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Revision as of 17:17, 19 December 2016

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Qasim Salau, M.B.B.S., FMCPaed [3]

Synonyms and keywords: Disinfectant colitis, Corrosive colitis, Iatrogenic colitis.

Overview

Chemical colitis is a type of colitis, an inflammation of the large intestine or colon, caused by the introduction of harsh chemicals to the colon by an enema or other procedure. Chemical colitis can resemble ulcerative colitis, infectious colitis and pseudomembranous colitis endoscopically.

Prior to 1950, hydrogen peroxide enemas were commonly used for certain conditions. This practice will often result in chemical colitis.

Soap enemas may also cause chemical colitis. [1] Harsh chemicals, such as compounds used to clean colonoscopes, are sometimes accidentally introduced into the colon during colonoscopy or other procedures. This can also lead to chemical colitis.

Chemical colitis may trigger a flare of ulcerative colitis or Crohn's disease.

Historical Perspective

Classification

Pathophysiology

Pathogenesis

Chemical colitis usually results from accidental or intentional rectal introduction of chemicals such as endoscopy cleaning solutions (glutaraldehyde and hydrogen peroxide), radiologic contrast material, hydrogen peroxide, soaps, formalin, hydrofluoric acid, alcohol, ammonia, lye, hot water, and herbal substances. Rarely it occurs from accidental ingestion of chemicals, such as accidental swallowing of hydrogen peroxide mouthwash during oral procedures.[2][3][4][5][6][7]

  • The most common implicated chemical agents in the pathogenesis of chemical colitis are glutaraldehyde and/or hydrogen peroxide disinfectants. The improper cleaning of the endoscopes allows the disinfectants to remain on the endoscopes, subsequently causing a chemical proctocolitis when the endoscopes are used.
  • The main mechanism for developing chemical colitis is the direct contact of the chemical agent with the mucosa, subsequently causing corrosive injury to the mucosa and activation of the inflammatory pathway. Reactive oxygen formation, lipid peroxidation and vascular smooth muscle contraction also occur in hydrogen peroxide-induced chemical colitis.
  • The primary mucosa toxin in glutaraldehyde is not fully known. However, it may be related to aldehyde. In addition to direct damage, glutaraldehyde is thought to activate arachidonic acid pathway and recruitment of inflammatory cells and substances. [5]
  • The symptoms of chemical colitis typically develop within 48 hours, often less than 12 hours after introduction of the chemical, but may sometimes take days to weeks when frequent small dilute amount is ingested.[7]

Genetics

There are no identified genetic factors associated with chemical colitis.

Gross Pathology

Gross pathology findings in most cases shows predominant superficial mucosa involvement. The mucosa is erythematous, friable, edematous with areas of necrosis. Also, multiple shallow mucosal ulcers with fibrinous and/ or purulent exudate and hemorrhage are present. In addition, in hydrogen peroxide-induced colitis, gas may be seen in the colonic wall.[3][8][9]

Microscopic Histopathology

  • Microscopy shows loss of superficial glands and epithelium, mucosa congestion, capillary hemorrhage and erosions and presence of polymorphonuclear inflammatory infiltrates in the crypts. Chronic inflammatory infiltrates (lymphoplasma cells) may also be seen in formalin-induced colitis. In hydrogen peroxide-induced colitis, the goblet cells in the mucosa appear as empty vacuoles, so-called “pseudolipomatosis". [3][8][9]
  • Pseudomembranes composed of necrotic tissue and exudates may occasionally be seen lining the crypt.[3]

Differentiating chemical colitis from other Diseases

Chemical colitis must be differentiated from other causes of bloody diarrhea, especially acute causes and abdominal pain. Although the symptoms of chemical colitis may overlap with other causes of colitis, history of prior use of enema containing a known chemical agent shortly before onset of symptom will help in distinguishing the cause.


The table below lists the differential diagnosis of common causes of colitis:[10][11]

Diseases History and Symptoms Physical Examination Laboratory findings Other Findings
Diarrhea Rectal bleeding Abdominal pain Atopy Dehydration Fever Hypotension Malnutrition Blood in stool (frank or occult) Microorganism in stool Pseudomembranes on endoscopy Lab Test 4
Allergic Colitis + ++ + ++ ++
Chemical colitis + ++ ++ + + +
Infectious colitis ++ ++ + +++ +++ ++ + ++ +
Radiation colitis + ++ + + +
Ischemic colitis + ++ ++ + ++ +

Epidemiology and Demographics

Age

Gender

Race

Risk Factors

Screening

There are no established screening guidelines for chemical colitis[12]

Natural History, Complications and Prognosis

Natural History

Complications

Prognosis

Diagnosis

Diagnostic Criteria

Symptoms

Physical Examination

Laboratory Findings

Endoscopy

Other Diagnostic Studies

Barium enema

CT scan

Treatment

Medical Therapy

Surgical Therapy

Prevention

Primary prevention

Secondary prevention

References

  1. K. Harish, Severe colitis induced by soap enemas, Indian J. Gastroent., 2006 [1]
  2. Tortora A, Purchiaroni F, Scarpellini E, Ojetti V, Gabrielli M, Vitale G; et al. (2012). "Colitides". Eur Rev Med Pharmacol Sci. 16 (13): 1795–805. PMID 23208963.
  3. 3.0 3.1 3.2 3.3 Sheibani S, Gerson LB (2008). "Chemical colitis". J Clin Gastroenterol. 42 (2): 115–21. doi:10.1097/MCG.0b013e318151470e. PMID 18209577.
  4. Lim CH, Lee HY, Kim WC, Cho SH, Jeong HS, Jeon YJ; et al. (2011). "[A case of chemical colitis caused by hydrogen peroxide enema]". Korean J Gastroenterol. 58 (2): 100–2. PMID 21873825.
  5. 5.0 5.1 West AB, Kuan SF, Bennick M, Lagarde S (1995). "Glutaraldehyde colitis following endoscopy: clinical and pathological features and investigation of an outbreak". Gastroenterology. 108 (4): 1250–5. PMID 7698592.
  6. Shih HY, Wu DC, Huang WT, Chang YY, Yu FJ (2011). "Glutaraldehyde-induced colitis: case reports and literature review". Kaohsiung J Med Sci. 27 (12): 577–80. doi:10.1016/j.kjms.2011.06.036. PMID 22208542.
  7. 7.0 7.1 Zanelli M, Ragazzi M, De Marco L (2016). "Chemical gastritis and colitis related to hydrogen peroxide mouthwash". Br J Clin Pharmacol. doi:10.1111/bcp.13100. PMID 27696496.
  8. 8.0 8.1 Kara M, Turan I, Polat Z, Dogru T, Bagci S (2010). "Chemical colitis caused by peracetic acid or hydrogen peroxide: a challenging dilemma". Endoscopy. 42 Suppl 2: E3–4. doi:10.1055/s-0029-1215260. PMID 20066605.
  9. 9.0 9.1 Morini S, Campo SM, Zullo A, Guarini A, Ridola L, Hassan C (2009). "Chemical colitis induced by peracetic acid: further evidence". Endoscopy. 41 (4): 383. doi:10.1055/s-0029-1214493. PMID 19340747.
  10. Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.
  11. Khan AM, Faruque AS, Hossain MS, Sattar S, Fuchs GJ, Salam MA (2004). "Plesiomonas shigelloides-associated diarrhoea in Bangladeshi children: a hospital-based surveillance study". J Trop Pediatr. 50 (6): 354–6. doi:10.1093/tropej/50.6.354. PMID 15537721.
  12. US preventive service task force.chemical colitis. http://www.uspreventiveservicestaskforce.org/accessed on December 5, 2016

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