Noninfectious colitides: collagenous colitis, lymphocytic colitis, diversion colitis, and chemically induced colitis

Approach to the adult patient with chronic diarrhea: A literature review

Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or malabsorption causes, pancreatobiliary diseases, and functional or gut-brain axis disorders associated with dysbiosis or gastrointestinal motility alterations. Due to such a broad differential diagnosis, it is important to categorize chronic diarrhea into five main groups: drug side effect, postoperative, postinfectious, malabsorptive, inflammatory, and functional. The present review is a narrative analysis of the diagnostic approach, emphasizing key aspects of the clinical history, the utility of biomarkers (in breath, stool, urine, and serology) and malabsorption and motility tests, the role of radiologic and endoscopic studies, and the most common histologic findings. A diagnostic algorithm aimed at determining etiology and personalizing therapy is also proposed.

Approach to the adult patient with chronic diarrhea: a literature review

Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or malabsorption causes, pancreatobiliary diseases, and functional or gut-brain axis disorders associated with dysbiosis or gastrointestinal motility alterations. Due to such a broad differential diagnosis, it is important to categorize chronic diarrhea into five main groups: drug side effect, postoperative, postinfectious, malabsorptive, inflammatory, and functional. The present review is a narrative analysis of the diagnostic approach, emphasizing key aspects of the clinical history, the utility of biomarkers (in breath, stool, urine, and serology) and malabsorption and motility tests, the role of radiologic and endoscopic studies, and the most common histologic findings. A diagnostic algorithm aimed at determining etiology and personalizing therapy is also proposed.

Inflammatory polyps occur more frequently in inflammatory bowel disease than other colitis patients

BACKGROUND

Colitis is generally considered a risk factor for colon neoplasia. However, not all types of colitis seem to have equal neoplastic transformation potential.

AIM

To determine the prevalence of colorectal polyps in a predominantly African American population with inflammatory bowel disease (IBD) and Non-IBD/Non-Infectious Colitis (NIC).

METHODS

We retrospectively evaluated medical records of 1060 patients previously identified with colitis at Howard University Hospital, based on ICD-10 code. Among these, 485 patients were included in the study: 70 IBD and 415 NIC based on a thorough review of colonoscopy, pathology and clinical reports. Logistic regression analysis was applied to estimate the risk of polyps in patients with IBD compared to those with NIC after adjusting for age and sex. A subgroup analysis within the IBD group was performed.

RESULTS

Of the 485 patients, 415 were NIC and 70 were IBD. Seventy-three percent of the NIC patients and 81% of the IBD patients were African Americans. Forty six percent of IBD and 41% of NIC cases were male. IBD patients were younger than NIC patients (median age of 38 years vs. 50, P < 0.001). The prevalence of all types of polyps was 15.7 and 8.2% in the IBD and NIC groups, respectively (P = 0.045). Among patients with polyps, the prevalence of inflammatory polyps was higher in the IBD group (55%) compared to the NIC group (12%). After adjusting for age, sex and race, odds ratio of inflammatory polyps in IBD patients was 6.0 (P = 0.016). Adenoma prevalence was 4.3% (3/70) in IBD patients and 3.9% (16/415) in the NIC patients (p = 0.75). The anatomic distribution of lesions and colitis shows that polyps occur predominantly in the colitis field regardless of colitis type. More polyps were present in the ulcerative colitis patients when compared to Crohn's disease patients (27% vs. 5%, P < 0.001) within the IBD group.

CONCLUSION

Our study shows that inflammatory polyps are more common in IBD patients when compared to NIC patients. Most polyps were in the same location as the colitis.

The surgical treatment of acute and severe diversion colitis mimicking ulcerative colitis: a case report

BACKGROUND

Diversion colitis (DC) is characterized by nonspecific inflammation in the remaining colon or rectum, and loss of the fecal stream plays a major role in the disease's development. Although the majority of patients are asymptomatic, medical and/or surgical treatment is required for those who are symptomatic. There is a particular interest on how to manage patients with acute and severe clinical presentations, but the pathogenesis is not fully understood. We report the rare case of a man with acute and severe DC mimicking ulcerative colitis (UC) with extra-intestinal manifestations that was successfully managed with surgical treatment.

CASE PRESENTATION

A 68-year-old man with a history of laparoscopic intersphincteric resection of the rectum with diverting loop ileostomy for lower rectal cancer suffered from anastomotic stenosis requiring repeated endoscopic dilatation. His loop stoma was not reversed because these treatments were unsuccessful. He denied having a history of inflammatory bowel disease. Twelve years postoperatively, he developed a perineal abscess requiring drainage. Subsequently, he developed a high-grade fever, bloody discharge per anus, and skin ulcers in the right ankle and around the stoma. Because culture tests were negative for bacteria, it was deemed that his acute illness reflected an inflammatory response rather than an infectious disease. Colonoscopy revealed anastomotic stenosis, a colonic fistula, and mucosa that hemorrhaged easily, with lacerations. A pathological examination with biopsy revealed inflammatory infiltration without malignancy. After reviewing the patient's clinical episodes and discussing the case with physicians in multiple specialties, we performed total colectomy with end ileostomy in accordance with the abdominoperineal resection. The postoperative course was uneventful. A resected specimen showed atrophic mucosa with the disappearance of haustra in the distal colon, as well as edematous and dilated mucosa in the proximal colon. The pathological diagnosis was suggestive of UC, including erosion and ulceration in edematous wall, crypt abscess, and inflammatory infiltration into the mucosa. The skin ulcers in the right ankle and around the stoma healed over time.

CONCLUSIONS

DC can eventuate in a long-term period after fecal diversion surgery, possibly with extra-intestinal manifestations mimicking UC. Surgical treatment seems feasible for patients with acute and severe DC.

Noninfectious colitides

There are numerous etiologic and pathogenic mechanisms associated with colitis, ranging from infectious to noninfectious colitis. However, despite their different causes, their presentations are often similar making it difficult to formulate the correct diagnosis. This article describes the presentation, endoscopic and pathological findings of six different noninfectious colitides: diversion colitis, neutropenic enterocolitis, disinfectant colitis, corrosive colitis, nonsteroidal anti-inflammatory drug and salicylate-induced colitis, and toxic epidermal necrolysis. In addition, this article discusses the management and current treatment options for these six colitides.

Microscopic colitis (lymphocytic and collagenous), eosinophilic colitis, and celiac disease

Multiple tests are needed to diagnose a patient with noninfectious diarrhea. Some patients will be mistakenly labeled as diarrhea-predominant irritable bowel syndrome (IBS-D) because of nonspecific computed tomographic scans and grossly normal endoscopic findings. It is crucial to understand other less common pathologies to avoid these instances of misdiagnosis. This article focuses on microscopic colitis (MC), eosinophilic colitis (EC), and celiac disease. MC is an inflammatory condition of the colon that presents with two subtypes, only to be differentiated by histology. EC is a rare chronic inflammatory process. Depending on the extent of the disease, it can present with mild diarrhea, malabsorption, or at its worst, cause obstruction and perforation. Celiac disease affects the small bowel, but interestingly can present similarly to colitis. Both MC and EC respond to oral budesonide. Patients with celiac disease improve on gluten-free diets. These treatments are distinctly different from typical IBS-D care plans.

Transverse loop colostomy and colonic motility

BACKGROUND

The motility of the defunctionalized colon, distal to transverse loop colostomy, has never been studied "in vivo." The aim of our study was to evaluate the influence of transverse loop colostomy on colonic motility.

METHODS

Thirteen patients were examined before stoma closure by means of clinical evaluation and colonic manometry; we studied both the right and distal colon in both fasting and fed patients in order to detect motor activity.

RESULTS

Quantitative and qualitative manometric analyses showed that the diverted colon had motor activity even if no regular colonic motor pattern was observed. The spreading of aboral propagated contractions (PCs) was sometimes recorded from the right colon to the distal colon. The response of the proximal and distal colon to a standard meal, when compared to fasting values, increased more than 40 and 35 %, respectively. Stool and gas ejections from the colostomy were never related to a particular type of colonic motility: Motor quiescence such as PCs was chaotically related to stool escape.

CONCLUSIONS

In conclusion, motility of the defunctionalized colon is preserved in patients with transverse loop colostomy.

Dietary flaxseed intake exacerbates acute colonic mucosal injury and inflammation induced by dextran sodium sulfate

Flaxseed (FS), a dietary oilseed, contains a variety of anti-inflammatory bioactives, including fermentable fiber, phenolic compounds (lignans), and the n-3 polyunsaturated fatty acid (PUFA) α-linolenic acid. The objective of this study was to determine the effects of FS and its n-3 PUFA-rich kernel or lignan- and soluble fiber-rich hull on colitis severity in a mouse model of acute colonic inflammation. C57BL/6 male mice were fed a basal diet (negative control) or a basal diet supplemented with 10% FS, 6% kernel, or 4% hull for 3 wk prior to and during colitis induction via 5 days of 2% (wt/vol) dextran sodium sulfate (DSS) in their drinking water (n = 12/group). An increase in anti-inflammatory metabolites (hepatic n-3 PUFAs, serum mammalian lignans, and cecal short-chain fatty acids) was associated with consumption of all FS-based diets, but not with anti-inflammatory effects in DSS-exposed mice. Dietary FS exacerbated DSS-induced acute colitis, as indicated by a heightened disease activity index and an increase in colonic injury and inflammatory biomarkers [histological damage, apoptosis, myeloperoxidase, inflammatory cytokines (IL-6 and IL-1β), and NF-κB signaling-related genes (Nfkb1, Ccl5, Bcl2a1a, Egfr, Relb, Birc3, and Atf1)]. Additionally, the adverse effect of the FS diet was extended systemically, as serum cytokines (IL-6, IFNγ, and IL-1β) and hepatic cholesterol levels were increased. The adverse effects of FS were not associated with alterations in fecal microbial load or systemic bacterial translocation (endotoxemia). Collectively, this study demonstrates that although consumption of a 10% FS diet enhanced the levels of n-3 PUFAs, short-chain polyunsaturated fatty acids, and lignans in mice, it exacerbated DSS-induced colonic injury and inflammation.

Biopsy interpretation of colonic biopsies when inflammatory bowel disease is excluded

The interpretation of colonic biopsies related to inflammatory conditions can be challenging because the colorectal mucosa has a limited repertoire of morphologic responses to various injurious agents. Only few processes have specific diagnostic features, and many of the various histological patterns reflect severity and duration of the disease. Importantly the correlation with endoscopic and clinical information is often cardinal to arrive at a specific diagnosis in many cases.

Infectious proctitis: when to suspect it is not inflammatory bowel disease

BACKGROUND

Proctitis is a common problem and is most frequently associated with inflammatory bowel diseases. However, the incidence of infectious proctitis appears to be rising, especially in men who have sex with men. This may be due to the rise of people participating in receptive anal sex as well as the increase in sexually transmitted infections. The most frequently reported pathogens include Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, and herpes simplex.

DIAGNOSIS

Symptoms of infectious proctitis can include rectal blood and mucous discharge, anorectal pain, ulcers, and occasionally lymphadenopathy and fever. History and physical examination are crucial in establishing a diagnosis, supported by endoscopy, histology, serology, culture and PCR.

TREATMENT

Treatment with antibiotics or antivirals is usually initiated, either empirically or after establishing a diagnosis. Co-infections, HIV testing, and treatment of sexual partners should always be considered.