Colitis

What is Colitis?

Colitis is a condition where the inner lining of the colon becomes inflamed. It can be a short-term or a long-term issue, and it’s becoming more common around the world. Symptoms of colitis often include loose stools, abdominal pain, a constant urge to pass stools, frequent bowel movements, high temperature, fatigue and the presence of blood in stool. However, there are different types of colitis caused by various factors such as infections, the body’s immune system attacking its own cells, lack of blood flow, certain medications, weaknesses in the immune system, or even exposure to radiation.

The issue is that all these different types of colitis can cause similar symptoms, so it’s important to assess patients correctly. Unfortunately, there’s a shortage of detailed, comprehensive guides on how to approach the evaluation of patients with colitis. Most existing literature tends to focus on a single type of colitis or are solely about specific colitis related diseases. This summarized review aims to discuss causes, trends, underlying mechanisms, symptoms, evaluation process, diagnosis, potential complications, and how to manage patients with colitis.

What Causes Colitis?

Colitis in adults can occur due to a variety of reasons such as infection, inflammatory bowel disease, microscopic colitis, decreased blood supply to the colon (ischemia), reaction to certain drugs, as a result of disorders that weaken the immune system, or following radiation therapy.

The most common infections that cause colitis are bacterial, such as Campylobacter jejuni, Escherichia coli, Salmonella, Shigella, Mycobacterium tuberculosis, and Clostridium difficile. Other possible infectious causes can include parasites like Entamoeba histolytica, and viruses such as cytomegalovirus.

Inflammatory bowel disease refers to conditions like Crohn’s disease and Ulcerative colitis, which cause long-term inflammation in the digestive tract.

Microscopic colitis is a common cause of chronic watery diarrhea, especially in older individuals. It involves two main type; collagenous colitis and lymphocytic colitis, which are very similar clinically. The main difference is whether there is a thick, collagen band beneath the lining of the colon. It can often occur alongside autoimmune disorders such as celiac disease, type one diabetes, thyroid dysfunction, and psoriasis.

Ischemic colitis happens when the blood flow to the colon is less than what is needed for its normal functioning, leading to ulceration, inflammation, and bleeding.

Colitis can also be caused by certain medications, such as non-steroidal inflammatory drugs, aspirin, proton pump inhibitors, Hreceptor antagonists, beta blockers, statins, immunosuppressive drugs, vasopressors.

Furthermore, disorders that weaken the immune system can result in colitis, as well as radiation therapy for gynecological, urological, and rectal cancers which can cause radiation colitis.

Risk Factors and Frequency for Colitis

Many people around the world suffer from various stomach-related illnesses caused by different bacteria. Campylobacter jejuni, for example, is the top bacterial cause of diarrhea across the globe, affecting about 25-30 people out of every 100,000. The prevalence of diseases caused by Salmonella and Shigella is slightly lower, with about 20 cases in every 100,000 people.

Inflammatory bowel disease is also a widespread issue. People in North America and Europe get it more than anyone else. In the United States, for example, about 263 per 100,000 adults are dealing with inflammatory bowel disease.

• Microscopic colitis usually affects older adults between 50 and 70 years old.
• It affects more women than men, with up to 9 women affected for every man.
• The incidence rate ranges from 1 to 30 per 100,000 people per year.

The number of people with ischemic colitis, a certain type of bowel disease, has been growing over the years. Back in the late 70s, there were about 6.1 cases per 100,000 people per year. However, from 2005 to 2009, that number jumped to 22.9 per 100,000. That increase could be due to better medical treatments and the use of endoscopy for diagnosis. As more people are living longer, this number will likely keep growing because ischemic colitis is more common as people age and those with other health conditions.

M.tuberculosis colitis is a widespread problem in many countries, especially with a resurgence of tuberculosis in the West. There are about 9.4 million cases of tuberculosis worldwide each year, and the death rate for this disease varies. On average, 23 to 25% of people with tuberculosis will die from it, but that number can jump to more than 50% in some African countries with high HIV rates.

Signs and Symptoms of Colitis

Colitis is a condition marked by inflammation of the colon, leading to uncomfortable symptoms like belly pain, watery diarrhea, fever, urgency for bowel movements, and blood in stool. Doctors have to be vigilant for certain warning signs, such as the patient’s age, changes in their heartbeat, diarrhea at night, muscle spasm in the rectum (tenesmus), sudden weight loss, existing conditions, history of certain health problems (like heart failure or autoimmune disorders), their medication history, signs indicating an unusually wide colon (toxic megacolon), and anemia.

In addition to the intestinal symptoms, a person with ulcerative colitis, a type of colitis, can experience symptoms unrelated to their digestive tract. These can include:

• Joint problems
• Eye changes (like episcleritis, scleritis, uveitis)
• Skin conditions (such as erythema nodosum and pyoderma gangrenosum)
• Other conditions, including sacroiliitis, ankylosing spondylitis, liver dysfunction, and primary sclerosing cholangitis

Testing for Colitis

Diagnosing colitis, a condition causing inflammation in the lining of the colon, involves clinical findings, lab tests, and sometimes a procedure that looks inside the colon. However, before conducting a procedure like an endoscopy, it’s important to consider the patient’s overall health and initial test results.

Because colitis can often result from a colon infection, microbiological tests for bacteria and parasites should be performed first. Doctors should also order a set of blood tests which can include complete blood count, ESR, CRP, and other parameters. An experimental lab test that might help diagnose colitis involves checking the levels of D-lactate in the blood, although this is not a universally adopted practice.

Patients with colitis might need heart-related tests such as an electrocardiogram and Holter monitoring, particularly if their colitis is due to impaired blood supply to the colon. Normal X-rays may not be very helpful, but they can show complications like an unusually large colon, a blocked bowel or a ripped intestine. Multidetector CT scans, which create thin slice images, can clearly show inflammation in the colon wall and help understand how far the disease has spread.

To confirm a diagnosis of colitis, a colonoscopy or proctosigmoidoscopy is usually required. These examine the colon and rectum with a tiny camera on a thin, flexible tube. In some cases, the colon may appear normal, but there may be swelling or redness present. In other instances, ulcers might be visible.

Lastly, depending on the suspected type of colitis, certain additional tests may be conducted. For example, the presence of certain antibodies can suggest Crohn’s disease or ulcerative colitis, and an increase in a specific protein (carcinoembryonic antigen) may be indicative of active ulcerative colitis.

Treatment Options for Colitis

Infections of the colon, known as infectious colitis, don’t always require antibiotics for treatment. Mild to moderate infections caused by C. jejuni or Salmonella bacteria typically resolve on their own without antibiotics. Antibiotics are usually reserved for patients with severe symptoms like dysentery and high fever, or patients with certain underlying conditions such as AIDS, cancer, organ transplant, prosthetic implants, heart valve disease, or those of advanced age.

When dealing with mild to moderate cases of C. difficile infection, a medication called metronidazole is typically used. For severe infections by C. difficile, oral vancomycin is recommended. If the case is particularly complicated, a combination of oral vancomycin and intravenous metronidazole is preferred. Infections caused by cytomegalovirus are treated with a drug called valganciclovir.

If you have ulcerative colitis, a category of medications called 5-aminosalicylic acid (5-ASA) drugs is generally used for treating and preventing the recurrence of mild and moderate conditions. Use of these drugs in the management of Crohn’s disease, however, is a subject of debate. For patients with mild to moderately severe Crohn’s disease, or recurring ulcerative colitis not responding to 5-ASA drugs, immunomodulator drugs such as azathioprine, 6-mercaptopurine, and methotrexate are commonly prescribed. Certain biological therapies available can also help manage Crohn’s disease.

While corticosteroids can be effective in inducing remission of inflammatory bowel disease, they’re not recommended for long-term use and can cause severe side effects. If medical therapy is ineffective, surgery may be advised.

For a condition called microscopic colitis, stopping any potential trigger medications and quitting smoking is essential. Though anti-diarrheal medications might help, a drug named budesonide is usually the first choice for treatment.

If you are diagnosed with ischemic colitis and are not showing any signs of peritoneal irritation, doctors often recommend medical management. This may include intravenous fluids, increasing cardiac output, supplementing oxygen, resting the bowel, providing nutrition through a vein (parenteral nutrition), using broad-spectrum antibiotics and close monitoring. However, if symptoms get worse or there is an intestinal perforation, surgical intervention may become necessary.

In the case of tuberculous colitis, a combination of anti-tuberculosis drugs is recommended over a course of nine months, which needs regular follow-ups to monitor the response to treatment.

What else can Colitis be?

• Irritable bowel syndrome: a chronic disorder that affects the large intestine
• Celiac disease: a condition where the immune system reacts to eating gluten. If people with Celiac disease continue to have watery bowel movements even after following a strict gluten-free diet, they might need to be checked for microscopic colitis
• Colorectal cancer: a type of cancer that starts in the rectum or colon
• Diverticulitis: a condition where small pouches or bulges forming in the digestive system get inflamed or infected
• Toxic megacolon: a dangerous condition where the large intestine gets inflamed and swells to several times its normal size
• Viral/bacterial gastroenteritis: this is a stomach and intestine infection that causes diarrhea, vomiting, nausea, and stomach cramping. It’s often caused by a virus or bacteria
• Other types of colitis: a condition where the colon gets inflamed for different reasons

Possible Complications When Diagnosed with Colitis

There are several complications that can come from having colitis, such as:

• Intestinal perforation – when there is a hole in the intestine
• Bowel problems like strictures (narrowing of the intestine), fistulas (abnormal connection between the intestine and another organ), abscesses (collection of pus), and blockages
• Loss of control over bowel movements
• Pelvic abscess – collection of pus in the pelvic region
• Enterocutaneous fistulas, specifically in individuals with Crohn’s disease
• Pouchitis – inflammation of the ileal pouch, which is a surgically created pouch in the digestive system
• Guillain-Barre syndrome – this is usually associated with Campylobacter jejuni colitis, cytomegalovirus colitis, and has been reported in individuals with ulcerative colitis
• Hemolytic uremic syndrome – this usually happens with enterohemorrhagic E. coli or Shigella infections
• Encephalopathy and seizures – this is typically seen with Shigella infections

Toxic megacolon is a serious but rare condition that can result from colitis. It is when parts or the entirety of the colon swell abnormally, causing severe illness. It’s associated with a high risk of death, approximately 19%. This condition is common in diseases like ulcerative colitis and pseudomembranous colitis, accounting for over 60% of cases. Other conditions related to colon inflammation, like Campylobacter and shigella colitis, can also result in toxic megacolon.