- Bo Shen, MD
Bo Shen, MD
- The Ed and Joey Endowed Chair, Professor of Medicine
- Director of Center for Inflammatory Bowel Diseases
- The Cleveland Clinic Foundation
Diversion colitis is characterized by inflammation of the defunctionalized, bypassed colon following surgery [1,2]. Most patients with diversion colitis are asymptomatic, but in a small proportion of patients, symptoms can significantly impact quality of life .
This topic will review the epidemiology, pathogenesis, clinical manifestations, diagnosis, and management of diversion colitis. The epidemiology, clinical manifestations, diagnosis, and management of ulcerative colitis and Crohn disease are discussed in detail, separately. (See "Definition, epidemiology, and risk factors in inflammatory bowel disease" and "Management of mild to moderate ulcerative colitis" and "Management of severe ulcerative colitis" and "Approach to adults with steroid-refractory and steroid-dependent ulcerative colitis" and "Clinical manifestations, diagnosis and prognosis of Crohn disease in adults" and "Overview of the medical management of mild to moderate Crohn disease in adults" and "Overview of the medical management of severe or refractory Crohn disease in adults".)
Diversion colitis or diversion proctitis is a nonspecific inflammatory disorder that occurs in segments of the colon and rectum that are diverted from the fecal stream by surgery (eg, creation of a loop colostomy/ileostomy or an end colostomy/ileostomy with closure of the distal colon segment [eg, Hartmann's procedure]).
The true incidence of diversion colitis is unknown. Several small observational studies have demonstrated histologic changes of diversion colitis in the distal colonic segment of 70 to 100 percent of patients with fecal diversion, and endoscopic evidence in 70 to 91 percent of patients [4-11]. Diversion colitis or proctitis is more common in patients with underlying inflammatory bowel disease (ie, Crohn disease and ulcerative colitis) than those with colon malignancy and diverticular diseases (See 'Endoscopy and biopsy' below.)
ETIOLOGY AND PATHOGENESIS
Diversion colitis typically occurs in diverted segments of the colon following surgery for congenital, inflammatory, or neoplastic disorders. Patients usually have a loop colostomy (or ileostomy) or an end colostomy (or ileostomy) with closure of the distal colon segment (eg, Hartmann's procedure). Diversion of the fecal stream results in a deficiency of short-chain fatty acids (SCFAs) and other luminal nutrients in colonocytes in the diverted segment of the colon. It is hypothesized that the lack of these compounds or interference with their metabolism by alterations in gut flora may have a role in the development of colitis [12,13].
- Glotzer DJ, Glick ME, Goldman H. Proctitis and colitis following diversion of the fecal stream. Gastroenterology 1981; 80:438.
- Morson BC, Dawson IM. Gastrointestinal Pathology, 1st ed, Blackwell Scientific Publications, London 1972. p.485.
- Son DN, Choi DJ, Woo SU, et al. Relationship between diversion colitis and quality of life in rectal cancer. World J Gastroenterol 2013; 19:542.
- Korelitz BI, Cheskin LJ, Sohn N, Sommers SC. The fate of the rectal segment after diversion of the fecal stream in Crohn's disease: its implications for surgical management. J Clin Gastroenterol 1985; 7:37.
- Ma CK, Gottlieb C, Haas PA. Diversion colitis: a clinicopathologic study of 21 cases. Hum Pathol 1990; 21:429.
- Geraghty JM, Talbot IC. Diversion colitis: histological features in the colon and rectum after defunctioning colostomy. Gut 1991; 32:1020.
- Haque S, Eisen RN, West AB. The morphologic features of diversion colitis: studies of a pediatric population with no other disease of the intestinal mucosa. Hum Pathol 1993; 24:211.
- Grant NJ, Van Kruiningen HJ, Haque S, West AB. Mucosal inflammation in pediatric diversion colitis: a quantitative analysis. J Pediatr Gastroenterol Nutr 1997; 25:273.
- Ferguson CM, Siegel RJ. A prospective evaluation of diversion colitis. Am Surg 1991; 57:46.
- Orsay CP, Kim DO, Pearl RK, Abcarian H. Diversion colitis in patients scheduled for colostomy closure. Dis Colon Rectum 1993; 36:366.
- Whelan RL, Abramson D, Kim DS, Hashmi HF. Diversion colitis. A prospective study. Surg Endosc 1994; 8:19.
- Harig JM, Soergel KH, Komorowski RA, Wood CM. Treatment of diversion colitis with short-chain-fatty acid irrigation. N Engl J Med 1989; 320:23.
- Roediger WE. The starved colon--diminished mucosal nutrition, diminished absorption, and colitis. Dis Colon Rectum 1990; 33:858.
- Jørgensen JR, Clausen MR, Mortensen PB. Oxidation of short and medium chain C2-C8 fatty acids in Sprague-Dawley rat colonocytes. Gut 1997; 40:400.
- Velázquez OC, Lederer HM, Rombeau JL. Butyrate and the colonocyte. Production, absorption, metabolism, and therapeutic implications. Adv Exp Med Biol 1997; 427:123.
- Pacheco RG, Esposito CC, Müller LC, et al. Use of butyrate or glutamine in enema solution reduces inflammation and fibrosis in experimental diversion colitis. World J Gastroenterol 2012; 18:4278.
- Neut C, Colombel JF, Guillemot F, et al. Impaired bacterial flora in human excluded colon. Gut 1989; 30:1094.
- Neut C, Guillemot F, Colombel JF. Nitrate-reducing bacteria in diversion colitis: a clue to inflammation? Dig Dis Sci 1997; 42:2577.
- Baek SJ, Kim SH, Lee CK, et al. Relationship between the severity of diversion colitis and the composition of colonic bacteria: a prospective study. Gut Liver 2014; 8:170.
- Korelitz BI, Cheskin LJ, Sohn N, Sommers SC. Proctitis after fecal diversion in Crohn's disease and its elimination with reanastomosis: implications for surgical management. Report of four cases. Gastroenterology 1984; 87:710.
- Lim AG, Langmead FL, Feakins RM, Rampton DS. Diversion colitis: a trigger for ulcerative colitis in the in-stream colon? Gut 1999; 44:279.
- Jowett SL, Cobden I. Diversion colitis as a trigger for ulcerative colitis. Gut 2000; 46:294.
- Caltabiano C, Máximo FR, Spadari AP, et al. 5-aminosalicylic acid (5-ASA) can reduce levels of oxidative DNA damage in cells of colonic mucosa with and without fecal stream. Dig Dis Sci 2011; 56:1037.
- Martinez CA, de Campos FG, de Carvalho VR, et al. Claudin-3 and occludin tissue content in the glands of colonic mucosa with and without a fecal stream. J Mol Histol 2015; 46:183.
- Daferera N, Kumawat AK, Hultgren-Hörnquist E, et al. Fecal stream diversion and mucosal cytokine levels in collagenous colitis: A case report. World J Gastroenterol 2015; 21:6065.
- Komorowski RA. Histologic spectrum of diversion colitis. Am J Surg Pathol 1990; 14:548.
- Ona FV, Boger JN. Rectal bleeding due to diversion colitis. Am J Gastroenterol 1985; 80:40.
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- Lu ES, Lin T, Harms BL, et al. A severe case of diversion colitis with large ulcerations. Am J Gastroenterol 1995; 90:1508.
- Edwards CM, George B, Warren BF. Diversion colitis: new light through old windows. Histopathology 1999; 35:86.
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- Gill P, Chetty R. Filiform polyps and filiform polyp-like lesions are common in defunctioned or diverted colorectum resection specimens. Ann Diagn Pathol 2013; 17:341.
- Greenson JK, Odze RD. Inflammatory disorders of the large intestine. In: Surgical Pathology of the GI Tract, Liver, Biliary Tract, and Pancreas, 2nd ed, Odze RD, Goldblum JR (Eds), Elsevier, Inc, Philadelphia 2009. p.355.
- Tsironi E, Irving PM, Feakins RM, Rampton DS. "Diversion" colitis caused by Clostridium difficile infection: report of a case. Dis Colon Rectum 2006; 49:1074.
- Chetty R, Hafezi S, Montgomery E. An incidental enterocolic lymphocytic phlebitis pattern is seen commonly in the rectal stump of patients with diversion colitis superimposed on inflammatory bowel disease. J Clin Pathol 2009; 62:464.
- Asplund S, Gramlich T, Fazio V, Petras R. Histologic changes in defunctioned rectums in patients with inflammatory bowel disease: a clinicopathologic study of 82 patients with long-term follow-up. Dis Colon Rectum 2002; 45:1206.
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- Zuckerman GR, Prakash C, Merriman RB, et al. The colon single-stripe sign and its relationship to ischemic colitis. Am J Gastroenterol 2003; 98:2018.
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- Roe AM, Warren BF, Brodribb AJ, Brown C. Diversion colitis and involution of the defunctioned anorectum. Gut 1993; 34:382.
- Vernia P, Cittadini M, Caprilli R, Torsoli A. Topical treatment of refractory distal ulcerative colitis with 5-ASA and sodium butyrate. Dig Dis Sci 1995; 40:305.
- Schauber J, Bark T, Jaramillo E, et al. Local short-chain fatty acids supplementation without beneficial effect on inflammation in excluded rectum. Scand J Gastroenterol 2000; 35:184.
- Guillemot F, Colombel JF, Neut C, et al. Treatment of diversion colitis by short-chain fatty acids. Prospective and double-blind study. Dis Colon Rectum 1991; 34:861.
- Kiely EM, Ajayi NA, Wheeler RA, Malone M. Diversion procto-colitis: response to treatment with short-chain fatty acids. J Pediatr Surg 2001; 36:1514.
- Tripodi J, Gorcey S, Burakoff R. A case of diversion colitis treated with 5-aminosalicylic acid enemas. Am J Gastroenterol 1992; 87:645.
- de Oliveira-Neto JP, de Aguilar-Nascimento JE. Intraluminal irrigation with fibers improves mucosal inflammation and atrophy in diversion colitis. Nutrition 2004; 20:197.
- Gundling F, Tiller M, Agha A, et al. Successful autologous fecal transplantation for chronic diversion colitis. Tech Coloproctol 2015; 19:51.
- Chaim FM, Sato DT, Rodrigues MR, et al. Evaluation of the application of enemas containing sucralfate in tissue content of neutral and acid mucins in experimental model of diversion colitis. Acta Cir Bras 2014; 29:544.
- Alvarenga V Jr, Pacheco RG, Esposito CC, et al. Ascidian (chordate-tunicate) and mammalian heparin enemas attenuate experimental diversion colitis. Surgery 2014; 155:217.
- Winther KV, Bruun E, Federspiel B, et al. Screening for dysplasia and TP53 mutations in closed rectal stumps of patients with ulcerative colitis or Crohn disease. Scand J Gastroenterol 2004; 39:232.
- Fazio VW, Kiran RP, Remzi FH, et al. Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients. Ann Surg 2013; 257:679.
- de Montbrun SL, Johnson PM. Proximal diversion at the time of ileal pouch-anal anastomosis for ulcerative colitis: current practices of North American colorectal surgeons. Dis Colon Rectum 2009; 52:1178.
- Das P, Smith JJ, Lyons AP, et al. Assessment of the mucosa of the indefinitely diverted ileo-anal pouch. Colorectal Dis 2008; 10:512.
- Kiran RP, Kirat HT, Rottoli M, et al. Permanent ostomy after ileoanal pouch failure: pouch in situ or pouch excision? Dis Colon Rectum 2012; 55:4.
- ETIOLOGY AND PATHOGENESIS
- CLINICAL MANIFESTATIONS
- - History
- - Laboratory studies
- - Endoscopy and biopsy
- DIFFERENTIAL DIAGNOSIS
- Surgical reanastomosis
- Short-chain fatty acid enemas
- 5-aminosalicylic acid (5-ASA)
- CANCER SCREENING
- DIVERSION POUCHITIS
- SUMMARY AND RECOMMENDATIONS