Colitis

Colitis Microchapters
Overview
Classification Allergic colitis Infectious colitis Ischemic colitis Drug-induced colitis Chemical colitis Radiation colitis
Differential Diagnosis
Causes

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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: Colitis, 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.

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.

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).
• Adult

Classification by duration of symptoms

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

Differentiating Colitis from Other Diseases

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

• 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
• Upper 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 Adults

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

Differentiating between different forms 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:

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	+	+	++			+			++		+

Diagnostic Tests

Common tests which may reveal diagnosis of colitis include:

• Abdominal X-rays
• 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 exacerbation of 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.

Images

Gross pathology

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  Allergic proctocolitis

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  Radiation Proctitis

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  Pseudomembranous colitis. (WC)

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  Pseudomembranous colitis.

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  Ulcerative colitis.

Microscopic pathology

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  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

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

References

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