Version May 2024
INTRODUCTION — Diversion colitis or diversion proctitis is a nonspecific inflammatory disorder that occurs in segments of the colon and rectum that are diverted from the fecal stream by surgery (eg, creation of a loop colostomy/ileostomy or an end colostomy/ileostomy with closure of the distal colon segment [eg, Hartmann's procedure]).
The construction of ileostomy or colostomy with fecal diversion is routinely performed in patients who have medically refractory benign or malignant colorectal diseases, those who undergo distal bowel resection and anastomosis, or reconstruction in the distal bowel. Diversion colitis is characterized by inflammation of the defunctionalized, bypassed colon following surgery [1,2]. Most patients with diversion colitis are asymptomatic, but in a small proportion of patients, symptoms can significantly impact quality of life [3].
This topic will review the management of diversion colitis. The epidemiology, clinical manifestations and diagnosis of diversion colitis are discussed in detail, separately. (See "Diversion colitis: Clinical manifestations and diagnosis".)
SYMPTOMATIC PATIENTS
Surgical restoration of intestinal continuity — In symptomatic patients with diversion colitis, restoring intestinal continuity by surgical reanastomosis is the treatment of choice as it is associated with a high rate of resolution of inflammation resulting from fecal diversion (algorithm 1 and image 1) [4]. In patients who are candidates for surgery, early reanastomosis is preferred because, with a delay in reestablishment of bowel continuity, symptoms often become more frequent and severe, and there is a progressive decrease in capacity and involution of the defunctionalized anorectum [5,6].
In patients with Crohn disease, if the distal segment was not involved endoscopically and histologically before diversion, early reanastomosis will improve symptoms and may help avert stricture formation in the lumen of diverted colorectum [5]. (See "Diversion colitis: Clinical manifestations and diagnosis", section on 'Differential diagnosis'.)
If it is unclear if the symptoms are due to diversion colitis or active inflammatory bowel disease (IBD) in the diverted colon, treatment response to a short-chain fatty acid (SCFA) enema can help distinguish between them as a symptomatic response to SCFA enemas supports the diagnosis of diversion colitis. In these patients, a response to SCFA enemas should be followed by surgical reanastomosis [7]. (See 'Short-chain fatty acid enemas' below.)
In patients with active distal IBD that precludes surgical restoration of intestinal continuity, medical management of diversion colitis is indicated (see 'Initial treatment' below). In a study of 138 patients with fecal diversion for severe perianal Crohn disease, 30 (22 percent) achieved stoma closure, 45 (33 percent) kept a stoma with diverted rectum in place, and 63 (45 percent) had to have proctectomy with permanent stoma during a mean follow-up of 5.7 years [8]. Factors that predicted inability to achieve stoma closure were disease involvement of the rectum and presence of setons of perianal disease [8].
Although randomized trials are lacking, in small observational studies, reanastomosis has been reported to be curative within three months and may also restore anal sphincter function [9,10]. However, the reestablishment of bowel continuity may not lead to complete resolution of endoscopic and histologic inflammation, the clinical significance of which is unclear [11].
Patients who cannot undergo surgical reanastomosis
Initial treatment
Short-chain fatty acid enemas — SCFA enemas are used as initial therapy in patients with diversion colitis who are unable or unwilling to undergo surgery (algorithm 1). We also use SCFA enemas in patients with known distal IBD in whom the diagnosis of diversion colitis is unclear as a response to SCFA enemas supports the diagnosis of diversion colitis [12]. SCFA enemas require preparation at compounding pharmacies. It can also be expensive and produce an odor resulting in poor adherence [7]. (See "Diversion colitis: Clinical manifestations and diagnosis".)
●Dose and duration – Various dosing regimens of SCFA enemas for induction have been reported in the literature, ranging from 10 mL once or twice a day to 60 mL enema twice a day for four weeks [4,13-16]. The author uses the following composition for SCFA enemas: sodium acetate (60 mmol), sodium propionate (30 mmol), and sodium n-butyrate (40 mmol) with additional sodium chloride (22 mmol) to yield an osmolality of 280 to 290 mosmol/L, which is similar to plasma. The pH is adjusted to 7.4 with sodium hydroxide or hydrochloric acid. A 60 mL enema is instilled into the diverted distal bowel once daily for up to four weeks. In patients whose symptoms improve but flare with discontinuation, SCFA enemas are continued at a reduced dose as long-term maintenance (eg, one enema daily and then three times a week at bedtime).
●Efficacy – The initial observation that the diverted segment of the colorectum contained negligible concentrations of SCFAs, and response in four adult patients to administration of D-glucose in a pilot study, provided the rationale for the use of SCFA [7]. Other studies in adults have had a small sample size and results have been conflicting [7,13,14,17]. As examples:
•In a prospective study that included 13 patients with diversion colitis, treatment with SCFA for 14 days was not associated with endoscopic or histologic remission [14]. However, this study was limited by the short duration of treatment. In addition, most patients had only mild endoscopic and histologic changes of diversion colitis at baseline.
•A randomized crossover trial included 10 patients with IBD (nine Crohn disease and one ulcerative colitis) who had undergone colectomy with creation of a Hartmann pouch a median of 15 months prior to the start of the trial. Patients were treated with SCFA instillation or placebo for three weeks. In this study, treatment with SCFA was not associated with an improvement in inflammation [13]. However, most patients had severe inflammation by endoscopy and histology that might have been more consistent with the underlying IBD than with diversion colitis.
•In another randomized trial, 20 patients with fecal diversion (more than 30 days) for IBD, colorectal cancer, or diverticular disease were assigned to sodium butyrate enemas or saline enemas [15]. Of the 17 patients with diversion colitis/proctitis who completed the trial, there was a significant improvement in endoscopy scores in the treatment but not the control group. Histologic scores of inflammation in both groups were numerically increased at the end of the trial. Mucosal atrophy scores were reduced or unchanged in SCFA group but increased in the control group over the course of the study. However, this difference was not statistically significant.
It has been suggested that children diverted for reasons other than IBD seem to respond more consistently to SCFA enemas than adults; however, few observational studies have been published and the long-term response to SCFAs is unknown [4,17].
5-aminosalicylic acid (5-ASA) — In patients whose symptoms fail to improve after four weeks of treatment with SCFA enemas, we suggest topical 5-aminosalicylic acids (ASAs; mesalamine) (algorithm 1). In patients with diversion colitis who have underlying IBD, regardless of whether IBD involves the diverted segment, we use topical 5-ASAs in conjunction with SCFAs [18]. Topical 5-ASAs are widely available as suppositories or enemas (eg, mesalamine suppository 1 gram twice daily, mesalamine retention enema 4 grams twice daily). However, evidence to support topical 5-ASA use in diversion colitis is limited to case reports [19].
Persistent symptoms
Topical glucocorticoids — The use of glucocorticoids should be limited to patients with diversion colitis who do not respond to or only partially respond to therapy with SCFA enemas and topical mesalamine (algorithm 1). For patients who completely fail to respond to SCFA and/or topical 5-ASA agents, a four-week course of topical corticosteroids can be used as the sole agent. For patients who have a partial response to SCFA and/or topical 5-ASA agents, topical corticosteroids can be used in addition to the existing regimen [20].
Topical preparations of glucocorticoids include enemas, suppositories, and foam (eg, hydrocortisone enema 100 mg twice daily, hydrocortisone suppository 30 mg twice daily, hydrocortisone foam 10 percent 90 mg twice daily, and budesonide foam 2 mg daily). Topical steroids have not been systemically studied for the treatment of diversion colitis and their use is based on their efficacy in patients with other forms of colitis. In this author's experience, patients with diversion colitis/proctitis along with underlying IBD may have a more favorable response to the topical glucocorticoid therapy than those without underlying IBD. However, it is important to note that adrenal suppression and other systemic adverse effects do occur in patients with long-term use of topical glucocorticoids. (See "Major adverse effects of systemic glucocorticoids", section on 'Organ-based toxicity of systemic glucocorticoids'.)
Surgical proctectomy in selected patients — Proctectomy or sigmoid colectomy with proctectomy is reserved for patients with refractory symptoms of diversion proctitis or colitis. In patients with colitis-associated dysplasia in the diverted bowel, this is definitive treatment for the diversion colitis [21,22]. However, completion colectomy, proctectomy, and pouch excision carry a risk for anal stump leak or abscess [23].
Therapies with uncertain benefit — There are several approaches that have been evaluated in small studies of patients with diversion colitis that we do not routinely recommend due to lack of sufficient evidence of benefit. However, they may be used as adjunctive nonsurgical options for patients with refractory symptoms after consideration of potential harm, cost, and patient preference.
●Probiotics – In a randomized controlled trial, 69 patients with diversion colitis after undergoing loop ileostomy closure for colorectal cancer were assigned to treatment with administration of a probiotic (consisting of four strains of Lactobacillus, three strains of Bifidobacterium, and one strain of Streptococcus) via the efferent limb of stoma or placebo for 20 days. Improvement in endoscopic and histologic inflammation before stoma closure and symptoms of diversion colitis after stoma closure were observed in a significantly higher number of patients in the study group than that in the control group [24]. However, the pre-stoma closure probiotic stimulation of the diverted bowel failed to improve postoperative ileus, time-to-tolerating diet, passage of flatus and stools, or length of hospital stay for the stoma closure surgery. The role of probiotics in the treatment of diversion colitis in patients with underling IBD has not been systemically evaluated.
●Fecal microbiota transplantation – Autologous fecal microbiota transplantation has been associated with endoscopic remission in patients with diversion colitis in small observational studies of patients without underlying IBD [25-27].
●Other – Infliximab, an anti-tumor necrosis factor agent used in the treatment of IBD, has been used to treat refractory diversion colitis in a patient without underlying IBD [28,29]. Other topical agents, which showed efficacy in reduction of mucosal inflammation or pro-inflammatory mediators, include sucralfate (in an animal model) [30,31], heparin [32], dietary fiber [33], curcumin enema [34], and leukocytapheresis [35]. High-concentration dextrose (50 percent) has been used for management of refractory bleeding (picture 1) [36] due to diversion colitis.
ASYMPTOMATIC PATIENTS — There is a lack of consensus on whether asymptomatic patients who are not at high risk of colorectal cancer due to inflammatory bowel disease (IBD) or other risk factors require treatment of endoscopic and/or histologic chronic inflammation. Inflammation may persist in non-IBD patients, even after bowel continuity is restored, but the clinical significance of this is unclear [11]. In asymptomatic patients with fecal diversion for more than one year, we perform yearly lower gastrointestinal endoscopy to monitor disease activity, remove bezoars or polyps, and treat strictures, if present. Despite the risk of procedure-associated bowel perforation, bleeding, or bacterial translocation, the author treats diversion-associated strictures for relief of symptoms and to facilitate surveillance for dysplasia. However, the procedure is preferably performed at centers of excellence with endoscopic and colorectal surgery expertise. Topical treatment of diversion colitis (eg, short-chain fatty acid enemas) may be offered to asymptomatic patients with severe endoscopic inflammation to reduce the risk for bowel wall fibrosis and, theoretically, neoplasia.
PREVENTION AND MANAGEMENT OF COMPLICATIONS
Colorectal cancer surveillance — We do not perform routine colorectal cancer (CRC) surveillance in the diverted segment unless the underlying condition for which the surgery was performed is associated with an increased risk of cancer. The risk for the development of dysplasia or CRC in the diverted colorectum in patients without other risk factors for CRC (eg, a history of CRC, a hereditary colorectal cancer syndrome, underlying inflammatory bowel disease [IBD]) is low.
Surveillance endoscopy of the diverted large bowel is indicated only in patients with permanent fecal diversion and one of the following risk factors that place them at high risk for dysplasia or CRC [21,37]:
●Preoperative diagnosis of colitis-associated neoplasia in the segment of bowel, with or without endoscopic therapy for the neoplasia
●Long history (>8 years) of ulcerative colitis or Crohn colitis involving the colon and rectum
●Concurrent primary sclerosing cholangitis
●Large bowel strictures
●Pelvic radiation
●Personal history of colon cancer or hereditary colorectal cancer syndrome
●CRC in a first-degree relative diagnosed at age 50 years or younger
●Biopsy protocol – Four random biopsies every 10 cm should be taken using a modified Seattle protocol. Additionally, any endoscopically visible lesion should be biopsied or resected for histologic evaluation. The role of chromoendoscopy in the surveillance of colitis-associated neoplasia in the diverted pouch has not been established as the friability of the mucosa makes the application of dye challenging. Endoscopic polypectomy can be safely performed in patients with a diverted colon. However, we avoid endoscopic mucosal resection and submucosal dissection for flat lesions due to the risk of perforation (picture 2). (See "Chromoendoscopy".)
●Surveillance interval – Yearly surveillance endoscopy of the diverted large bowel or ileal pouch is recommended in patients with:
•Precolectomy diagnosis of colorectal neoplasia in IBD or non-IBD patients
•History of dysplasia of the pouch
•Familial adenomatous polyposis
In all other patients at high-risk for dysplasia or CRC, surveillance endoscopy is recommended every one to three years [37].
Temporary bacterial translocation can occur in patients with a long-term diverted bowel who undergo endoscopic or surgical procedure of the segment of bowel. Spontaneous pyogenic liver abscess has been reported in a patient with precolectomy ulcerative colitis and diverted ileal pouch [38]. However, routine antibiotic prophylaxis in patients with diversion colitis undergoing endoscopic or surgical intervention in the diverted segment is controversial [37].
Endoscopic therapy of diversion-associated strictures and fecal bezoars — Based on the location and severity, diversion-associated strictures may require dilatation (digital, bougie, or endoscopic balloon dilatation) or endoscopic stricturotomy (image 2 and picture 3) [39,40]. Large, symptomatic bezoars can be removed endoscopically (picture 4). The endoscopic management of strictures is discussed in detail separately. (See "Surgical management of Crohn disease", section on 'Endoscopic dilatation'.)
SUMMARY AND RECOMMENDATIONS
●Symptoms of diversion colitis and goals of treatment – Diversion colitis is an inflammatory process that occurs in segments of the colorectum that are diverted from the fecal stream by surgery. Most patients with histologically evident diversion colitis are asymptomatic. The most common symptoms in adults are tenesmus, urgency, bloody and/or mucus discharge, and abdominal pain. Persistent inflammation and long-term non-use may result in stricture formation in the diverted bowel and accumulation of mucus materials with formation of a bezoar. The goal of treatment is relief of symptoms. (See "Diversion colitis: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)
●Observation of asymptomatic patients – There is a lack of consensus on whether asymptomatic patients who are not at high risk of colorectal cancer due to inflammatory bowel disease (IBD) or other risk factors require treatment of endoscopic and/or histologic inflammation. Inflammation may persist in non-IBD patients, even after bowel continuity is restored, but the clinical significance of this is unclear. In asymptomatic patients with fecal diversion for more than one year, we perform yearly lower gastrointestinal endoscopy to monitor disease activity, remove bezoars or polyps, and treat strictures, if present. (See 'Asymptomatic patients' above.)
●Symptomatic patients
•Surgical restoration of intestinal continuity – In patients with symptomatic diversion colitis in whom restoration of intestinal continuity is feasible, we suggest surgical reanastomosis rather than medical management (algorithm 1) (Grade 2C). In patients who are candidates for surgery, early reanastomosis is preferred because, with a delay in reestablishment of bowel continuity, symptoms often become more frequent and severe, and there is a progressive decrease in capacity and involution of the defunctionalized anorectum. (See 'Surgical restoration of intestinal continuity' above.)
•Patients who are not candidates for restoration of intestinal continuity
-Short-chain fatty acid enemas: For symptomatic patients who are not candidates for reanastomosis, we suggest a trial of short-chain fatty acid (SCFA) enemas (Grade 2C).
-Topical 5-ASA agents: For patients who do not respond to a trial of SCFA enemas, we suggest treatment with topical 5-aminosalicylic acid (ASA) agents (Grade 2C). In patients with diversion colitis who have underlying IBD, regardless of whether IBD involves the diverted segment, we use topical 5-ASAs in conjunction with SCFAs.
-Topical glucocorticoids in selected patients: In patients who fail to respond completely to SCFA and/or topical 5-ASA agents, we use topical glucocorticoids. Topical glucocorticoids may be particularly useful in patients with underlying IBD. However, long-term use should be avoided to avoid glucocorticoid side effects.
-Proctectomy or sigmoid colectomy with proctectomy for refractory symptoms: We reserve proctectomy or sigmoid colectomy with proctectomy for patients with refractory symptoms of diversion proctitis or colitis. Completion colectomy, proctectomy, and pouch excision carry a risk for anal stump leak or abscess formation.
●Assessment of colorectal cancer risk – The risk for the development of dysplasia or colorectal cancer (CRC) in the diverted colorectum in patients without other risk factors for CRC (eg, a history of CRC, a hereditary colorectal cancer syndrome, underlying IBD) is low. (See 'Colorectal cancer surveillance' above.)
Surveillance endoscopy of the diverted bowel is indicated only in patients with permanent fecal diversion and one of the following risk factors that place them at high risk for dysplasia or CRC:
•Preoperative diagnosis of colitis-associated neoplasia in the segment of bowel, with or without endoscopic therapy for the neoplasia
•Long history (>8 years) of ulcerative colitis or Crohn colitis involving the colon and rectum
•Concurrent primary sclerosing cholangitis
•Large bowel strictures
•Pelvic radiation
•Family history of CRC in a first-degree relative diagnosed at age 50 years or younger
•Familial adenomatous polyposis
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Dr. Richard I. Breuer, who contributed to an earlier version of this topic review.
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