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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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