Chemical colitis

Evaluation and management of pediatric refractory constipation: Recommendations from the NASPGHAN neurogastroenterology and motility committee

Refractory constipation (RC) in pediatric patients should be recognized as a distinct condition with long-term impacts on patient and family quality of life. RC requires a more targeted diagnostic evaluation and complex management strategy that may involve management by pediatric neurogastroenterology and motility specialists and multidisciplinary teams including surgeons. Currently, there is a lack of a clear definition, evaluation, and management strategies for RC. This is the first North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition position paper to address pediatric RC regarding its definition, evaluation, and management.

Successful endoscopic management of severe low rectal stenosis caused by chemical burns

Chemical burns of the rectum are so rare that there are few cases reported about this situation. In fact, chemical burns of the rectum can cause severe serious consequence, such as bleeding, perforation and necrosis, even developing to persistent rectal stricture. Here we present a case report of a 12-year-old child with rectal stenosis who imitates the use of corkage and inserts rust remover into the rectum unsupervised by family members. He underwent endoscopic balloon dilation followed by submucosal injection of bleomycin at the stenosis point.

Medical management of anorectal malformations

BACKGROUND

Anorectal malformations (ARMs) are congenital anomalies of the anorectum and the genitourinary system that result in a broad spectrum of hindgut anomalies. Despite surgical correction patients continue to have late postoperative genitourinary and colorectal dysfunction that have significant impact on quality of life.

AIM

This paper will review the current evidence and discuss the evaluation and management of postoperative patients with ARMs who present with persistent defecation disorder.

METHODS

A literature search was conducted using PubMed/MEDLINE/EMBASE databases applying the following terms: ARMs, imperforate anus, constipation, faecal incontinence, neurogenic bowel, posterior sagittal anorectoplasty.

RESULTS

Patients who present with postoperative defecation disorders require timely diagnostic and surgical evaluation for anatomic abnormalities prior to initiation of bowel management. Goals of management are to avoid constipation in young children, achieve faecal continence in early childhood and facilitate independence in older children and adolescents. Treatment options vary from high dose stimulant laxatives to high-volume retrograde and antegrade enemas that facilitate mechanical colonic emptying.

CONCLUSIONS

Appropriate diagnostic work-up and implementation of treatment can decrease long-term morbidity and improve quality of life in postoperative patients with ARMs who presents with defecation disorders.

Evaluation and Management of Postsurgical Patient With Hirschsprung Disease Neurogastroenterology & Motility Committee: Position Paper of North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)

Children with Hirschsprung disease have postoperative long-term sequelae in defecation that contribute to morbidity and mortality and significantly impact their quality of life. Pediatric patients experience ongoing long-term defecation concerns, which can include fecal incontinence (FI) and postoperative obstructive symptoms, such as constipation and Hirschsprung-associated enterocolitis. The American Pediatric Surgical Association has developed guidelines for management of these postoperative obstructive symptoms and FI. However, the evaluation and management of patients with postoperative defecation problems varies among different pediatric gastroenterology centers. This position paper from the Neurogastroenterology & Motility Committee of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition reviews the current evidence and provides suggestions for the evaluation and management of postoperative patients with Hirschsprung disease who present with persistent defecation problems.

An Update of Pharmacological Management in Children with Functional Constipation

Functional constipation is a common problem in childhood worldwide and has a great impact on social, physical, and emotional functioning of affected children and their caregivers. It is a clinical diagnosis based on the Rome IV criteria. Non-pharmacological treatment involves education, demystification, lifestyle advice, and toilet training. Pharmacological treatment consists of disimpaction, maintenance treatment, and eventually weaning if possible. Polyethylene glycol is considered as the first choice of laxative for both disimpaction and maintenance treatment. Different osmotic laxatives, stimulant laxatives, lubricants, and enemas are available as alternative pharmacological treatment options. Novel drugs are emerging but evidence to support the widespread application of these drugs in the pediatric population is often lacking and more high-quality research is needed in this field. If children remain symptomatic despite optimal pharmacological treatment, botulinum toxin injections in the anal sphincter can be considered as an alternative, more invasive treatment option. This review provides an update on currently available literature concerning the pharmacologic treatment of functional constipation in children.

[Drug induced gastro-intestinal tract lesions: A pathologist point of view]

The number of drugs available to clinicians, especially targeted therapies, grows continuously. Some drugs are known to cause frequent digestive adverse effects, which may affect the gastro-intestinal tract in a diffuse or localized manner. Some treatments may leave relatively pathognomonic deposits, but histological lesions of iatrogenic origin are mostly non-specific. The diagnostic and etiological approach is often complex because of these non-specific aspects and also because (1) a single type of drug may cause different histological lesions, (2) different drugs may cause identical histological lesions, (3) the patient may receive different drugs, and (4) drug-induced lesions may mimic other pathological entities such as inflammatory bowel disease, celiac disease, or graft versus host disease. The diagnosis of iatrogenic gastrointestinal tract injury therefore requires close anatomic-clinical correlation. The iatrogenic origin can only be formally established if the symptomatology improves when the incriminating drug is stopped. This review aims to present the different histological patterns of gastrointestinal tract iatrogenic lesions, the potentially incriminate drugs, as well as the histological signs to look for in order to help the pathologist to distinguish an iatrogenic injury from another pathology of the gastrointestinal tract.

Chemical Gastroenterocolitis after Dental Root Canal Therapy with Camphorated and Mentholated Chlorophenol

A 78-year-old man with a history of pancolitis, after the treatment of dental abscess with oral antibiotics and local application of camphorated and mentholated chlorophenol (CMCP), presented with abdominal pain of 4-day duration, as well as hair loss in the area of moustache and finger nail lifting. He was already treated with rectal application of budesonide because of pancolitis, diagnosed 6 weeks ago and interpreted as an allergic reaction to clindamycin. For further investigation, we performed gastroscopy and colonoscopy, which showed the edematous mucosa with polypus-like changes of the whole mucosa of the stomach, duodenum, first part of the jejunum, distal ileum, complete colon, and rectum. The diagnosis was complicated and was achieved in synopsis with anamnestic details, such as endodontic application of camphorated chlorophenol. The patient symptoms abated after he commenced on mesalazine therapy.

Colitis Induced by Colon-Cleansing Agent

Constipation is one of the most common functional gastrointestinal disorders and affects 20% of the general population. Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal tract that affects the large intestine and is characterized by chronic abdominal pain and altered bowel habits. We report a case of a 35-year-old African American man with a past medical history of IBS who presented to the clinic with a chief complaint of abdominal pain and bloody diarrhea for 1 week. The patient stated that he used a colon-cleansing agent because of persistent constipation. Computed tomography scan of the patient's abdomen and pelvis with contrast was performed which showed diffuse contiguous segmental mural thickening and nodularity seen along the distal transverse, descending, and sigmoid colon. Colonoscopy showed moderate diffuse inflammation characterized by altered vascularity, erythema, and granularity from the rectum to the descending colon, and localized mild inflammation characterized by erythema was found at the ileocecal valve. The patient's clinical condition improved with symptomatic management over 10 days. Patients with IBS should be advised to restrain from using a colon-cleansing agent without advice from their primary doctor as it can lead to various complications.

Successful Conservative Treatment of an Elderly Patient with Corrosive Proctocolitis

Corrosive proctocolitis has occurred after accidental contamination of endoscopes in most patients. But accidental administration of corrosive agents for bowel cleansing can occur. The agents implicated for chemical colitis is 15% hydrochloric acid and 2% ethoxylated alcohol. We present a case of corrosive proctocolitis, present with anal pain and bloody diarrhea. Endoscopy revealed edema, erythema, and friability of the colonic mucosa. An experience of successful nonoperative treatments has been demonstrated.

Hydrogen Peroxide Enema-induced Proctitis in a Young Female: A Case Report

Hydrogen peroxide is a disinfectant commonly used for cleansing superficial wounds due to its oxidizing capacity. In the past, it has also been used for the management of meconium ileus in children as the oxidizing action of hydrogen peroxide potentiates peristalsis that relieves ileus or fecal impaction. The potential dangers were unknown till Pumphrey, in 1951, described the harmful effects of its use as an enema. We present a case of a 32-year-old female who was admitted for complaints of perianal pain. She used an enema, consisting of water and hydrogen peroxide, for constipation. It improved her symptoms but subsequently, she developed a burning sensation in her rectum. The patient had a colonoscopy which revealed severe proctitis up to 15 cm from the anal verge manifested by superficial mucosal ulceration, marked erythema, and edema with friable mucosa and hemorrhage. The patient was subsequently given mesalamine, and the symptoms resolved.

Chemical colitis caused by hydrogen peroxide vaginal douche: A case report

BACKGROUND

Hydrogen peroxide is one of the most common household disinfectants worldwide. Hydrogen peroxide has been documented as a rare cause of chemical colitis.

CASE SUMMARY

We present a case of 31 years old lady who presented to our hospital with rectal bleeding and abdominal pain after using hydrogen peroxide vaginal douche as an enema. She underwent colonoscopy which showed findings suggestive of chemical colitis and was managed conservatively. Hydrogen peroxide can induce chemical injury in the colon. Clinical presentation and endoscopic findings of chemical colitis are nonspecific. History taking is an important tool in identifying the underlying etiology. Review of literature showed few case reports, mostly were managed with oral antibiotics and conservative approach.

CONCLUSION

Chemical colitis is usually managed conservatively. Complications including perforation, stricture and peritonitis may happen and need aggressive treatment accordingly.

Review of Drug-induced Injury in Mucosal Biopsies From the Tubular Gastrointestinal Tract

The use of prescription and over-the-counter medications is on the rise in the US population, especially among those aged 65 and over, with over 46% of the population taking at least 1 prescription medication. Given the frequency of medication use, and that the majority of these medications are taken orally, it has become increasingly relevant for pathologist examining endoscopically obtained gastrointestinal tract mucosal biopsies to consider and recognize patterns of mucosal injury associated with various drugs. Reports on injuries associated with certain classes of drugs can be scattered among different sources, making a comprehensive view of various injury patterns and the drugs known to cause them difficult to obtain. Herein, we provide a comprehensive overview of the drugs known to cause mucosal injuries in the tubular gastrointestinal tract organized by the organ involved and the prominent pattern of injury.

Colonic inflammation affects myenteric alpha-synuclein in nonhuman primates

Background: Parkinson's disease (PD) patients frequently present gastrointestinal (GI) dysfunction that, in many cases, predates the onset of motor symptoms. In PD, the presynaptic protein alpha-synuclein (α-syn) undergoes pathological changes, including phosphorylation and aggregation leading to the formation of Lewy bodies, which can be found in neurons of the enteric nervous system (ENS). Inflammation has been proposed as a possible trigger of α-syn pathology. Interestingly, patients with inflammatory bowel disease and irritable bowel syndrome, conditions associated with GI inflammation, are at higher risk of developing PD. Captive common marmosets (Callithrix jacchus) develop colitis, providing a natural platform to assess the relationship between α-syn pathology and GI inflammation. Materials and Methods: Sections of proximal colon from marmosets with colitis (n=5; 5.3±2.3 years old; 4 male) and normal controls (n=5; 4.1±1.6 years old; 1 male) were immunostained against protein gene product 9.5 (PGP9.5), human leukocyte antigen DR (HLA-DR), cluster of differentiation 3 (CD3), cluster of differentiation 20 (CD20), glial fibrillary acidic protein (GFAP), 8-hydroxy-2'-deoxyguanosine (8-OHdG), α-syn, and serine 129 phosphorylated α-syn (p-α-syn). Immunoreactivity of each staining in the myenteric plexus was quantified using NIH ImageJ software. Results: Marmosets with colitis had significantly increased expression of inflammatory markers (HLA-DR, p<0.02; CD3, p<0.008), oxidative stress (8-OHdG, p<0.05), and p-α-syn (p<0.02) and decreased expression of α-syn (p<0.04) in the colonic myenteric ganglia compared to normal, healthy controls. Conclusion: Colonic inflammation is associated with changes in α-syn expression and phosphorylation in the myenteric plexus of common marmosets. Future evaluation of the vagus nerve and brain of animals with colitis will be key to assess the contribution of colitis-induced ENS α-syn pathology to PD-like pathology in the brain.

Bowel management in children with spina bifida

Spina bifida is a birth defect that commonly causes bowel and bladder dysfunction in children with a significant negative impact on quality of life and emotional wellbeing. Fecal continence improves satisfaction and the quality of life of both children and their caretakers. Bowel management in children with spina bifida is hampered by limited controlled studies and variable practice within different institutions and subspecialists. The goals of a successful bowel management program in children with spina bifida consist of predictable bowel movements, social continence, and eventual independence. Treatment options range from conservative interventions such as diets and oral laxatives that modify stool consistency and transit, to trans-anal irrigations and antegrade continence enemas that facilitate predictable recto-sigmoid emptying and provide a greater degree of independence. In children, the treatment approach should be implemented in the context of the child's developmental age in order to allow for optimum social integration with their age-appropriate peers. We present a review of a stepwise approach to bowel management in children with spina bifida and the challenges related to the proposed treatment options.

Bowel management in children with spina bifida

Spina bifida is a birth defect that commonly causes bowel and bladder dysfunction in children with a significant negative impact on quality of life and emotional wellbeing. Fecal continence improves satisfaction and the quality of life of both children and their caretakers. Bowel management in children with spina bifida is hampered by limited controlled studies and variable practice within different institutions and subspecialists. The goals of a successful bowel management program in children with spina bifida consist of predictable bowel movements, social continence, and eventual independence. Treatment options range from conservative interventions such as diets and oral laxatives that modify stool consistency and transit, to trans-anal irrigations and antegrade continence enemas that facilitate predictable recto-sigmoid emptying and provide a greater degree of independence. In children, the treatment approach should be implemented in the context of the child's developmental age in order to allow for optimum social integration with their age-appropriate peers. We present a review of a stepwise approach to bowel management in children with spina bifida and the challenges related to the proposed treatment options.

Hydrogen Peroxide Induced Colitis: A Case Report and Literature Review

Constipation is a common condition. Hydrogen peroxide enemas have rarely been reported as a home remedy for constipation in the pediatric age group. We present a case report and literature review of hydrogen peroxide induced colitis in pediatric siblings, aged 2 years and 9 years. The siblings presented with vomiting and bloody diarrhea an hour following the enema. Physical exam, vital signs, blood, and electrolyte counts were normal, but CT scans showed mucosal thickening of the rectum and colon. Their symptoms resolved after oral intake was curtailed and fluids were replaced intravenously. We discuss existing reports of complications from hydrogen peroxide enemas. Patients may present with abdominal pain and bloody diarrhea. Onset of symptoms varied from minutes to a day and bowel ulceration with necrosis and perforation has occurred, although fatality is rare. Diagnostic tests included computed tomography (CT) scan, sigmoidoscopy, or biopsy. Recovery period ranged from 3 days to 8 months. Public education regarding the dangers of hydrogen peroxide enemas is needed.

Consensus Review of Best Practice of Transanal Irrigation in Children

Pediatric patients with either functional or organic bowel dysfunction may suffer from constipation and fecal incontinence and represent a complex group in whom management is often difficult. Many noninvasive and invasive treatments have been proposed, with variable efficacy and adverse effects. Transanal irrigation (TAI) is now an accepted alternative, in both children and adults, for bowel dysfunction that has not responded to conservative and medical therapies. There is, however, still some uncertainty about the use of TAI in pediatric populations. Hence, a group of specialists from different nations and pediatric disciplines, all with long-standing experience of bowel management in children, performed a literature search and had round table discussions to determine the best-practice use of TAI in the pediatric patient population. Based on these findings, this article provides best-practice recommendations on indications, patient selection, important considerations before treatment, patient and family training, treatment regimens, troubleshooting, and practical aspects of TAI. We conclude that careful patient selection, a tailored approach, directly supervised training, and sustained follow-up are key to optimize outcomes with TAI in children with functional or organic bowel dysfunction.

Chemical colitis caused by hydrogen peroxide enema in a child: case report and literature review

A 2-year-old girl, previously healthy, was brought to the emergency department because of significant cramping abdominal pain with recurrent hematochezia after an accidental hydrogen peroxide enema (35%, 5 mL) by her caregiver. She was hospitalized to the pediatric department and treated with nothing per mouth, intravenous fluid and parenteral antibiotic therapy. Laboratory, radiologic and endoscopic evaluation was performed during the admission period. She was discharged in a fully recovered state on the tenth hospital day, and this is the first case report of acute chemical colitis by accidental hydrogen peroxide enema in children.

Soap Suds Enemas Are Efficacious and Safe for Treating Fecal Impaction in Children With Abdominal Pain

OBJECTIVES

Constipation is a common cause of pediatric abdominal pain and emergency department (ED) presentation. Despite the high prevalence, there is a dearth of clinical information and wide practice variation in childhood constipation management in the ED. The objective of the study was to assess the efficacy and safety of soap suds enema (SSE) in the therapy for fecal impaction in children with abdominal pain within the pediatric ED setting. The primary outcome was stool output following SSE. Secondary outcomes were adverse events, admissions, and return visits within 72 hours.

METHODS

The present study is a retrospective cross-sectional study performed in the ED at a quaternary care children's hospital of patients seen during a 12-month period who received an SSE for fecal impaction.

RESULTS

Five hundred twelve patients (53% girls, median age 7.8 years, range: 8 months-23 years) received SSE therapy during a 1-year period. Successful therapy (bowel movement) following SSE occurred in 419 (82%). Adverse events included abdominal pain in 24 (5%) and nausea/vomiting in 18 (4%). No SSE-related serious adverse events were identified. Following SSE, 405 (79%) were subsequently discharged, of which 15 (3.7%) returned to the ED for re-evaluation within 72 hours.

CONCLUSIONS

SSE is an efficacious and safe therapeutic option for the acute treatment of childhood fecal impaction in the ED setting.

Human Poisoning Through Atypical Routes of Exposure

There are over 2 million human exposure cases reported to United States poison centers annually. Much of the data involves exposure through ingestion, dermal contact, inhalation, ocular, or parenteral routes. There is limited data characterizing exposure via atypical routes. We conducted a retrospective review of the California Poison Control System Database for a 24-month period from January 2012 to December 2013 for poison exposure that occurred through the otic, vaginal, or rectal route. There were a total of 634 cases involving single-route and single-substance atypical poison exposure. There were 287 (45%) cases of otic exposure, 190 (30.0%) cases of vaginal exposure, and 157 (25%) cases of rectal exposure. Five hundred forty (85%) of the cases were unintentional. Gasoline exposure through the otic route occurred in 83 (13.1%) cases, followed by hydrogen peroxide (4.7%), acetaminophen (3.8%), and miconazole (2.7%). Adverse effects occurred in 336 (53%) cases. No deaths were reported. The most common treatment was observation only, occurring in 396 (62.4%) cases. The majority of the cases did not warrant hospital evaluation (73.5%). This is the first retrospective characterization study of atypical routes of poison exposure. These results may provide education to providers and the public regarding risks of exposure to substances through atypical routes.

Colorectal emergencies and related complications: a comprehensive imaging review--imaging of colitis and complications

OBJECTIVE

Colorectal emergencies are a common presentation in the emergency medicine setting and their timely diagnosis plays a crucial role in avoiding dreaded complications. The quintessential role of a radiologist lies in identifying the cause, narrowing the differential diagnosis according to imaging features, and, most importantly, identifying the associated complications.

CONCLUSION

This review focuses on imaging features of the spectrum of colitides and the complications related to colitides.

Relationship between the pH of enema solutions and intestinal damage in rabbits

Mechanical enemas can lead to intestinal mucosal injuries and bowel barrier damage, presenting as electrolyte disturbances and functional intestinal disorders. Most researchers believe that the mechanism of injury is related to osmolality, volume and temperature of the solution, infusion pressure, and the composition of the enema tube. We hypothesized that the pH of the enema solution may also contribute to intestinal damage. We administered enema solutions--normal saline, soapsuds, or vinegar (neutral, alkaline, or acidic solutions, respectively)--to three groups of rabbits (n = 20 per group). The solutions were standardized for volume and temperature and the soapsuds and vinegar solutions were adjusted to be isotonic with normal saline or deionized water. We also included a control group (n = 20) in which the enema tubes were inserted but no solution was administered. We biopsied 3 sites (rectum and distal and proximal colon). Damage to intestinal mucosa was observed by light microscopy and transmission electron microscopy. In order to explore the detection of damage using noninvasive methods, cyclooxygenase (COX)-2 gene expression was measured in the exfoliated cells gathered from postenema defecation. Epithelial loss, inflammatory reaction, and cellular microstructure damage was increased in the vinegar and soapsuds groups. Also, exfoliated cells in these groups had higher COX-2 expression than the normal saline group. The acidic and alkaline enema solutions thus caused more severe damage to the intestinal mucosa compared to the neutral liquid, supporting our hypothesis. Further, the detection of COX-2 expression shows promise as a noninvasive method for estimating enema-induced damage.

Computed tomography in patients with abdominal pain and diarrhoea: does the benefit outweigh the drawbacks?

The role of computed tomography (CT) in the evaluation of abdominal pain is well established. However, concern exists in regard to procedure-related radiation levels, contrast-medium toxicity and costs. We sought to determine whether the use of abdominal CT caused major changes in the management of patients who had abdominal pain and diarrhoea. We reviewed all abdominal CT examinations that were performed at our hospital from October through December 2010. We selected 574 scans that had been performed in patients who presented with or without diarrhoea. We examined the selected medical records to determine whether the CT scan changed patients' management. A scan was considered to be management changing if a decisive intervention occurred on the basis of the scan results. Among 124 scans in patients with diarrhoea and 450 scans in patients without diarrhoea, the scan results changed management in 13 of the patients with diarrhoea (11%) and in 233 of those without diarrhoea (52%) (P < 0.001). When management changed, the changes resulted from findings unrelated to diarrhoea. Despite its defined role in the assessment of abdominal pain, CT of patients that also had diarrhoea seldom caused a major change in management. The probability of CT causing such a change does not outweigh the cost, radiation risk or potential for contrast-induced nephropathy.

Histopathological Changes in the Gastrointestinal Tract Due to Medications

In keeping with the stated goal of providing the surgical pathologist with tools to recognize abnormalities of the gastrointestinal (GI) tract due to drugs (AGIDS), in part II of this review we embark in a more organ-based description of AGIDS. Adequate space is given to the numerous adverse gastrointestinal effects of nonsteroidal anti-inflammatory drugs. Pill esophagitis, esophagitis dissecans, proton pump inhibitors’ effects, diaphragm disease, and the recently described effects of drugs such as olmesartan, mycophenolate, and of compounds such as yttrium-90 are highlighted among several others. The inclusion of drug effects in the differential diagnosis of “conventional” diseases (such as gastric antral vascular ectasia, graft-versus-host disease, ischemic colitis, acute colitis, collagenous enteritis, inflammatory bowel disease) is underscored to avoid sometimes significant diagnostic pitfalls. We reiterate the message of the necessary collaboration between pathologist and clinician in the recognition of these entities to provide the best patient care.

The care of constipated children in primary care in different countries

AIM

To investigate and compare the approach to childhood constipation by primary care physicians (PCP) in three Western countries to give insight into adherence to current guidelines and in actual care.

METHODS

Prospective study utilizing a two-page survey regarding the approach to children suspected to have functional constipation (FC). A total of 413 of 1016 (41%) distributed surveys were returned out of which 383 were suitable for analysis. Surveys were answered anonymously. Survey responses were analysed and are reported in a descriptive way.

RESULTS

In Italy, the Netherlands, and the USA, respectively, 75, 187 and 121 surveys were returned by PCP. The majority of PCP (62%) considered stool withholding as a result of painful defecation to be the most common cause of childhood constipation. Rectal examination was used as a standard diagnostic tool for the evaluation of FC by only 31% of PCP with significant differences among the countries (p < 0.05) and a minimum in the Netherlands (11%). Abdominal X-ray is used by 49% to diagnose FC. 63% of PCP were convinced that hard stool can be softened by drinking more water. Polyethylene glycol was the most common prescribed drug (85%). Significant differences were found among countries in the use of senna and bisacodyl suppositories (p < 0.05).

CONCLUSION

Significant differences in practice exist among PCP from different countries regarding the performance of a digital rectal examination, need for additional diagnostic tests and use of laxatives in childhood constipation.

Glutaraldehyde-induced colitis: case reports and literature review

Glutaraldehyde-induced colitis is an uncommon colitis in clinical practice. Because the involvement of colonic segment is determined by the endoscopic part where glutaraldehyde remains, a recent history of endoscopy and a demarcated involvement of colonic segment are the most characteristic signs of glutaraldehyde-induced colitis. The typical clinical scenario is acute onset of lower abdominal pain, fever, and bloody stool. Laboratory data usually show leukocytosis and elevated C-reactive protein. The endoscopic pictures of involved segments are compatible with acute colitis, including hyperemic, edematous, with or without multiple erosions. Acute ischemic colitis and infectious colitis should be differentiated at the outset of the disease. Stool pathogen tests are usually negative. Parenteral empiric antibiotic may be considered if severe transmural edema of the involved segment is observed in computed tomography. Conservative treatment, including bowel rest and parenteral hydration, is able to stabilize the condition in a week. Herein, we present two cases of acute proctocolitis caused by glutaraldehyde after uneventful colonoscopy.

Is "ischemic" colitis ischemic?

Ischemic colitis appears to be a collection of diseases rather than a single entity. On the one hand, there is the colitis that truly appears to be caused by a lack of blood flow and, on the other hand, there is the disease that is called "ischemic" for lack of a better diagnosis-the colitis that is more "idiopathic" than "ischemic." Four widely held tenets of "ischemic" colitis are wrong: 1) the colon is not particularly sensitive to ischemia; 2) ischemic colitis is rarely preceded by a period of global hypoperfusion; 3) the "watershed areas" are not disproportionately affected; and 4) colonoscopy with biopsy is not specific for the disease. The cause of "ischemic" colitis is unknown. Therefore it is, until proven otherwise, "acute idiopathic colitis."

Segmental colitis associated with diverticulosis: complication of diverticular disease or autonomous entity?

Segmental colitis associated with diverticulosis (SCAD) is a disease that affects colon harboring diverticula, mostly located in the sigmoid region. It has been considered a rare disease for many years, but new studies may contribute to easier recognition. Although its pathogenesis is not yet well defined, in the past SCAD has been considered a complication of diverticular disease, whilst new endoscopic, histological, and clinical data have encouraged the concept that SCAD includes pathogenetic and therapeutic aspects peculiar to inflammatory bowel diseases. We therefore describe herein current knowledge about this disease, and why it can be considered a truly autonomous entity instead of a complication of diverticular disease.

Glutaraldehyde-induced colitis: three case reports

Glutaraldehyde (2% solution) is an effective and widely used disinfecting solution for cold sterilization of endoscopic instruments. Direct contact of glutaraldehyde solution with colonic mucosa can cause self-limited colitis. As it rarely occurs as a complication of colonoscopy, glutaraldehyde-induced colitis is generally reported only as case reports in the literature. We report three cases of glutaraldehyde-induced colitis after colonoscopy. All lesions resolved with supportive treatment. We stress the need for thorough rinsing of the surface and channels of the endoscope with water to avoid the occurrence of this complication.

Chemical colitis due to glutaraldehyde: case series and review of the literature

Chemical colitis can occur as a result of accidental contamination of endoscopes or by intentional/accidental administration of enemas containing various chemicals.We present three cases of glutaraldehyde induced colitis and review the cases in the literature. Glutaraldehyde induced colitis presents clinically with severe abdominal pain, bloody and mucoid diarrhea, rectal bleeding, and tenesmus 48-72 h after colonoscopy. Endoscopic findings are nonspecific and mimic ischemic colitis, inflammatory bowel disease, and infectious colitis. The timing of symptoms and the knowledge that glutaraldehyde is a chemical irritant to colonic mucosa is important for the diagnosis. The treatment is mainly supportive but sometimes necessitates mesalamine, prednisolone, or metronidazole and the resolution is rapid. In endoscopy units, strict adherence to published disinfection protocols is very important and the cleaning, rinsing and drying protocols also deserve the same attention.

Lupus mesenteric vasculitis can cause acute abdominal pain in patients with SLE

Lupus mesenteric vasculitis (LMV) is a unique clinical entity found in patients who present with gastrointestinal manifestations of systemic lupus erythematosus, and is the main cause of acute abdominal pain in these patients. LMV usually presents as acute abdominal pain with sudden onset, severe intensity and diffuse localization. Other causes of abdominal pain, such as acute gastroenteritis, peptic ulcers, acute pancreatitis, peritonitis, and other reasons for abdominal surgery should be ruled out. Prompt and accurate diagnosis of LMV is critical to ensure implementation of appropriate immunosuppressive therapy and avoidance of unnecessary surgical intervention. The pathology of LMV comprises immune-complex deposition and complement activation, with subsequent submucosal edema, leukocytoclastic vasculitis and thrombus formation; most of these changes are confined to small mesenteric vessels. Abdominal CT is the most useful tool for diagnosing LMV, which is characterized by the presence of target signs, comb signs, and other associated findings. The presence of autoantibodies against phospholipids and endothelial cells might provide information about the likelihood of recurrence of LMV. Immediate, high-dose, intravenous steroid therapy can lead to a favorable outcome and prevent serious complications such as bowel ischemia, necrosis and perforation.