Disease: Colitis

    Colitis facts

    • Colitis is inflammation of the inner lining of the colon. It may cause abdominal pain and diarrhea with or without blood. Fever may be present.
    • There are numerous causes of colitis including infection, inflammatory bowel disease, ischemic, and microscopic colitis.
    • Blood in the stool is never normal and should not be ignored.
    • Depending upon the history and physical examination, further testing may be required to find the cause of colitis.
    • Treatment of colitis often is supportive and is aimed at maintaining adequate hydration and pain control while a diagnosis is being pursued.

    What is colitis?

    Colitis is inflammation of the inner lining of the colon and can be associated with diarrhea, abdominal pain, bloating, and blood in the stool. This inflammation may be due to a variety of reasons, including the following:

    • infection,
    • loss of blood supply to the colon,
    • inflammatory bowel disease, and
    • invasion of the colon wall with lymphocytic white blood cells or collagen.
    Anatomy of the colon

    The colon, or large intestine, is a hollow, muscular tube that processes waste products of digestion from the small intestine, removes water and ultimately eliminates the remnants as feces (stool) through the anus. The colon is located within the abdominal cavity, the sac that contains the intestine.

    The colon is surrounded by many layers of tissue. The innermost layer of the colon is the mucosa that comes into contact with the waste products of digestion. is The mucosa absorbs water and electrolytes back into the blood vessels that are located just below the surface in the submucosa. This is surrounded by a circular layer of muscles and then another outer layer of longitudinal muscles that run along the length of the colon. The muscles work together to help rhythmically squeeze liquid waste from the cecum through the entire length of the colon. Water is gradually removed, turning the waste into formed stool, so that it is excreted out of the anus in solid form.

    The colon frames the organs within the peritoneum and its segments are named based on their location.

    • The colon begins in the right lower quadrant of the abdomen, where the terminal ileum, the last part of the small intestine, attaches to the cecum, the first segment of the colon. The appendix is attached to the cecum.
    • The ascending colon begins at the cecum and arises from the right lower abdomen to the right upper abdomen near the liver.
    • The colon then makes a sharp left turn called the hepatic flexure (hepatic=liver), and is referred to as the transverse colon, as it makes its way to the left upper quadrant of the abdomen near the spleen.
    • There is a sharp downward turn called the splenic flexure, and it is referred to as the descending colon as it runs from the left upper quadrant to the left lower quadrant of the abdomen.
    • When it descends into the pelvis, it is referred to as the sigmoid colon.
    • The last several centimeters of the colon are referred to as the rectum.
    • The anus is the final portion of the colon.

    Picture of the Large Intestine or Colon

    What are the causes (types) of colitis?

    Colitis describes inflammation of the colon (col=colon + itis=inflammation). While many causes of colon inflammation may be self-limiting and can be treated with diet and observation, it is important to determine why inflammation has occurred, because of the potential for a more serious diagnosis.

    Infectious colitis

    Many bacteria reside in the colon; they live in harmony with the body and cause no symptoms. However, some infections can result if a virus, bacteria, or parasite invade the small and/or large intestine.

    Common most common bacteria that cause colitis include:

    • Campylobacter,
    • Shigella,
    • E. Coli,
    • Yersinia, and
    • Salmonella.

    These infections usually occur because the patient has eaten contaminated food. Symptoms can include diarrhea with or without blood, abdominal cramps and dehydration from water loss because of numerous watery, bowel movements. Other organs can also be affected by the infection or the toxins that the bacteria can produce.

    Clostridium difficile, commonly referred to as C. Diff, is a bacterial cause of colitis that often occurs after a person has been prescribed an antibiotic or has been hospitalized. C. diff is found in the colon of healthy people and co-exists with other "normal" bacteria. But when antibiotics are prescribed, susceptible bacteria in the colon can be destroyed, allowing the clostridia to grow unchecked, causing colitis. Patchy membranes form along the colon mucosa and some health care professionals will refer to C. diff colitis as pseudomembranous colitis. The bacteria is also found on many surfaces in the hospital (for example, bedrails, toilets, and stethoscopes), and the infection may spread from person to person (it is contagious). Unfortunately, this infection is becoming more common outside the hospital environment and people can develop community acquired C diff colitis without exposure to antibiotics or a medical facility.

    Worldwide, the most common parasite infection to cause colitis is Entamoeba histolytica. It is acquired by drinking infected water and can also be passed from person to person because of poor sanitation and hygiene.

    Ischemic colitis

    The colon can be thought of as a hollow muscle. It requires a normal blood supply to deliver oxygen and nutrients for the muscle to function normally. When the colon loses its supply of blood and becomes ischemic (isch= restricted + emia=blood supply), it may become inflamed. Ischemia or lack of blood supply causes inflammation of the colon leading to pain, fever, and diarrhea (bowel movements may contain blood).

    • As a person ages, the arteries that supply blood to the colon gradually narrow and can cause ischemic colitis. Risk factors for narrowed arteries are the same as atherosclerotic heart disease, peripheral artery disease (PAD), and include diabetes, high blood pressure, high cholesterol, and smoking.
    • Ischemia may be caused by low blood pressure or anemia (low red blood cell count), which can decrease oxygen delivery to the colon.
    • The blood supply to the colon may be compromised when blood vessels are mechanically obstructed, for example by a twisting of the bowel (volvulus) or a herniation of the colon through openings in the abdomen wall (an incarcerated hernia).

    Inflammatory bowel disease

    Ulcerative colitis and Crohn's disease are the two types of inflammatory bowel disease (IBD) that give rise to colitis.

    Ulcerative colitis always begins in the rectum may spread to the rest of the rest of the colon, moving from the rectum to the sigmoid, descending, transverse, and finally ascending colon. It is consisdered an autoimmune disease and symptoms include abdominal pain, and bloody, diarrheal bowel movements.

    Crohn's disease may occur anywhere in the gastrointestinal tract (GI), including the esophagus, stomach, small intestine, and colon. In Crohn's disease there may be "skip lesions," that is, abnormal segments of the GI tract interspersed with normal segments.

    Microscopic colitis

    There are two types of microscopic colitis, 1) collagenous colitis and 2) lymphocytic colitis. Either collagen or lymphocytes (a type of white blood cell) infiltrate into the layers of the wall of the colon, presumably a result of inflammation. This is an uncommon illness and may be an auto-immune disease. The diarrhea often is watery, and no blood is present in the stool.

    Allergic colitis in infants

    In infants younger than one year of age, colitis is often due to allergies to cow or soy milk. Allergic colitis may be seen in breastfed babies, where mothers drink cow's milk and pass that protein into their breast milk.

    What are the symptoms of colitis?

    Inflammation of the colon causes the muscle layers to go into intermittent spasm and cause colicky or cramp-like pain that comes and goes. The pain usually is in the lower abdomen, but can be felt anywhere along the course of the colon. Since the muscles fail to contract in a normal pattern and the colonic contents move through the colon rapidly, there is little opportunity for water to be reabsorbed. This leads to watery diarrhea. If the lining of the colon becomes inflamed and breaks down, bleeding may occur. In ulcerative colitis, small ulcers form and are the cause of bleeding.

    With colitis, particularly colitis involving the distal colon (rectum and sigmoid colon), the pain often crescendos and precedes a diarrheal bowel movement. After the bowel movement, the pain may subside but then returns with the next episode of diarrhea.

    Depending upon the cause of the colitis, other organ systems in the body may be involved and produce symptoms. There may be fever, chills, malaise, fatigue, and dehydration. Symptoms of dehydration include weakness, lightheadedness, and decreased urine output.

    Ulcerative colitis is an autoimmune disease and may have associated symptoms outside of the colon. These can include joint swelling, eye inflammation (iritis), canker sores in the mouth (aphthous ulcer), and skin inflammations (pyoderma gangrenosum).

    When should I contact my doctor about colitis?

    Diarrhea is a common symptom of colitis. It, is usually self-limited, and resolves on its own with supportive care, including rest and a short course of a clear fluid diet. However, if the diarrhea persists for more than three weeks, if there is blood in the stool, or the person has signs of dehydration, medical care should be obtained.

    • Blood in the stool is never normal and should always be evaluated. Common causes of blood in the stool include hemorrhoids; however, other serious causes of bleeding need to be investigated. Colitis is not the only cause of rectal bleeding. Others causes include diverticular disease of the colon (diverticulitis), colon polyps, anal fissures, and cancer.
    • Chronic diarrhea can lead to dehydration, and if severe enough, dehydration may require treatment with fluids. The symptoms of dehydration may include:
      • lightheadedness (dizziness) especially when changing from a sitting or lying position to standing position (orthostatic hypertension)
      • weakness,
      • dry mouth, dry eyes, and
      • decreased output of urine.
    • High fever associated with diarrhea may be a warning sign that a significant infection may be present.
    • Abdominal pain is not normal, and while diarrhea may be associated with mild cramps, the presence of increasing abdominal pain, requires need to seek prompt medical attention.

    How is colitis diagnosed?

    Patient history
    • In patients with abdominal pain and diarrhea, it is important to find out when the symptoms began, how long they have lasted, whether they come and go, and what makes them better or worse.
    • Travel history is important, especially if the patient has recently visited an area with potentially contaminated water or poor food hygiene. Patients often ask if the symptoms are caused by food poisoning, but that is a difficult question to answer immediately. Usually this occurs with consumption of poorly handled and stored food in a home or a family gathering event.
    • Blood in the stool, whether it is mixed in with the bowel movement, or just drops in the toilet bowl, is not normal. While it may be due to hemorrhoids, other potential causes that are more worrisome may need to be explored. Questions might be asked about bowel habits, weight loss, weakness, or family history of bowel disorders including cancer or colon polyps. Depending on the health care professional's concerns, information may need to be obtained about other body systems, past medical history, social habits (including smoking, drinking, and occupational hazards or risks).
    Physical examination

    Once the history is taken, physical examination will be helpful in determining the potential causes of the symptoms.

    • Signs of more severe disease with dehydration may include orthostatic changes in blood pressure and pulse rate, where vital signs are taken both laying down and standing up. In patients who are dehydrated, have had rectal bleeding, or are anemic; blood pressure and pulse may be normal when they lie flat but may change when standing; the blood pressure falls and the pulse rate rises.
    • Temperature often is checked for fever.
    • Examination of the abdomen includes palpitating or feeling for tenderness and masses in the abdomen. Bowel sounds are often listened for with a stethescope.
    • The exam also may include a rectal examination to test the stool for blood and feel for a possible rectal mass.
    • If there is a concern for ischemic bowel as the cause of colitis, the examination may assess the heart and blood vessels, looking for signs of atherosclerosis or narrowing of arteries.
    • In patients where the clinical diagnosis is colitis secondary to a viral infection, no further testing is needed. However, this would not apply to a patient who appears ill, dehydrated, or has significant pain, fever, or blood in the stool.
    Other tests

    A complete blood count (CBC) measures hemoglobin and hematocrit, looking for anemia. If the red blood cell count is elevated, it may be due to dehydration, where total body water is decreased and the blood becomes concentrated.

    The CBC also measures the white blood cell count, which may be elevated as the body responds to infection. However, an elevated white blood cell count does not necessarily equal infection, since elevation may be due to the body's reaction to any stress or inflammation.

    Electrolytes may be measured looking for changes in the sodium, potassium, chloride and bicarbonate levels in the blood that help determine the severity of dehydration and loss of fluid.

    Kidney function may be checked by measuring the BUN (blood urea nitrogen) and creatinine levels; this may be an important clue as well to the severity of dehydration.

    Urinalysis may reveal dehydration if the specific gravity (urine concentration) is elevated or if there are ketones present.

    Stool samples may be collected for culture, searching for bacterial and parasitic infections as the cause of colitis. Stool may also be tested for blood.

    Imaging and procedures

    Colonoscopy: The length of the colon can be directly viewed by colonoscopy. A gastroenterologist uses a thin, flexible tube equipped with a fiberoptic camera to view the inside lining of the colon. The appearance of the colonic lining often allows the doctor to make the diagnosis and also provides the opportunity to look for tumors and polyps. Biopsies - small bits of tissue - can be obtained from the mucosal lining during colonoscopy and evaluated under the microscope to determine the cause of colitis. Biopsy is the only way to diagnose microscopic colitis.

    Computerized tomography and barium enema are tests that are performed by a radiologist to explore the potential cause of colitis. CT scan of the abdomen has become a more common test to evaluate patients with abdominal pain. However, it is important for the health care professional to balance the risk of radiation with the reward of the information that can be obtained.

    What are the causes (types) of colitis?

    Colitis describes inflammation of the colon (col=colon + itis=inflammation). While many causes of colon inflammation may be self-limiting and can be treated with diet and observation, it is important to determine why inflammation has occurred, because of the potential for a more serious diagnosis.

    Infectious colitis

    Many bacteria reside in the colon; they live in harmony with the body and cause no symptoms. However, some infections can result if a virus, bacteria, or parasite invade the small and/or large intestine.

    Common most common bacteria that cause colitis include:

    • Campylobacter,
    • Shigella,
    • E. Coli,
    • Yersinia, and
    • Salmonella.

    These infections usually occur because the patient has eaten contaminated food. Symptoms can include diarrhea with or without blood, abdominal cramps and dehydration from water loss because of numerous watery, bowel movements. Other organs can also be affected by the infection or the toxins that the bacteria can produce.

    Clostridium difficile, commonly referred to as C. Diff, is a bacterial cause of colitis that often occurs after a person has been prescribed an antibiotic or has been hospitalized. C. diff is found in the colon of healthy people and co-exists with other "normal" bacteria. But when antibiotics are prescribed, susceptible bacteria in the colon can be destroyed, allowing the clostridia to grow unchecked, causing colitis. Patchy membranes form along the colon mucosa and some health care professionals will refer to C. diff colitis as pseudomembranous colitis. The bacteria is also found on many surfaces in the hospital (for example, bedrails, toilets, and stethoscopes), and the infection may spread from person to person (it is contagious). Unfortunately, this infection is becoming more common outside the hospital environment and people can develop community acquired C diff colitis without exposure to antibiotics or a medical facility.

    Worldwide, the most common parasite infection to cause colitis is Entamoeba histolytica. It is acquired by drinking infected water and can also be passed from person to person because of poor sanitation and hygiene.

    Ischemic colitis

    The colon can be thought of as a hollow muscle. It requires a normal blood supply to deliver oxygen and nutrients for the muscle to function normally. When the colon loses its supply of blood and becomes ischemic (isch= restricted + emia=blood supply), it may become inflamed. Ischemia or lack of blood supply causes inflammation of the colon leading to pain, fever, and diarrhea (bowel movements may contain blood).

    • As a person ages, the arteries that supply blood to the colon gradually narrow and can cause ischemic colitis. Risk factors for narrowed arteries are the same as atherosclerotic heart disease, peripheral artery disease (PAD), and include diabetes, high blood pressure, high cholesterol, and smoking.
    • Ischemia may be caused by low blood pressure or anemia (low red blood cell count), which can decrease oxygen delivery to the colon.
    • The blood supply to the colon may be compromised when blood vessels are mechanically obstructed, for example by a twisting of the bowel (volvulus) or a herniation of the colon through openings in the abdomen wall (an incarcerated hernia).

    Inflammatory bowel disease

    Ulcerative colitis and Crohn's disease are the two types of inflammatory bowel disease (IBD) that give rise to colitis.

    Ulcerative colitis always begins in the rectum may spread to the rest of the rest of the colon, moving from the rectum to the sigmoid, descending, transverse, and finally ascending colon. It is consisdered an autoimmune disease and symptoms include abdominal pain, and bloody, diarrheal bowel movements.

    Crohn's disease may occur anywhere in the gastrointestinal tract (GI), including the esophagus, stomach, small intestine, and colon. In Crohn's disease there may be "skip lesions," that is, abnormal segments of the GI tract interspersed with normal segments.

    Microscopic colitis

    There are two types of microscopic colitis, 1) collagenous colitis and 2) lymphocytic colitis. Either collagen or lymphocytes (a type of white blood cell) infiltrate into the layers of the wall of the colon, presumably a result of inflammation. This is an uncommon illness and may be an auto-immune disease. The diarrhea often is watery, and no blood is present in the stool.

    Allergic colitis in infants

    In infants younger than one year of age, colitis is often due to allergies to cow or soy milk. Allergic colitis may be seen in breastfed babies, where mothers drink cow's milk and pass that protein into their breast milk.

    What are the symptoms of colitis?

    Inflammation of the colon causes the muscle layers to go into intermittent spasm and cause colicky or cramp-like pain that comes and goes. The pain usually is in the lower abdomen, but can be felt anywhere along the course of the colon. Since the muscles fail to contract in a normal pattern and the colonic contents move through the colon rapidly, there is little opportunity for water to be reabsorbed. This leads to watery diarrhea. If the lining of the colon becomes inflamed and breaks down, bleeding may occur. In ulcerative colitis, small ulcers form and are the cause of bleeding.

    With colitis, particularly colitis involving the distal colon (rectum and sigmoid colon), the pain often crescendos and precedes a diarrheal bowel movement. After the bowel movement, the pain may subside but then returns with the next episode of diarrhea.

    Depending upon the cause of the colitis, other organ systems in the body may be involved and produce symptoms. There may be fever, chills, malaise, fatigue, and dehydration. Symptoms of dehydration include weakness, lightheadedness, and decreased urine output.

    Ulcerative colitis is an autoimmune disease and may have associated symptoms outside of the colon. These can include joint swelling, eye inflammation (iritis), canker sores in the mouth (aphthous ulcer), and skin inflammations (pyoderma gangrenosum).

    When should I contact my doctor about colitis?

    Diarrhea is a common symptom of colitis. It, is usually self-limited, and resolves on its own with supportive care, including rest and a short course of a clear fluid diet. However, if the diarrhea persists for more than three weeks, if there is blood in the stool, or the person has signs of dehydration, medical care should be obtained.

    • Blood in the stool is never normal and should always be evaluated. Common causes of blood in the stool include hemorrhoids; however, other serious causes of bleeding need to be investigated. Colitis is not the only cause of rectal bleeding. Others causes include diverticular disease of the colon (diverticulitis), colon polyps, anal fissures, and cancer.
    • Chronic diarrhea can lead to dehydration, and if severe enough, dehydration may require treatment with fluids. The symptoms of dehydration may include:
      • lightheadedness (dizziness) especially when changing from a sitting or lying position to standing position (orthostatic hypertension)
      • weakness,
      • dry mouth, dry eyes, and
      • decreased output of urine.
    • High fever associated with diarrhea may be a warning sign that a significant infection may be present.
    • Abdominal pain is not normal, and while diarrhea may be associated with mild cramps, the presence of increasing abdominal pain, requires need to seek prompt medical attention.

    How is colitis diagnosed?

    Patient history
    • In patients with abdominal pain and diarrhea, it is important to find out when the symptoms began, how long they have lasted, whether they come and go, and what makes them better or worse.
    • Travel history is important, especially if the patient has recently visited an area with potentially contaminated water or poor food hygiene. Patients often ask if the symptoms are caused by food poisoning, but that is a difficult question to answer immediately. Usually this occurs with consumption of poorly handled and stored food in a home or a family gathering event.
    • Blood in the stool, whether it is mixed in with the bowel movement, or just drops in the toilet bowl, is not normal. While it may be due to hemorrhoids, other potential causes that are more worrisome may need to be explored. Questions might be asked about bowel habits, weight loss, weakness, or family history of bowel disorders including cancer or colon polyps. Depending on the health care professional's concerns, information may need to be obtained about other body systems, past medical history, social habits (including smoking, drinking, and occupational hazards or risks).
    Physical examination

    Once the history is taken, physical examination will be helpful in determining the potential causes of the symptoms.

    • Signs of more severe disease with dehydration may include orthostatic changes in blood pressure and pulse rate, where vital signs are taken both laying down and standing up. In patients who are dehydrated, have had rectal bleeding, or are anemic; blood pressure and pulse may be normal when they lie flat but may change when standing; the blood pressure falls and the pulse rate rises.
    • Temperature often is checked for fever.
    • Examination of the abdomen includes palpitating or feeling for tenderness and masses in the abdomen. Bowel sounds are often listened for with a stethescope.
    • The exam also may include a rectal examination to test the stool for blood and feel for a possible rectal mass.
    • If there is a concern for ischemic bowel as the cause of colitis, the examination may assess the heart and blood vessels, looking for signs of atherosclerosis or narrowing of arteries.
    • In patients where the clinical diagnosis is colitis secondary to a viral infection, no further testing is needed. However, this would not apply to a patient who appears ill, dehydrated, or has significant pain, fever, or blood in the stool.
    Other tests

    A complete blood count (CBC) measures hemoglobin and hematocrit, looking for anemia. If the red blood cell count is elevated, it may be due to dehydration, where total body water is decreased and the blood becomes concentrated.

    The CBC also measures the white blood cell count, which may be elevated as the body responds to infection. However, an elevated white blood cell count does not necessarily equal infection, since elevation may be due to the body's reaction to any stress or inflammation.

    Electrolytes may be measured looking for changes in the sodium, potassium, chloride and bicarbonate levels in the blood that help determine the severity of dehydration and loss of fluid.

    Kidney function may be checked by measuring the BUN (blood urea nitrogen) and creatinine levels; this may be an important clue as well to the severity of dehydration.

    Urinalysis may reveal dehydration if the specific gravity (urine concentration) is elevated or if there are ketones present.

    Stool samples may be collected for culture, searching for bacterial and parasitic infections as the cause of colitis. Stool may also be tested for blood.

    Imaging and procedures

    Colonoscopy: The length of the colon can be directly viewed by colonoscopy. A gastroenterologist uses a thin, flexible tube equipped with a fiberoptic camera to view the inside lining of the colon. The appearance of the colonic lining often allows the doctor to make the diagnosis and also provides the opportunity to look for tumors and polyps. Biopsies - small bits of tissue - can be obtained from the mucosal lining during colonoscopy and evaluated under the microscope to determine the cause of colitis. Biopsy is the only way to diagnose microscopic colitis.

    Computerized tomography and barium enema are tests that are performed by a radiologist to explore the potential cause of colitis. CT scan of the abdomen has become a more common test to evaluate patients with abdominal pain. However, it is important for the health care professional to balance the risk of radiation with the reward of the information that can be obtained.

    Source: http://www.rxlist.com

    Many bacteria reside in the colon; they live in harmony with the body and cause no symptoms. However, some infections can result if a virus, bacteria, or parasite invade the small and/or large intestine.

    Common most common bacteria that cause colitis include:

    • Campylobacter,
    • Shigella,
    • E. Coli,
    • Yersinia, and
    • Salmonella.

    These infections usually occur because the patient has eaten contaminated food. Symptoms can include diarrhea with or without blood, abdominal cramps and dehydration from water loss because of numerous watery, bowel movements. Other organs can also be affected by the infection or the toxins that the bacteria can produce.

    Clostridium difficile, commonly referred to as C. Diff, is a bacterial cause of colitis that often occurs after a person has been prescribed an antibiotic or has been hospitalized. C. diff is found in the colon of healthy people and co-exists with other "normal" bacteria. But when antibiotics are prescribed, susceptible bacteria in the colon can be destroyed, allowing the clostridia to grow unchecked, causing colitis. Patchy membranes form along the colon mucosa and some health care professionals will refer to C. diff colitis as pseudomembranous colitis. The bacteria is also found on many surfaces in the hospital (for example, bedrails, toilets, and stethoscopes), and the infection may spread from person to person (it is contagious). Unfortunately, this infection is becoming more common outside the hospital environment and people can develop community acquired C diff colitis without exposure to antibiotics or a medical facility.

    Worldwide, the most common parasite infection to cause colitis is Entamoeba histolytica. It is acquired by drinking infected water and can also be passed from person to person because of poor sanitation and hygiene.

    Source: http://www.rxlist.com

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