Drug-induced colitis: Difference between revisions

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__NOTOC__
__NOTOC__
{{SI}}                                                                  
{{SI}}  
'''For the main page on colitis, please click [[Colitis|here]]'''<br>
'''For more information on allergic colitis, please click [[Allergic colitis|here]]'''<br>
'''For more information on infectious colitis, please click [[Infectious colitis|here]]'''<br>
'''For more information on ischemic colitis, please click [[Ischemic colitis|here]]'''<br>
'''For more information on chemical colitis, please click [[Chemical colitis|here]]'''<br>
'''For more information on radiation colitis, please click [[Radiation colitis|here]]'''<br>
                                                         
{{CMG}}; {{AE}} {{QS}}
{{CMG}}; {{AE}} {{QS}}
   
   
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==Overview==
==Overview==
Drug-induced colitis is inflammation of the large intestine or colon, caused by the introduction of drugs or chemicals to the colon usually by the oral route but occasionally through the rectum. Non-steroidal anti-inflammatory drugs (NSAIDs) are the most common drugs implicated in drug-induced colitis and also the most commonly used drugs worldwide. Drug-induced colitis can resemble ulcerative colitis, infectious colitis and ischemic colitis endoscopically. Most cases of drug-induced colitis resolve after stopping the offending medication.<ref name="pmid8500743">{{cite journal| author=Bjarnason I, Hayllar J, MacPherson AJ, Russell AS| title=Side effects of nonsteroidal anti-inflammatory drugs on the small and large intestine in humans. | journal=Gastroenterology | year= 1993 | volume= 104 | issue= 6 | pages= 1832-47 | pmid=8500743 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8500743  }} </ref><ref name="pmid123">{{cite book | last = Odze | first = Robert | title = Odze and Goldblum surgical pathology of the GI tract, liver, biliary tract, and pancreas | publisher = Saunders/Elsevier | location = Philadelphia, PA | year = 2015 | isbn = 978-1455707478 }} </ref>


==Historical Perspective==
*NSAID-induced colitis was first described by Debenham, a Canadian doctor, in 1966 following a patient who developed ulcer in the caecum during oxyphenbutazone therapy.<ref name="pmid5934387">{{cite journal| author=Debenham GP| title=Ulcer of the cecum during oxyphenbutazone (tandearil) therapy. | journal=Can Med Assoc J | year= 1966 | volume= 94 | issue= 22 | pages= 1182-4 | pmid=5934387 | doi= | pmc=1935486 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5934387  }} </ref>
*Diaphragm disease was first mentioned in 1987, by Lang et al to describe small bowel strictures from NSAIDs use.<ref name="pmid3384981">{{cite journal| author=Lang J, Price AB, Levi AJ, Burke M, Gumpel JM, Bjarnason I| title=Diaphragm disease: pathology of disease of the small intestine induced by non-steroidal anti-inflammatory drugs. | journal=J Clin Pathol | year= 1988 | volume= 41 | issue= 5 | pages= 516-26 | pmid=3384981 | doi= | pmc=1141503 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3384981  }} </ref>
*Sheers and Williams in 1989, subsequently described similar diaphragm disease in the colon of patients on NSAIDs.<ref name="pmid2572870">{{cite journal| author=Sheers R, Williams WR| title=NSAIDs and gut damage. | journal=Lancet | year= 1989 | volume= 2 | issue= 8672 | pages= 1154 | pmid=2572870 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2572870  }} </ref>


==Historical Perspective==
*[Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
*In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
*In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].
==Classification==
==Classification==
*There is no established classification method for drug-induced colitis. However, it may be classified based on the pathophysiology pattern, type of drug and duration of symptoms.<ref name="pmid27472233">{{cite journal| author=Marginean EC| title=The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract. | journal=Arch Pathol Lab Med | year= 2016 | volume= 140 | issue= 8 | pages= 748-58 | pmid=27472233 | doi=10.5858/arpa.2015-0451-RA | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27472233  }} </ref><ref>{{cite book | last = Odze | first = Robert | title = Odze and Goldblum surgical pathology of the GI tract, liver, biliary tract, and pancreas | publisher = Saunders/Elsevier | location = Philadelphia, PA | year = 2015 | isbn = 978-1455707478 }}</ref>
*There is no established classification method for drug-induced colitis. However, it may be classified based on the pathophysiology pattern, type of drug and duration of symptoms.<ref name="pmid27472233">{{cite journal| author=Marginean EC| title=The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract. | journal=Arch Pathol Lab Med | year= 2016 | volume= 140 | issue= 8 | pages= 748-58 | pmid=27472233 | doi=10.5858/arpa.2015-0451-RA | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27472233  }} </ref><ref name="pmid123">{{cite book | last = Odze | first = Robert | title = Odze and Goldblum surgical pathology of the GI tract, liver, biliary tract, and pancreas | publisher = Saunders/Elsevier | location = Philadelphia, PA | year = 2015 | isbn = 978-1455707478 }} </ref>


===Classification based on histologic pattern===
===Classification based on histologic pattern===
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Based on the duration of symptoms, drug-induced colitis can be classified into:
Based on the duration of symptoms, drug-induced colitis can be classified into:
*Acute
*Acute
*Chronic e.g. diaphragm disease (results from prolonged use of NSAIDs)
*Chronic e.g. diaphragm disease (results from long-term use of NSAIDs)


==Pathophysiology==
==Pathophysiology==
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===Gross Pathology===
===Gross Pathology===
Gross pathology findings in drug-induced colitis depends on the causative drug.
Gross pathology findings in drug-induced colitis depends on the causative drug.
*NSAID-induced colitis is characterized by nonspecific mucosal erosions and ulcers of varying degree, with intervening areas of normal mucosa. Perforations and fibrosis may also be seen. The lesions are predominantly on the right and may be single or multiple, sparing the rectum.<ref name="pmid27472233">{{cite journal| author=Marginean EC| title=The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract. | journal=Arch Pathol Lab Med | year= 2016 | volume= 140 | issue= 8 | pages= 748-58 | pmid=27472233 | doi=10.5858/arpa.2015-0451-RA | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27472233  }} </ref><ref name="pmid24339669">{{cite journal| author=Tonolini M| title=Acute nonsteroidal anti-inflammatory drug-induced colitis. | journal=J Emerg Trauma Shock | year= 2013 | volume= 6 | issue= 4 | pages= 301-3 | pmid=24339669 | doi=10.4103/0974-2700.120389 | pmc=3841543 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24339669  }} </ref><ref name="pmid3774712">{{cite journal| author=Ravi S, Keat AC, Keat EC| title=Colitis caused by non-steroidal anti-inflammatory drugs. | journal=Postgrad Med J | year= 1986 | volume= 62 | issue= 730 | pages= 773-6 | pmid=3774712 | doi= | pmc=2418853 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3774712  }} </ref><ref name="pmid24942356">{{cite journal| author=Philpott HL, Nandurkar S, Lubel J, Gibson PR| title=Drug-induced gastrointestinal disorders. | journal=Postgrad Med J | year= 2014 | volume= 90 | issue= 1065 | pages= 411-9 | pmid=24942356 | doi=10.1136/postgradmedj-2013-100316rep | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24942356  }} </ref><ref name="pmid14651719">{{cite journal| author=Price AB| title=Pathology of drug-associated gastrointestinal disease. | journal=Br J Clin Pharmacol | year= 2003 | volume= 56 | issue= 5 | pages= 477-82 | pmid=14651719 | doi= | pmc=1884388 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14651719  }} </ref>
*NSAID-induced colitis is characterized by nonspecific mucosal erosions and ulcers of varying degree, with intervening areas of normal mucosa. Perforations and fibrosis may also be seen. The lesions are predominantly on the right and may be single or multiple, sparing the rectum.<ref name="pmid27472233">{{cite journal| author=Marginean EC| title=The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract. | journal=Arch Pathol Lab Med | year= 2016 | volume= 140 | issue= 8 | pages= 748-58 | pmid=27472233 | doi=10.5858/arpa.2015-0451-RA | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27472233  }} </ref><ref name="pmid24339669">{{cite journal| author=Tonolini M| title=Acute nonsteroidal anti-inflammatory drug-induced colitis. | journal=J Emerg Trauma Shock | year= 2013 | volume= 6 | issue= 4 | pages= 301-3 | pmid=24339669 | doi=10.4103/0974-2700.120389 | pmc=3841543 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24339669  }} </ref><ref name="pmid3774712">{{cite journal| author=Ravi S, Keat AC, Keat EC| title=Colitis caused by non-steroidal anti-inflammatory drugs. | journal=Postgrad Med J | year= 1986 | volume= 62 | issue= 730 | pages= 773-6 | pmid=3774712 | doi= | pmc=2418853 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3774712  }} </ref><ref name="pmid24942356">{{cite journal| author=Philpott HL, Nandurkar S, Lubel J, Gibson PR| title=Drug-induced gastrointestinal disorders. | journal=Postgrad Med J | year= 2014 | volume= 90 | issue= 1065 | pages= 411-9 | pmid=24942356 | doi=10.1136/postgradmedj-2013-100316rep | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24942356  }} </ref><ref name="pmid14651719">{{cite journal| author=Price AB| title=Pathology of drug-associated gastrointestinal disease. | journal=Br J Clin Pharmacol | year= 2003 | volume= 56 | issue= 5 | pages= 477-82 | pmid=14651719 | doi= | pmc=1884388 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14651719 }} </ref><ref name="pmid10826432">{{cite journal| author=Püspök A, Kiener HP, Oberhuber G| title=Clinical, endoscopic, and histologic spectrum of nonsteroidal anti-inflammatory drug-induced lesions in the colon. | journal=Dis Colon Rectum | year= 2000 | volume= 43 | issue= 5 | pages= 685-91 | pmid=10826432 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10826432 }} </ref>


*Pseudomembranes may be seen in NSAID colitis and antibiotic induced ''[[Clostridium difficile]]'' colitis.
*Pseudomembranes may be seen in NSAID-induced colitis and antibiotic induced ''[[Clostridium difficile]]'' colitis.


===Microscopic Histopathology===
===Microscopic Histopathology===
*On histology, NSAID-induced colitis findings include ulcers that are often discrete and superficial with increased polymorphonuclear inflammatory cells especially eosinophils. The area of pathology is surrounded by normal colonic mucosa. Submucosal fibrosis with disruption of normal mucosal architecture is seen in diaphragm disease.<ref name="pmid27472233">{{cite journal| author=Marginean EC| title=The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract. | journal=Arch Pathol Lab Med | year= 2016 | volume= 140 | issue= 8 | pages= 748-58 | pmid=27472233 | doi=10.5858/arpa.2015-0451-RA | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27472233  }} </ref>
*On histology, NSAID-induced colitis findings include ulcers that are often discrete and superficial with minimal inflammatory cells which are mainly eosinophils and lymphocytes. The area of pathology is surrounded by normal colonic mucosa. In diaphragm disease, characteristic submucosal fibrosis (the fibers pointing in the direction of peristalsis) with submucosal architectural destruction and normal or minimal inflammation of the overlying epithelium is seen. <ref name="pmid27472233">{{cite journal| author=Marginean EC| title=The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract. | journal=Arch Pathol Lab Med | year= 2016 | volume= 140 | issue= 8 | pages= 748-58 | pmid=27472233 | doi=10.5858/arpa.2015-0451-RA | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27472233 }} </ref><ref name="pmid14651719">{{cite journal| author=Price AB| title=Pathology of drug-associated gastrointestinal disease. | journal=Br J Clin Pharmacol | year= 2003 | volume= 56 | issue= 5 | pages= 477-82 | pmid=14651719 | doi= | pmc=1884388 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14651719  }} </ref><ref name="pmid10826432">{{cite journal| author=Püspök A, Kiener HP, Oberhuber G| title=Clinical, endoscopic, and histologic spectrum of nonsteroidal anti-inflammatory drug-induced lesions in the colon. | journal=Dis Colon Rectum | year= 2000 | volume= 43 | issue= 5 | pages= 685-91 | pmid=10826432 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10826432  }} </ref><ref name="pmid19937416">{{cite journal| author=Geramizadeh B, Taghavi A, Banan B| title=Clinical, endoscopic and pathologic spectrum of non-steroidal anti-inflammatory drug-induced colitis. | journal=Indian J Gastroenterol | year= 2009 | volume= 28 | issue= 4 | pages= 150-3 | pmid=19937416 | doi=10.1007/s12664-009-0053-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19937416 }} </ref>


*Other histology findings associated with drug-induced colitis include increased epithelial apoptosis, especially involvement of the crypts, presence of pseudomembranes and features of microscopic colitis (presence of lymphocytes within the crypts in an otherwise normal looking mucosa).<ref name="pmid27472233">{{cite journal| author=Marginean EC| title=The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract. | journal=Arch Pathol Lab Med | year= 2016 | volume= 140 | issue= 8 | pages= 748-58 | pmid=27472233 | doi=10.5858/arpa.2015-0451-RA | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27472233  }} </ref>
*Other histologic findings associated with drug-induced colitis include increased epithelial apoptosis especially involvement of the crypts, presence of pseudomembranes, cytoplasmic vacuoles,  and features of microscopic colitis (presence of subepithelial thickening and/ or increased lymphocytes within the crypts in an otherwise normal looking mucosa).<ref name="pmid27472233">{{cite journal| author=Marginean EC| title=The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract. | journal=Arch Pathol Lab Med | year= 2016 | volume= 140 | issue= 8 | pages= 748-58 | pmid=27472233 | doi=10.5858/arpa.2015-0451-RA | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27472233 }} </ref><ref name="pmid14651719">{{cite journal| author=Price AB| title=Pathology of drug-associated gastrointestinal disease. | journal=Br J Clin Pharmacol | year= 2003 | volume= 56 | issue= 5 | pages= 477-82 | pmid=14651719 | doi= | pmc=1884388 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14651719 }} </ref>


==Causes==
==Causes==
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|-
|-
|Ischemic colitis
|Ischemic colitis
|NSAIDs, digoxin, diuretics, cocaine, ergotamine, serotonin agonists/antagonists, amphetamines, glutaraldehyde, antibiotics, chemotherapy drugs, drugs that cause constipation, laxatives, vasopressor agents, estrogen, progesteron, mycophenolic acid
|NSAIDs, digoxin, diuretics, cocaine, ergotamine, serotonin agonists/antagonists, amphetamines, glutaraldehyde, antibiotics, chemotherapeutic drugs, drugs that cause constipation, laxatives, vasopressor agents, estrogen, progesteron, mycophenolic acid
|-
|-
|Microscopic colitis
|Microscopic colitis
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|-
|-
|Apoptotic colitis
|Apoptotic colitis
|NSAIDs, oral sodium phosphate, laxatives, chemotherapy drugs (especially anti-metabolites), and cyclosporine A
|NSAIDs, oral sodium phosphate, laxatives, chemotherapeutic drugs (especially anti-metabolites), and cyclosporine A
|-
|-
|Neutropenic necrotizing enterocolitis
|Neutropenic necrotizing enterocolitis
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|}
|}


==Differentiating [disease name] from other Diseases==
==Differentiating drug-induced colitis from other Diseases==
*Drug-induced colitis must be differentiated from other diseases that cause diarrhea especially bloody diarrhea and abdominal pain. The symptoms of drug-induced colitis may overlap with other diseases.  
*Drug-induced colitis must be differentiated from other diseases that cause diarrhea especially bloody diarrhea and abdominal pain. The symptoms of drug-induced colitis may overlap with other forms of colitis such as inflammatory bowel disease and ischemic colitis.<ref name="pmid10826432">{{cite journal| author=Püspök A, Kiener HP, Oberhuber G| title=Clinical, endoscopic, and histologic spectrum of nonsteroidal anti-inflammatory drug-induced lesions in the colon. | journal=Dis Colon Rectum | year= 2000 | volume= 43 | issue= 5 | pages= 685-91 | pmid=10826432 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10826432  }} </ref>
The table below lists the differential diagnosis of common causes of colitis:<ref name="pmid14702426">{{cite journal| author=Thielman NM, Guerrant RL| title=Clinical practice. Acute infectious diarrhea. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 1 | pages= 38-47 | pmid=14702426 | doi=10.1056/NEJMcp031534 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14702426  }} </ref><ref name="pmid15537721">{{cite journal| author=Khan AM, Faruque AS, Hossain MS, Sattar S, Fuchs GJ, Salam MA| title=Plesiomonas shigelloides-associated diarrhoea in Bangladeshi children: a hospital-based surveillance study. | journal=J Trop Pediatr | year= 2004 | volume= 50 | issue= 6 | pages= 354-6 | pmid=15537721 | doi=10.1093/tropej/50.6.354 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15537721  }} </ref>
 
{|
*The symptoms of colitis such as diarrhea especially bloody diarrhea and abdominal pain are seen are seen in all forms of colitis. The table below lists the differential diagnosis of common causes of colitis:<ref name="pmid14702426">{{cite journal| author=Thielman NM, Guerrant RL| title=Clinical practice. Acute infectious diarrhea. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 1 | pages= 38-47 | pmid=14702426 | doi=10.1056/NEJMcp031534 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14702426  }} </ref><ref name="pmid15537721">{{cite journal| author=Khan AM, Faruque AS, Hossain MS, Sattar S, Fuchs GJ, Salam MA| title=Plesiomonas shigelloides-associated diarrhoea in Bangladeshi children: a hospital-based surveillance study. | journal=J Trop Pediatr | year= 2004 | volume= 50 | issue= 6 | pages= 354-6 | pmid=15537721 | doi=10.1093/tropej/50.6.354 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15537721  }} </ref>
{|
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |Diseases
! rowspan="2" |Diseases
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! colspan="4" |Physical Examination
! colspan="4" |Physical Examination
! colspan="4" |Laboratory findings
! colspan="4" |Laboratory findings
! rowspan="2" |Other Findings
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Diarrhea
!Diarrhea
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|style="background: #DCDCDC; padding: 5px; text-align: center;" |Ischemic colitis
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==Epidemiology and Demographics==
==Epidemiology and Demographics==
The overall prevalence and incidence of chemical colitis is not known.<ref name="pmid18209577">{{cite journal| author=Sheibani S, Gerson LB| title=Chemical colitis. | journal=J Clin Gastroenterol | year= 2008 | volume= 42 | issue= 2 | pages= 115-21 | pmid=18209577 | doi=10.1097/MCG.0b013e318151470e | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18209577 }} </ref>
The overall prevalence and incidence of drug-induced colitis is not known.<ref name="pmid3265394">{{cite journal| author=Tanner AR, Raghunath AS| title=Colonic inflammation and nonsteroidal anti-inflammatory drug administration. An assessment of the frequency of the problem. | journal=Digestion | year= 1988 | volume= 41 | issue= 2 | pages= 116-20 | pmid=3265394 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3265394 }} </ref>


===Epidemiology===
===Epidemiology===
The overall prevalence and incidence of chemical colitis are not known. Although, most reports of chemical colitis have been related to inadvertent residual contamination of endoscopes with the disinfectants glutaraldehyde and/ or hydrogen peroxide or following radio-contrast studies.
*The overall prevalence and incidence of drug-induced colitis is not known. NSAIDs are the most common prescribed drugs worldwide and most reports of drug-induced colitis have been related to their use.  
 
*The incidence of NSAID-induced colitis is reported as 10 percent of all cases of colitis.<ref name="pmid3265394">{{cite journal| author=Tanner AR, Raghunath AS| title=Colonic inflammation and nonsteroidal anti-inflammatory drug administration. An assessment of the frequency of the problem. | journal=Digestion | year= 1988 | volume= 41 | issue= 2 | pages= 116-20 | pmid=3265394 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3265394  }} </ref><ref name="pmid7682167">{{cite journal| author=Bakshi R, Ezzet N, Frey L, Lasry D, Salliere D| title=Efficacy and tolerability of diclofenac dispersible in painful osteoarthrosis. | journal=Clin Rheumatol | year= 1993 | volume= 12 | issue= 1 | pages= 57-61 | pmid=7682167 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7682167  }} </ref>
*The incidence of glutaraldehyde-induced colitis ranges from 0.1% to 4.7%.


===Demography===
===Demography===
====Age====
====Age====
Patient of all age group can develop chemical colitis. However, the incidence of may be higher in elderly due to increased frequency of diagnostic and/ or therapeutic endoscopy in this age group.
NSAID-induced colitis is more common among the elderly. This may be related to the increased use of NSAIDs in this age group.<ref name="pmid24339669">{{cite journal| author=Tonolini M| title=Acute nonsteroidal anti-inflammatory drug-induced colitis. | journal=J Emerg Trauma Shock | year= 2013 | volume= 6 | issue= 4 | pages= 301-3 | pmid=24339669 | doi=10.4103/0974-2700.120389 | pmc=3841543 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24339669  }} </ref>
 
====Gender====
====Gender====
The prevalence and incidence of chemical colitis does not vary by gender.
The prevalence and incidence of NSAID-induced colitis is more in women than men. <ref name="pmid123">{{cite book | last = Odze | first = Robert | title = Odze and Goldblum surgical pathology of the GI tract, liver, biliary tract, and pancreas | publisher = Saunders/Elsevier | location = Philadelphia, PA | year = 2015 | isbn = 978-1455707478 }} </ref>


====Race====
====Race====
There is no racial predilection to chemical colitis
There is no racial predilection to drug-induced colitis


==Risk Factors==
==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
*Common risk factors in the development of NSAID-induced colitis include: <ref name="pmid123">{{cite book | last = Odze | first = Robert | title = Odze and Goldblum surgical pathology of the GI tract, liver, biliary tract, and pancreas | publisher = Saunders/Elsevier | location = Philadelphia, PA | year = 2015 | isbn = 978-1455707478 }} </ref><ref name="pmid24339669">{{cite journal| author=Tonolini M| title=Acute nonsteroidal anti-inflammatory drug-induced colitis. | journal=J Emerg Trauma Shock | year= 2013 | volume= 6 | issue= 4 | pages= 301-3 | pmid=24339669 | doi=10.4103/0974-2700.120389 | pmc=3841543 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24339669  }} </ref>
:*Elderly age group
:*Long-term NSAID use
:*Alcohol use
:*Smoking
 
== Natural History, Complications and Prognosis==
== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].  
===Natural History===
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*The severity and extent of drug-induced colitis depend on the offending drug and duration of use the drug.
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*The natural history of NSAID-induced colitis is poorly defined. In the majority of patients the symptoms often develop insidiously following months of use of NSAIDs and may require hospitalization in about 20% of them. Early symptoms include abdominal pain, diarrhea and intestinal bleeding. There symptoms usually resolve following stoppage of the offending NSAID and symptomatic treatment. Long-term NSAID use may result in development of intestinal diaphragm strictures which persist.<ref name="pmid24339669">{{cite journal| author=Tonolini M| title=Acute nonsteroidal anti-inflammatory drug-induced colitis. | journal=J Emerg Trauma Shock | year= 2013 | volume= 6 | issue= 4 | pages= 301-3 | pmid=24339669 | doi=10.4103/0974-2700.120389 | pmc=3841543 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24339669  }} </ref><ref name="pmid19937416">{{cite journal| author=Geramizadeh B, Taghavi A, Banan B| title=Clinical, endoscopic and pathologic spectrum of non-steroidal anti-inflammatory drug-induced colitis. | journal=Indian J Gastroenterol | year= 2009 | volume= 28 | issue= 4 | pages= 150-3 | pmid=19937416 | doi=10.1007/s12664-009-0053-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19937416  }} </ref><ref name="pmid20361083">{{cite journal| author=Aftab AR, Donnellan F, Zeb F, Kevans D, Cullen G, Courtney G| title=NSAID-induced colopathy. A case series. | journal=J Gastrointestin Liver Dis | year= 2010 | volume= 19 | issue= 1 | pages= 89-91 | pmid=20361083 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20361083  }} </ref><ref name="pmid9203940">{{cite journal| author=Evans JM, McMahon AD, Murray FE, McDevitt DG, MacDonald TM| title=Non-steroidal anti-inflammatory drugs are associated with emergency admission to hospital for colitis due to inflammatory bowel disease. | journal=Gut | year= 1997 | volume= 40 | issue= 5 | pages= 619-22 | pmid=9203940 | doi= | pmc=1027164 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9203940  }} </ref>
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
 
*Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].
===Complications===
Complications of NSAID-induced colitis include:<ref name="pmid24339669">{{cite journal| author=Tonolini M| title=Acute nonsteroidal anti-inflammatory drug-induced colitis. | journal=J Emerg Trauma Shock | year= 2013 | volume= 6 | issue= 4 | pages= 301-3 | pmid=24339669 | doi=10.4103/0974-2700.120389 | pmc=3841543 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24339669  }} </ref>
*Perforation
*Peritonitis
*Diaphragm-like strictures
*Iron deficiency anemia
 
===Prognosis===
The prognosis of drug-induced colitis varies with the offending drug. It is generally good with resolution of symptoms following treatment.<ref name="pmid27472233">{{cite journal| author=Marginean EC| title=The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract. | journal=Arch Pathol Lab Med | year= 2016 | volume= 140 | issue= 8 | pages= 748-58 | pmid=27472233 | doi=10.5858/arpa.2015-0451-RA | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27472233  }} </ref><ref name="pmid123">{{cite book | last = Odze | first = Robert | title = Odze and Goldblum surgical pathology of the GI tract, liver, biliary tract, and pancreas | publisher = Saunders/Elsevier | location = Philadelphia, PA | year = 2015 | isbn = 978-1455707478 }} </ref>
 
== Diagnosis ==
== Diagnosis ==
===Diagnostic Criteria===
===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
*There is no definitive diagnostic criteria for drug-induced colitis. Diagnosis of drug-induced colitis is primarily clinical, based on detailed history, physical examination and endoscopic findings.
:*[criterion 1]
 
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]
=== Symptoms ===
=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Obtaining a complete history including drug history is important in making a diagnosis of drug-induced colitis. Symptoms of drug-induced colitis are not specific,
*Symptoms of [disease name] may include the following:
*Symptoms of NSAID-induced may include the following:
:*[symptom 1]
:*Diffuse abdominal pain which is colicky
:*[symptom 2]
:*Diarrhea
:*[symptom 3]
:*Rectal bleeding
:*[symptom 4]
:*Vomiting
:*[symptom 5]
 
:*[symptom 6]
*Chronic symptoms include:
:*Symptoms of iron-deficiency anemia
=== Physical Examination ===
:*Recurring episodes of constipation due to partial intestinal obstruction in patients with diaphragm disease
*Patients with [disease name] usually appear [general appearance].
:*Failure to thrive
*Physical examination may be remarkable for:
 
:*[finding 1]
===Physical Examination===
:*[finding 2]
 
:*[finding 3]
*Physical examination findings in patients with NSAID-induced colitis may be remarkable for:
:*[finding 4]
:*[[Abdominal tenderness]] which is often diffuse
:*[finding 5]
:*[[Pallor]] due to anemia
:*[finding 6]
:*Signs of [[dehydration]] such as lethargy, [[Tachycardia]] and [[Hypotension]]
:*[[Fever]] due to dehydration or in individuals who have developed sepsis
:*Toxic appearance in those with bowel perforation and sepsis
:*Weight loss in patients with diaphragm disease
 
=== Laboratory Findings ===
=== Laboratory Findings ===
*There are no specific laboratory findings associated with [disease name].
There are no specific laboratory findings associated with chemical colitis. Initial investigations should include hematological, biochemistry profiles and stool examination.
====Hematology====
*[[Anemia]]
 
====Electolytes====
*[[Hyponatremia]]
 
====Stool Examination====
Stool analysis may show
*[[Fecal occult blood]]
*Stool culture is negative.
 
===Endoscopy===
*Endoscopy is required for diagnosis of drug-induced colitis.
*Endoscopic features in NSAID-induced colitis include:<ref name="pmid19937416">{{cite journal| author=Geramizadeh B, Taghavi A, Banan B| title=Clinical, endoscopic and pathologic spectrum of non-steroidal anti-inflammatory drug-induced colitis. | journal=Indian J Gastroenterol | year= 2009 | volume= 28 | issue= 4 | pages= 150-3 | pmid=19937416 | doi=10.1007/s12664-009-0053-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19937416  }} </ref><ref name="pmid24339669">{{cite journal| author=Tonolini M| title=Acute nonsteroidal anti-inflammatory drug-induced colitis. | journal=J Emerg Trauma Shock | year= 2013 | volume= 6 | issue= 4 | pages= 301-3 | pmid=24339669 | doi=10.4103/0974-2700.120389 | pmc=3841543 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24339669  }} </ref><ref name="pmid10826432">{{cite journal| author=Püspök A, Kiener HP, Oberhuber G| title=Clinical, endoscopic, and histologic spectrum of nonsteroidal anti-inflammatory drug-induced lesions in the colon. | journal=Dis Colon Rectum | year= 2000 | volume= 43 | issue= 5 | pages= 685-91 | pmid=10826432 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10826432  }} </ref><ref name="pmid20361083">{{cite journal| author=Aftab AR, Donnellan F, Zeb F, Kevans D, Cullen G, Courtney G| title=NSAID-induced colopathy. A case series. | journal=J Gastrointestin Liver Dis | year= 2010 | volume= 19 | issue= 1 | pages= 89-91 | pmid=20361083 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20361083  }} </ref>
:*Normal mucosal which may be seen in as much as 45% of the patients.
:* Nonspecific mucosa changes such as friable, hyperemic, edematous mucosa with/ or without erosions and ulcers. This findings may be seen in any part of the colon, but more commonly on the right side.
:*In diaphragm disease, multiple diaphragm-like membrane strictures are seen with normal or minimally inflamed surrounding mucosa.


*A  [positive/negative] [test name] is diagnostic of [disease name].
*An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
*Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
===Imaging Findings===
*There are no [imaging study] findings associated with [disease name].
*[Imaging study 1] is the imaging modality of choice for [disease name].
*On [imaging study 1], [disease name] is characterized by [finding 1], [finding 2], and [finding 3].
*[Imaging study 2] may demonstrate [finding 1], [finding 2], and [finding 3].
=== Other Diagnostic Studies ===
=== Other Diagnostic Studies ===
*[Disease name] may also be diagnosed using [diagnostic study name].
*Other diagnostic test include
*Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].
 
====CT scan====
There is no specific CT scan feature for NSAID-induced colitis.  
====Xray====
There is no specific Xray feature of NSAID-induced colitis. However, it may help to rule out complications such as intestinal obstruction and perforation.<ref name="pmid24339669">{{cite journal| author=Tonolini M| title=Acute nonsteroidal anti-inflammatory drug-induced colitis. | journal=J Emerg Trauma Shock | year= 2013 | volume= 6 | issue= 4 | pages= 301-3 | pmid=24339669 | doi=10.4103/0974-2700.120389 | pmc=3841543 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24339669  }} </ref>
 
== Treatment ==
== Treatment ==
=== Medical Therapy ===
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
*There is no specific treatment for NSAID-induced colitis; the mainstay of therapy is medical supportive care.<ref name="pmid24339669">{{cite journal| author=Tonolini M| title=Acute nonsteroidal anti-inflammatory drug-induced colitis. | journal=J Emerg Trauma Shock | year= 2013 | volume= 6 | issue= 4 | pages= 301-3 | pmid=24339669 | doi=10.4103/0974-2700.120389 | pmc=3841543 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24339669  }} </ref>
*Medical treatment include:
*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
:*Stoppage of use the offending NSAID
*[Medical therapy 1] acts by [mechanism of action 1].
:*Correction of anemia
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
:*Correction of dehydration and electrolyte derangements by giving intravenous fluids or oral rehydration therapy whenever it is feasible
:*Broad-spectrum antibiotic given as an adjunct therapy
=== Surgery ===
 
*Surgery is the mainstay of therapy for [disease name].
=== Surgical Therapy ===
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
Surgical intervention may occasionally be required in NSAID-induced colitis. It is usually reserved for management of complications such as bowel perforation and stenosis. Surgical treatment include endoscopic dilatation, open dilatation or bowel resection. <ref name="pmid10882981">{{cite journal| author=Smith JA, Pineau BC| title=Endoscopic therapy of NSAID-induced colonic diaphragm disease: two cases and a review of published reports. | journal=Gastrointest Endosc | year= 2000 | volume= 52 | issue= 1 | pages= 120-5 | pmid=10882981 | doi=10.1067/mge.2000.105979 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10882981  }} </ref><ref name="pmid10385740">{{cite journal| author=Gopal DV, Katon RM| title=Endoscopic balloon dilation of multiple NSAID-induced colonic strictures: case report and review of literature on NSAID-related colopathy. | journal=Gastrointest Endosc | year= 1999 | volume= 50 | issue= 1 | pages= 120-3 | pmid=10385740 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10385740  }} </ref><ref name="pmid1234">{{cite journal| author=Lazaraki G, Chatzimavroudis G, Pilpilidis I, Paikos D, Soufleris K, Triantafillidis I, Gatopoulou A, Katsinelos P| title=Endoscopic Balloon Dilatation of NSAID-Induced Sigmoid Diaphragm-Stricture. | journal=Annals of Gastroenterology | year= 2007 | volume= 20 | issue= 2 | pages= 142-5 | pmid=1234 | doi= | pmc= | url=http://www.annalsgastro.gr/index.php/annalsgastro/article/view/574 }} </ref>
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].
 
=== Prevention ===
=== Prevention ===
*There are no primary preventive measures available for [disease name].
*There are no established preventive measures available for NSAID-induced colitis.
*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].


*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 16:31, 3 March 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Qasim Salau, M.B.B.S., FMCPaed [2]

Synonyms and keywords: Drug-related colitis, Drug-induced enterocolitis, Non-steroidal anti-inflammatory drug (NSAID) induced colitis; Chemotherapeutic drug-induced colitis

Overview

Drug-induced colitis is inflammation of the large intestine or colon, caused by the introduction of drugs or chemicals to the colon usually by the oral route but occasionally through the rectum. Non-steroidal anti-inflammatory drugs (NSAIDs) are the most common drugs implicated in drug-induced colitis and also the most commonly used drugs worldwide. Drug-induced colitis can resemble ulcerative colitis, infectious colitis and ischemic colitis endoscopically. Most cases of drug-induced colitis resolve after stopping the offending medication.[1][2]

Historical Perspective

  • NSAID-induced colitis was first described by Debenham, a Canadian doctor, in 1966 following a patient who developed ulcer in the caecum during oxyphenbutazone therapy.[3]
  • Diaphragm disease was first mentioned in 1987, by Lang et al to describe small bowel strictures from NSAIDs use.[4]
  • Sheers and Williams in 1989, subsequently described similar diaphragm disease in the colon of patients on NSAIDs.[5]

Classification

  • There is no established classification method for drug-induced colitis. However, it may be classified based on the pathophysiology pattern, type of drug and duration of symptoms.[6][2]

Classification based on histologic pattern

Based on the pathophysiology, drug-induced colitis may be classified into:

Pathophysiologic pattern of colitis Drugs
Focal active colitis NSAIDs, sodium phosphate (oral)
Eosinophilic colitis NSAIDs, carbamazepine, antiplatelet drugs, estrogen, progesteron, gold
Ischemic colitis NSAIDs, digoxin, diuretics, cocaine, ergotamine, serotonin agonists/antagonists, amphetamines, glutaraldehyde, antibiotics, chemotherapy drugs, drugs that cause constipation, laxatives, vasopressor agents, estrogen, progesteron, mycophenolic acid
Microscopic colitis NSAIDs, Protein pump inhibitors (lansoprazole), H2 receptor blockers (e.g. ranitidine), ticlopidine, simvastatin, carbamazepine, sertraline, oral penicillin
Pseudomembranous colitis Antibiotic-associated Clostridium difficile colitis (e.g. penicillins, clindamycin, cephalosporins, fluoroquinolones)
Apoptotic colitis NSAIDs, oral sodium phosphate, laxatives, chemotherapy drugs (especially anti-metabolites), and cyclosporine A
Neutropenic necrotizing enterocolitis Chemotherapy drugs
Immune-mediated colitis Antibody to cytotoxic T-lymphocyte–associated antigen (CTLA4)

Classification based on type of drugs

Drug-induced colitis can be classified based on the type of drugs into:

  • Non-steroidal anti-inflammatory drugs (NSAID)-induced colitis
  • Chemotherapy drug-induced colitis
  • Antibiotic-associated Clostridium difficile colitis
  • H2 receptor blockers induced colitis

Classification based on duration of symptoms

Based on the duration of symptoms, drug-induced colitis can be classified into:

  • Acute
  • Chronic e.g. diaphragm disease (results from long-term use of NSAIDs)

Pathophysiology

Pathogenesis

  • The pathogenesis of drug-induced colitis depends on the causative drug. The most common drugs implicated in drug-induced colitis are NSAIDs.
    • The exact mechanism by which NSAID cause colitis is not completely understood. NSAIDs can either induce new-onset colitis or exacerbate a pre-existing colitis.[7][8][9][10]
      • NSAIDs inhibit cyclooxygenase and thus prostaglandin production. Prostaglandin helps to maintain mucosal integrity. NSAIDs also impair oxidative phosphorylation, increasing risk of oxidative injury to the gut.
      • Direct damage to the intestinal mucosa is another proposed mechanism in NSAID related injury, since the rectum is often spared with colitis mainly limited to the right side of the colon.
      • Increased intestinal permeability to antigens following the use of NSAIDs is another hypothesized mechanism. This is said to cause the activation of the immune system and subsequent inflammation.

Genetics

  • There is no specific genetic cause for drug-induced colitis

Gross Pathology

Gross pathology findings in drug-induced colitis depends on the causative drug.

  • NSAID-induced colitis is characterized by nonspecific mucosal erosions and ulcers of varying degree, with intervening areas of normal mucosa. Perforations and fibrosis may also be seen. The lesions are predominantly on the right and may be single or multiple, sparing the rectum.[6][7][8][9][10][11]
  • Pseudomembranes may be seen in NSAID-induced colitis and antibiotic induced Clostridium difficile colitis.

Microscopic Histopathology

  • On histology, NSAID-induced colitis findings include ulcers that are often discrete and superficial with minimal inflammatory cells which are mainly eosinophils and lymphocytes. The area of pathology is surrounded by normal colonic mucosa. In diaphragm disease, characteristic submucosal fibrosis (the fibers pointing in the direction of peristalsis) with submucosal architectural destruction and normal or minimal inflammation of the overlying epithelium is seen. [6][10][11][12]
  • Other histologic findings associated with drug-induced colitis include increased epithelial apoptosis especially involvement of the crypts, presence of pseudomembranes, cytoplasmic vacuoles, and features of microscopic colitis (presence of subepithelial thickening and/ or increased lymphocytes within the crypts in an otherwise normal looking mucosa).[6][10]

Causes

  • The most common causes of drug-induced colitis are NSAIDs.

Causes of drug-induced colitis include:


Pathophysiologic pattern of colitis Drugs
Focal active colitis NSAIDs, sodium phosphate (oral)
Eosinophilic colitis NSAIDs, carbamazepine, antiplatelet drugs, estrogen, progesteron, gold
Ischemic colitis NSAIDs, digoxin, diuretics, cocaine, ergotamine, serotonin agonists/antagonists, amphetamines, glutaraldehyde, antibiotics, chemotherapeutic drugs, drugs that cause constipation, laxatives, vasopressor agents, estrogen, progesteron, mycophenolic acid
Microscopic colitis NSAIDs, Protein pump inhibitors (lansoprazole), H2 receptor blockers (e.g. ranitidine), ticlopidine, simvastatin, carbamazepine, sertraline, oral penicillin
Pseudomembranous colitis Antibiotic-associated Clostridium difficile colitis (e.g. penicillins, clindamycin, cephalosporins, fluoroquinolones)
Apoptotic colitis NSAIDs, oral sodium phosphate, laxatives, chemotherapeutic drugs (especially anti-metabolites), and cyclosporine A
Neutropenic necrotizing enterocolitis Chemotherapy drugs
Immune-mediated colitis Antibody to cytotoxic T-lymphocyte–associated antigen (CTLA4)

Differentiating drug-induced colitis from other Diseases

  • Drug-induced colitis must be differentiated from other diseases that cause diarrhea especially bloody diarrhea and abdominal pain. The symptoms of drug-induced colitis may overlap with other forms of colitis such as inflammatory bowel disease and ischemic colitis.[11]
  • The symptoms of colitis such as diarrhea especially bloody diarrhea and abdominal pain are seen are seen in all forms of colitis. The table below lists the differential diagnosis of common causes of colitis:[13][14]
Diseases History and Symptoms Physical Examination Laboratory findings
Diarrhea Rectal bleeding Abdominal pain Atopy Dehydration Fever Hypotension Malnutrition Blood in stool (frank or occult) Microorganism in stool Pseudomembranes on endoscopy Lab Test 4
Allergic Colitis + ++ + ++ ++
Chemical colitis + ++ ++ + + ++ +
Infectious colitis ++ ++ ++ +++ +++ ++ + ++ ++ +
Radiation colitis + ++ + + + ++
Ischemic colitis + + ++ + + + + ++
Drug-induced colitis + + ++ + ++ +

Epidemiology and Demographics

The overall prevalence and incidence of drug-induced colitis is not known.[15]

Epidemiology

  • The overall prevalence and incidence of drug-induced colitis is not known. NSAIDs are the most common prescribed drugs worldwide and most reports of drug-induced colitis have been related to their use.
  • The incidence of NSAID-induced colitis is reported as 10 percent of all cases of colitis.[15][16]

Demography

Age

NSAID-induced colitis is more common among the elderly. This may be related to the increased use of NSAIDs in this age group.[7]

Gender

The prevalence and incidence of NSAID-induced colitis is more in women than men. [2]

Race

There is no racial predilection to drug-induced colitis

Risk Factors

  • Common risk factors in the development of NSAID-induced colitis include: [2][7]
  • Elderly age group
  • Long-term NSAID use
  • Alcohol use
  • Smoking

Natural History, Complications and Prognosis

Natural History

  • The severity and extent of drug-induced colitis depend on the offending drug and duration of use the drug.
  • The natural history of NSAID-induced colitis is poorly defined. In the majority of patients the symptoms often develop insidiously following months of use of NSAIDs and may require hospitalization in about 20% of them. Early symptoms include abdominal pain, diarrhea and intestinal bleeding. There symptoms usually resolve following stoppage of the offending NSAID and symptomatic treatment. Long-term NSAID use may result in development of intestinal diaphragm strictures which persist.[7][12][17][18]

Complications

Complications of NSAID-induced colitis include:[7]

  • Perforation
  • Peritonitis
  • Diaphragm-like strictures
  • Iron deficiency anemia

Prognosis

The prognosis of drug-induced colitis varies with the offending drug. It is generally good with resolution of symptoms following treatment.[6][2]

Diagnosis

Diagnostic Criteria

  • There is no definitive diagnostic criteria for drug-induced colitis. Diagnosis of drug-induced colitis is primarily clinical, based on detailed history, physical examination and endoscopic findings.

Symptoms

  • Obtaining a complete history including drug history is important in making a diagnosis of drug-induced colitis. Symptoms of drug-induced colitis are not specific,
  • Symptoms of NSAID-induced may include the following:
  • Diffuse abdominal pain which is colicky
  • Diarrhea
  • Rectal bleeding
  • Vomiting
  • Chronic symptoms include:
  • Symptoms of iron-deficiency anemia
  • Recurring episodes of constipation due to partial intestinal obstruction in patients with diaphragm disease
  • Failure to thrive

Physical Examination

  • Physical examination findings in patients with NSAID-induced colitis may be remarkable for:

Laboratory Findings

There are no specific laboratory findings associated with chemical colitis. Initial investigations should include hematological, biochemistry profiles and stool examination.

Hematology

Electolytes

Stool Examination

Stool analysis may show

Endoscopy

  • Endoscopy is required for diagnosis of drug-induced colitis.
  • Endoscopic features in NSAID-induced colitis include:[12][7][11][17]
  • Normal mucosal which may be seen in as much as 45% of the patients.
  • Nonspecific mucosa changes such as friable, hyperemic, edematous mucosa with/ or without erosions and ulcers. This findings may be seen in any part of the colon, but more commonly on the right side.
  • In diaphragm disease, multiple diaphragm-like membrane strictures are seen with normal or minimally inflamed surrounding mucosa.

Other Diagnostic Studies

  • Other diagnostic test include

CT scan

There is no specific CT scan feature for NSAID-induced colitis.

Xray

There is no specific Xray feature of NSAID-induced colitis. However, it may help to rule out complications such as intestinal obstruction and perforation.[7]

Treatment

Medical Therapy

  • There is no specific treatment for NSAID-induced colitis; the mainstay of therapy is medical supportive care.[7]
  • Medical treatment include:
  • Stoppage of use the offending NSAID
  • Correction of anemia
  • Correction of dehydration and electrolyte derangements by giving intravenous fluids or oral rehydration therapy whenever it is feasible
  • Broad-spectrum antibiotic given as an adjunct therapy

Surgical Therapy

Surgical intervention may occasionally be required in NSAID-induced colitis. It is usually reserved for management of complications such as bowel perforation and stenosis. Surgical treatment include endoscopic dilatation, open dilatation or bowel resection. [19][20][21]

Prevention

  • There are no established preventive measures available for NSAID-induced colitis.

References

  1. Bjarnason I, Hayllar J, MacPherson AJ, Russell AS (1993). "Side effects of nonsteroidal anti-inflammatory drugs on the small and large intestine in humans". Gastroenterology. 104 (6): 1832–47. PMID 8500743.
  2. 2.0 2.1 2.2 2.3 2.4 Odze, Robert (2015). Odze and Goldblum surgical pathology of the GI tract, liver, biliary tract, and pancreas. Philadelphia, PA: Saunders/Elsevier. ISBN 978-1455707478.
  3. Debenham GP (1966). "Ulcer of the cecum during oxyphenbutazone (tandearil) therapy". Can Med Assoc J. 94 (22): 1182–4. PMC 1935486. PMID 5934387.
  4. Lang J, Price AB, Levi AJ, Burke M, Gumpel JM, Bjarnason I (1988). "Diaphragm disease: pathology of disease of the small intestine induced by non-steroidal anti-inflammatory drugs". J Clin Pathol. 41 (5): 516–26. PMC 1141503. PMID 3384981.
  5. Sheers R, Williams WR (1989). "NSAIDs and gut damage". Lancet. 2 (8672): 1154. PMID 2572870.
  6. 6.0 6.1 6.2 6.3 6.4 Marginean EC (2016). "The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract". Arch Pathol Lab Med. 140 (8): 748–58. doi:10.5858/arpa.2015-0451-RA. PMID 27472233.
  7. 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 Tonolini M (2013). "Acute nonsteroidal anti-inflammatory drug-induced colitis". J Emerg Trauma Shock. 6 (4): 301–3. doi:10.4103/0974-2700.120389. PMC 3841543. PMID 24339669.
  8. 8.0 8.1 Ravi S, Keat AC, Keat EC (1986). "Colitis caused by non-steroidal anti-inflammatory drugs". Postgrad Med J. 62 (730): 773–6. PMC 2418853. PMID 3774712.
  9. 9.0 9.1 Philpott HL, Nandurkar S, Lubel J, Gibson PR (2014). "Drug-induced gastrointestinal disorders". Postgrad Med J. 90 (1065): 411–9. doi:10.1136/postgradmedj-2013-100316rep. PMID 24942356.
  10. 10.0 10.1 10.2 10.3 Price AB (2003). "Pathology of drug-associated gastrointestinal disease". Br J Clin Pharmacol. 56 (5): 477–82. PMC 1884388. PMID 14651719.
  11. 11.0 11.1 11.2 11.3 Püspök A, Kiener HP, Oberhuber G (2000). "Clinical, endoscopic, and histologic spectrum of nonsteroidal anti-inflammatory drug-induced lesions in the colon". Dis Colon Rectum. 43 (5): 685–91. PMID 10826432.
  12. 12.0 12.1 12.2 Geramizadeh B, Taghavi A, Banan B (2009). "Clinical, endoscopic and pathologic spectrum of non-steroidal anti-inflammatory drug-induced colitis". Indian J Gastroenterol. 28 (4): 150–3. doi:10.1007/s12664-009-0053-9. PMID 19937416.
  13. Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.
  14. Khan AM, Faruque AS, Hossain MS, Sattar S, Fuchs GJ, Salam MA (2004). "Plesiomonas shigelloides-associated diarrhoea in Bangladeshi children: a hospital-based surveillance study". J Trop Pediatr. 50 (6): 354–6. doi:10.1093/tropej/50.6.354. PMID 15537721.
  15. 15.0 15.1 Tanner AR, Raghunath AS (1988). "Colonic inflammation and nonsteroidal anti-inflammatory drug administration. An assessment of the frequency of the problem". Digestion. 41 (2): 116–20. PMID 3265394.
  16. Bakshi R, Ezzet N, Frey L, Lasry D, Salliere D (1993). "Efficacy and tolerability of diclofenac dispersible in painful osteoarthrosis". Clin Rheumatol. 12 (1): 57–61. PMID 7682167.
  17. 17.0 17.1 Aftab AR, Donnellan F, Zeb F, Kevans D, Cullen G, Courtney G (2010). "NSAID-induced colopathy. A case series". J Gastrointestin Liver Dis. 19 (1): 89–91. PMID 20361083.
  18. Evans JM, McMahon AD, Murray FE, McDevitt DG, MacDonald TM (1997). "Non-steroidal anti-inflammatory drugs are associated with emergency admission to hospital for colitis due to inflammatory bowel disease". Gut. 40 (5): 619–22. PMC 1027164. PMID 9203940.
  19. Smith JA, Pineau BC (2000). "Endoscopic therapy of NSAID-induced colonic diaphragm disease: two cases and a review of published reports". Gastrointest Endosc. 52 (1): 120–5. doi:10.1067/mge.2000.105979. PMID 10882981.
  20. Gopal DV, Katon RM (1999). "Endoscopic balloon dilation of multiple NSAID-induced colonic strictures: case report and review of literature on NSAID-related colopathy". Gastrointest Endosc. 50 (1): 120–3. PMID 10385740.
  21. Lazaraki G, Chatzimavroudis G, Pilpilidis I, Paikos D, Soufleris K, Triantafillidis I, Gatopoulou A, Katsinelos P (2007). "Endoscopic Balloon Dilatation of NSAID-Induced Sigmoid Diaphragm-Stricture". Annals of Gastroenterology. 20 (2): 142–5. PMID 1234.

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