Colitis

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List of terms related to Colitis

For more information on allergic colitis, please click here
For more information on infectious colitis, please click here
For more information on ischemic colitis, please click here
For more information on chemical colitis, please click here
For more information on drug-induced colitis, please click here
For more information on radiation colitis, please click here

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, allergy (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 colitis. 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 allergic proctocolitis (FPIAP)
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 NSAID-induced colitis
Vascular	Ischemic colitis
Drug induced	NSAID-induced colitis
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

Schematic of Anatomical Classification of Colitis

Affected anatomical areas:
*Regions 4 to 6: Enterocolitis
*Region 6: Colitis
*Regions 6 to 8: Proctocolitis
*Regions 7 to 8:Proctitis

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.

Pathophysiology

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

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

• 

  Allergic proctocolitis

• 

  Radiation Proctitis

• 

  Pseudomembranous colitis. (WC)

• 

  Pseudomembranous colitis.

• 

  Ulcerative colitis.

Microscopic pathology

• 

  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

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 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
Trauma	No underlying causes
Urologic	No underlying causes
Miscellaneous	Microscopic colitis

Causes in Alphabetical Order

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3

Life Threatening Causes

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

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.

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)

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

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