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Miscellaneous colitides

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

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  1. Miscellaneous colitides Ian Botterill St James’s University Hospital, Leeds

  2. 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

  3. ‘critical care’ colitides C. Difficile Ischaemic colitis Radiation proctocolitis CMV Graft v host

  4. Initial assessment • History / PMSH crucial - symptoms - aetiological factors • Resuscitation • Bloods / inflammatory markers • Stool culture / stool chart • AXR • Lower GI endoscopy • CT

  5. 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

  6. 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

  7. 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

  8. 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

  9. C Difficile: 2nd line therapy Oral vancomycin Indication - non responders - C/I to metronidazole 125mg qds - cure 85-99% - relapse 15-30% - risk: VRE

  10. 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

  11. 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

  12. Ischaemic colitis Crampy ‘hind-gut’ pain Dark red bleeding Wide spectrum severity Typically splenic flexure

  13. 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

  14. Ischaemic colitis: uncommon associations • hypercoaguable states - sickle cell - the ‘pill’ - pregnancy - pancreatitis • drugs (vasospastic & diuretics) - sumatriptan - cocaine - pseudoephidrine - loop diuretics

  15. 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

  16. 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

  17. 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

  18. 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

  19. Radiation proctitis Acute - diarrhoea & urgency - bleeding Chronic radiation proctopathy - bleeding (neovacularisation) - functional

  20. Chronic radiation proctopathy 5% - 40% ‘Radiation proctopathy symptom assessment scale’ (RPSAS) - diarrhoea / urgency - proctalgia - tenesmus - bleeding - incontinence DCR 2005;48:1-8

  21. 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

  22. 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

  23. Radiation proctopathy -2y brachytherapy Do not biopsy rectal wall following brachytherapy for prostate cancer - risk: recto-urethral fistula

  24. 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

  25. 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

  26. CMV & UC: Treatment • Consider the diagnosis • Use caution pre-commencing Ciclosporin A - check histology / immunology • Treatment - Ganciclovir - ↓ standard immunosuppression

  27. 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

  28. Summary 1 Assorted misfits causing regular pain & suffering

  29. Summary 2 • good history & stool culture • biopsy • medical care • occasional colectomy

  30. Summary 3 Unhappy coexistence……

  31. Summary 4 Recurrences despite seemingly successful eradication……

  32. Summary 5 Some forms can hit back…..

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