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Miscellaneous colitides. Ian Botterill St James’s University Hospital, Leeds. Classification of miscellaneous colitides. 2y infection - bacterial ( C Diff , campylobacter, salmonella, shigella ) - viral ( CMV , rotavirus ) - amoebic

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Miscellaneous colitides

Miscellaneous colitides

Ian Botterill

St James’s University Hospital, Leeds


Classification of miscellaneous colitides
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


Critical care colitides
‘critical care’ colitides

C. Difficile

Ischaemic colitis

Radiation proctocolitis

CMV

Graft v host


Initial assessment
Initial assessment

  • History / PMSH crucial - symptoms - aetiological factors

  • Resuscitation

  • Bloods / inflammatory markers

  • Stool culture / stool chart

  • AXR

  • Lower GI endoscopy

  • CT


Clostridium difficile
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
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
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
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 2 nd line therapy
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
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
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
Ischaemic colitis

Crampy ‘hind-gut’ pain

Dark red bleeding

Wide spectrum severity

Typically splenic flexure


Ischaemic colitis1
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
Ischaemic colitis: uncommon associations

  • hypercoaguable states - sickle cell - the ‘pill’ - pregnancy - pancreatitis

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


Ischaemic colitis aortic surgery
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 benefitAnn Vasc Surg 1999;13:533-8 Acta Ch Belgica 2000;100:21-7 J Vasc Surg 2004;39:792-6


Ischaemic colitis adverse factors
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
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
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
Radiation proctitis

Acute - diarrhoea & urgency - bleeding

Chronic radiation proctopathy - bleeding (neovacularisation) - functional


Chronic radiation proctopathy
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
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
Radiation colitis -miscellaneous treatments

  • Retinol palmitate (Vit A) - controlled, blinded, crossover trial - reduction in RPSAS

  • Oestrogen / progesterone

  • Hyperbaric oxygen

    DCR 1993;36:962-5 Am J Gastro 1998;93:2356-8 Int Urol Neph 1996;28:643-7 DCR 2005


Radiation proctopathy 2 y brachytherapy
Radiation proctopathy -2y brachytherapy

Do not biopsy rectal wall following brachytherapy for prostate cancer - risk: recto-urethral fistula


Cytomegalovirus colitis
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
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 / MSOFDCR 2004;47:722-6 DCR 2003;46:S59-65


Cmv uc treatment
CMV & UC: Treatment

  • Consider the diagnosis

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

  • Treatment - Ganciclovir - ↓ standard immunosuppression


Graft versus host enterocolitis
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
Summary 1

Assorted misfits causing regular pain & suffering


Summary 2
Summary 2

  • good history & stool culture

  • biopsy

  • medical care

  • occasional colectomy


Summary 3
Summary 3

Unhappy coexistence……


Summary 4
Summary 4

Recurrences despite seemingly successful eradication……


Summary 5
Summary 5

Some forms can hit back…..


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