eun-ran kim - mobile smcgismcgi.co.kr/sgea/infectious_colitis.pdf · eun-ran kim division of ......
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Eun-Ran Kim
Division of Gastroenterology, Department of Medicine
Samsung Medical Center
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Colitis
– an inflammation of the colon
– diagnosed when the patient has diarrhea (≥ 3 unformed stools/day)
and has evidence of colonic inflammation of the following:
• Positive fecal markers
: numerous leukocytes, positive lactoferrin, or calprotectin
• Passage of many small volume stools containing gross blood
• Endoscopy revealing mucosal inflammation
Acute, chronic and persistent
– Acute : develops within 14 days of diarrhea onset
– Chronic : 30 or more days after development of diarrhea
Colitis (Colitides)
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Differential diagnosis
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The cause of infectious colitis
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Common microbial cause
Emerg Infect Dis 2011 Jan;17(1):7-15
Journal of Infect ion (2012) 64,374-386
(2000-2008)
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Most cause of infectious colitis : bacterial enteropathogens
Symptoms
: diarrhea with or without dysentery, abdominal pain, fever
Important microbial pathogens
– All regions : Salmonella, Shigella, Campylobacter
– Developing tropical & semitropical regions : Entamoeba histolytica
– Industrialized : Shiga toxin-producing Escherichia coli (STEC)
– Hospitalized : C. difficile infection (CDI)
≥ 30 days : consider IBD, or in endemic area, Entamoeba
histolytica or Schistosoma mansoni (africa)
Infectious colitis
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Pathogenesis
– Invaded colonic mucosa
• Systemic sign and symptoms including fever, chill, toxicity
• Salmonella, Shigella, Campylobacter
– Non-invasive
• Attach to colonic mucosa, localozed inflammation
• Clostridium difficile, enteroaggregative, or STEC
Regardless of the etiology, clinical symptoms are quite similar.
Infectious colitis
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the most important diagnostic test
: a single stool culture for bacterial causes of colitis
It is hard to prove the existence of pathogens.
: In more than 50% of cases of dysentery, an etiologic agent is not
identified despite using optimal diagnostic methods.
Patients whose symptoms have not improved within 1 week should
undergo a sigmoidoscopy or colonoscopy.
Infectious colitis
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Endoscopy is not warranted for the initial evaluation.
Should be considered for patients with
– persistent symptoms
– inconclusive diagnosis after routine blood & stool tests
– failure to respond to empirical therapy
Suitable initial investigation : Flexible sigmoidoscopy with biopsy
– Acute diarrhea : suspected diffuse colitis (C. difficile )
– Chronic diarrhea : pregnant, significant comobidity, symptoms
characteristics of left sided colonic disease (tenesmus, urgency)
Colonoscopy : if the findings at sigmoidoscopy are inconclusive
The role of endoscopy
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Prominent endoscopic features
– patchy or diffuse mucosal edema, mucosal erythema, focal or
coalescent haemorrhagic spots
– a variety of ulcerations occasionally with cobblestone appearance,
and spontaneous bleeding
Duration
– Acute : UC or ischemic colitis-like
– Subacute or chronic : CD-like
Location
– Shigella : intense involvement of the rectosigmoid
– Salmonella, Yersinia, Amoeba : cecum and ascending colon
Endoscopic findings
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Endoscopic similarities
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UC (ulcerative colitis) –like
– Shigella, Salmonella, Campylobacter, Amoeba, CMV
CD (Crohn’s disease)-like
– Salmonella, Campylobacter, Yersinia, Amoeba, intestinal Tbc,
CMV
Endoscopic findings
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Shigella
UC-like
Yersinia
CD-like
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Case
69 yrs old man
3 days ago, lower abdominal pain, diarrhea with fever
1 day ago, hematochezia
WBC 15240/L, CRP 24.08 g/dL
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Stool Culture :
Shigella sonnei
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Stool Culture :
Shigella sonnei
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Histologic findings : Chronic inflammatory changes
– crypt architecture distorsion, crypt atrophy, basal lymphoid
aggregates
Differential diagnosis
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Shigellosis
UC-like
Involvement : Rectosigmoid
15% : pancolitis
Prominent endoscopic findings
- erythema, severe edema
- irregular ulcers
- spontaneous bleeding
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UC-like CD-like
Salmonellosis Involvement: terminal ileum, right side colon
Erythema, edema, granularity, loss of the normal vascular pattern
More severe : diffuse erythema, pitting edema, ulceration
(punctuate, aphthoid, aphthae, irregular (stellate), deep)
occasionally, denuded extensive areas of colonic mucosa
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CD-like
Yersinia
Involvement : Right side colon
Endoscopic findings
- erosions, various forms of
ulcerations (usually punctuate)
- on other occasions,
mimics ulcerative colitis
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Amebic colitis
UC-like CD-like
Involvement: cecum and Rt. Colon (70%), rectum and S colon
Acute: Diffuse erythema, granularity, friability resembling UC.
Chronic form : discrete or localized mucosal ulcers with a
characteristic pounched-out appearance (rolled edges) helps the
differential diagnosis from CD. (A flask shaped ulcer)
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Usually non-specific but includes discrete ulcerations, varying
from punctate and superficial erosions to deep ulcers .
Histology
: typical inclusions which confirm the diagnosis
CMV colitis
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Intestinal tuberculosis
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Intestinal tuberculosis
CD : anorectal lesions, longitudinal ulcers, aphthous ulcers
and cobblestone pattern
Tbc : involvement of less than 4 segments, a patulous IC valve,
transverse ulcers, and scars or pseudopolyps
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Distal or Left side colon
white yellow mucosal lesions including pseudomembranous
1/3 : non-specific erosions or erythemas
Clostridium difficile
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Treatment
Empiric antibiotic therapy
– oral fluoroquinolone for 3-5 days
(in the absence of suspected EHEC or fluoroquinolone-resistant campylobacter infection)
• ciprofloxacin 500 mg twice daily
• norfloxacin 400 mg twice daily
• levofloxacin 500 mg once daily
Consideration
– with moderate to severe travelers' diarrhea as characterized by more
than four unformed stools daily, fever, blood, pus, or mucus in the stool
– with more than eight stools per day, volume depletion, symptoms for
more than one week, those in whom hospitalization is being
considered, and immunocompromised hosts
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Eun-Ran Kim
Division of Gastroenterology, Department of Medicine
Samsung Medical Center
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51 yrs old man
Previously healthy
1 day ago, sudden onset of abdominal pain, followed by
hematochezia
Case
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Old age
Sudden onset of abdominal pain & hemtochezia
Endoscopy
– hyperemia, edema, ulceration
– rectal sparing
– resolved within 1-2 weeks
– Bx : coagulation necrosis
Ischemic colitis
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29 yrs old female
2001.1. cervix ca -> radiation + chemotherapy
2001.8. hematochezia
Case
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Radiation history due to cervix ca. or prostatic ca.
Endoscopy
– proximal rectum & distal sigmoid colon
– mucosal friability
– granularity with spontaneous bleeding
– multiple telangiectasia
Radiation colitis
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48 yrs old female
10 years ago, constipation with straining
Anal bleeding, mucoid stool, tenesmus, lower abdominal pain
Case
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Colonoscopy
Colonoscopic Biopsy
: chronic inflammation
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Defecography
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A chronic course characterized by rectal bleeding,
disordered defecation, tenesmus and mucorrhea
Endoscopy
– anterior wall, 4 to 15 cm from the anal verge
– shallow ulcers with white, sloughy base surrounded by
a thin rim of erythematous mucosa
Solitary rectal ulcer syndrome
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Histology
– characteristic
– obliteration of lamina propria by fibromuscular
proliferation of the muscularis mucosa
– streaming of fibroblasts and muscle fibers up between
crypts
– thickening of muscularis mucosa
– branching, distorted glandular crypts
– diffuse collagen infiltration of lamina propria
Solitary rectal ulcer syndrome
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Sodium phosphate
– aphthous ulcers
– focal cryptitis
Bisacodyl suppository
– mucosal hyperemia
– obliteration of vascular pattern
Bowel preparation
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Bowel preparation
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Non specific colitis
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중년 남성
Low abdominal discomfort
Bx : focal active inflammation, terminal ileum
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Diarrhea (-) Hematochezia (-) Wt loss (-) Oral ulcer (-)
ESR/CRP : normal
“복통이나 설사가 심해지거나 혈변이 생기면 들리세요”
Colonoscopy, 1 year later
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Gastrointest Endosc 2010;72:1226
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2개월 전 외부 병원에서 건강 검진으로 대장내시경 시행
Young female
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현재 특이 증상 없음
건강 검진 1주일전 발열, 복통, 설사
Colonoscopy 6 months later
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Conclusions
장염의 정확한 진단을 위해서는 자세한 병력청취가 중요하다.
대장내시경 소견의 이해도 중요하다.
그러나 환자의 병력과 여러 가지 검사 소견을 종합적으로
검토하여야 한다.
때로는 경과 관찰로 환자의 변화를 파악하는 것도 중요하다.