Clinical method & Therapeutics

1. Diseases of intestine
By
Dr. Laraib Jameel Rph
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2. Colitis
• Definition: Colitis describes inflammation of the inner
lining of the colon and can be associated
with diarrhea, abdominal pain, bloating, and blood in the
stool
• Physiology: The colon is located within the peritoneum.
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 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. The mucosa
absorbs water and electrolytes back into the blood vessels
that are located just below the surface in the submucosa.

4. • Different Types of Colitis
• There are many different forms of colitis, including:
• Ulcerative colitis
• Crohn’s colitis
• Diversion colitis
• Ischemic colitis
• Infectious colitis
• Fulminant colitis
• Collagenous colitis
• Chemical colitis
• Microscopic colitis
• Lymphocytic colitis
• Atypical colitis

5. • 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 bacteria that cause colitis include
• Campylobacter,
• Shigella,
• E. Coli
• 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.

6. • 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 coexists 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 over the colon
mucosa and some health-care professionals refer to C. diffcolitis
as pseudomembranous colitis. The bacteria also may be found on
many surfaces in the hospital (for example, bedrails, toilets, and
stethoscopes), and the infection may spread from person to person
(it is highly contagious).
• 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

7. • Ischemic Colitis
• The arteries that supply blood to the colon are like any other artery
in the body. They have the potential to become narrow due
to atherosclerosis (just like blood vessels in the heart, which can
cause angina, or narrowed vessels in the brain can cause a stroke).
When these arteries become narrow, the colon may lose its blood
supply and become inflamed.
• The colon can also lose its blood supply for mechanical reasons. A
couple of examples include volvulus, where the bowel twists on
itself, or an incarcerated hernia, where a portion of the colon gets
trapped in an out pouching of the abdominal wall, which prevents
blood from flowing to the affected portion.
• In individuals who are at risk for decreased blood flow to the colon,
ischemic colitis can occur if the blood pressure falls. This may occur
with dehydration, anemia, or shock.

8. • Blood clots can also travel or embolism to
block an artery and decrease blood flow to the
bowel. Individuals who have the common
heart rhythm disturbance, atrial fibrillation,
are at risk of forming small clots in the heart,
which break off and block the blood supply to
the bowel. This is the same mechanism that
can cause a stroke or TIA (transient ischemic
attack) if the blockage occurs in an artery that
supplies the brain.

9. • Microscopic colitis:
• Two diseases make up this group of colon inflammation, collagenous
colitis and lymphocytic colitis. This is an uncommon illness that is seen
more frequently in older women. The cause is unknown but an
autoimmune potential may exist.
• 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 as a result of
inflammation. This is an uncommon illness and may be an autoimmune
disease. The diarrhea often is watery, and no blood is present in the stool.
• COLLAGENOUS COLITIS CAUSES INFLAMMATION OF EPITHELIAL TISSUES:
line the colon, helps in digestion, communicate with immune system.
• Collagenous- protein forms connective tissue

10. • Chemical Colitis
• If chemicals are instilled into the colon,
inflammation and damage can occur. One of the
complications of an enema is inflammation of the
mucosal lining of the colon caused by harsh
chemicals.
• Medication-associated colitis
• Colitis can be caused by some over-the-counter
and prescription medications such as NSAIDs
(nonsteroidal anti-inflammatory drugs),
mycophenolate, ipilimumab, and retinoic acid.

11. • Atypical colitis:
• Nonspecific colitis, or also known as atypical colitis. It can be the
case of microscopic colitis, IBD or any other.
• Allergic colitis in infants
• In infants younger than 1 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.
• Fulminant colitis: (fulminant- to explode/destroy) This includes
the damage of the thickness of the intestinal wall. The normal
contractions of the intestinal wall stop temporarily. Eventually, the
colon loses muscle tone and begins to expand. X-rays of the
abdomen can show trapped gas inside the paralyzed sections of the
intestine.

12. • Collagenous colitis refers to a type of microscopic colitis
• Collagenous colitis is a type of microscopic colitis, characterized by a thick, non-
elastic band of collagen under the lining of the colon. Collagen is a type of
structural protein in the body.
• Collagenous colitis causes general inflammation of the epithelium or base layer of
cells that lining the colon.
• Colon epithelial cells are vital to the organ's overall performance because they
help digestion and maintain the relationship between the body's immune system
and the healthful communities of microbes in the gut.
• Trillions of microbes, such as bacteria and viruses, live in the gastrointestinal tract
and aid in digestion.
• When colon epithelial cells are damaged or destroyed, a variety of digestive
symptoms occur. In cases of collagenous colitis, the layer of collagen — a
connective tissue protein that helps support the epithelial cells — becomes
roughly five times thicker than normal.
• Much like many other inflammatory gastrointestinal conditions, researchers are
not sure why collagenous colitis occurs. Most research indicates that it likely has a
genetic basis and may be related to other autoimmune conditions.

13. Colitis
• Symptoms of colitis will depend upon the type of colitis a person
has, but in general, colitis most often is associated with abdominal
pain and diarrhea.
• Other symptoms of colitis that may or may not be present include
• Blood in the bowel movement may be present depending on the
underlying disease. Diarrhea can sometimes cause hemorrhoids,
which can bleed. However, blood with a bowel movement is not
normal and the affected person should contact their health-care
professional or seek other medical care.
• The constant urge to have a bowel movement (tenesmus).
• The abdominal pain may come in waves, building to diarrhea, and
then waning.
• There may be constant pain.
• Fever, chills, and other signs of infection and inflammation may be
present depending upon the cause of colitis.

14. • Diagnosis:
• a physical examination on the patient by taking vital signs, and focusing on the abdomen feeling for
areas of tenderness, for masses, or abnormally enlarged organs.
• The health-care professional also will take a past medical history to assess the risk factors
for peripheral vascular disease (narrowing of the arteries), for example, smoking, high blood
pressure, high cholesterol, and diabetes. These risk factors are important in exploring ischemic
bowel as the cause for colitis.
• The health-care professional may ask the patient the following questions:
• When and what time did the symptoms start?
• How long does the pain last?
• How frequent is the diarrhea?
• Are any other associated symptoms or signs?
• Has the patient traveled recently, been on an unusual diet, or has used or drank noncommercial
water (for example, drinking from a well or river water on a camping trip) This may assist in the
diagnosis to bacterial infections such as Shigella, Campylobacter, or Yersinia; or parasite infections
such as giardia.
• Has the patient recently used antibiotics? Recent use of antibiotics may direct the health-care
professional to consider Clostridium difficile (C Diff) as the cause.
• Has there been any blood in the stool?

15. • Laboratory Tests
• The history will assist the health-care professional decide the tests to order and what cultures
would be appropriate. Blood tests help assess the stability of the patient, and also explore any
potential issues associated with colitis.
• A complete blood count (CBC) will assess the red blood cell count, the white blood cell count, and
the number of platelets.
– The red blood cell count will help define the amount of bleeding.
– White blood cell counts elevate when the body is undergoing physical (exercise, physiological, or
emotional stress
– Platelets help blood to clot, so knowing the platelet number in a patient with bleeding may be useful.
• Electrolyte abnormalities can occur with diarrhea. Low sodium (hyponatremia) and low
potassium (hypokalemia) levels may occur and cause symptoms far removed from the initial colitis
signs and symptoms.
• Kidney function may be assessed by measuring the BUN (blood urea nitrogen) and creatinine levels.
• Erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) are nonspecific test of
inflammation in the body.
• Stool samples may be collected for culture, looking for infection as the cause of colitis

16. • Colonoscopy
• If a specific cause of colitis is not readily apparent, then
colonoscopy may be considered. A gastroenterologist will
insert a long flexible fiber optic camera into the anus and
examine the full length of the colon. The appearance of the
colon by itself may be enough to make the diagnosis.
• Biopsies (small pieces of tissue) may be taken from the
lining of the colon and examined by a pathologist (a
medical doctor specializing in the diagnosis of tissues) to
help confirm the diagnosis. Microscopic colitis
(lymphocytic and collagenous) can only be diagnosed with
biopsy of the affected area.

17. • Imaging
• Computerized tomography (CT) may be used to image
the colon and the rest of the abdomen. Different types
of colitis have distinctive patterns that may help a
radiologist recognize a specific diagnosis. A CT
scan may be ordered urgently if the history and
physical examination performed by the health-care
professional leads to concern that an urgent or
emergent problem exists that might require surgery.
On occasion, a barium enema or other imaging tests
such as ultrasound may be used to evaluate the
anatomy of the colon and assist in diagnosis.

18. • 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.

19. Colitis
• Treatment:
• The definitive treatment of colitis depends upon the cause. Many
cases require little more than symptomatic care, including clear
fluids to rest the bowel and medications to control pain. Some
patients become acutely ill and will need intravenous (IV) fluids and
other interventions to treat their illness.
• Infections: Depending on the cause, infections that cause diarrhea
and colitis may or may not require antibiotics. Viral infections
resolve with the supportive care of fluids and time. Some bacterial
infections like Salmonella also do not need antibiotic therapy; the
body is able to get rid of the infection on its own. However, other
bacterial infections like Clostridium difficilealways require treatment
with antibiotics.

20. • Ischemic colitis: Treatment of ischemic colitis is initially supportive,
using intravenous fluids to rest the bowel and prevent dehydration.
If adequate blood supply to the bowel isn't restored, surgery may
be required to remove parts of the bowel that have lost blood
supply and become necrotic (tissue that has died).
• Inflammatory bowel disease (IBD): Inflammatory bowel diseases
(IBDs) like ulcerative colitis and Crohn's disease, are often
controlled by a combination of medications that are used in a step-
wise approach. Initially, anti-inflammatory medications are used,
and if these are less than successful, medications that suppress the
immune system can be added. In the most severe cases, surgery
may be required to remove all or parts of the colon and small
intestine.

21. • Diarrhea and abdominal pain: Most causes of colitis
present with diarrhea and crampy abdominal pain.
These symptoms are also found with mild illnesses like
viral enterocolitis (inflammation of the small intestine
and colon). Initial treatment at home may include a
clear fluid diet for 24 hours, rest,
and acetaminophen (Tylenol) or the
NSAID ibuprofen (Advil, Motrin, etc.) as needed for
pain. Often symptoms resolve quickly and no further
care is needed. Loperamide (Imodium) is an effective
medicine to control diarrhea if there is no blood or
fever present.

22. • Diet: A clear fluid diet may be the best way to treat the
diarrhea associated with colitis. Clear fluids are
absorbed in the stomach and no waste products are
delivered to the colon, allowing it to rest. Clear fluids
without carbonation (bubbles) include anything that
one can see through, and also includes popsicles and
Jell-O.
• Depending up on the cause of colitis, there may be
some foods that can be tolerated and others that make
the symptoms worse or produce “flares.” Keep a food
diary to help identify and eliminate trigger foods, and
identify and eat more foods that soothe or calm the
colon.

23. Proctitis
• Definition: Proctitis is defined as inflammation of
your anus (the opening) and it is inflammation of
the lining of the rectum (lower part of the
intestine leading to the anus), called the rectal
mucosa. Stool passes through the rectum on its
way out of the body.
• Proctitis affects the last 6 inches (10-15cm
length/whole length of rectum) of the rectum.
Proctitis involves an inflammatory change of the
rectum (within 15 cm of the dentate line).

25. • Causes:
• Proctitis has many causes, but sexually transmitted diseases (STDs) are
the most common. Gonorrhea, syphilis, herpes, anal warts,
and chlamydia are the most common cause of sexually transmitted
proctitis. Proctitis is increasingly more common in homosexual men and in
people engaging in oral-anal or anal intercourse with many partners.
• Other causes include the following:
• Nonsexually transmitted infections
• Autoimmune diseases of the colon such as Crohn disease and ulcerative
colitis
• Harmful physical agents
– Chemicals
– Foreign objects placed in the rectum
– Trauma to your anorectal area
– Radiation (a side effect from treatment for another illness)
– Antibiotics (a side effect from treatment for another illness)

26. • Anal warts: A virus known as human papillomavirus (HPV) causes anal
warts, which begin as soft, fleshy growths around the anus. These warts
can extend to affect the lower part of the rectum. You may have anal
itching, varying degrees of pain, and, with time, bleeding and discharge.
• Anorectal trauma: Trauma to your anus or rectum, in which the anal and
rectal linings stretch and tear, can be a potential cause of proctitis.
• Radiation proctitis: Radiation therapy is used to treat prostate cancer in
men and cancers of the female organs such as the cervix and uterus. The
rectum is close to these organs and is at risk for damage from the
radiation.
• rectal infections that occur after antibiotic use, such as from the
bacteria Clostridium difficile
• infections that aren’t sexually transmitted, such as infections from
bacteria like salmonella and shigella

27. • Infections. Sexually transmitted infections, spread
particularly by people who engage in anal intercourse,
can result in proctitis. Sexually transmitted infections
that can cause proctitis include gonorrhea, genital
herpes and chlamydia.
• Infections associated with foodborne illness, such as
salmonella, shigella and campylobacter infections, also
can cause proctitis.
• Antibiotics. Sometimes antibiotics used to treat an
infection can kill helpful bacteria in the bowels,
allowing the harmful Clostridium difficile bacteria to
grow in the rectum.

28. • Types of proctitis:
• Diversion proctitis. Proctitis can occur in people following some types of colon
surgery in which the passage of stool is diverted from the rectum to a surgically
created opening (stoma).
• Food protein-induced proctitis. This can occur in infants who drink either cow's
milk- or soy-based formula. Infants breast-fed by mothers who eat dairy products
also may develop proctitis.
• Eosinophilic proctitis. This condition occurs when a type of white blood cell
(eosinophil) builds up in the lining of the rectum. Eosinophilic proctitis affects only
children younger than 2.
• Other types are:
• Antibiotic-Induced Proctitis
• Gonorrheal Proctitis
• Herpetic Proctitis
• Ischemic Proctitis
• Radiation Proctitis
• Syphilitic Proctitis

29. • Symptoms:
• A common symptom of proctitis is called tenesmus. Tenesmus is a
frequent urge to have a bowel movement. Inflammation and irritation of
the rectum and rectal lining cause tenesmus (Urgent need to urinate &
deficate & little being passed during)
• Other symptoms of proctitis can include:
• pain in your rectum, anus, and abdominal region
• bleeding from your rectum
• passing of mucus or discharge from your rectum
• watery diarrhea
• A frequent or continuous feeling that you need to have a bowel
movement
• Pain on the left side of your abdomen
• A feeling of fullness in your rectum
• Diarrhea

30. • Diagnosis:
• Tests and procedures used to diagnose proctitis include:
• Blood tests. These can detect blood loss or infections.
• Stool test. You may be asked to collect a stool sample for testing. A stool test may
help determine if your proctitis is caused by a bacterial infection.
• Scope exam of the last portion of your colon.During this test (flexible
sigmoidoscopy), your doctor uses a slender, flexible, lighted tube to examine the
last part of your colon (sigmoid), as well as the rectum. During the procedure,
your doctor can also take small samples of tissue (biopsy) for laboratory analysis.
• Diagnosis of proctitis is made when sigmoidoscopy reveals inflammation of the
mucus lining of the rectum with a clearly demarcated upper border above which
the lining is normal.
• Scope exam of your entire colon. This test (colonoscopy) allows your doctor to
view your entire colon using a thin, flexible, lighted tube with an attached camera.
Your doctor can also take a biopsy during this test.
• Tests for sexually transmitted infections. These tests involve obtaining a sample
of discharge from your rectum or from the tube that drains urine from your
bladder (urethra).

31. • The remainder of the colon and small
intestine is found to be normal by barium x-
rays, while colonoscopy and rectal biopsy may
show changes which are indistinguishable
from those of chronic ulcerative colitis

32. • Treatment options for proctitis
• The goals of proctitis treatment are to reduce inflammation, control pain, and
treat infection. Specific treatments depend on the cause of proctitis. Managing
underlying conditions helps to relieve symptoms. Medications may be used to
treat STIs and other infections. Surgery may be needed if you have proctitis
with ulcerative colitis or Crohn’s diseases.
• Medication
• Several types of medication are used to treat proctitis:
• Anti-inflammatory drugs, such as corticosteroids, reduce inflammation and
provide pain relief.
• Antibiotics and antifungals clear up STIs and other infections.
• Immunosuppressants and biologics treat symptoms of Crohn’s disease and other
autoimmune diseases.
• Your doctor will prescribe medication based on the symptoms of your proctitis and
its underlying cause. Medications may be taken orally or intravenously, applied
topically, or delivered by an enema. With an enema, treatment is placed directly
into your rectum.

33. • The treatment of proctitis is determined by cause.
• Gonococcal proctitis responds to standard intramuscular injection with
procaine penicillin or spectinomycin, but less consistently to oral
treatment with penicillin or tetracycline.
• Primary herpetic proctitis responds well to acyclovir. Chlamydial proctitis
responds to tetracycline.
• Treatment of idiopathic (unknown cause) ulcerative proctitis is very similar
to that of ulcerative colitis and Crohn's disease, and includes a nonlaxative
diet, the administration of antidiarrheal drugs such as diphenoxylate
hydrochloride with atropine sulfate (Lomotil) or loperamide.
• Topical corticosteroids may be applied in the form of suppositories,
steroid enemas or steroid foam. Enemas or suppositories should be
administered at bedtime to maximize their retention. Other symptoms
may be treated by pain-killing and antispasmodic drugs.
• You may eventually need surgery if you have ulcerative colitis or Crohn’s
disease and frequent cases of proctitis

34. • Herbal Treatment: The term “herb” is derived from the
Latin word herba meaning “grass.” The term has been
applied to plants of which the leaves, stems, or fruit are
used for food, for medicines, or for their scent or flavor.
Herbal medicine refers to folk and traditional medicinal
practice based on the use of plants and plant extracts for
the treatment of medical conditions
• aloe vera gel, wheat grass juice, Boswellia serrata,
and bovine colostrum enemas in the management of
patients with ulcerative colitis.
• herbal remedies for the treatment of IBD include slippery
elm, fenugreek, devil's claw, Mexican yam, tormentil,
and Wei tong ning.

35. • Butyrate
• Butyrate is an important energy source for intestinal epithelial cells
and plays a role in the maintenance of colonic homeostasis.
Butyrate enemas have been studied for use in treating UC. Some
studies have shown that the topical use of butyrate may help
decrease the inflammation in the colon.
• Licorice
• Licorice, which is derived from the root of the plant, Glycyrrhiza
Glabra is used extensively for a variety of conditions and ailments.
Licorice has also got immune modulatory and adaptogenic
property, which is required for the pathogenesis of UC. A number of
active chemicals, including glycyrrhizin are thought to account for
its biologic activity. Diammonium glycyrrhizinate is a substance that
is extracted and purified from licorice, and may be useful in the
treatment of UC

36. • Slippery elm (Ulmus fulva)
• Slippery elm is a supplement that is made from the
powdered bark of the slippery elm tree. It has long been
used by Native Americans to treat cough, diarrhea, and
other GI complaints. Recently, slippery elm has been
studied for use as a supplement for IBD
• The wheat grass (Triticum aestivum)
• The wheat grass juice has been used for the treatment of
various GI conditions. A double-blind study has
demonstrated that supplementation with wheat grass juice
for 1 month results in clinical improvement in 78% of
people with UC, compared with 30% of those receiving a
placebo

37. • Curcumin
• Curcumin is a compound in turmeric (Curcuma longa) that has been
reported to have anti-inflammatory activity. It has been found to induce
the flow of bile, which helps break down fats. Additionally, it could reduce
the secretion of acid from the stomach and protect against injuries such as
inflammation along the stomach (gastritis) or intestinal walls and ulcers
from certain medications, stress, or alcohol.
• Bromelain
• Bromelain is an anti-inflammatory and has been used as a digestive aid
and a blood thinner, as well as to treat sports injuries, sinusitis, arthritis,
and swelling. Bromelain has been studied for use as a supplement for
IBD, especially UC. Emerging research on pineapple suggests that
pineapple's “active” component, bromelain, may help relieve the
inflammation associated with UC

38. • Guggulsterone is a plant steroid found in the
resin of the guggul plant, is an anti-
inflammatory compound with the capacity to
prevent and ameliorate T-cell–induced colitis.
These data ground the use of GS, a natural
cholesterol-lowering agent, in the treatment
of chronic inflammatory diseases