Diversion colitis: a trigger for ulcerative colitis in the in-stream colon?

Novel application of infliximab for diversion colitis

Diversion colitis (DC) that was refractory to standard treatments was successfully treated with infliximab. A 24-year-old man with a transverse colostomy suffered from severe DC. Topical steroids, 5-aminosalicylic acid (5-ASA) enemas and synbiotics were initially effective, and the colostomy was successfully closed with a covering ileostomy to minimise the risk of anastomotic leakage owing to the damaged colon. DC subsequently relapsed in the entire colon and was refractory to the previous protocol and autologous faecal transplantation. Intravenous methylprednisolone and oral 5-ASA were discontinued owing to possible adverse effects. Infliximab with intravenous prednisolone was introduced, and the protocol was so effective in suppressing the acute colitis that total colectomy was avoided. The stoma was subsequently closed, and the patient is currently symptom-free. Infliximab is used for ulcerative colitis but could also be effective against severe DC.

Subtotal colectomy in ulcerative colitis—long term considerations for the rectal stump

BACKGROUND

The initial operation of choice in many patients presenting as an emergency with ulcerative colitis is a subtotal colectomy with end ileostomy. A percentage of patients do not proceed to completion proctectomy with ileal pouch anal anastomosis.

AIM

To review the existing literature in relation to the significant long-term complic-ations associated with the rectal stump, to provide an overview of options for the surgical management of remnant rectum and anal canal and to form a consolidated guideline on endoscopic screening recommendations in this cohort.

METHODS

A systematic review was carried out in accordance with PRISMA guidelines for papers containing recommendations for endoscopy surveillance in rectal remnants in ulcerative colitis. A secondary narrative review was carried out exploring the medical and surgical management options for the retained rectum.

RESULTS

For rectal stump surveillance guidelines, 20% recommended an interval of 6 mo to a year, 50% recommended yearly surveillance 10% recommended 2 yearly surveillance and the remaining 30% recommended risk stratification of patients and different screening intervals based on this. All studies agreed surveillance should be carried out via endoscopy and biopsy. Increased vigilance is needed in endoscopy in these patients. Literature review revealed a number of options for surgical management of the remnant rectum.

CONCLUSION

The retained rectal stump needs to be surveyed endoscopically according to risk stratification. Great care must be taken to avoid rectal perforation and pelvic sepsis at time of endoscopy. If completion proctectomy is indicated the authors favour removal of the anal canal using an intersphincteric dissection technique.

Evaluation of intestinal microbiota, short-chain fatty acids, and immunoglobulin a in diversion colitis

It is reported that an increase in aerobic bacteria, a lack of short-chain fatty acids (SCFAs), and immune disorders in the diverted colon are major causes of diversion colitis. However, the precise pathogenesis of this condition remains unclear. The aim of the present study was to examine the microbiota, intestinal SCFAs, and immunoglobulin A (IgA) in the diverted colon. Eight patients underwent operative procedures for colostomies. We assessed the diverted colon using endoscopy and obtained intestinal samples from the diverted colon and oral colon in these patients. We analyzed the microbiota and SCFAs of the intestinal samples. The bacterial communities were investigated using a 16S rRNA gene sequencing method. The microbiota demonstrated a change in the proportion of some species, especially Lactobacillus, which significantly decreased in the diverted colon at the genus level. We also showed that intestinal SCFA values were significantly decreased in the diverted colon. Furthermore, intestinal IgA levels were significantly increased in the diverted colon. This study was the first to show that intestinal SCFAs were significantly decreased and intestinal IgA was significantly increased in the diverted colon. Our data suggest that SCFAs affect the microbiota and may play an immunological role in diversion colitis.

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Anaerobic bacteria like Lactobacillus significantly decreased in the diverted colon.

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Fecal short-chain fatty acids significantly decreased in the diverted colon.

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Acetic acid also decreased significantly in the diverted colon.

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Fecal immunoglobulin A levels were significantly increased in the diverted colon.

Adherence to a Mediterranean diet is associated with a lower risk of later-onset Crohn's disease: results from two large prospective cohort studies

OBJECTIVE

To examine the relationship between Mediterranean diet and risk of later-onset Crohn's disease (CD) or ulcerative colitis (UC).

DESIGN

We conducted a prospective cohort study of 83 147 participants (age range: 45-79 years) enrolled in the Cohort of Swedish Men and Swedish Mammography Cohort. A validated food frequency questionnaire was used to calculate an adherence score to a modified Mediterranean diet (mMED) at baseline in 1997. Incident diagnoses of CD and UC were ascertained from the Swedish Patient Register. We used Cox proportional hazards modelling to calculate HRs and 95% CI.

RESULTS

Through December of 2017, we confirmed 164 incident cases of CD and 395 incident cases of UC with an average follow-up of 17 years. Higher mMED score was associated with a lower risk of CD (P_trend=0.03) but not UC (P_trend=0.61). Compared with participants in the lowest category of mMED score (0-2), there was a statistically significant lower risk of CD (HR=0.42, 95% CI 0.22 to 0.80) but not UC (HR=1.08, 95% CI 0.74 to 1.58). These associations were not modified by age, sex, education level, body mass index or smoking (all P_interaction >0.30). The prevalence of poor adherence to a Mediterranean diet (mMED score=0-2) was 27% in our cohorts, conferring a population attributable risk of 12% for later-onset CD.

CONCLUSION

In two prospective studies, greater adherence to a Mediterranean diet was associated with a significantly lower risk of later-onset CD.

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.

A Case Report of Ulcerative Colitis Induced by Therapy of Colorectal Carcinoma

Although patients with ulcerative colitis have an increased risk for colon cancer which is associated with disease activity, location of involvement or the accompanying primary sclerosing cholangitis, ulcerative colitis induced by resections for colorectal carcinoma or chemotherapy drugs are very rare as case presentations in the literature. Fifty-nine year-old female patient with the diagnosis of sigmoid colon carcinoma have been developed ulcerative colitis 2 months after low anterior resection and oral capecitabine treatment. Development of colitis after colon cancer may be associated with some causes as mutual genetic factors that take part at the pathophysiological mechanisms liable from occurrence of ulcerative colitis and colorectal carcinoma, chemotherapy agents, perioperative stress and underlying silent ulcerative colitis. It is unclear which role is certain. Increasing reports like this case will be useful in resolving this issue.

How to cite this article

Temel T, Ozgenel SM, Canaz F, Arik D, Tokmak S, Ozakyol AH. A Case Report of Ulcerative Colitis Induced by Therapy of Colorectal Carcinoma. Euroasian J Hepato-Gastroenterol 2015;5(2):115-117.

Comparison of prophylactic and therapeutic use of short-chain fatty acid enemas in diversion colitis: a study in Wistar rats

OBJECTIVES

To study the effect of short-chain fatty-acids on atrophy and inflammation of excluded colonic segments before and after the development of diversion colitis.

INTRODUCTION

Diversion colitis is a chronic inflammatory process affecting the dysfunctional colon, possibly evolving with mucous and blood discharge. The most favored hypotheses to explain its development is short-chain fatty-acid deficiency in the colon lumen.

METHODS

Wistar rats were submitted to colostomy with distal colon exclusion. Two control groups (A1 and B1) received rectally administered physiological saline, whereas two experimental groups (A2 and B2) received rectally administered short-chain fatty-acids. The A groups were prophylactically treated (5th to 40th days postoperatively), whereas the B groups were therapeutically treated (after post-operative day 40). The mucosal thickness of the excluded colon was measured histologically. The inflammatory reaction of the mucosal lamina propria and the lymphoid tissue response were quantified through established scores.

RESULTS

There was a significant thickness recovery of the colonic mucosa in group B2 animals (p = 0.0001), which also exhibited a significant reduction in the number of eosinophilic polymorphonuclear cells in the lamina propria (p = 0.0126) and in the intestinal lumen (p = 0.0256). Group A2 showed no mucosal thickness recovery and significant increases in the numbers of lymphocytes (p = 0.0006) and eosinophilic polymorphonuclear cells in the lamina propria of the mucosa (p = 0.0022).

CONCLUSION

Therapeutic use of short-chain fatty-acids significantly reduced eosinophilic polymorphonuclear cell numbers in the intestinal wall and in the colonic lumen; it also reversed the atrophy of the colonic mucosa. Prophylactic use did not impede the development of mucosal atrophy.

Evaluation by computerized morphometry of histopathological alterations of the colon wall in segments with and without intestinal transit in rats

PURPOSE

To evaluate histopathological alterations of the colon wall in segments with and without intestinal transit, by computer-assisted imaging, and to correlate these with the length of time diversion.

METHODS

Thirty male Wistar rats were subjected to intestinal transit diversion by a proximal colostomy and distal mucosa fistula. The animals were divided into three experimental groups according to how long after the initial surgical procedure they were sacrificed: six, twelve and eighteen weeks. Colon segments with and without transit were subjected to histopathological study. The variables colon crypt length, mucosal ulceration, muscle layer thickness of the muscularis mucosa, submucosa and muscularis propria, vascular congestion, number of caliciform cells, inflammatory grade and degree of inflammation, comparing the two colon segments in the different experimental groups were studied. Intestinal crypt length, muscle layer thickness of the mucosa, submucosa and muscularis propria and caliciform cells were measured by computer-assisted imaging method. Mean equality, variance analysis and correlation tests were used in the statistical analysis, and the significance level was set at 5%.

RESULTS

Comparison between segments with and without transit showed that the latter presented reduced length of colon crypts and increased muscle layer thickness of the muscularis mucosa, submucosa and muscularis propria. There were greater quantities of ulceration of the mucosal and greater degree of inflammation with increasing time without transit. Mucosal ulceration, submucosal vascular congestion, increased thickness of the submucosal and muscularis propria layers, presence of caliciform cells, inflammatory infiltrate and inflammatory grade correlated significantly with the length of time without transit.

CONCLUSIONS

Histological alterations occurred in all layers of the colon wall, in the segments without intestinal transit. Ulcerations in the intestinal mucosa, increased number of caliciform cells, greater vascular congestion of the submucosal layer and inflammatory reaction were related to increasing length of time without transit.

Ischaemia: a pathogenetic clue in diversion colitis?

OBJECTIVE

It is not common that, after diversion of the faecal stream by a colostomy, the defunctioned colon develops colitis. The pathogenesis of this colitis is still unclear and it has been proposed that ischaemia may play a major role. Our aim is to look for signs of ischaemia in a group of patients developing colitis after diversion colostomy for various causes.

METHOD

Surgical specimens from 32 patients resected for colitis developed after diverting colostomy were examined with routine (haematoxylin-eosin) and Elastic-Van Gieson and Perls' stains.

RESULTS

The histological features related to mucosal crypt architecture, crypt epithelium and inflammation were mild, non specific or related to the underlying disease. Fibrosis was present in 21 (65.6%) patients, superficial coagulative necrosis was found in 18 (56%) patients, splitting and/or thickening of muscularis mucosae was present in 20 (62%) patients. The vessels were substantially normal or ectasic without thrombi or alterations in the wall. Evident ischaemia with coagulative necrosis, submucosal oedema and focal fibrosis was detected in only two (6%) patients and an intermediate picture between acute and chronic ischaemia was present in 16 (50%) patients.

CONCLUSION

It is possible that ischaemia plays some role in the pathogenesis of diversion colitis; however, further studies are needed to firmly establish its role.

Diagnostic difficulties in inflammatory bowel disease pathology

This review summarizes some of the common diagnostic problems encountered by pathologists when evaluating patients with chronic colitis and in whom inflammatory bowel disease (IBD) is either suspected or within the differential diagnosis. Both ulcerative colitis (UC) and Crohn's disease (CD) show characteristic, but non-specific, pathological features that may overlap and result in a diagnosis of 'indeterminate colitis' (IC). However, other reasons why pathologists may entertain a diagnosis of IC include failure to recognize or accept certain 'hardcore' histological features as indicative of CD, an attempt to classify cases of chronic colitis based on mucosal biopsy material or in the absence of adequate clinical and radiographic information, and the presence of other disease processes that mask, or mimic, IBD. In addition, some cases of UC may show unusual CD-like features, such as discontinuous or patchy disease, ileal inflammation, extracolonic inflammation, granulomatous inflammation in response to ruptured crypts, aphthous ulcers, or transmural inflammation. Furthermore, other forms of colitis, such as microscopic colitis, diverticulitis and diversion colitis may, on occasion, also show IBD-like changes. The clinical and pathological features that aid in the distinction between these entities, and others, are covered in detail in this review.

Acute onset of ulcerative colitis following an operation for sigmoid colon cancer

We describe a case of ulcerative colitis (UC) where clinical symptoms began abruptly within a few weeks after colon resection. The patient, a 44-year-old woman, was first referred to our hospital for the treatment of colon cancer. During the past several years, she had not had any inflammatory bowel disease-like clinical symptoms, such as frequent diarrhea or abdominal discomfort. Before the operation, both macroscopic and microscopic examination revealed that no remarkable inflammatory change was associated with the cancer in any area of her colon. At 10 days after the operation, she started to complain of frequent watery diarrhea. Two weeks after the operation, she was readmitted to our hospital because of frequent bloody diarrhea, fever, and abdominal discomfort. Based on endoscopic and histological examinations, she was diagnosed as having severe UC and was treated with hyperalimentation, predonisolone, mesalazine, and granulocyte apheresis. However, she did not respond to this combination therapy. At 45 days after the first operation, owing to sudden onset hemorrhagic shock, she underwent a second colectomy. The resected specimen of the entire colon showed severe pancolitis, and histological examination revealed severe inflammatory changes in the lamina propria together with crypt distortion, all of which were consistent with UC.

Intraluminal irrigation with fibers improves mucosal inflammation and atrophy in diversion colitis

OBJECTIVE

We investigated the effect of irrigating the colorectal mucosa of patients with a colostomy using a solution of fibers.

METHODS

Eleven patients (10 male and 1 female; mean age, 34 y; age range, 16-49 y) with loop colostomy due to trauma underwent endoscopic evaluation of the rectum and the proximal and distal mucosa from the colostomy. An endoscopic score (range, 0-10) was used to quantify the intensity of the inflammation at the mucosa. Biopsies were taken from the colostomy border and from the rectum. The mean crypt depth of the five best-oriented glands was registered. Then the diverted colorectal segment was irrigated with a solution containing 5% fibers (10 g/d) for 7 d. The patients underwent repeated endoscopic and biopsy procedures, and then the colostomy was closed.

RESULTS

The endoscopic score was higher (P < 0.01) at the distal border (2, 0-5) and the rectum (4, 1-10) when compared with the proximal border (0, 0-1). After treatment, the score at the diverted colon (1, 0-2) diminished (P = 0.03). The macroscopic score of the rectum also decreased after the infusion (4, 1-10, versus 3, 0-4; P = 0.03). Crypt depth at the proximal mucosa was higher than at the diverted mucosa (301 +/- 36 microm versus 205 +/- 76 microm; P < 0.01). After treatment, crypt depth at the diverted mucosa (280 +/- 64 microm) increased (P = 0.03). The rectum mucosa did not change before and after the treatment.

CONCLUSION

Irrigation with fibers improves inflammation at the defunctionalized colon.

Diversion procto-colitis: response to treatment with short-chain fatty acids

BACKGROUND/PURPOSE

Diversion procto-colitis (DPC) results from a deficiency of luminal short-chain fatty acids (SCFAs). Endoscopic and histopathologic features of the disorder are almost universally present in defunctioned bowel, but symptomatic DPC is less common.

METHODS

Five children with symptomatic DPC underwent endoscopy and rectosigmoid biopsies. An endoscopic index (EI) was used to quantify disease severity. An SCFA mixture was administered into the defunctioned bowel.

RESULTS

A good clinical response and improvement in the endoscopic index occurred in all children. Undiversion or rectal excision was carried out in 4 and was curative in each case. One child is awaiting a redo pull through.

CONCLUSIONS

DPC should be considered in children with a defunctioned colon presenting with evidence of colitis. Histopathology provides supportive evidence and SCFAs may provide effective relief of symptoms. Stoma reversal or rectal excision is curative.

Diverticular colitis: diagnosis and management

Diverticular colitis is a recently recognized nosological entity in which a chronic focal mucosal sigmoid colitis occurs in association with diverticulosis. It usually presents with rectal bleeding and may be difficult to distinguish clinically, endoscopically and pathologically from other segmental colitides including ulcerative, Crohn's, ischaemic, infective and NSAID-induced colitis as well as diverticulitis. Uncontrolled data suggests that most patients respond satisfactorily to treatment with a high fibre diet, antibiotics and/or aminosalicylates, but a minority with persistent or recurrent symptoms require sigmoid resection. This paper reviews the literature on diverticular colitis and concludes with an algorithm suggesting the optimal management of patients who present with rectal bleeding in association with segmental sigmoid colitis and diverticulosis.

Colitis following fecal diversion: still a challenge

After fecal diversion, nonspecific colitis may be seen in the defunctionalized colon. The purpose of this prospective study is to identify specific findings that could help in the differential diagnosis between diversion colitis and other inflammatory bowel diseases in order to avoid inappropriate diagnosis and therapy. It was studied, prospectively, thirteen consecutive patients from two public hospitals of Rio de Janeiro who had undergone temporary colostomy for indications other than inflammatory bowel disease. They were submitted to endoscopy with biopsy of both proximal and distal colorectal segments, and prospectively evaluated before and after restoration of intestinal continuity. Endoscopy with biopsy of both proximal and distal excluded colorectal segments showed a nonspecific mucosal and submucosal inflammation, resembling ulcerative colitis ( p < 0.01). There was endoscopic resolution in all patients once restoration of intestinal continuity was established (p < 0.01) and also histologic improvement after the stoma closure. In conclusion there are no specific findings that make possible an unequivocal distinction between diversion colitis and other nonspecific inflammatory diseases. Diagnosis should be achieved if after stoma closure occur remission of endoscopic large bowel inflammatory signs with improvement in mucosal histologic appearance and prompt relief of clinical complaints.