colitis

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COLITIS

COLITIS : "DOCTOR, HAVE I COLITIS?"

Notes by doctor Claudio Italiano from Italy see also index gastroenterology

Subjects who suffer of occasional diarrhoeal discharges, perhaps are affected by stressful events (eg. examination, a fight!). They don’t suffer of colitis, which is a specific inflammation process of the colon mucosa, particularly localized to the rectum-sigma. Most of the cases, it’s an irritable colon syndrome, which, although annoying, recognizes its etiopathogenetic origin in a motor disorder of the colon, with painful spasms, or an inflammatory disease. The syndrome is classificated in constipation and / or diarrhea variety, always accompanied by pain and colic spasms. See also the link on inflammatory diseases.
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Colitis classification .
The colitis are an mucousal inflammation of the bowel which recognizes specific causes (eg infections) and aspecific causes like as the inflammatory bowel disease.
Infectious colitis are caracterized by diarrhoeal discharges and depend on bacterial etiology in 50% of cases, eg. Campylobacter jejuni, Salmonella spp and some pathogenic strains of E.coli. But in other cases by viral etiology like in the rotavirus infections.
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COLITIS FROM INFECTIOUS AGENTS
Typhus and paratyphus.
They are caused by Salmonella typhi and paratyphi, A and B, bacterial diseases which people contracts orally, through contaminated food ( vegetables cultivated by sewage, mussels grown up in stagnant water etc..). After incubatione of 7 - 20 days, it appears fever, anorexia, bradycardia, like first symptoms. After it appears a pinkish rush, splenomegaly, vomit and diarrhoea, with the involvement of lymphatic Peyer tissue , along the bowel longitudinal axis which can give oval ulceration. Diarrhoea is a type peas puree color and is accompanied by an abdominal meteorism, leukopenia (ie decrement in white blood cells on emocromo). Diagnosis test is the Widal Test at the end of 2 ° week, ie after the incubation, while the emocoltura can be positive in the first 7-10 days and coprocoltura after the third week.
Therapy: chloramphenicol in 4 doses / day, at doses until 1mg x kg; therapy must be continued almost for 15 days. It finds healing clinic when 3 coprocolture are negative. Alternatively, you can use thiamphenicol, or ampicillin 100 mg / kg / day or clotrimoxazolo. It’s' clear that you must provide for rehydration treatment of the patient (just look at the patient’s tongue which is dry like as a “parrot tongue”); It will, therefore, administered fluids in vein, saline s and glucosate solutions. If it’s present an enterorragia, you must put an ice bag on abdominal surface and if there is a severe toxaemia is indicated a cortisonic terapy (eg predisonis 40 mg ev). The typhoid bacillus carriers must be treated by ampicillin. Prophylaxis for those who came into contact is orally obtained, by vaccines, even with agents live and attenuated.

Yersinia.
The Y. Enterocolitica or pseudotubercolosis infections can cause gastrointestinal pathology. It’s a gram negative bacterium, anaerobious optional which can cause infection in humans and animals. It is transmitted by oral and fecal way. The Y. Enterocolitica can develope in children and young adults a similar appendicitis syndrome and is responsible for most cases of gastroenteric disease in temperate climates. In adults may appear a nodouses erythema and a reactive arthritis, and reaching a megacolon tossic syndome, miocarditis and glomerulonephritis. The symptoms can remain for several months. The diagnosis is difficult and is detected by the coprocoltura; RX direct examination of the small intestine which shows nodularity and superficial ulceration. Infection occurs primarily in children and is responsible for adenites; test used to diagnose are that cultural and serological tests.

Abdominal Tuberculosis.
The tubercular enteritis can develop like as a primary bowel lesion or a secondary lesion in another location. The tubercolaris enteritis is often secondary to pulmonary localization; Micobacterium infection with bovine tuberculosis is rare, thanks to treatments for central and milk pasteurization. The symptoms are aspecific: fever, night sweats, weight loss and anorexia, nausea and feeling of discomfort or diarrhea affecting half of the patients. The ileum-cecal region is the most frequently affected; sometimes there is a palpable mass in the right iliac fossa, a positive Mantoux reaction (that is for tuberculosis) can be helpful for diagnosis, because the picture reminds us radiological's disease Crohn with ulceration and stenosis of the distal small intestine. There may be, even here (attention for differential diagnosis with Crohn!) ulceration and stenosis, we said, and parietal ipertrophia. There are characteristics mucosal lesions: confluent granuloma, expression of a chronic inflammatory process that draws cells of the white line at epiteliod transformation. Granuloma, as a result, are replaced by fibrous tissue that justifies strictures and inflammation.

Colitis from shighelle and entoameba istolitica.
These diseases are caracterized by acute diarrhoea and blood in feces, with leucocytes. The rectal biopsy performed by endoscopy, highlights specific lesions like marked edema, mucousal erosion, which is friable and bleeding, infiltrates of leukocytes and histological appearance of degenerate and rarefied crypts. In amebical colitis the infection is determinated by Entamoeba histolytica, and it is a tropical characteristic infection, due to the poor hygienic conditions, which may also affect the liver, by a cyst, called amebical cyst. The amebical cystic is the must environment diffused form, very widespread, which reaches into the human bowel by contaminated food; In the intestines becomes mobile trophozoita, which is the vegetative form: it is possible, however, that these cysts don’t cause symptoms. Amoebical disease have a various clinical aspects, from asymptomatic carrier to severe and acute colitis. Colitis is characterized by spasm pain in lowe abdominal squares, watery, mucus blood faeces emission, and only blood emission in the most serious cases, with bowel perforation. The sigmoidoscopy shows in 80% of cases the typical sores, bleeding ulcers with multiple surface, usually localized to the blind and / or rectum, are circular type drilling ticket ulcers and can penetrate in muscle layer, with thin oedematous board; amoebae are also evident in fecal smear. However, the diagnosis is made by serological tests, in order to differential diagnosis with chronic inflammatory bowel disease. With the chronic form can be stenosis and amoeboma, due to large granulomatoses masses (chronic inflammation result). The rapid response to metronidazole, 500 mg 3-4/die for 7-10 days to make a difference with carcinoma lesions. During an histological examination of amoebomi, however, the amoebae are easy distingued by PAS colour.

Colitis from Cytomegalovirus.
The CMV is not responsible for symptomatic colitis in immunocompetent subjects, but in patients affected by AIDS or cyclosporine therapy immunosuppressed, CMV is responsible for a potentially lethal disease, because drug therapeutic efficacy is limited. The virus is responsible for ischemic damnage form with deep mucosal ulceration and bowel perforation. Colonoscopy highlights aspecifical inflammation, sometimes with neoplastic aspect of ulcers.

Schistosomiasis.
The S. affects more than 200 million people in underdeveloped countries; Schistosoma mansoni and S.japonicum that can induce proctocolitis because they lay eggs in the venous system of higher mesenteric vein system (female S. japonicum), while S. Mansoni in the lower mesenteric vein system. The affected bowel mucosa presents ulcer, raised,with polypoid lesions and granulomatose reactions. The schistosoma can also go to the liver, by the portal system until a presinusoidal location, where is responsible for a granulomatous reaction, as a result of obstruction to the portal flow and portal presinusoidal hypertension. Constant is the detection of peripheral eosinophilia, hepatosplenomegaly, lymphadenopathy and proctitis with friable.

ASPECIFIC AND IDIOPATIC COLITIS

Pseudomembranous colitis.
The pseudomembran formation on the colic mucosa is an event that can occur in highly variable cases like as in mercury poisoning, intestinal ischemia or broncopolmonitis, but especially in antibiotic colitis. In a third of subjects symptoms come to an evident stop by suspension of antibiotic therapy, even when metronidazole has been used, which is generally used for its resolution. It seems that Clostridium difficile is the patogenetic agent, because the the normal intestinal bacterial flora is lose. The C. Diffcile secerne at least three termolabel toxins, and although the toxin A, B and C all lead to the accumulation of fluid in the small intestine, the A and C toxins also cause disepiteliation, but only the A is responsible for necrosis and severe bleeding. The clinical picture is represented by profuse diarrhea, abdominal cramps and abdomen poorly treatable, due to the massive use of antibiotic terapy. The abdominal RX shows aspecific signs: swollen intestinal loops. The pseudomembrans are formed by a series of small yellowish plates, with many foci and destroyed crypts.

Crohn's disease and RCU

They are rectum, sigmoid and ileum mucosal rectum inflammatory aspecific processes (terminal ileitis). Colonoscopy shows in Crohn’s disease the presence of severe, confluent, linear and serpiginouses ulcers or mucosal aspect clobestone. The right colon is more interested in the Crohn's disease. The appearance of fistulas is characteristic. Ulcerative colitis is generally limited to the rectum-sigma; It affects the rectum and proximal colon. The symptoms are diarrhea with blood and rectal spasm. It possible the association with skin lesions: pyoderma gangrenosum. The mucosa rectum-sigma by endoscopy appears finely grained, iperemica, bleeding and friable, until reaching the framework of III grade proctitis with severe ulcers, bleeding at spontaneous contact by the instrument. You can see ulcers like circular rectal craters, and by opaque clisma is showed a mucosa that sometimes takes pseudopolipoid aspects (post-inflammatory polyps). The perforation risk is possible, or intractable bleeding, tossic megacolon, bowel cancer. By coprocoltural examination you can exclude infectious inflammation.