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

The aetiology of ulcerative colitis is unknown. Two patientswithout pre-existing inflammatory bowel disease in whom end colostomy for faecal incontinence was complicated by diversion colitis in thedefunctioned rectosigmoid colon, are described. In both instances, colitis with the clinical, colonoscopic, and microscopic features ofulcerative colitis developed about a year later in the previously normal in-stream colon proximal to the colostomy. These cases suggestthat diversion colitis may be a risk factor for ulcerative colitis inpredisposed individuals and that ulcerative colitis can be triggered byanatomically discontinuous inflammation elsewhere in the large intestine.

Keywords:ulcerative colitis, diversion colitis

     

Proctitis following fecal diversion

Nonspecific colitis, histologically similar to ulcerative colitis, may be seen in the defunctionalized colon of patients who have undergone fecal diversion for indications other than inflammatory bowel disease. Little is known about this entity, which may have important diagnostic and therapeutic implications in any patient who undergoes fecal diversion. A case of symptomatic diversion colitis is presented. A review of the records of all patients who underwent fecal diversion in our hospital between 1978 and 1983 yielded one additional patient with asymptomatic colitis in the defunctionalized rectum. Further review of the literature produced only two articles pertaining to diversion colitis, underscoring the lack of recognition of this entity in this group of patients.     

Diversion colitis and pouchitis: A mini-review

Diversion colitis is characterized by inflammation of the mucosa in the defunctioned segment of the colon after colostomy or ileostomy. Similar to diversion colitis, diversion pouchitis is an inflammatory disorder occurring in the ileal pouch, resulting from the exclusion of the fecal stream and a subsequent lack of nutrients from luminal bacteria. Although the vast majority of patients with surgically-diverted gastrointestinal tracts remain asymptomatic, it has been reported that diversion colitis and pouchitis might occur in almost all patients with diversion. Surgical closure of the stoma, with reestablishment of gut continuity, is the only curative intervention available for patients with diversion disease. Pharmacologic treatments using short-chain fatty acids, mesalamine, or corticosteroids are reportedly effective for those who are not candidates for surgical reestablishment; however, there are no established assessment criteria for determining the severity of diversion colitis, and no management strategies to date. Therefore, in this mini-review, we summarize and review various recently-reported treatments for diversion disease. We are hopeful that the information summarized here will assist physicians who treat patients with diversion colitis and pouchitis, leading to better case management.     

Diversion Colitis in Children with Severe Gastrointestinal Motility Disorders

We found colitis in 11 of 14 children, 4 months to 7 yr after surgical diversion of the colon for chronic intestinal pseudo-obstruction. Colonoscopic examination was incidental during placement of a catheter for colon manometry and transit studies. All 14 children had complained of diffuse, poorly localized abdominal pain, but only three had a history of bloody stools. Diversion colitis had not previously been suspected in six of eight affected children without hematochezia. Biopsies showed a nonspecific acute and chronic inflammation and/or nodular lymphoid hyperplasia. There was no correlation between the duration of the colonic diversion and the severity of the colitis. Diversion colitis may be an indolent inflammatory nidus and a potential cause for repeated bacteremia, abdominal pain, and bleeding.     

Spectrum of non-inflammatory bowel disease and non-infectious colitis

A variety of inflammatory diseases of the colon, which can be differentiated from inflammatory bowel disease （IBD） and infectious colitis by their clinical, endoscopic and histological characteristics, are reported as non- IBD and non-infectious colitis. These diseases include microscopic colitis, ischemic colitis, segmental colitis associated with diverticula, radiation colitis, diversion colitis, eosinophilic colitis and Behcet＇s colitis. The etiopathogenesis of most of these diseases remains obscure and the epidemiological data are rather limited. These conditions are often troublesome for the patient and are associated with diagnostic difficulties for the physician. In many cases the treatment is empirical and there is a need for future research using randomized controlled trials.     

Diversion colitis. Pathologic findings in a resected sigmoid colon and rectum

We present here the detailed pathologic findings in the resected colon and rectum from a paraplegic patient with severely symptomatic diversion colitis and lack of anorectal function. Previous reports of the pathology of this condition have been confined to biopsy findings. A diffuse nodularity caused by lymphoid hyperplasia and an inflammatory process confined to the colorectal mucosa with erosions, crypt abscesses, mucin granulomas, and aphthoid ulcers were the main features. There was minimal distortion of crypt architecture. The pathologic features of this entity are compared to those of other inflammatory disorders of the colon and rectum.     

Aphthous ulceration in diversion colitis. Clinical implications

Two cases of aphthous ulceration apparently due to diversion colitis are described. There was no evidence of Crohn's disease initially or at follow-up. Aphthous ulceration of the colon and diversion colitis are reviewed, and the nonspecificity of aphthae for Crohn's disease is stressed. The presence of aphthous ulcers in a diverted colon should not preclude colostomy closure.     

Diversion colitis in Crohn disease. A case report and review of the literature

A 45 year old man, suffering from Crohn's disease of the colon, and a 25 year old woman, with ileocolitis Crohn, developed a diversion colitis in the remaining distal segment of the colorectum after ileostomy. After reanastomosis, which was done 11 and 2 years later, the diversion colitis vanished spontaneously. This case report and the data in literature indicate the opinion, that reanastomosis of the distal colon should be done early after diversion, if there are no specific signs of Crohn's disease in the remaining colorectum.     

Diversion colitis in patients scheduled for colostomy closure

Despite recent work, diversion colitis remains poorly defined. Thirty-four patients, scheduled for colostomy closure, were prospectively evaluated with flexible sigmoidoscopy for diversion colitis. Biopsies and cultures were obtained if colitis was identified at endoscopy. All biopsy materials and cultures were consistent with inflammation only. The vast majority of patients were in good general health, and their colostomies were constructed as the result of trauma. Eight patients (24 percent) had normal-appearing colons at an average of 16.6 weeks following diversion. Twenty-six patients (76 percent) demonstrated mild to severe colitis at an average of 29.9 weeks following diversion. Three complications occurred in 22 patients after colostomy closure: two wound infections in patients with colitis and one in a patient with a normal colon. We conclude that diversion colitis in an otherwise individual constitutes no increased risk of infection following colostomy closure.     

Impaired bacterial flora in human excluded colon.

We compared the rectal microflora of 16 patients with surgically excluded colorectum with 16 healthy controls. The cause of diversion was inflammatory bowel disease (n = 10), colon cancer (n = 3), miscellaneous (n = 3). Six patients had a diversion colitis. In the excluded colorectum, the total bacterial count was only slightly lower than controls but the variety of the flora was significantly reduced. This reduction was confined to strict anaerobes, mainly the genus Eubacterium and Bifidobacterium. Among aerobes, enterobacteria were more often isolated than in controls. This altered microflora of excluded colorectum could be involved in the mucosal damage observed in some cases.     

Diversion colitis: histological features in the colon and rectum after defunctioning colostomy.

Diversion of the faecal stream by ileostomy or colostomy leads to inflammation in the defunctioned segment, known as diversion colitis. The affected bowel is rapidly restored to normality by reanastomosis. Diversion colitis should not be mistaken for inflammatory bowel disease, for which reanastomosis would be inappropriate. Studies of biopsy material from patients with diversion colitis have shown a variety of histological features, but no consistent pattern. The histology in resection specimens of defunctioned large bowel from 15 patients with no pre-existing inflammatory bowel disease was studied. Nine patients had symptoms of abdominal pain or rectal discharge of blood or mucus that developed between 9 months and 17 years after diversion procedure. The histology was abnormal in all. Findings were similar in 14 patients, regardless of the duration of faecal diversion, and comprised diffuse mild chronic inflammation with or without mild crypt architectural abnormalities, crypt abscesses, or follicular lymphoid hyperplasia. One patient had more severe changes, resembling active ulcerative colitis. These features in biopsy specimens are unlikely to be diagnostic but should provide useful information in avoiding a mistaken diagnosis of inflammatory bowel disease in these patients.     

Faecal diversion for Crohn's colitis: a model to study the role of the faecal stream in the inflammatory process.

The high incidence of clinical remission after faecal diversion for Crohn's colitis suggests the faecal stream may play a part in the inflammatory mechanism. The effect of faecal diversion (n = 22) and restoration of intestinal continuity (n = 10) was assessed in patients with Crohn's colitis and compared with controls. Faecal diversion produced significant improvement in the disease activity index mean (SEM) (before 176 (9); after 114 (9), p < 0.01) and serum albumin concentrations (before 33 (3.0); after 38 (3.0), p < 0.05) in all patients with Crohn's colitis. The crypt cell production rate (CCPR) was maintained after faecal diversion for Crohn's colitis but fell in the control group (before = 3.6 (0.8)), at two (1.4 (0.4), p < 0.02), and six weeks (1.6 (0.4), p < 0.05). Mucosal glucosamine synthetase activity, reflecting glycoprotein synthesis, was significantly lower in patients with Crohn's colitis (analysis of variance p < 0.05) after diversion but was maintained in the control group. Restoration of intestinal continuity failed to produce reciprocal changes. The sustained cellular proliferation and fall in glycoprotein synthesis in Crohn's colitis after faecal diversion may represent the end of an exaggerated protective response and regenerative hyperplasia after exclusion of the faecal stream. This study suggests the faecal stream may participate in the inflammatory process in Crohn's colitis. The underlying mechanism is unknown.     

The Role of Short-Chain Fatty Acid Metabolism in Colonic Disorders

During the past decade it has become evident that colonic mucosal metabolism is more complex than previously suspected. Luminal short-chain fatty acids (SCFAs) are recognized as an essential fuel source for colonocytes, particularly in the distal colon. Their absence may explain the development of diversion colitis; however, this has not been confirmed by clinical trials. The histologic, endoscopic, and metabolic similarities between diversion colitis and ulcerative colitis suggest that a nutritional SCFA deficiency state may play a role in the pathogenesis of these disorders. Diversion colitis and continent urinary diversion, utilizing distal and proximal colon reservoirs, provide in vivo models to study normal colonic mucosa in circumstances of reduced intraluminal SCFA concentrations and altered luminal effluent. Further studies utilizing these models would enhance our understanding of the regional differences in mucosal cell metabolism and adaptability and, hopefully, provide therapeutic alternatives for the management of colonic disorders. The welfare of colonic mucosa, as it relates to SCFA metabolism, awaits another exciting decade of investigation.     

Synchronous occurrence of collagenous colitis and pseudomembranous colitis.

Synchronous collagenous and pseudomembranous colitis has not been previously reported. A 73-year-old woman presented with chronic watery diarrhea and abdominal cramping of six weeks' duration. Biopsies of the colon revealed findings of collagenous colitis involving the endoscopically normal right colon, and superimposed collagenous and pseudomembranous colitis involving the rectosigmoid colon. Endoscopically, the left colon revealed discrete ulcerative plaques, and Clostridium difficile toxin A assay was positive. The patient partially responded to a three-week regimen of metronidazole, and symptoms resolved completely with subsequent steroid therapy. At follow-up endoscopy four months later, colon biopsies demonstrated persistence of subepithelial collagen but no pseudomembranes. The patient remained asymptomatic during this interval. Collagenous colitis has been reported in association with other inflammatory bowel diseases, including lymphocytic colitis, sprue and idiopathic inflammatory bowel disease. This unique association of collagenous colitis with an endotoxigenic inflammatory bowel disease is presented with a review of related disease features.     

Endoscopic Examination of the Colon and Rectum Distal to a Colostomy

We report results of the endoscopic examination of the colon distal to a colostomy in 85 patients. Almost half had symptoms related to the excluded bowel. Whereas severe colitis or tumor may be asymptomatic, many patients had discomfort, pain, bleeding, and discharge. Endoscopic examination revealed abnormal findings in 80% of the patients. These were as uncomplicated as mucous plugs or as serious as polyps or carcinoma. We found a high incidence of diversion colitis in the excluded colon. Because of these abnormal findings, endoscopy of the bowel distal to a colostomy at regular intervals is recommended. Mucous plugs and scybala should be treated by irrigation, while polyps and carcinoma should be treated as they would in the nondiverted colon. Diversion colitis can be treated medically with local steroids, or surgically. In most cases, even in severe colitis, we recommend closure of the colostomy. Removal of the excluded colon is seldom necessary.     

Microcarcinoids and diversion colitis in a colon defunctioned for 18 years

Submucosal microcarcinoids are described in association with diversion colitis in a colon defunctioned for 18 years. Coexistent florid neuronal hyperplasia is postulated as a cause of microcarcinoid formation.     

Histopathology of non-IBD colitis practical recommendations from pathologists of IG-IBD Group

Pathologists are often called upon to diagnose colitides that differ from the two main forms of inflammatory bowel disease (IBD). These non-IBD colitides include infectious colitis, microscopic colitis, ischemic colitis, eosinophilic colitis, autoimmune enterocolitis, segmental colitis associated with diverticulosis, drug-induced colitis, radiation colitis and diversion colitis. The diagnosis of these different disease entities relies on the histopathological examination of endoscopic biopsies of the gastrointestinal tract. This paper reviews the main histomorphological characteristics of the various Non-IBD colitides.     

Onerous concomitant complications of ulcerative colitis: a case report

Ulcerative colitis is a chronic inflammatory disease of the colon characterized by intermittent exacerbations and remissions. It may be complicated with colon cancer or autoimmune-related extracolonic problems. Herein, we present a woman with ulcerative colitis who developed sarcoidosis, colon cancer, primary sclerosing cholangitis, and cholangiocarcinoma. To our knowledge, such associations in a patient have not been reported before.     

Peptide YY concentrations in normal ileum and colon and in idiopathic inflammatory bowel disease

Concentrations of the candidate endocrine and paracrine peptide, peptide YY, were measured by specific radioimmunoassay in tissue extracts prepared from normal ileum, normal colon, Crohn's disease, and ulcerative colitis. In both the ascending and descending colon, there were significantly decreased mean concentrations of peptide YY in Crohn's colitis and ulcerative colitis, compared to mean concentrations in normal colon. There was no age-related decrease of concentrations of peptide YY in normal colon. The decrease in concentrations of peptide YY in colon obtained from patients with inflammatory bowel disease did not appear related either to the duration of the clinical symptoms of the disease or to the severity of colonic inflammation. Further studies of the physiological function of peptide YY in man are needed to determine whether these findings might be useful in understanding a component of the pathophysiology of idiopathic inflammatory bowel disease.     

EVALUATION OF COLONOSCOPIC FINDINGS IN PATIENTS WITH DIARRHEAGENIC ESCHERICHIA COLI‐INDUCED HEMORRHAGIC COLITIS

Background: We evaluated the clinical significance of colonoscopic findings in the acute infectious phase of diarrheagenic Escherichia coli (E. coli)‐induced hemorrhagic colitis. Methods: According to the strain of cultured pathogen, 38 patients with diarrheagenic E. coli‐induced hemorrhagic colitis were divided into an enterohemorrhagic E. coli (EHEC) group consisting of 20 patients and a non‐EHEC group consisting of 18 patients. The inflammatory findings were classified into five grades primarily according to the severity of the edema, and attendant on the degree of erythema. The inflammatory grade was determined for each part of the colon, rectum, and terminal ileum. Results: In the EHEC group, colonoscopy manifested characteristic findings of an inflammatory gradient in most patients. Additionally, in approximately half of the patients, longitudinal ulcers were observed in part of the transverse colon and/or the descending colon. In the non‐EHEC group, inflammatory findings were milder than those of EHEC‐induced colitis, and were restricted to the left‐side colon in most patients. In five of 18 patients, colonoscopic findings closely resembled those of transient ischemic colitis. In two of 18 patients, geographic ulcerations were seen in the left‐side colon. In 11 of 18 patients, only mild inflammations were observed in restricted segments of the colon. Conclusions: In the EHEC group, colonoscopy manifested characteristic findings not seen in other colonic diseases, and which are useful in predicting the probability of EHEC as the causative pathogen in patients with hemorrhagic colitis. In the non‐EHEC group, colonoscopic findings did not demonstrate the common inflammatory findings seen in the EHEC group.