Symptoms and Treatment of Colitis
The primary symptoms of colitis include diarrhea (often with blood or mucus), abdominal pain, rectal urgency, and tenesmus, with severity varying based on the specific type and extent of colonic inflammation. 1
Common Symptoms of Colitis
- Diarrhea: Increased frequency of bowel movements, often watery or loose, which may contain blood or mucus 1
- Rectal bleeding: Presence of blood in stool, ranging from streaks to frank bleeding 1
- Abdominal pain: Cramping or discomfort, often in the lower abdomen 1
- Urgency: Strong, sudden need to have a bowel movement 1
- Tenesmus: Feeling of incomplete evacuation after bowel movements 2
- Fatigue: Common symptom that significantly impacts quality of life 1
- Fever: May indicate more severe inflammation or infection 1
- Nocturnal bowel movements: Disrupted sleep due to nighttime diarrhea 1
Symptom Severity Classification
Symptoms can be classified by severity, which guides treatment decisions:
- Mild colitis: Increase of <4 bowel movements per day above baseline, minimal or no systemic symptoms 1
- Moderate colitis: Increase of 4-6 bowel movements per day, mild to moderate abdominal pain, blood in stool 1
- Severe colitis: Increase of >6 bowel movements per day, severe abdominal pain, significant bleeding, fever, and potentially hemodynamic instability 1
Types of Colitis and Specific Symptoms
Ulcerative Colitis
- Bloody diarrhea is the hallmark symptom 3, 2
- Rectal urgency and tenesmus are prominent 1, 2
- Symptoms typically begin in the rectum and extend proximally 3, 2
Infectious Colitis
- Acute onset of symptoms, often with fever 4, 5
- Purulent, bloody stools 4
- May have recent history of contaminated food or water exposure 4, 5
Microscopic Colitis
- Watery diarrhea without blood 6
- Defecatory urgency and fecal incontinence 6
- More common in older adults and women 6
Immune Checkpoint Inhibitor-Induced Colitis
- Can develop 6-8 weeks after starting immunotherapy 1
- May rapidly progress within days, particularly with certain medications like ipilimumab 1
Diagnostic Approach
- Stool evaluation: Rule out infectious causes (C. difficile, bacterial pathogens, parasites) 1, 7
- Inflammatory markers: Fecal calprotectin and lactoferrin help assess inflammation severity 1, 7
- Endoscopic evaluation: Confirms diagnosis and assesses severity 1, 7
- Laboratory tests: Complete blood count, CRP, electrolytes, liver and renal function tests 7
Treatment Approach
Treatment depends on the type and severity of colitis:
Ulcerative Colitis Treatment
- Mild to moderate disease: Oral and rectal 5-aminosalicylates (mesalamine) 7, 8
- Typical dosing: 2.4g to 4.8g daily for induction, 2.4g daily for maintenance 8
- Moderate to severe disease: Systemic corticosteroids, thiopurines, or biologics (anti-TNF, anti-integrins) 7, 3
- Refractory disease: May require surgical intervention in up to 15% of cases 3, 2
Infectious Colitis Treatment
- Identify pathogen: Through stool cultures and specific testing 4, 5
- Targeted antibiotics: Based on identified pathogen 7, 4
- Supportive care: Hydration and electrolyte replacement 7
Immune Checkpoint Inhibitor-Induced Colitis
- Grade 1: Low-fiber diet and close monitoring 7
- Grade 2 or higher: Systemic corticosteroids (0.5-2 mg/kg prednisone equivalent daily) 1
- Refractory cases: Infliximab or vedolizumab 1
Special Considerations
- Pregnancy: Mesalamine can be used during pregnancy with close monitoring 8
- Renal impairment: Evaluate renal function before and during mesalamine therapy 8
- Elderly patients: Higher risk of blood dyscrasias with mesalamine; monitor blood counts 8
- Warning signs: Severe abdominal pain, significant bleeding, or signs of peritonitis require urgent intervention 7
Treatment Pitfalls to Avoid
- Delayed diagnosis: Symptoms of immune checkpoint inhibitor colitis can mimic ulcerative colitis flare 1
- Inadequate infection screening: Always rule out infectious causes before starting immunosuppressive therapy 1, 7
- Medication side effects: Monitor for mesalamine-induced acute intolerance syndrome, which can mimic colitis flare 8
- Dehydration: Ensure adequate hydration, especially with mesalamine to prevent nephrolithiasis 8
- NSAID use: Avoid NSAIDs as they can exacerbate colonic inflammation 7