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Colitis differential

Discuss the various colitidis?

Indeterminate colitis

  • A precise diagnosis of UC or CD of the colon is not always possible either clinically or by histological examination of resected specimens. This occurs in approximately 5% of all patients with IBD.
  • Indeterminate colitis defined as disease with “clear evidence of inflammatory bowel disease but insufficient evidence to make a definite diagnosis of either UC or CD.” Up to 10% of patients have their diseases re classified.
  • The most common reasons for difficulties are: sparing of the rectum; confluent mucosal involvement favouring UC but with long skip areas (including distal colitis with periappendiceal or cecal patches) that were considered to favour CD; typical UC or proctitis in the presence of anorectal skin tags favouring CD; superimposed infectious colitis; and changing pattern due to therapy.
  • Features required for UC included diffuse disease, involvement of the rectum, no deep fissure ulcers, no transmural lymphoid aggregates, and no granulomas.
  • Histology-Heavy, diffuse, transmucosal lamina propria cell increase favours a diagnosis of UC, but patchy inflammation can also be seen in UC in adults. Diffuse crypt architectural irregularity is indicative of UC.
  • Serological markers- The combinations ASCA+/pANCA- and ASCA-/pANCA+ are strongly associated with CD and UC.
  • The distinction between UC and CD is important to decide the optimum medical and surgical treatment.

Diverticular colitis

  • Some patients with diverticular disease develop a segmental colitis affecting the sigmoid colon.
  • Endoscopic examination reveals a localized sigmoid inflammatory process with normal rectal and proximal colonic mucosa.The inflammatory changes may be mild to florid resembling IBD both endoscopically and histologically.
  • It frequently presents with bloody stools. In some abdominal pain or diarrhea may occur.
  • The inflammation is self limited and settles within a few weeks or months without recurrence. Optimal treatment is not known. A high fiber diet, antibiotics (ciprofloxacin plus metronidazole for 7-14 days) and/or aminosalicylates were found to be helpful in case reports.

Microscopic colitis

  • Microscopic colitis (MC), comprising collagenous and lymphocytic colitis, is characterized clinically by chronic watery diarrhea and a macroscopically normal colonic mucosa where diagnostic histopathological features are seen on microscopic examination.
  • Collagenous colitis is defined by a thickened sub epithelial collagen band (>10 um), with minimal lymphocytic infiltration. A diagnosis of lymphocytic colitis requires an increased number of intraepithelial lymphocytes (>20 lymphocytes per 100 epithelial cells), without a significantly thickened collagen band.
  • Aetiology of MC is unknown. However certain drugs like NSAIDs, simvastatin, omeprazole, lansoprazole, esomeprazole etc has been implicated. An association between MC and coeliac disease has been observed
  • It is a fairly common cause of diarrhoea in middle aged women.
  • Both disorders cause chronic or recurrent non-bloody, watery diarrhea. A chronic intermittent course occurs in the majority.
  • It is important to remember that MC has not been associated with increased mortality or severe deterioration. So treatment is largely symptomatic.
  • Treatment
    • Stop the NSAIDS or PPI
    • Screen for coeliac disease by serology. Gluten free diet, if coeliac confirmed
    • Loperamide
    • If symptoms persist use Budesonide. Budesonide is the best-documented treatment and significantly improves the clinical symptoms and the patient’s quality of life. Budesonide 9 mg daily for 4 wk (taper to 6mg for 2 week and 3 mg for 2 week) causes clinical response in up to 80% cases. The relapse rate is high after cessation of successful short-term budesonide therapy. In clinical practice, tapering doses of budesonide to 3-6 mg/d have been used as maintenance therapy and may well control clinical symptoms.
    • If Budesonide is not useful, aminosalicylates, cholestyramine, steroids and immunomodulators can be progressively tried.
    • Colectomy may be rarely needed

Radiation colitis

  • Radiation injury to the intestine may occur following radiation treatment for cancers. Acute radiation injury occurs during and within six weeks of therapy. Symptoms include diarrhoea and tenesmus. This settles after radiation is discontinued. Chronic radiation injury can present anytime up to 30 years after radiation exposure.
  • Pathology- Late radiation injury is due to progressive fibrosis associated with obliterative endarteritis and chronic mucosal ischemia.
  • Symptoms- Diarrhoea, bleeding and tenesmus. Stricture formation may lead to obstructive symptoms. Rectum and sigmoid is commonly involved as radiation to the urogential organs damages the distal sigmoid and rectum.
  • Endoscopy reveals pale and friable mucosa with telangiectasias. The changes could be continuous or patchy.  Histology is not diagnostic but helps exclude other causes of colitis like IBD.
  • Treatment is based upon the pattern and severity of symptoms. Most of the experience is derived from case reports
  1. Obstructive symptoms- stool softeners, balloon dilatation
  2. Bleeding- mild bleeding can be left alone and generally settles on its own. If bleeding is significant- APC is used. Alternatives are sucralfate enema (20 mL of a 10 percent sucralfate suspension in water twice daily) or oral/topical aminosalicylates
  3. Tenesmus or rectal pain- sucralfate or steroid enemas

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