miscellaneous colitides ian botterill st james’s university hospital, leeds
TRANSCRIPT
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Miscellaneous colitides
Ian BotterillSt James’s University Hospital,
Leeds
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Classification of miscellaneous colitides
• 2y infection - bacterial (C Diff, campylobacter, salmonella, shigella) - viral (CMV, rotavirus)
- amoebic• Not 2y infection
- ischaemic - radiation - immunological (GVHD) - microcytic (lymphocytic,
collagenous) - non steroidal- diverticular
- diversion
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C. Difficile
Ischaemic colitis
Radiation proctocolitis
CMV
Graft v host
‘critical care’ colitides
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Initial assessment
• History / PMSH crucial- symptoms - aetiological factors
• Resuscitation • Bloods / inflammatory markers• Stool culture / stool chart• AXR• Lower GI endoscopy• CT
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Clostridium Difficile
• Commonest hospital acquired diarrhoea - profuse offensive diarrhoea - bleeding & fever uncommon
• Gram +ve spore forming anaerobic rod• Two enterotoxins (A&B) • ↑LOS by 3.5 days• ↑i-p costs ~$3000
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C Difficile: associations
• ampicillin, clindamycin, cephalosporins
• any antibiotic possible- metronidazole & vancomycin
• 1-8/52 post antibiotics
• associations- chemoRx / laxatives / enteral
feeding - elderly & coexistent morbidity - recent GI surgery
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C Difficile: diagnosis
• ↑ WCC (leukaemoid reaction – poor prognosis)• ↓↓ albumin ( poor prognosis)
• Stool culture - EIA for B toxin: fast / less accurate- tissue cytotoxicity assay: slow /
accurate• Imaging - colonic thickening / ‘accordion’
sign • Flexi sig - pseudomembranes (not
pathognomoinic) - 1/3 rd have only proximal disease
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C Difficile: treatment
• Cessation causative antibiotics- 20% resolve
• Avoid anti-diarrhoeals • If ABx essential > quinolones,aminoglycosides• Metronidazole -
x10-14/7 - cure ~98% - relapse ~10%
Reviews Gastro Disorders 2004;4:186-194
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C Difficile: 2nd line therapy
• Oral vancomycin• Indication - non responders
- C/I to metronidazole• 125mg qds -
cure 85-99% - relapse 15-30% - risk: VRE
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C Difficile: non responders
• metronidazole i-v• vancomycin retention enemas
• bacitracin 80,000u/d• teicoplanin• cholestyramine (not with vancomycin)• immunoglobulin • Faecal exchange enemas Gastroenterology
1980;78:431-4 Clin Inf Dis 1996;22:813-18
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C Difficile: surgery
• 0.5% - 4%• Indications
- toxic dilation / ‘sepsis’ / perforation
• Colon: oedematous & flaccid but quite normal- still resect
• Subtotal colectomy & ileostomy
• Mortality 30-80%
Surgery 1994;116:491-6 BJS 1998;85:229-31
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Ischaemic colitis
• Crampy ‘hind-gut’ pain• Dark red bleeding
• Wide spectrum severity
• Typically splenic flexure
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Ischaemic colitis
• Common associations- elderly (F>M)
- cardiac & respiratory disease - temporary low flow states - aortic surgery / aortic stenting
Ann Vasc Surg 1999;13:533-8
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Ischaemic colitis: uncommon associations
• hypercoaguable states- sickle cell
- the ‘pill’- pregnancy- pancreatitis
• drugs (vasospastic & diuretics)- sumatriptan- cocaine- pseudoephidrine- loop diuretics
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Ischaemic colitis & aortic surgery
• incidence: - emergency surgery 5-10%
- elective surgery 1%
• lactate WCC / flexi sig / imaging• surgery for full thickness necrosis:
- colectomy & ileostomy- mortality ~50-60%
• routine IMA reimplantation? - no benefit
Ann Vasc Surg 1999;13:533-8 Acta Ch Belgica 2000;100:21-7 J Vasc Surg 2004;39:792-6
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Ischaemic colitis: adverse factors
• Shock / peritonitis• Chronic renal failure • Right colon involvement
• Prior pelvic irradiation
• Absence arterial flow in bowel wall (doppler USS)
AJR 2000;175:1151-4 Am J Gastro
2000;95:195-8 J Vasc Surg 1996;23:706-9
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Ischaemic colitis: management
• Iv fluids / O2 / anti-platelet agent
• Stool culture / AXR / CT• Flexible sigmoidoscopy
• Embolic source - echo / ECG / USS- source of embolism 40% - anticoagulation 30%- new anti-arrthythmic
25%• Hypercoagulability screen
- positive 30%
SMJ 2004;97:120-3 AJG 2003;98:1573-7
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Ischaemic colitis: outcomes
• Overall mortality 5-29%• Mortality post surgery ~40%
DCR 2004;47:180-4 Gastro Clin N Am 1998;27:827-60 Surgery
2003;134:624-9 AJG 2000;95:195-8
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Radiation proctitis
• Acute- diarrhoea & urgency
- bleeding• Chronic radiation proctopathy
- bleeding (neovacularisation) - functional
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Chronic radiation proctopathy
• 5% - 40%• ‘Radiation proctopathy symptom
assessment scale’ (RPSAS)- diarrhoea / urgency
- proctalgia- tenesmus
- bleeding-
incontinence DCR 2005;48:1-8
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Radiation proctopathy: bleeding
• 5ASA derivatives / steroid enemas • Argon plasma coagulation
• Topical formalin• Short chain fatty acid enemas
Gastro Endos 1999;50:221-4 Am J Surg 1999;177:396-8 Lancet 2000;356:1232-5 Lancet 2000;356:1232-5
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Radiation colitis-miscellaneous treatments
• Retinol palmitate (Vit A) - controlled,
blinded, crossover trial - reduction in RPSAS
• Oestrogen / progesterone• Hyperbaric oxygen
DCR 1993;36:962-5Am J Gastro 1998;93:2356-8
Int Urol Neph 1996;28:643-7 DCR 2005
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Radiation proctopathy -2y brachytherapy
• Do not biopsy rectal wall following brachytherapy for prostate cancer
- risk: recto-urethral fistula
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Cytomegalovirus colitis
• immunosuppressed - HIV / post-organ transplant / chemotherapy
• UC
• abdo pain, fever, wt loss, urgency, bleeding• colonoscopy - multiple
discrete ulcers - proximal colon alone in 1/3
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CMV & ulcerative colitis
• Histology (inclusion bodies / IHC)- 20% of colectomy specimens - causative or epiphenomenon?
• Immunology- antigenaemia in 30% of pts with severe
UC • ↑ immunosuppression > symptomatic
deterioration• Worse outcomes: toxic megacolon / MSOF
DCR 2004;47:722-6DCR 2003;46:S59-65
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CMV & UC: Treatment
• Consider the diagnosis
• Use caution pre-commencing Ciclosporin A - check histology / immunology
• Treatment- Ganciclovir- ↓ standard immunosuppression
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Graft versus host enterocolitis
• Post bone marrow transplant - whole body irradiation / chemo
• Profuse bloody diarrhoea• CT /flexi sig: pan-enteric inflammation
• Rx: TPN / steroids / budesonide
• Mortality: 91%• Survival: 7/12 (2-35/12)
SJUH data
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Summary 1
Assorted misfits causing regular pain & suffering
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- good history & stool culture
- biopsy
- medical care
- occasional colectomy
Summary 2
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Unhappy coexistence……
Summary 3
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Recurrences despite seemingly successful eradication……
Summary 4
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Some forms can hit back…..
Summary 5