost part of the lamina propria.
  • Ischemic proctocolitis shows marked mucosal congestion with areas of necrosis and ulceration on gross patholgy.

• 

  Allergic proctocolitis

• 

  Radiation Proctitis

• 

  Pseudomembranous colitis. (WC)

• 

  Pseudomembranous colitis.

• 

  Ulcerative colitis.

Microscopic pathology

• Food protein-induced proctocolitis is characterized by marked eosinophil infiltrates in the mucosa of the rectosigmoid area.
  • The mucosa architecture is usually preserved on microscopy.
• In pseudomembranous colitis microscopy shows
  • Heaped necrotic tissue
  • Polymorphonuclear neutrophils in the lamina propria, breeching the epithelium like a "volcanic eruption".
  • With or without capillary thrombi
• On microscopy, the characteristic finding in ulcerative colitis is presence of lymphocytes and plasma cells in the deeper aspect of the lamina propria (basal lymphoplasmacytosis).
  • Crypt architecture is destroyed.
  • Abscesses may also be seen in the crypts.

• 

  Ulcerative colitis. H&E staining showing crypt abscess, a characteristic finding in ulcerative colitis

• 

  Ulcerative colitis. H&E stain showing marked lymphocytic infiltration (blue/purple) of the intestinal mucosa and distortion of the architecture of the crypts.

• 

  Ischemic colitis. H&E staining showing changes seen in ischemic colitis

• 

  Pseudomembranous colitis. H& E staining showing pseudomembranes in Clostridium colitis

Causes

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

Causes of proctocolitis by Organ System

Cardiovascular	Ischemic colitis
Chemical/Poisoning	Glutaraldehyde, Coffee enema, Hydrogen peroxide
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	Chlorpropamide; NSAIDS such as Flufenamic acid, mefenamic acid, naproxen, ibuprofen, indomethacin; Antibiotics (especially penicillins, cephalosporins, fluoroquinolones, clindamycin) but any antibiotic can cause it and penicillin
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	No underlying causes
Iatrogenic	Radiation, Glutaradehyde
Infectious Disease	Chlamydia trachomatis, Neisseria gonorrheae, Treponema pallidum, HSV, CMV, Shigella dysenteriae, Salmonella, Enterohemorrhagic Escherichia coli, Clostridium difficile, Campylobacter species, Yersinia, Entameoba histolytica
Musculoskeletal/Orthopedic	No underlying causes
Neurologic	No underlying causes
Nutritional/Metabolic	Food protein-induced proctocolitis
Obstetric/Gynecologic	No underlying causes
Oncologic	No underlying causes
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal/Electrolyte	No underlying causes
Rheumatology/Immunology/Allergy	Food protein-induced protocolitis, Ulcerative colitis
Sexual	Chlamydia trachomatis, Neisseria gonorrheae, Treponema pallidum, HSV, CMV, 'Shigella dysenteriae
Trauma	No underlying causes
Urologic	No underlying causes
Miscellaneous	Microscopic colitis

Causes in Alphabetical Order

• Chlorpropamide

• Disease B

• Disease C

Differentiating Colitis from Other Diseases

Causes of proctocolitis are diverse and may overlap with other disease. The differential diagnosis of proctocolitis can be classified into two according to age group.

Differential diagnosis in Infants

• Swallowed maternal blood syndrome
• Anorectal fissure
• Necrotizing enterocolitis especially in preterm babies
• Vitamin K dependent hemorrhage
• Other Coagulopathies: (hereditary such as coagulation factor deficiency or acquired such as disseminated intravascular coagulopathy)
• Food protein-induced enterocolitis
• Intussusception
• Gastrointestinal Infections
• Meckel diverticulum
• Intestinal duplication cysts
• Vascular malformations
• Inflammatory bowel disease(early onset)
• Hirschsprung disease complicated by enterocolitis
• Volvolus
• Gastro-duodenal ulcers
• Gastrointestinal duplication cyst
• Liver disease with clotting factor deficiency
• Lymphonodular hyperplasia

Differential diagnosis in Infants

• Colorectal malignancy
• Crohn's disease
• Behcet's disease
• Arteriovenous malformation
• Diverticuclosis
• Infection
• Coagulopathy
• Systemic lupus erythematosus(SLE)

Epidemiology and Demographics

The causes of proctocolitis are diverse and overlap with other diseases.

Prevalence and Incidence

• The exact prevalence and incidence of proctocolitis is difficult to establish due to diverse causes and appropriate diagnostic criteria
• The prevalence and incidence of proctocolitis may be influenced by the patient’s age, genetic factors and race

• Food protein-induced proctocolitis (FPIP): Exact prevalence unknown
  • Reported to be 1.6 in 1000 children under 1 year for cow-milk protein allergy in a population based study
  • Prevalence of FPIP is documented to range from a low of 16 percent to a high of 64 percent among infants with rectal bleeding
  • Sixty percent of infants with FPIP are babies who are on exclusive breastfeeding
  • FPIP is the most common cause of non-infectious colitis in infancy
• The prevalence of proctocolitis from an adults study in a developed country between 1979 and 1983 was 58.4 cases per 100,000
  • The incidence of proctocolitis from the same study was 6.8 cases per 100,000 individuals per year
• Regarding radiation proctitis the incidence is not fully known due in part to no standard definition and method of reporting
  • The incidence of radiation proctitis following external beam radiation studies range from 2% to 39%, brachytherapy 8% to 13%, while that of intensity-modulated radiation therapy (IMRT) range from 1% to 9%
  • Also, the incidence of acute radiation proctitis occurs in 20% of individuals undergoing radiation therapy, while chronic radiation proctitis occurs in 2% to 20% of individuals having radiation therapy
• Ischemic proctocolitis makes up 3% to 5% of cases of ischemic injury to the colon

Age

• Food protein-induced proctocolitis is mainly a disease of infants, with onset usually in the first two to three months of life. An adolescent form may develop later.
• The incidence of infectious proctocolitis that is not acquired as a sexually transmitted infection (STI) is higher among pediatric age group
• Ischemic proctocolitis is more common among the elderly with average age range of 65 to 70 years
• Other causes of proctocolitis are more common among the adult population than pediatric age group

Gender

• Infectious proctocolitis from STI is more common in men
• The other causes of proctocolitis have no sex predilection

Race

• There is no racial predilection for proctocolitis

Risk Factors

Common risk factors for developing proctocolitis include:

Risk factors for food protein-induced proctocolitis (FPIP)

• Family history of atopy/ previous sibling with FPIP
• Use of formula feeds

Risk factors for ischemic proctocolitis

• Elderly or debilitated patients who have multiple comorbidities.
• Cardiovascular disease including atherosclerotis and peripheral vascular disease
• Diabetes mellitus
• Aortoiliac surgery
• Hemodialysis
• Pulmonary vascular disease
• Shock
• Sepsis

Risk factors for radiation proctocolitis

• Dose of radiation > 70 Gy
• Diabetes
• Peripheral vascular disease
• Co-existing inflammatory bowel disease
• HIV/AIDS

Risk factors for sexually transmitted infectious proctocolitis

• Men who have sex with men
• Unprotected anal sex
• HIV/AIDS
• Previously diagnosed sexually transmitted infection
• Casual sex acquaintance especially meeting on the internet/ multiple
• Recent foreign travel
• Co-existing ulcerative colitis

Risk factors for Clostridium difficile proctocolitis

• Elderly
• Use of antimicrobials especially broad spectrum antibiotics such as penicillins, cephalosporins, clindamycin and fluoroquinolones
• Chemotherapy
• Immune hypo-function
• Gastrointestinal surgery including proctocolectomy
• Mechanical bowel preparation
• Constipation
• Gut ischemia
• Hirschsprung disease
• Altered gut motility
• Malnutrition

Risk factors for drug/ chemical related proctocolitis

• Elderly age group
• Prolonged medication use e.g NSAIDs
• Improper cleaning/ rinsing of glutaraldehyde disinfectant used in endoscopes

Screening

Proctocolitis in MSM

• According to the CDC routine screening, at least annually for common sexually transmitted diseases should be done in sexually active MSM
• A test for rectal infection with N. gonorrhoeae and C. trachomatis in men who have had receptive anal intercourse during the preceding year (using nucleic acid amplification testing (NAAT) of a rectal swab is the preferred approach)
• More frequent STD screening at 3-6 month intervals is indicated for MSM who have multiple or anonymous partners and in those who use illicit drug (particularly methamphetamine use) or whose sex partners participate in these activities

Other causes of proctocolitis

• Screening is not recommended for the other causes of proctocolitis

Natural History, Complications, and Prognosis

Natural History

The natural history of proctocolitis depends on the cause Food protein-induced proctocolitis (FPIP)

• The symptoms of FPIP typically develop in the first two or three months of life in an exclusively breastfed infant. Symptoms resolve within 48hrs to 96 hrs following avoidance of trigger protein. Spontaneous resolution of symptoms may occur in 20% of the children without elimination of the offending protein. Most infants will be able to tolerate the offending protein by 1 to 3 years of age.

• The natural history of FPIP that develop in adolescence or early adulthood is not fully characterized

Ischemic colitis

The presentation depends on the degree of bowel involvement. Mortality is high among those with full thickness bowel ischemia.

Treatment

Medical Therapy

• All patients with proctocolitis should be treated.
• Treatment of proctocolitis is similar to that of proctitis.
• Generally, the following regimen is recommended:

Preferred regimen: Ceftriaxone 250 mg IM AND Doxycycline 100 mg PO bid for 7 days

To view additional treatment and special considerations for the management of proctitis/proctocolitis, click here.

See also

• Colitis
• Proctitis

References

Template:WH Template:WS Template:Jb1