Eun-Ran Kim

Division of Gastroenterology, Department of Medicine

Samsung Medical Center

Colitis

– an inflammation of the colon

– diagnosed when the patient has diarrhea (≥ 3 unformed stools/day)

and has evidence of colonic inflammation of the following:

• Positive fecal markers

: numerous leukocytes, positive lactoferrin, or calprotectin

• Passage of many small volume stools containing gross blood

• Endoscopy revealing mucosal inflammation

Acute, chronic and persistent

– Acute : develops within 14 days of diarrhea onset

– Chronic : 30 or more days after development of diarrhea

Colitis (Colitides)

Differential diagnosis

The cause of infectious colitis

Common microbial cause

Emerg Infect Dis 2011 Jan;17(1):7-15

Journal of Infect ion (2012) 64,374-386

(2000-2008)

Most cause of infectious colitis : bacterial enteropathogens

Symptoms

: diarrhea with or without dysentery, abdominal pain, fever

Important microbial pathogens

– All regions : Salmonella, Shigella, Campylobacter

– Developing tropical & semitropical regions : Entamoeba histolytica

– Industrialized : Shiga toxin-producing Escherichia coli (STEC)

– Hospitalized : C. difficile infection (CDI)

≥ 30 days : consider IBD, or in endemic area, Entamoeba

histolytica or Schistosoma mansoni (africa)

Infectious colitis

Pathogenesis

– Invaded colonic mucosa

• Systemic sign and symptoms including fever, chill, toxicity

• Salmonella, Shigella, Campylobacter

– Non-invasive

• Attach to colonic mucosa, localozed inflammation

• Clostridium difficile, enteroaggregative, or STEC

Regardless of the etiology, clinical symptoms are quite similar.

Infectious colitis

the most important diagnostic test

: a single stool culture for bacterial causes of colitis

It is hard to prove the existence of pathogens.

: In more than 50% of cases of dysentery, an etiologic agent is not

identified despite using optimal diagnostic methods.

Patients whose symptoms have not improved within 1 week should

undergo a sigmoidoscopy or colonoscopy.

Infectious colitis

Endoscopy is not warranted for the initial evaluation.

Should be considered for patients with

– persistent symptoms

– inconclusive diagnosis after routine blood & stool tests

– failure to respond to empirical therapy

Suitable initial investigation : Flexible sigmoidoscopy with biopsy

– Acute diarrhea : suspected diffuse colitis (C. difficile )

– Chronic diarrhea : pregnant, significant comobidity, symptoms

characteristics of left sided colonic disease (tenesmus, urgency)

Colonoscopy : if the findings at sigmoidoscopy are inconclusive

The role of endoscopy

Prominent endoscopic features

– patchy or diffuse mucosal edema, mucosal erythema, focal or

coalescent haemorrhagic spots

– a variety of ulcerations occasionally with cobblestone appearance,

and spontaneous bleeding

Duration

– Acute : UC or ischemic colitis-like

– Subacute or chronic : CD-like

Location

– Shigella : intense involvement of the rectosigmoid

– Salmonella, Yersinia, Amoeba : cecum and ascending colon

Endoscopic findings

Endoscopic similarities

UC (ulcerative colitis) –like

– Shigella, Salmonella, Campylobacter, Amoeba, CMV

CD (Crohn’s disease)-like

– Salmonella, Campylobacter, Yersinia, Amoeba, intestinal Tbc,

CMV

Endoscopic findings

Shigella

UC-like

Yersinia

CD-like

Case

69 yrs old man

3 days ago, lower abdominal pain, diarrhea with fever

1 day ago, hematochezia

WBC 15240/L, CRP 24.08 g/dL

Stool Culture :

Shigella sonnei

Stool Culture :

Shigella sonnei

Histologic findings : Chronic inflammatory changes

– crypt architecture distorsion, crypt atrophy, basal lymphoid

aggregates

Differential diagnosis

Shigellosis

UC-like

Involvement : Rectosigmoid

15% : pancolitis

Prominent endoscopic findings

- erythema, severe edema

- irregular ulcers

- spontaneous bleeding

UC-like CD-like

Salmonellosis Involvement: terminal ileum, right side colon

Erythema, edema, granularity, loss of the normal vascular pattern

More severe : diffuse erythema, pitting edema, ulceration

(punctuate, aphthoid, aphthae, irregular (stellate), deep)

occasionally, denuded extensive areas of colonic mucosa

CD-like

Yersinia

Involvement : Right side colon

Endoscopic findings

- erosions, various forms of

ulcerations (usually punctuate)

- on other occasions,

mimics ulcerative colitis

Amebic colitis

UC-like CD-like

Involvement: cecum and Rt. Colon (70%), rectum and S colon

Acute: Diffuse erythema, granularity, friability resembling UC.

Chronic form : discrete or localized mucosal ulcers with a

characteristic pounched-out appearance (rolled edges) helps the

differential diagnosis from CD. (A flask shaped ulcer)

Usually non-specific but includes discrete ulcerations, varying

from punctate and superficial erosions to deep ulcers .

Histology

: typical inclusions which confirm the diagnosis

CMV colitis

Intestinal tuberculosis

Intestinal tuberculosis

CD : anorectal lesions, longitudinal ulcers, aphthous ulcers

and cobblestone pattern

Tbc : involvement of less than 4 segments, a patulous IC valve,

transverse ulcers, and scars or pseudopolyps

Distal or Left side colon

white yellow mucosal lesions including pseudomembranous

1/3 : non-specific erosions or erythemas

Clostridium difficile

Treatment

Empiric antibiotic therapy

– oral fluoroquinolone for 3-5 days

(in the absence of suspected EHEC or fluoroquinolone-resistant campylobacter infection)

• ciprofloxacin 500 mg twice daily

• norfloxacin 400 mg twice daily

• levofloxacin 500 mg once daily

Consideration

– with moderate to severe travelers' diarrhea as characterized by more

than four unformed stools daily, fever, blood, pus, or mucus in the stool

– with more than eight stools per day, volume depletion, symptoms for

more than one week, those in whom hospitalization is being

considered, and immunocompromised hosts

Eun-Ran Kim

Division of Gastroenterology, Department of Medicine

Samsung Medical Center

51 yrs old man

Previously healthy

1 day ago, sudden onset of abdominal pain, followed by

hematochezia

Case

Old age

Sudden onset of abdominal pain & hemtochezia

Endoscopy

– hyperemia, edema, ulceration

– rectal sparing

– resolved within 1-2 weeks

– Bx : coagulation necrosis

Ischemic colitis

29 yrs old female

2001.1. cervix ca -> radiation + chemotherapy

2001.8. hematochezia

Case

Radiation history due to cervix ca. or prostatic ca.

Endoscopy

– proximal rectum & distal sigmoid colon

– mucosal friability

– granularity with spontaneous bleeding

– multiple telangiectasia

Radiation colitis

48 yrs old female

10 years ago, constipation with straining

Anal bleeding, mucoid stool, tenesmus, lower abdominal pain

Case

Colonoscopy

Colonoscopic Biopsy

: chronic inflammation

Defecography

A chronic course characterized by rectal bleeding,

disordered defecation, tenesmus and mucorrhea

Endoscopy

– anterior wall, 4 to 15 cm from the anal verge

– shallow ulcers with white, sloughy base surrounded by

a thin rim of erythematous mucosa

Solitary rectal ulcer syndrome

Histology

– characteristic

– obliteration of lamina propria by fibromuscular

proliferation of the muscularis mucosa

– streaming of fibroblasts and muscle fibers up between

crypts

– thickening of muscularis mucosa

– branching, distorted glandular crypts

– diffuse collagen infiltration of lamina propria

Solitary rectal ulcer syndrome

Sodium phosphate

– aphthous ulcers

– focal cryptitis

Bisacodyl suppository

– mucosal hyperemia

– obliteration of vascular pattern

Bowel preparation

Bowel preparation

Non specific colitis

중년 남성

Low abdominal discomfort

Bx : focal active inflammation, terminal ileum

Diarrhea (-) Hematochezia (-) Wt loss (-) Oral ulcer (-)

ESR/CRP : normal

“복통이나 설사가 심해지거나 혈변이 생기면 들리세요”

Colonoscopy, 1 year later

Gastrointest Endosc 2010;72:1226

2개월 전 외부 병원에서 건강 검진으로 대장내시경 시행

Young female

현재 특이 증상 없음

건강 검진 1주일전 발열, 복통, 설사

Colonoscopy 6 months later

Conclusions

장염의 정확한 진단을 위해서는 자세한 병력청취가 중요하다.

대장내시경 소견의 이해도 중요하다.

그러나 환자의 병력과 여러 가지 검사 소견을 종합적으로

검토하여야 한다.

때로는 경과 관찰로 환자의 변화를 파악하는 것도 중요하다.