Colitis

	Colitis Microchapters
Overview
Classification Allergic colitis Infectious colitis Ischemic colitis Drug-induced colitis Chemical colitis Radiation colitis
Differential Diagnosis
Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: M.Umer Tariq [2]; Maham Khan [3]; Ogheneochuko Ajari, MB.BS, MS [4]; Rim Halaby, M.D. [5]; Qasim Salau, M.B.B.S., FMCPaed [6]

Synonyms and keywords: Colitis, Proctocolitis, Proctitis, Enterocolitis.

Overview

Colitis is the inflammation of the colon, that can be either acute or chronic. Colitis may be caused by microorganisms such as Chlamydia trachomatis, Neisseria gonorrhoeae, Shigella dysenteriae, HSV, allergy (food protein-induced allergic proctocolitis), drugs (NSAIDs) and radiation. Colitis may co-exist with enteritis (inflammation of the small bowel), proctitis (inflammation of the rectum) or both. The symptoms of colitis such as diarrhea especially bloody diarrhea and abdominal pain (which may be mild) are seen in all forms of colitis. Colitis may be fulminant with a rapid downhill clinical course. In addition to the diarrhea, fever, and anemia may be reported. The patient with fulminant colitis has severe abdominal pain and presents a clinical picture similar to that of septicemia, where shock is present. Treatment of colitis depends on the etiology. It may include the elimination of cows-milk protein or other food allergens from the diet, administration of antibiotics and general anti-inflammatory medications such as mesalamine or its derivatives, steroids, or one of a number of other drugs that ameliorate inflammation. The mainstay of therapy for infectious colitis is antimicrobial therapy. A common antibiotic regimen in treatment of patients with colitis is a combination of ceftriaxone and doxycycline. Supportive therapies such as correction of dehydration and anemia, and reducing the intake of carbohydrates, lactose products, soft drinks, and caffeine is often done for most patients with colitis. Irritable bowel syndrome (spastic colitis or spastic colon) has been called colitis, causing confusion despite colitis not being a feature of the disease. Immune mediated colitis is the experimental name in animal studies of ulcerative colitis. It is a synonym of ulcerative colitis, but it should not be used as a synonym when referring to ulcerative colitis.

Classification

There is no established classification system for colitis. However, it may be classified based on etiology, age and duration of symptom.

Classification by etiology

Classes of Colitis	Disorders
Autoimmune	Ulcerative colitis Crohn's colitis
Allergic	Food protein-induced allergic proctocolitis (FPIAP) Food protein-induced enterocolitis syndrome (FPIES)
Infectious colitis	Pseudomembranous colitis (Clostridium difficile) Enterohemorrhagic colitis (Shigella dysenteriae or Shigatoxigenic group of Escherichia coli (STEC)) Protozoan (Entamoeba histolytica) Chlamydia proctocolitis
Idiopathic	Lymphocytic colitis Collagenous colitis
Iatrogenic	Diversion colitis Chemical colitis Radiation colitis NSAID-induced colitis
Vascular	Ischemic colitis
Drug induced	NSAID-induced colitis
Unclassifiable	Indeterminate colitis (features of both Crohn's disease and ulcerative colitis) Atypical colitis

Classification by Anatomy

Colitis may co-exist with inflammation involving other parts of the gastrointestinal tract. It can be classified based on anatomy into:

Proctitis: When it involves the rectum
Colitis: When it involves the inflammation is limited to the colon
Proctocolitis: When it involves the rectum and colon (usually the distal part of the colon 12cm to 15cm above the anus (sigmoid colon)^[1]^[2]
Enterocolitis: When it involves the small intestine in addition to the colon

Schematic of Anatomical Classification of Colitis

**Affected anatomical areas: By Edelhart Kempeneers - Gray's Anatomy, Public Domain, https://commons.wikimedia.org/w/index.php?curid=534843^[3]**
***Regions 4 to 6:** Enterocolitis
***Region 6:** Colitis
***Regions 6 to 8:** Proctocolitis
***Regions 7 to 8:**Proctitis

Classification by Age

Infantile (first six months of life)^[4]^[5]^[6]
Adult

Classification by duration of symptoms

Acute: Less than three months.^[7]
Chronic: Longer than three months. Often months to years.^[7]

Differential Diagnosis

The differential diagnosis of colitis can be classified into two categories according to age group. A work up for colitis must include the following differentials:

Differential diagnosis in Infants

Swallowed maternal blood syndrome
Anorectal fissure
Necrotizing enterocolitis especially in preterm babies
Vitamin K dependent hemorrhage
Other coagulopathies: (hereditary such as coagulation factor deficiency or acquired such as disseminated intravascular coagulopathy)
Intussusception
Upper Gastrointestinal Infections
Enteritis
Meckel diverticulum
Intestinal duplication cysts
Vascular malformations
Inflammatory bowel disease(early onset)
Hirschsprung disease complicated by enterocolitis
Volvulus
Gastro-duodenal ulcers
Gastrointestinal duplication cyst
Liver disease with clotting factor deficiency
Lymphonodular hyperplasia

Differential diagnosis in Adults

Differentiating Between Different Types of Colitis

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 differentiates among the common causes of colitis:^[8]^[9]

Diseases	History and Symptoms				Physical Examination				Laboratory findings
Diseases	Diarrhea	Rectal bleeding	Abdominal pain	Atopy	Dehydration	Fever	Hypotension	Malnutrition	Blood in stool (frank or occult)	Microorganism in stool	Pseudomembranes on endoscopy
Allergic Colitis	+	++	+	++					++
Chemical colitis	+	++	++		+	+			++		+
Infectious colitis	++	++	++		+++	+++	++	+	++	++	+
Radiation colitis	+	++	+		+			+	++
Ischemic colitis	+	+	++		+	+	+	+	++
Drug-induced colitis	+	+	++			+			++		+

Diagnostic Tests

Common tests which may reveal diagnosis of colitis include:

Abdominal X-rays
Testing the stool for blood and pus
Sigmoidoscopy
Colonoscopy

Additional tests include stool cultures and blood tests, including blood chemistry tests. A high erythrocyte sedimentation rate (ESR) is one typical finding in acute exacerbation of colitis.

Causes

Common Causes

Common causes of proctocolitis include infectious agents such as Chlamydia trachomatis (which causes lymphogranuloma venereum), Neisseria gonorrhoeae, HSV, Shigella dysenteriae and Campylobacter species. It can also be allergic (e.g. food protein-induced proctocolitis), idiopathic (e.g. microscopic colitis), vascular (e.g. ischemic colitis), or autoimmune (e.g. inflammatory bowel disease).

Causes by Organ System

Cardiovascular	EVAR, vasculitis
Chemical / poisoning	Chemical colitis from Glutaraldehyde, Coffee enema, Hydrogen peroxide, lanthanum
Dental	Dental braces
Dermatologic	Albinism, Behcet disease, scleroderma, vasculitis
Drug Side Effect	Alosetron, ampicillin Oral, auranofin, azithromycin, aztreonam Injection, cefaclor, cefadroxil, cefamandole Nafate Injection, cefazolin Sodium Injection, cefepime Injection, cefepime, cefoperazone Sodium Injection, cefotaxime Sodium Injection, cefotetan Disodium Injection, cefoxitin Sodium Injection, cefpodoxime, ceftazidime Injection, ceftazidime, ceftizoxime Sodium Injection, ceftriaxone Sodium Injection, cefuroxime Sodium Injection, cephalexin, cephalosporin, cephradine Oral, cidofovir, cilansetron, clindamycin, co-amoxiclav, corticosteroid, darifenacin, desogestrel and ethinyl estradiol, dicloxacillin, dirithromycin, enoxacin, ertapenem, erythromycin and Sulfisoxazole, flucytosine, glycopyrrolate, hyoscyamine, idelalisib, imipenem and Cilastatin Sodium Injection, ipilimumab, ixabepilone, levofloxacin Oral, lincomycin hydrochloride, linezolid, lomefloxacin, loracarbef, methotrexate, miconazole Injection, moxifloxacin, nafcillin Sodium Injection, nivolumab, norfloxacin, ofloxacin injection, oxacillin Sodium Injection, oxcarbazepine, oxybutynin, peginterferon alfa-2a, penicillin, pergolide, piperacillin sodium injection, pramipexole, prednisolone, procyclidine, propantheline, pseudoephedrine, quinolone, ramosetron, reserpine, solifenacin, sparfloxacin, tegaserod
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	Aganglionic megacolon, alpha 1-antitrypsin deficiency, autistic enterocolitis, bacterial gastroenteritis, cap polyposis, chemical colitis, colitis ulcerosa, collagenous colitis, colonic ischemia, Crohn's disease, diversion colitis, diverticulosis, Gerson diet, infectious colitis, inflammatory bowel disease, intestinal ischemia, irritable bowel syndrome, ischemic colitis, lymphocytic colitis, microscopic colitis, multiple organ dysfunction syndrome, primary sclerosing cholangitis, protein losing enteropathy, pseudomembranous colitis, radiation colitis, radiation proctitis, solitary rectal ulcer syndrome, toxic megacolon, typhlitis, ulcerative colitis
Genetic	Albinism, alpha 1-antitrypsin deficiency
Hematologic	No underlying causes
Iatrogenic	Diversion colitis, EVAR, radiation colitis, radiation proctitis
Infectious Disease	Bacillary dysentery, bacterial gastroenteritis, balantidium coli, campylobacter jejuni, chlamydia trachomatis, clostridium difficile, cryptosporidiosis, cytomegalovirus, entamoeba histolytica, escherichia coli O157:H7, giardiasis, infectious colitis, isosporiasis, neisseria gonorrhoeae, neonatal necrotizing enterocolitis, pigbel, salmonella, schistosoma, sepsis, shigella, strongyloides stercoralis, syphilis, treponema pallidum, yersinia enterocolitica
Musculoskeletal / Ortho	Ankylosing Spondylitis
Neurologic	No underlying causes
Nutritional / Metabolic	Gerson diet, lysinuric protein intolerance, milk allergy, pigbel, soy protein
Obstetric/Gynecologic	No underlying causes
Oncologic	No underlying causes
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	Autistic enterocolitis
Pulmonary	Multiple organ dysfunction syndrome
Renal / Electrolyte	Multiple organ dysfunction syndrome
Rheum / Immune / Allergy	Ankylosing spondylitis, Behcet disease, common variable immunodeficiency, allergic colitis (Food protein-induced colitis), scleroderma, vasculitis, Ulcerative colitis
Sexual	Typical STI such as Chlamydia trachomatis, Neisseria gonorrheae, Treponema pallidum, HSV, CMV, Unusual STI Shigella dysenteriae
Trauma	No underlying causes
Urologic	No underlying causes
Miscellaneous	Microscopic colitis

Causes in Alphabetical Order

Life Threatening Causes

Example include toxic megacolon, ischemic colitis, infectious colitis such as escherichia coli O157:H7 and shigella.

References

↑ 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control and Prevention (2015).http://www.cdc.gov/std/tg2015/proctitis.htm Accessed on August 29, 2016
↑ Hamlyn E, Taylor C (2006). "Sexually transmitted proctitis". Postgrad Med J. 82 (973): 733–6. doi:10.1136/pmj.2006.048488. PMC 2660501. PMID 17099092.
↑ WikiMedia Commons https://commons.wikimedia.org/wiki/File:Gastro-intestinal_tract.png. Accessed on September 09, 2016
↑ Nowak-Węgrzyn A (2015). "Food protein-induced enterocolitis syndrome and allergic proctocolitis". Allergy Asthma Proc. 36 (3): 172–84. doi:10.2500/aap.2015.36.3811. PMC 4405595. PMID 25976434.
↑ Pumberger W, Pomberger G, Geissler W (2001). "Proctocolitis in breast fed infants: a contribution to differential diagnosis of haematochezia in early childhood". Postgrad Med J. 77 (906): 252–4. PMC 1741985. PMID 11264489.
↑ Alfadda AA, Storr MA, Shaffer EA (2011). "Eosinophilic colitis: epidemiology, clinical features, and current management". Therap Adv Gastroenterol. 4 (5): 301–9. doi:10.1177/1756283X10392443. PMC 3165205. PMID 21922029.
↑ ^7.0 ^7.1 Hauer-Jensen M, Denham JW, Andreyev HJ (2014). "Radiation enteropathy--pathogenesis, treatment and prevention". Nat Rev Gastroenterol Hepatol. 11 (8): 470–9. doi:10.1038/nrgastro.2014.46. PMC 4346191. PMID 24686268.
↑ Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.
↑ 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.
↑ Mohan P, Ramakrishnan MK, Revathy S, Jayanthi V (2011). "Granulomatous colitis in oculocutaneous albinism". Dig Liver Dis. 43 (1): e1. doi:10.1016/j.dld.2009.09.006. PMID 19833565.
↑ Gié O, Clerc D, Giulieri S, Demartines N (2014). "[Clostridial colitis: diagnosis and strategies for management]". Rev Med Suisse. 10 (434): 1309–13. PMID 25073304.

Template:WH Template:WS

[1] 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control and Prevention (2015).http://www.cdc.gov/std/tg2015/proctitis.htm Accessed on August 29, 2016

[pmid17099092-2] Hamlyn E, Taylor C (2006). "Sexually transmitted proctitis". Postgrad Med J. 82 (973): 733–6. doi:10.1136/pmj.2006.048488. PMC 2660501. PMID 17099092.

[gitractcolitis-3] WikiMedia Commons https://commons.wikimedia.org/wiki/File:Gastro-intestinal_tract.png. Accessed on September 09, 2016

[pmid25976434-4] Nowak-Węgrzyn A (2015). "Food protein-induced enterocolitis syndrome and allergic proctocolitis". Allergy Asthma Proc. 36 (3): 172–84. doi:10.2500/aap.2015.36.3811. PMC 4405595. PMID 25976434.

[pmid11264489-5] Pumberger W, Pomberger G, Geissler W (2001). "Proctocolitis in breast fed infants: a contribution to differential diagnosis of haematochezia in early childhood". Postgrad Med J. 77 (906): 252–4. PMC 1741985. PMID 11264489.

[pmid21922029-6] Alfadda AA, Storr MA, Shaffer EA (2011). "Eosinophilic colitis: epidemiology, clinical features, and current management". Therap Adv Gastroenterol. 4 (5): 301–9. doi:10.1177/1756283X10392443. PMC 3165205. PMID 21922029.

[pmid24686268-7] 7.0 ^7.1 Hauer-Jensen M, Denham JW, Andreyev HJ (2014). "Radiation enteropathy--pathogenesis, treatment and prevention". Nat Rev Gastroenterol Hepatol. 11 (8): 470–9. doi:10.1038/nrgastro.2014.46. PMC 4346191. PMID 24686268.

[pmid14702426-8] Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.

[pmid15537721-9] 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.

[pmid19833565-10] Mohan P, Ramakrishnan MK, Revathy S, Jayanthi V (2011). "Granulomatous colitis in oculocutaneous albinism". Dig Liver Dis. 43 (1): e1. doi:10.1016/j.dld.2009.09.006. PMID 19833565.

[pmid25073304-11] Gié O, Clerc D, Giulieri S, Demartines N (2014). "[Clostridial colitis: diagnosis and strategies for management]". Rev Med Suisse. 10 (434): 1309–13. PMID 25073304.

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