Miscellaneous colitides

Ian BotterillSt James’s University Hospital,

Leeds

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

C. Difficile

Ischaemic colitis

Radiation proctocolitis

CMV

Graft v host

‘critical care’ colitides

Initial assessment

• History / PMSH crucial- symptoms - aetiological factors

• Resuscitation • Bloods / inflammatory markers• Stool culture / stool chart• AXR• Lower GI endoscopy• CT

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

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

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

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

C Difficile: 2nd line therapy

• Oral vancomycin• Indication - non responders

- C/I to metronidazole• 125mg qds -

cure 85-99% - relapse 15-30% - risk: VRE

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

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

Ischaemic colitis

• Crampy ‘hind-gut’ pain• Dark red bleeding

• Wide spectrum severity

• Typically splenic flexure

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

Ischaemic colitis: uncommon associations

• hypercoaguable states- sickle cell

- the ‘pill’- pregnancy- pancreatitis

• drugs (vasospastic & diuretics)- sumatriptan- cocaine- pseudoephidrine- loop diuretics

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

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

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

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

Radiation proctitis

• Acute- diarrhoea & urgency

- bleeding• Chronic radiation proctopathy

- bleeding (neovacularisation) - functional

Chronic radiation proctopathy

• 5% - 40%• ‘Radiation proctopathy symptom

assessment scale’ (RPSAS)- diarrhoea / urgency

- proctalgia- tenesmus

- bleeding-

incontinence DCR 2005;48:1-8

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

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

Radiation proctopathy -2y brachytherapy

• Do not biopsy rectal wall following brachytherapy for prostate cancer

- risk: recto-urethral fistula

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

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

CMV & UC: Treatment

• Consider the diagnosis

• Use caution pre-commencing Ciclosporin A - check histology / immunology

• Treatment- Ganciclovir- ↓ standard immunosuppression

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

Summary 1

Assorted misfits causing regular pain & suffering

- good history & stool culture

- biopsy

- medical care

- occasional colectomy

Summary 2

Unhappy coexistence……

Summary 3

Recurrences despite seemingly successful eradication……

Summary 4

Some forms can hit back…..

Summary 5