What is the treatment for diversion colitis?

Treatment of Diversion Colitis

Restoration of bowel continuity through surgical closure of the stoma is the definitive treatment for diversion colitis, while short-chain fatty acid enemas, mesalamine, or corticosteroids are effective alternatives for patients who cannot undergo surgery. 1

Understanding Diversion Colitis

• Diversion colitis is an inflammatory condition that develops in segments of the colorectum after surgical diversion of the fecal stream (colostomy or ileostomy) 1
• The condition is characterized by inflammation of the mucosa in the defunctioned segment of the colon 1
• It is believed to occur due to nutritional deficiency in the colonic epithelium, specifically the absence of short-chain fatty acids, which are the preferred metabolic substrates of colonic epithelium 2
• While most patients remain asymptomatic, diversion colitis may develop in almost all patients with fecal diversion 1

Clinical Presentation

• Symptomatic patients may present with:

  • Rectal discharge (hemorrhagic or purulent) 3
  • Rectal bleeding 4
  • Abdominal pain 3, 4
  • Tenesmus (feeling of incomplete evacuation) 3

• Endoscopic findings typically include:

  • Mucosal nodularity 3
  • Erythema and friability of the mucosa 3
  • Aphthous ulceration 3
  • Granular appearance of the colonic mucosa 4

Treatment Algorithm

First-line Treatment:

• Surgical restoration of bowel continuity (closure of stoma with reestablishment of gut continuity) is the only curative intervention and should be performed in patients who:
  • Have temporary diversion 5
  • Desire stoma closure 5
  • Have acceptable surgical risk 5

For patients who cannot undergo surgical reestablishment:

1. Short-chain fatty acid (SCFA) enemas:

   • Considered first-line medical therapy 2
   • Administered twice daily initially, then reduced to daily or twice weekly for maintenance 2
   • Treatment duration of 4-6 weeks typically results in resolution of symptoms and endoscopic findings 2

2. 5-Aminosalicylic acid (5-ASA):

   • Effective as enemas or suppositories 5, 4
   • Can reduce rectal pain and bleeding within 6 weeks of treatment 4

3. Corticosteroid enemas:

   • Alternative option for symptomatic patients 5
   • Particularly useful when inflammation is more severe 5

For asymptomatic patients:

• Regular endoscopic surveillance of both functional and non-functional bowel according to accepted screening guidelines 5

For symptomatic patients with permanent diversion who fail medical therapy:

• Resection of the excluded bowel should be considered if the patient is an acceptable surgical candidate 5

Special Considerations

• Diversion colitis may be mistaken for inflammatory bowel disease due to similar endoscopic appearance 2
• Histological features (lymphoid follicular hyperplasia, chronic inflammatory changes) may resolve more slowly than the gross endoscopic appearance 2, 3
• In patients with spinal cord injury and colostomy, diversion colitis should be considered as a potential cause of abdominal discomfort 4

Treatment Efficacy

• Surgical reestablishment of bowel continuity has the highest success rate and is curative 1, 5
• SCFA enemas have shown effectiveness in resolving symptoms and endoscopic findings within 4-6 weeks 2
• 5-ASA treatment can significantly reduce symptoms within 6 weeks 4
• Without treatment, the condition persists indefinitely unless the excluded segment is reanastomosed 2