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Diversion colitis 25 years later: the phenomenon of the disease. Szczepkowski Marek,Banasiewicz Tomasz,Kobus Adam International journal of colorectal disease BACKGROUND:Diversion colitis (DC) seems to be common in stoma patients, and the restoration of the continuity of the digestive tract is crucial for relief from the inflammatory process. No prospective studies of the late effects of DC on the lower gastrointestinal (GI) tract mucosa and the clinical condition of patients have been reported. METHODS:Data from 23 patients who underwent stoma creation were analysed during the reversal period (A) and at an average of 3 months (B1) and 5.6 years (B2) after restoration of GI tract continuity. Every monitoring visit included endoscopy, histology and assessment of the clinical condition of patients. RESULTS:Shortly after GI tract restoration (B1), a significant decrease in inflammation was observed. The Ki67 positivity percentage increased, but this was not significant. At an average of 5.6 years after restoration (group B2), the clinical symptoms were mild. More patients presented with endoscopically detected inflammation of the mucosa, but its severity was not significantly higher than that at 3 months after reversal. Histological inflammation was more common, and its severity was significantly higher than that shortly after reversal but similar to that before reversal. The Ki67 positivity percentage decreased at the last examination (B2). CONCLUSIONS:The results of this study show a complex recurrence of histological inflammation several years after GI tract restoration but without clinical and endoscopic inflammation and with good clinical condition. DC can potentially have a late influence on the rectal mucosa, even after stoma closure. 10.1007/s00384-017-2802-z

An updated review on the treatment for diversion colitis and pouchitis, with a focus on the utility of autologous fecal microbiota transplantation and its relationship with the intestinal microbiota. Bioscience of microbiota, food and health Diversion colitis (DC) is characterized by mucosal inﬂammation in the defunctioned segment of the colon following a colostomy or ileostomy. The major causes of DC are an increase in the number of aerobic bacteria, a lack of short-chain fatty acids (SCFAs), and immune disorders in the diverted colon. However, its exact pathogenesis remains unknown. Various treatment strategies for DC have been explored, although none have been definitively established. Treatment approaches such as SCFAs, 5-aminosalicylic acid enemas, steroid enemas, and irrigation with fibers have been attempted, yielding various degrees of efficacies in mitigating mucosal inflammation. However, only individual case reports demonstrating the limited effect of the following therapies have been published: leukocytapheresis, dextrose (hypertonic glucose) spray, infliximab, an elemental diet, and coconut oil. The usefulness of probiotics for treating DC has recently been reported. Furthermore, fecal microbiota transplantation (FMT) has emerged as a promising treatment for DC. This review provides an update on the treatment strategies of DC, with a particular focus on FMT and its relationship with the intestinal microbiota. FMT may become the first choice of treatment for some patients in the future because of its low medical costs, ease of use, and minimal side effects. Furthermore, FMT can also be used for postoperative DC prophylaxis. 10.12938/bmfh.2024-014

Diversion colitis--20 years a-growing. Haque S,West A B Journal of clinical gastroenterology During the last decade, clinical and pathologic studies of diversion colitis have led to a better understanding of its nature. The clinical features are well described, and the endoscopic appearances, and gross and microscopic pathology are now defined. Thus, firm diagnosis and distinction from other colitides, notably ulcerative colitis and Crohn's disease, are possible in most cases. Restoration of the fecal stream cures diversion colitis, which in some cases may be successfully treated with short-chain fatty acid enemas, although the efficacy of this method remains to be substantiated. An understanding of the pathogenesis of diversion colitis (currently unknown) may lead to better methods of prevention and treatment.

Diversion colitis: a nutritional deficiency syndrome? Agarwal V P,Schimmel E M Nutrition reviews The dependence of cells of the colonic epithelium upon lumenal short-chain fatty acids (SCFA) for some of their energy supply is well known. SCFA (mainly acetic, propionic, and n-butyric acids) comprise the predominant solutes in the aqueous phase of colonic contents and are produced by anaerobic bacterial fermentation of polysaccharides. Acetic acid is the principal fatty acid, but n-butyric acid is the preferred energy source for colonocytes, both in normal human colon and in colons of patients with ulcerative colitis. Four patients with diversion colitis, an inflammatory process in surgically excluded colon and rectum, were successfully treated by colonic instillation of a solution of mixed SCFA. This review examines the evidence that diversion colitis may be a new type of nutritional-deficiency syndrome based upon a local mucosal requirement for SCFA. 10.1111/j.1753-4887.1989.tb02857.x

[Progression of pathogenesis, diagnosis and treatment of diversion colitis]. Sun Q,Huang Y,Hu Z Q Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery Diversion colitis (DC) is a common non-specific inflammation of the malfunctioning bowel segment after diversion of feces. Although most patients develop DC during stoma, there are no obvious clinical symptoms, and a small number of patients show abdominal pain, mucus discharge and hematochezia. The erythema, diffuse particles and vascular texture blur are the most prominent endoscopic manifestations, and the lymphatic follicular hyperplasia is the most prominent pathological manifestations.Reconstruction of intestinal continuity is the best way to cure recanted colitis. In this review, we summarize and review the mechanism of occurrence, clinical features, diagnosis and treatment of DC, which will be helpful for the effective control and prevention of DC. 10.3760/cma.j.cn.441530-20191031-00468

Diversion colitis--new light through old windows. Edwards C M,George B,Warren B Histopathology Diversion proctocolitis is an iatrogenic disorder caused by surgical diversion of the faecal stream away from the colorectal mucosa. Such surgery may be necessary in cases of tumour, trauma or inflammatory conditions of the colorectum. Histopathological change is characterized by a chronic lymphoplasmacytic inflammatory infiltrate, and the hallmark feature, lymphoid follicular hyperplasia. Histological appearances are determined by the disease state of the colonic mucosa prior to faecal diversion. Macroscopic appearances may vary considerably, but often include aphthoid ulceration. The exact pathogenesis of the condition remains unclear, but the removal of short-chain fatty acids, present in the faecal stream, is considered an important aetiological factor. Current research areas, including the microbiology and cellular kinetics of diversion colitis, are discussed along with clinical features and treatments.

Diversion Colitis: Macro and Microscopic Findings after Probiotics Stimulation. Rodríguez-Padilla Ángela,Morales-Martín Germán,Pérez-Quintero Rocío,Gómez-Salgado Juan,Rada-Morgades Ricardo,Ruiz-Frutos Carlos Biology The use of a loop ileostomy as the defunctioning procedure of choice to protect a distal colonic anastomosis causes histological and endoscopic changes in the intestinal mucosal architecture, which have been related to chronic inflammation and changes in the microflora that consequently impact the intestinal structure and function following fecal stream diversion. The aim of this study was to evaluate the histological and endoscopic changes on the colonic mucosa in patients with diversion colitis after stimulation of the efferent loop with probiotics prior to closure of the protective ileostomy. A prospective, randomized, double-blind, controlled study was designed. All patients who underwent surgery for colorectal carcinoma with protective ileostomy between January 2017 and December 2018 were included. These patients were pending reconstructive surgery and were diagnosed with endoscopic and histological diversion colitis. Divided into two groups, a group stimulated with probiotics (SG) and a control group (CG). 34 cases and 35 controls were included in the study. Histological and endoscopic changes were evaluated after stimulation, after restorative surgery and during the short-term follow-up after surgery. A decrease in endoscopic pathological findings (mucosal friability, mucous erosions, polyps, edema, erythema and stenosis) and in histological findings (follicular hyperplasia, eosinophils, cryptic abscesses, lymphocyte infiltration, plasma cell infiltration and architecture distortion) was observed in SG. These results were statistically significant with a < 0.001. The stimulation of the efferent loop of the ileostomy in patients with diversion colitis produced a decrease of the endoscopic and histological severity of colitis in the short term. 10.3390/biology10040303

Diversion colitis and pouchitis: A mini-review. Tominaga Kentaro,Kamimura Kenya,Takahashi Kazuya,Yokoyama Junji,Yamagiwa Satoshi,Terai Shuji World journal of gastroenterology Diversion colitis is characterized by inﬂammation of the mucosa in the defunctioned segment of the colon after colostomy or ileostomy. Similar to diversion colitis, diversion pouchitis is an inﬂammatory disorder occurring in the ileal pouch, resulting from the exclusion of the fecal stream and a subsequent lack of nutrients from luminal bacteria. Although the vast majority of patients with surgically-diverted gastrointestinal tracts remain asymptomatic, it has been reported that diversion colitis and pouchitis might occur in almost all patients with diversion. Surgical closure of the stoma, with reestablishment of gut continuity, is the only curative intervention available for patients with diversion disease. Pharmacologic treatments using short-chain fatty acids, mesalamine, or corticosteroids are reportedly effective for those who are not candidates for surgical reestablishment; however, there are no established assessment criteria for determining the severity of diversion colitis, and no management strategies to date. Therefore, in this mini-review, we summarize and review various recently-reported treatments for diversion disease. We are hopeful that the information summarized here will assist physicians who treat patients with diversion colitis and pouchitis, leading to better case management. 10.3748/wjg.v24.i16.1734

Effect of butyrate enemas on the colonic mucosa in distal ulcerative colitis. Scheppach W,Sommer H,Kirchner T,Paganelli G M,Bartram P,Christl S,Richter F,Dusel G,Kasper H Gastroenterology Short-chain fatty acid irrigation has been shown to ameliorate inflammation in diversion colitis. In this study the effect of butyrate enemas was tested in 10 patients with distal ulcerative colitis who had been unresponsive to or intolerant of standard therapy for 8 weeks. They were treated for 2 weeks with sodium butyrate (100 mmol/L) and 2 weeks with placebo in random order (single-blind trial). Before and after treatment, clinical symptoms were noted and the degree of inflammation was graded endoscopically and histologically. Rectal proliferation was assessed by autoradiography. After butyrate irrigation, stool frequency (n/day) decreased from 4.7 +/- 0.5 to 2.1 +/- 0.4 (P less than 0.01) and discharge of blood ceased in 9 of 10 patients. The endoscopic score fell from 6.5 +/- 0.4 to 3.8 +/- 0.8 (P less than 0.01). The histological degree of inflammation decreased from 2.4 +/- 0.3 to 1.5 +/- 0.3 (P less than 0.02). Overall crypt proliferation was unchanged, but the upper crypt-labeling index fell from 0.086 +/- 0.019 to 0.032 +/- 0.003 (P less than 0.03). On placebo, all of these parameters were unchanged. These data support the view that butyrate deficiency may play a role in the pathogenesis of distal ulcerative colitis and that butyrate irrigation ameliorates this condition. 10.1016/0016-5085(92)91094-k

Diversion colitis. Pathologic findings in a resected sigmoid colon and rectum. Murray F E,O'Brien M J,Birkett D H,Kennedy S M,LaMont J T Gastroenterology We present here the detailed pathologic findings in the resected colon and rectum from a paraplegic patient with severely symptomatic diversion colitis and lack of anorectal function. Previous reports of the pathology of this condition have been confined to biopsy findings. A diffuse nodularity caused by lymphoid hyperplasia and an inflammatory process confined to the colorectal mucosa with erosions, crypt abscesses, mucin granulomas, and aphthoid ulcers were the main features. There was minimal distortion of crypt architecture. The pathologic features of this entity are compared to those of other inflammatory disorders of the colon and rectum.

Proctitis and colitis following diversion of the fecal stream. Glotzer D J,Glick M E,Goldman H Gastroenterology Inflammation limited to excluded segments of the colon was observed in 10 patients without prior inflammatory bowel disease who had undergone colostomy or ileostomy for various indications. With the exception of 1 patient who complained of mucoid rectal discharge, the patients were asymptomatic when the lesion was discovered; 2 others subsequently developed mild symptoms. The proctoscopic findings were similar in appearance to those of mild ulcerative colitis. In 8 of 10 patients the inflammatory changes were confined to the distal few centimeters of the rectum, while in the remaining 2 patients the entire excluded segment was affected. Microscopic alterations were focal and included crypt abscesses, epithelial cell degeneration, acute and chronic inflammation in the lamina propria, and regenerative changes in the crypts. The inflammation persisted for as long as 8 yr in the 5 patients who did not have restoration of intestinal continuity, but subsided in the 5 patients whose colostomies were closed. The prior as subsequent clinical courses of these patients, together with the focal, nonspecific microscopic features, strongly suggest that the inflammation in these patients resulted from diversion of the fecal stream and was not a recognized form of specific or idiopathic colitis. Diversion-related colitis must not be confused with other forms of inflammation since this may result in improper therapy and/or delay in treatment of the condition for which the fecal diversion was performed.