colitis



Overview

Multiple causes of acute and chronic inflammatory lesions of the colonic mucosa mainly abdominal pain, diarrhea, mucopurulent blood stools constipation and other manifestations caused by microbial infections, environmental factors, intestinal microecological abnormalities, genetic factors, immune imbalance, etc. Mainly general treatment, drug therapy, traditional Chinese medicine treatment, surgical treatment, etc.

Definition

Colitis refers to acute and chronic inflammatory lesions of the colonic mucosa caused by various factors such as bacterial and other microbial infections, environment, intestinal microecological abnormalities, genetics, and immunity.

Classification

Classification according to etiology

Infectious colitis

This refers to infections caused by various pathogenic microorganisms, including bacteria, viruses, fungi, and parasites, etc. These pathogenic microorganisms can damage the colonic mucosa and produce an inflammatory response, leading to the development of colitis.

Non-infectious colitis

Abnormal body immune mechanism: such as inflammatory bowel disease including Crohn’s disease, ulcerative colitis, etc., the development of which is mainly caused by immune imbalance.

Intestinal ischemia: various causes of intestinal ischemia, such as mesenteric artery thrombosis, embolism, etc., can cause ischemic colitis.

Physical factors: related to X-ray exposure, etc., such as radiation therapy after pelvic surgery, can cause intestinal damage, which can lead to radiation colitis.

Drugs and toxic factors: such as eating poisons to corrode the intestinal mucosa or long-term intake of antibiotics and other drugs lead to colitis [1-2].

Classification according to the time of onset

Acute colitis

In China, the incidence rate is higher in summer and fall, with no gender difference, and the general incubation period is 12-36 hours. It occurs mostly due to improper diet, such as eating unclean or cold food, overeating and so on.

Clinical manifestations mainly include fever, nausea, vomiting, abdominal pain, diarrhea, etc., which may lead to dehydration or even shock in severe cases.

Chronic colitis

Clinical manifestations are long-term chronic or recurrent abdominal pain, diarrhea and indigestion, etc. In severe cases, there may be mucus stools or watery stools.

The degree of diarrhea varies from 3 to 4 times a day in mild cases, or alternating with diarrhea and constipation; in severe cases, it can be every 1 to 2 hours, and even fecal incontinence can occur.

Morbidity

Crohn’s disease is most common in adolescents, with a peak age of onset of 18 to 35 years[1] .

Ulcerative colitis can occur at any age and is most common in 20 to 40 years old[1] .

Ischemic colitis is more common in middle-aged and elderly patients, often older than 60 years.

Antibiotic-associated colitis occurs more often in the elderly and children during hospitalization.

Etiology

Causes

Microbial infection

Shigella, Salmonella, amoeba, Schistosoma, EBV, cytomegalovirus, etc. enter the intestines and cause infection, which in turn causes infectious colitis.

Environmental factors

The incidence of global inflammatory bowel disease has continued to increase in recent decades. Inflammatory bowel disease in China was rare in the past, but the number of cases has increased significantly in the last 10 years or so, and certain environmental factors may play an important role in this disease [3].

Genetic factors

There is a genetic predisposition to the development of inflammatory bowel disease. Some studies have found that certain gene mutations in the white race population are associated with the development of inflammatory bowel disease, and the incidence rate of patients’ close relatives is significantly higher than that of the general population, but no genes associated with the development of inflammatory bowel disease have been found in China, so the genetic background of different races is not the same [3-5].

Intestinal microecology

Some experiments have found that the intestinal microecology of patients with inflammatory bowel disease is different from that of the normal population, and certain inflammatory bowel diseases are effectively treated with antibiotics, indicating that intestinal microorganisms play an important role in inflammatory bowel disease.

Immune Imbalance

Various factors cause partial inflammatory activation in the body, imbalance of inflammatory and anti-inflammatory factors, and increased secretion of inflammatory factors, causing persistent inflammation of the intestinal mucosa and damage to the barrier function.

Insufficient local intestinal blood supply

As atherosclerosis easily triggers insufficient intestinal blood supply, or intestinal reflux is blocked, resulting in hypoxic damage to the intestinal wall, producing inflammatory lesions and causing ischemic colitis [6].

Radiation or chemotherapy treatment factors

Radiation therapy for abdominal, or pelvic tumors, causing intestinal damage, causing acute and chronic radiation colitis. Or injecting chemotherapy into the colon, causing intestinal mucosal injury, leading to chemical colitis [7].

Antibiotics.

Clostridium difficile infection is caused due to prolonged use of antibiotics. The bacterium itself is non-invasive, but the toxins it produces can indirectly cause inflammatory lesions and necrosis of intestinal epithelial cells.

Drugs, caustic chemicals

Enteritis due to damage to the intestinal mucosa caused by specific drugs such as NSAIDs or corrosive chemicals.

High risk factors

People who have been using broad-spectrum antibacterial drugs for a long time, or patients with severe underlying diseases, use of immunosuppressants or immunocompromised, the elderly, diabetes mellitus, gastrointestinal surgeries, malnutrition, renal failure, etc. are prone to antibiotic-associated colitis.

People with diabetes, hypertension, hyperlipidemia are prone to atherosclerosis and subsequent ischemic colitis.

Symptoms

There are many types of colitis, and the symptoms vary according to the cause, duration, and severity of the disease.

Main symptoms

Abdominal pain

Mostly mild to moderate abdominal pain, left lower abdomen or lower abdomen hidden pain, can also involve the whole abdomen.

Diarrhea

The amount of diarrhea varies and can be more than 10 times a day. The feces of amebic infection is jam-like, ischemic colitis can discharge bright red or purple-brown blood, and antibiotic-associated colitis can be up to dozens of times a day of large amount of watery feces in the severe cases.

Mucus, pus and blood stools

Mucus, pus and blood stools may occur in the active stage of ulcerative colitis, and bloody stools may occur in chemical colitis due to erosion of the intestinal mucosa.

Constipation

Radiation colitis and ulcerative colitis present with narrowing of the intestinal lumen, which manifests as constipation and difficulty in defecation.

Associated symptoms

Colitis may be accompanied by lethargy, fatigue and fever.

Extra-intestinal manifestations of inflammatory bowel disease: peripheral arthritis, anterior uveitis, recurrent oral ulcers, etc.

Complications

Intestinal hemorrhage

Inflammation of the intestinal tract and invasion of the intestinal mucosa lead to bleeding, and pus and blood stools will appear.

Intestinal perforation

Inflammation invades inward, and in severe cases, intestinal perforation may occur, causing peritoneal irritation signs, abdominal distension, abdominal pain, abdominal wall tension, and refusal to be pressed.

Intestinal obstruction

Colitis causes intestinal scarring and narrowing, or intestinal mucosal edema, affecting intestinal peristalsis, and intestinal obstruction will occur, manifesting as stopping gas and bowel movement, abdominal pain, etc.

Colon cancer

Mostly seen in ulcerative colitis, Crohn’s disease, chronic irritation of colon lesions may cause intestinal cancer.

Toxic megacolon

Commonly seen in ulcerative colitis, when the infection is severe, it may easily lead to systemic infectious toxicity and colonic dilatation. Patients may have high fever, tachycardia, lowered blood pressure, drowsiness, etc.; there are dehydration and electrolyte balance disorders, and bowel shape, abdominal pressure pain, loss of bowel sounds, etc. can be seen on examination.

Extra-intestinal lesions

Oral ulcer, peripheral arthritis, erythema nodosum, anterior uveitis, ankylosing spondylitis.

Consultation

Department of Medicine

Gastroenterology

If you have abdominal pain, diarrhea, or mucus, pus, or blood in the stool, we recommend that you consult a doctor promptly.

Department of Infectious Diseases

Consult the Department of Infectious Diseases if you have a history of exposure (e.g., people in the infected area, food, water, etc.) and suspect bacillary or amoebic dysentery.

Emergency Medicine

If you have severe abdominal pain that cannot be relieved, large amounts of blood in the stool, persistent high fever, confusion, or other critical conditions, go to the Emergency Department.

Preparation

Consultation: Registration, Preparation of documents, Frequently Asked Questions

Tips for the Emergency Department

Wear loose-fitting clothes to make it easier for the doctor to examine you.

If you have recently taken medication, you should record the name of the medication and its dosage so that you can inform the doctor.

If you have been to the doctor recently, you should bring along the relevant medical records, laboratory tests and examination reports.

If you are considering colonoscopy, please make an appointment in advance.

Preparation Checklist

Symptom list

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

Where is the abdominal pain and what is the nature of the pain?

How many times a day do you have bowel movements?

Is the stool yellow and loose? Watery? Mucus with blood?

Can you see the feces as white or red mucus-like? Do you have abdominal pain?

Do you want to go to the toilet when you have abdominal pain? Is the abdominal pain relieved after going to the toilet?

Any recent symptoms such as fatigue, lethargy, fever, etc.?

List of medical history

Have you eaten cold, moldy, spicy or irritating food recently?

Any history of exposure to infected areas?

Has anyone in the family had prolonged or recent diarrhea, mucous bloody stools, or abdominal pain?

Any previous surgery, such as abdominal surgery? Had a colonoscopy or gastroscopy?

Do you have a stressful life and work? Is this attack related to emotions?

Checklist

Test results of the last six months, which can be brought to the doctor’s office

Laboratory tests: routine blood test, routine stool test.

Imaging tests: abdominal CT, magnetic resonance imaging (MRI).

Endoscopy: colonoscopy.

List of medications

5-aminosalicylic acid: mesalazine, olsalazine, etc.

Glucocorticoid: prednisone, hydrocortisone, methylprednisolone, etc.

Immunosuppressants: azathioprine, mercaptopurine, etc.

Biological agents: infliximab, etc.

Antibiotics: ciprofloxacin, metronidazole, vancomycin, ceftriaxone, etc.

Non-steroidal anti-inflammatory drugs: ibuprofen, acetaminophen, aspirin, etc.

Diagnosis

Diagnosis is based on

medical history

Possible past history of exposure to infected areas such as amoeba and schistosomiasis, family history of colitis, history of prolonged treatment with antibiotics, history of atherosclerosis and diabetes mellitus.

Clinical manifestations

Symptoms

Mainly abdominal pain, diarrhea, mucopurulent blood stools, constipation, often accompanied by emaciation, malaise, fever, etc. Occasionally, there are peripheral arthritis, oral ulcers, anterior uveitis and other extra-intestinal lesions.

Physical signs

Abdominal tenderness, rebound pain, abdominal muscle tension, and diminished bowel sounds may be present in severe cases.

Laboratory Tests

Routine blood tests

Routine blood tests may indicate infection if leukocytes and neutrophils are elevated, and active gastrointestinal bleeding may be present in colitis if hemoglobin and red blood cell counts decline progressively.

Routine Stool Test

A routine stool test will reveal occult blood tests, white blood cells, and red blood cells.

If there are elevated stool leukocytes and red blood cells, it suggests the possibility of colitis and the presence of infection.

Fecal Pathology

It can determine whether there are bacteria, parasites and other pathogens, and clarify the pathogens of colitis infection.

Immunologic examination

Antinuclear antibody profile, neutrophil antibodies and other tests can assist in the diagnosis of the presence of inflammatory bowel disease such as ulcerative colitis and Crohn’s disease.

Imaging tests

CT scan of the abdomen or intestines

It is mainly to check whether there are lesions in the abdominal organs such as liver, gallbladder, pancreas and spleen, or whether there is obstruction of intestinal tubes, accumulation of gas and fluid, etc. It can be used to identify diseases such as pancreatitis, ischemic bowel disease, intestinal obstruction and other diseases.

Abdominal MRI

Helps to identify the presence or absence of intestinal lesions such as tumors.

Colonoscopy

It can directly observe the inflammatory changes, bleeding and ulceration of the colon, and if necessary, tissue biopsy and treatment are feasible.

Pathologic examination

Specimens of lesions are obtained through colonoscopy, surgery, etc., and pathologic biopsy is performed. According to the pathological manifestations, the diagnosis can be clarified.

Differential diagnosis

Intestinal tuberculosis

Similarity: both have abdominal pain and mushy stools.

Differences: intestinal tuberculosis is caused by infection with Mycobacterium tuberculosis, abdominal pain is in the right lower abdomen or around the umbilicus, and there is no pus and blood in the stool. It is often accompanied by a history of tuberculosis, and ascites is common on imaging. Patients with colitis have no history of tuberculosis and often have pus and blood in the stool.

Irritable bowel syndrome

Similarities: both present with abdominal pain and diarrhea.

Differences: symptoms of irritable bowel syndrome may be manifested by the absence of pus and blood in the stool, and the absence of organic lesions on colonoscopy. Colitis is characterized by pus and blood in the stool, and erythema, ulceration, and even bleeding of the mucosa can be seen in colonoscopy.

Treatment

Aims of treatment: to relieve symptoms and promote mucosal healing, prevent complications and improve the quality of life of patients.

Treatment Principle: For different kinds of colitis, medication and surgery should be adopted according to the cause of the disease.

General treatment

Colitis can be treated with high sugar, high protein, low fat and low residue diet, and patients with severe symptoms need to be fasted and given nutritional supplements intravenously.

If anemia is caused by blood in stool, blood transfusion can be given; hypoproteinemia can be transfused with human albumin.

When the abdominal pain is severe, drugs such as atropine and scopolamine can be applied to slow down intestinal peristalsis and reduce the secretion of intestinal fluid, which can help to relieve pain.

If vomiting or severe dehydration occurs, water and electrolytes can be supplemented intravenously.

Drug treatment

Aminosalicylic acid preparation

Applicable to patients with inflammatory bowel disease.

Commonly used drugs include mainly Osalazine and Mesalazine.

Glucocorticoid

Suitable for patients with inflammatory bowel disease.

Commonly used drugs include methylprednisolone, prednisone and so on.

Immunosuppressants

Used for the maintenance treatment of patients with poor efficacy of aminosalicylic acid preparation and hormone dependence.

Commonly used immunosuppressants such as methotrexate, azathioprine.

When azathioprine is used in large doses and for too long, it can have serious bone marrow suppression, which can lead to granulocytopenia and even aplastic anemia.

Biological agents

Applicable to patients with enteritis due to inflammatory bowel disease, when the use of aminosalicylic acid preparations, immunosuppressive drugs treatment effect is not obvious.

Commonly used drugs mainly include infliximab and adalimumab [8-10].

Anti-infective drugs

Viral colitis usually does not need antiviral treatment, and can be self-healed by symptomatic treatment.

For bacterial colitis, it is best to choose antimicrobial drugs according to the bacterial drug sensitivity results.

Treatment of bacterial infectious enteritis: commonly used are quinolones (such as norfloxacin, ofloxacin, ciprofloxacin), compound sulfamethoxazole, amoxicillin, ceftriaxone and so on. Drug allergies are contraindicated.

Praziquantel is the main treatment for schistosome infections.

Antibiotic-associated colitis: vancomycin is given orally and by enema after Clostridium difficile infection.

Treatment of amebic colitis: treatment with tetracycline and metronidazole.

In case of Candida albicans colitis you can apply fluconazole, voriconazole, dicentromycin B and other treatments.

Drugs to regulate intestinal flora

Such as bifidobacteria, lactobacillus, etc., can correct the intestinal flora imbalance, and also have a certain effect on the prevention of antibiotic-induced intestinal flora disorders.

Intestinal power drugs, antidiarrheal drugs

Suitable for patients with obvious diarrhea, commonly used drugs include trimethoprim and montelukast.

Surgery

If colitis is complicated by intestinal perforation, intestinal bleeding and other complications, and when conservative medical treatment is ineffective, surgical treatment can be performed. Surgical method is mostly to remove the diseased intestinal segment to achieve the therapeutic purpose.

When there is intestinal obstruction, bleeding, intestinal necrosis, perforation and fistula in chronic radiation injury, surgical resection of diseased intestinal tubes is needed due to the irreversibility of chronic ischemia and fibrosis of intestinal tubes.

Interventional therapy

If the diagnosis of non-occlusive intestinal ischemia is confirmed, vasodilators, such as opiate, can be injected into the arteries through the contrast catheter, and repeated angiography should be carried out during the period of using the drug in order to dynamically observe the condition of vasospasm.

Traditional Chinese Medicine (TCM)

Chinese medicine has unique theories and experiences in treating colitis.

Colitis belongs to the category of diarrhea and abdominal pain in Chinese medicine, and can be treated with Chinese herbal prescriptions, acupuncture, and Chinese herbal enemas under the diagnosis of a Chinese medicine practitioner.

Prognosis

Cure

For some mild cases of enteritis, the intestinal mucosa can be repaired by itself after reasonable diet and symptomatic treatment, and it can be cured by itself.

For old and weak patients with serious condition, if they cannot be treated in time, complications may occur, such as toxic megacolon, intestinal perforation, colon cancer, and even death.

Through active treatment most patients’ symptoms can be relieved, disease progression and recurrence can be controlled. Inflammatory bowel disease is a long-term chronic disease, easy to recur.

Harmful

Repeated episodes of the disease can easily affect the quality of life and mental health.

Some of them have the risk of complication of bowel perforation, toxic megacolon and colon cancer.

Daily

Daily Management

Dietary management

Disease flare-up period: patients should only eat liquid food. If diarrhea symptoms are more serious or there is a lot of sweating, it is necessary to supplement light saline and so on, to prevent the imbalance of water and electrolytes in the body.

Disease recovery period: patients should eat light and easy to digest semi-liquid food, small meals, strengthen nutrition.

Avoid eating unclean food, greasy and spicy stimulating food.

Life management

Infectious colitis should pay attention to good disinfection of tableware, stools and hand hygiene.

Participate in physical exercise appropriately.

Quit smoking and limit alcohol, and forbid coffee and strong tea.

Psychological support

Repeated illnesses will bring more psychological pressure to the patient, who can actively learn the knowledge about the disease, and can listen to music and movies in daily life to divert attention.

Family members should give psychological support so that the patient can maintain a positive and optimistic attitude to accept the treatment.

Follow-up and review

Chronic colitis patients need to exclude the possibility of cancer, and it is recommended that regular fecal examination and colonoscopy be performed.

Patients with extensive colitis should have colonoscopy every 1 year, and then every year after 20 years; patients with other types of recurrent colitis with a duration of more than 15 years should have colonoscopy every 1 year.

Prevention

Regularly wash and sterilize dishes that hold meals, as well as chopping boards and utensils used for cooking.

Avoid intake of potentially contaminated food and water, and avoid drinking raw water and eating raw food.

Keep your abdomen warm and avoid exertion, cold and flu.

When taking antibiotics, go to the hospital for regular checkups and adjust the dosage or stop the medication as prescribed by the doctor.

For people with high risk factors as mentioned above, they should be screened regularly with stool examination and colonoscopy for early detection, diagnosis and treatment.