Diversion colitis and pouchitis: A mini-review

Table 1 Clinical characteristics of case report

Case (No)	Reference	Reporting yr	Country	Age (yr)	Gender(male/female)	Primary illness(reason for diversion)	Type of diversion (surgical procedure)	Period of up to diagnosis from operation	Symptoms	Endoscopy findings	Pathological findings	Diagnosis
1	Glotzer et al[2]	1981	United States	49	M	Free perforation sigmoid diverticulum	Loop sigmoid colostomy	2.5 mo	No symptoms	Erythema, friability, petechiae, atrophy	Crypt abscess, surface epithelial cell degeneration, acute inflammation, chronic inflammation, regeneration	Diversion colitis
				56	F	Adenocarcinoma. Protect low anastomosis	Loop transverse colostomy	3 mo	No symptoms	Erythema, friability, petechiae	Normal	Diversion colitis
				78	M	Sigmoid diverticulitis with perforation	Loop sigmoid colostomy	6 mo	No symptoms	Erythema, friability, granularity	No biopsy	Diversion colitis
				70	F	Sigmoid diverticulitis found at pelvic operation	Loop sigmoid colostomy	3 mo	No symptoms	Erythema, friability, nodularity	Regeneration	Diversion colitis
				43	F	Sigmoid diverticulitis with perforation	Loop sigmoid colostomy	8 mo	No symptoms	Erythema, friability	Crypt abscess, acute inflammation.	Diversion colitis
				41	F	Fecal incontinence secondary to cordotomy for pain	Loop sigmoid colostomy	18 mo	No symptoms	Erythema, friability, petechiae	No biopsy	Diversion colitis
				65	M	Sigmoid diverticulitis with perforation	Loop transverse colostomy	3 yr	No symptoms	Erythema, friability, granularity, petechiae, inflammatory polyp	Crypt abscess, surface epithelial cell degeneration, chronic inflammation, regeneration.	Diversion colitis
				83	M	Sigmoid diverticulitis with perforation	Loop transverse colostomy	6 mo	No symptoms	Erythema, friability, granularity	Crypt abscess	Diversion colitis
				26	M	Fecal incontinence after T9-10 cord transection	Loop transverse colostomy	7 yr	Rectal discharge	Erythema, friability, petechiae	Surface epithelial cell degeneration, chronic inflammation.	Diversion colitis
				70	M	Colonic ileus secondary to anticholinergics for Parkinson's disease	Loop transverse colostomy	4 mo	No symptoms	Erythema, friability, petechiae, inflammatory polyp	Crypt abscess	Diversion colitis
2	lusk et al[39]	1984	United States	28	M	Perforated sigmoid colon for gunshot	Loop sigmoid colostomy	6 wk	No symptoms	Red granular rectum with aphthous ulcers	Moderate loss of goblet cells with focal edema and lymphocytosis of the lamina propria.	Diversion colitis
				68	M	Sigmoid carcinoma	Loop transverse colostomy	6 wk	No symptoms	Multiple aphthae	Not obtained	Diversion colitis
3	Scott et al[46]	1984	United States	21	M	Gunshot	Loop transverse colostomy	2 mo	No symptoms	Multiple, small, polypoid lesions in the rectum and sigmoid colon up to the cutaneous part of the mucous fistula.	Mucosal biopsies of the rectal lesions were interpreted as “chronic nonspecific colitis with pseudopolyps, probably from diversion colitis”.	Diversion colitis
4	Korelitz et al[42]	1984	United States	22	F	Crohn's Disease	Ileostomy and subtotal colectomy	2 yr	No symptoms	Friable, nodular	Not obtained	Diversion colitis
				34	F	Crohn's ileitis	Ileocolic anastomosis and Loop ileostomy	2 yr	No symptoms	Exudate	Focal chronic inflammation, edema, erosions, and an increased number of lymphoid follicles.	Diversion colitis
				31	M	Crohn's ileitis	Ileocolic anastomosis and Loop ileostomy	1 yr	No symptoms	Aphthous lesions	Chronic inflammation	Diversion colitis
				32	M	Crohn's ileitis	Ileocolic anastomosis and Loop ileostomy	1 yr	No symptoms	Friable, exudate	Not obtained	Perforation due to complication of barium enema and diversion colitis
5	Fernand et al[40]	1985	United States	67	F	Perforated sigmoid diverticulum	Loop sigmoid colostomy	22 yr	Rectal bleeding	N/A	Diffuse multiple superficial ulcerations and intense inflammatory infiltrates composed mainly of plasma cells, lymphocytes, and some eosinophils.	Diversion colitis
6	Frank et al[13]	1987	United States	38	M	Perineal laceration as result of a motor vehicle accident	End sigmoid colostomy	1 yr	Rectal bleeding	Diffuse nodularity and ulceration	Moderate to severe nonspecific inflammation.	Diversion colitis
7	Harig et al[5]	1989	United States	63	M	Neurogenic fecal incontinence	Mucus fistula	13 mo	Bloody discharge	Endoscopic index of 10	Inflammatory infiltrate of both acute and chronic cells in the lamina propria and the crypt abscess. Lining epithelial cells show decreased mucin secretion.	Diversion colitis
				63	F	Irradiation of rectum	Mucus fistula	2 wk	Bloody discharge	Endoscopic index of 10	Erosions, surface exudate, crypt abscesses, edema.	Diversion colitis
				54	M	Perianal fistulas	Rectosigmoid pouch	35 mo	Bloody discharge	Endoscopic index of 9	Lymph follicles	Diversion colitis
				56	M	Diverticulitis	Mucus fistula	N/A	N/A	Endoscopic index of 8	N/A	Diversion colitis
8	Triantafillidis et al[31]	1991	Greece	64	F	Diverticula with perforation	Hartman's type of operation laparotomy	16 mo	Bloody rectal discharge	Endoscopic index of 9 (quite inflamed with friability and erythema)	Severe inflammatory infiltration, formation of lymph follicles, surface erosions, edema, and crypt abnormalities.	Diversion colitis
9	Tripodi et al[43]	1992	United States	85	F	Small bowel perforation with a ruptured chronic pelvic abscess secondary to diverticular disease	End transverse colostomy	10 wk	Bloody rectal discharge	Erythematous and friable, with diffuse exudation, petechiae, and ulceration	Acute and chronic inflammation with cryptitis.	Diversion colitis
10	Lu et al[38]	1995	United States	45	F	Chronic constipation	Loop transverse colostomy	25 yr	Sepsis(no symptoms such as rectal bleeding)	Large ulcers with overlying pseudomembrane	Infiltration primarily with plasma cells and lymphocytes was noted, as well as a moderate numbers of polymorphonuclear cells, large lymphoid aggregates were seen in the lamina propria	Diversion colitis
11	Lai et al[47]	1997	United States	49	M	Intractable ileus,C6 ASIAB tetraplegic	Colostomy	10 yr	Rectal pain and bleeding.	Partial stricture 70 cm proximally to the rectum. The colonic mucosa appeared granular and friable with evidence of linear ulceration.	Extravasation of erythrocytes, lymphocytic and neutrophilic cells infiltrates, and edema were present within the lamina pro-pria. No evidence of malignancy and glandular dysplasia was found. Pathologic report was consistent with chronic colitis.	Diversion colitis
12	Lim et al[32]	1999	United Kingdom	60	F	Faecal incontinence for DM	End sigmoid colostomy	6 mo	Blood and mucus per rectum	Edematous mucosa with bloodstained mucopurulent exudate	Active chronic colitis with focal cryptitis and crypt abscesses.	Diversion colitis → UC
				16	M	Imperforate anus	Ileostomy and colostomy	6 mo	Blood and mucus per rectum	Granular, erythematous mucosa with contact bleeding	Active inflammation with polymorphs infiltrating crypts and a diffuse increase in lymphocytes and plasma cells in the lamina propria.	Diversion colitis → UC
13	Jowett et al[33]	2000	United Kingdom	75	F	Faecal incontinence	End colostomy	8 mo	Blood and mucus per rectum	Granular, congested, and oedematous mucosa with contact bleeding	Mixed inflammatory cell infiltrate with distortion of the crypt architecture and cryptitis.	Diversion colitis (→ UC)
14	Lim et al[35]	2000	United Kingdom	66	M	Sigmoid carcinoma	Hartmann’s procedure with colostomy.	18 mo	No symptoms	Mildly inflamed	Active colitis	Diversion colitis (→ UC)
15	Kiely et al[36]	2001	United Kingdom	6	M	Ulcerative colitis	Total colectomy and ileostomy	9 mo	Rectal bleeding	Endoscopic index of 8	Lymphoid hyperplasia, lymphoplasmacytosis, crypt abscesses and moderate mucosal architectural disruption.	Diversion proctocolitis
				3	M	Perforated typhoid disease	Subtotal colectomy and ileostomy	5 mo	Rectal bleeding and abdominal pains	Endoscopic index of 8	Lymphoplasmacytic infiltration of lamina propria, and architectural disruption.	Diversion proctocolitis
				8	F	Aplastic anemia, a large solitary rectal ulcer	Loop sigmoid colostomy	4 mo	Rectal discharge	Endoscopic index of 9	Lymphoplasmacytic and neurophilic infiltrate in the lamina propria, mucin depletion, and Paneth cell metaplasia.	Diversion proctocolitis
				3	M	Hirschsprung's disease	ileostomy	N/A	Rectal bleeding	Florid colitis	Lymphoid hyperplasia, lymphoplasmacytosis and mucin depletion,	Diversion proctocolitis
				10	M	Rectovesical fistula	Loop sigmoid colostomy	N/A	Rectal discharge	Florid colitis	Lymphoid hyperplasia, lymphoplasmacytosis.	Diversion proctocolitis
16	Komuro et al[41]	2003	Japan	46	M	Ascending colon diverticular perforation (systemic lupus erythematosus and chronic renal failure)	Loop transverse colostomy	N/A ( On surveillance colonoscopy)	No symptoms	Mild colitis with a decreased vascular pattern, oedema and mucosal tear	N/A	Diversion colitis
17	Tsironi et al[48]	2006	United Kingdom	40	M	UC pancolitis-type	Rectal stump and ileostomy, subtotal colectomy and ileostomy	5 mo	Blood and mucus per rectum	Severe chronic inflammation with ulceration and numerous inflammatory polyps	Diffuse chronic inflammation with patchy cryptitis	Divesion collitis with caused by clostridium difficile infection.
18	Boyce et al[37]	2008	United Kingdom	29	M	Life-long constipation	Subtotal colectomy	15 yr	Rectal bleeding and anal pain	The mucosa of the rectal stump was found to be chronically inflamed and ulcerated.	Inflammatory change	Diversion pouchitis
19	Haugen et al[49]	2008	United States	36	F	Faecal incontinence due to spina bifida	Laparoscopic sigmoid colostomy and creation of a Hartmann's pouch	N/A	Rectal discharge	N/A	N/A	Diversion colitis
20	Talisetti et al[50]	2009	United States	19	F	Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS)	Gastrostomy and ileostomy	4 yr	Abdominal pain and rectal bleeding	Friable mucosa with areas of pinpoint hemorrhage from the anal verge to 30 cm proximally	Acute cryptitis and scattered crypt abscesses, consistent with diversion colitis.	Diversion colitis
21	Kominami et al[51]	2013	Japan	84	M	Angiodysplasia S/O	Subtotal colectomy and ileostomy	5 yr	Blood in the stool	Granular, edematous mucosa with contact bleeding	Lymphoplasmacytic and neurophilic infiltrate in the lamina propria.	Diversion colitis
22	Watanabe et al[44]	2014	Japan	76	F	UC	3-stage pancolectomy with construction of an IPAA	13 yr	Bloody purulent rectal discharge	Severely active pouchitis with large erosions	N/A	Diversion pouchitis
23	Gundling et al[45]	2015	Germany	75	F	Chronic constipation	Permanent end-colostomy	N/A	Tenesmus and severe rectal pain	Severe DC was seen on colonoscopy	Confirmed histologically	Diversion colitis
24	Matsumoto et al[52]	2016	Japan	65	M	UC pancolitis-type	Subtotal colectomy and ileostomy	4 mo	Rectal bleeding	Moderate mucosal inflammation	Ulcer, granulation tissue and epithelial defect	Diversion colitis or exacerbation of UC was suspected.
25	Custon et al[29]	2017	United States	44	M	UC complicated by colitis-associated low-grade dysplasia	Total proctocolectomy with 2-stage IPAA	7 yr	Blood in the stool	Edematous and coated with old and fresh blood	N/A	Severe diversion pouchitis

Table 2 Clinical course of case reports

Case (No)	Ref.	Age (yr)	Gender(male/female)	Ineffective treatment	Effective treatment	Prognosis
1	Glotzer et al[2]	49	M	N/A	Closure 4 mo post-diversion	Asymptomatic. Proctoscopy and biopsy normal 2.5 and 30 mo postclosure.
		56	F	N/A	Closure 3 mo post-diversion	Recurrent Ca. Mucosa not inflamed grossly or microscopically 18 mo post closure.
		78	M	N/A	Closure 6 mo post-diversion	Asymptomatic 1 yr postclosure.
		70	F	N/A	Closure 5 mo post-diversion	Asymptomatic. Normal sigmoidoscopy 2 mo postclosure.
		43	F	N/A	Closure 2 yr post-diversion	Asymptomatic. Normal sigmoidoscopy 3 yr postclosure.
		41	F	N/A	None	Asymptomatic 2 yr after ileostomy.
		65	M	N/A	None	Abdominal cramps purulent rectal discharge. Continued inflammation 8 yr after colostomy.
		83	M	N/A	None	Asymptomatic. Continued mild inflammation 4.5 yr after colostomy.
		26	M	N/A	Steroid enemas	Inproved. Continued 8 yr after colostomy.
		70	M	N/A	Steroid enemas	Tenesmus, discharge and fever 4 yr after colostomy. Resolved with steroid enemas. Continued inflammation at 8 yr.
2	Lusk et al[39]	28	M	-	Colostomy closure	Normal at 16 mo follow-up.
		68	M	-	Colostomy closure	Normal at 7 wk after clousure.
3	Scott et al[46]	21	M	-	Colostomy closure	One month later, the patient was examined by flexible sigmoidoscopy, which demonstrated normal mucosa throughout with no sign of pseudopolyps.
4	Korelitz et al[42]	22	F	Steroid enemas	Ileocolic reanastomosis (ileostomy closure)	3 mo (interval from reanastomosis to normal sigmoidoscopy), 7 yr (duration normal).
		34	F	-	Ileostomy closure	1 mo (interval from reanastomosis to normal sigmoidoscopy), 2 yr (duration normal).
		31	M	-	Ileostomy closure	3 mo (interval from reanastomosis to normal sigmoidoscopy), 18 mo (duration normal).
		32	M	-	Ileostomy closure	2 mo (interval from reanastomosis to normal sigmoidoscopy), 14 mo (duration normal).
5	Fernand et al[40]	67	F	-	Left hemicolectomy and left salpingo-oophorectomy	She recoverd well and discharged 9 d later.
6	Frank et al[13]	38	M	Oral and topical steroids	Abdominoperineal resection of the diverted loop and permanent colostomy	No evidence of inflammatory bowel disease has developed. Barium study of the small bowel was normal 1 yr after surgery.
7	Harig et al[5]	63	M	N/A	Short-chain-fatty acid irrigation	N/A
		63	F	N/A	Short-chain-fatty acid irrigation	N/A
		54	M	N/A	Short-chain-fatty acid irrigation	N/A
		56	M	N/A	Short-chain-fatty acid irrigation	N/A
8	Triantafillidis et al[31]	64	F	-	5 aminosalicylic acid enemas comparison with Betamethasone enemas	There were no differences in the degree of clinical improvement, or in the endoscopic and histologic scores seen at the end of the trials, between betamethasone and 5-ASA.
9	Tripodi et al[43]	85	F	-	5-aminosalicylic acid enemas	Clinically asymptomatic at a 6-mo follow-up.
10	Lu et al[38]	45	F	Intravenous metronidazole	Colectomy of the diverted segment	Without complications and has been doing well postoeratively.
11	Lai et al[47]	49	M	-	Daily 5-ASA suppository and total parenteral nutrition	6 wk of treatment with 5-ASA, the patient had decreased rectal pain and bleeding.
12	Lim et al[32]	60	F	-	Oral prednisolone, oral mesalazine, and mesalazine enemas	PSL was tapered off over four months and she remained well.
		0	M	Closure of the loop ileostomy→oral prednisolone, oral olsalazine and oral metronidazole→sigmoid loop colostomy	The defunctioned rectosigmoid was partially removed, leaving the lower rectum and anal canal; the loop colostomy was refashioned into an end colostomy→colectomy and removal of residual rectal stump and anal canal was performed and an end ileostomy fashioned	He subsequently made a good recovery and steroid therapy was discontinued.
13	Jowett et al[33]	75	F	-	Topical steroid enemas.	UC
14	Lim et al[35]	66	M	-	Steroid enemas	6 mo later he developed ulcerative colitis.
15	Kiely et al[36]	6	M	PSL and AZA	SCFA	Oral PSL was continued at the reduced rate of 5mg on alternate days until he underwent an uneventful rectal excision and J-pouch anal anastomosis 1 mo later. Two months after this, his ileostomy was closed.
		3	M	Salazopyrine	SCFA	His ileostomy was closed 3 mo later, and he was remained symptom free.
		8	F	-	SCFA	Her ulceration was virtually healed and showed a reduction in endoscopic index from 9 to 3. Treatment was maintained until her colostomy was reversed a month later. After stoma closure, SCFAs were discontinued with no further recurrence of symptoms.
		3	M	N/A	SCFA	For redo pull-through
		10	M	N/A	SCFA	Rectal excision
16	Komuro et al[41]	46	M	-	-	The post endoscopic course was uneventful without any treatment.
17	Tsironi et al[48]	40	M	Mesalazine suppository and steroid enemas	Metronidazole suppository	Improved quickly and remains well and asymptomatic 12 wk after treatment.
18	Boyce et al[37]	29	M	-	Completion proctectomy	Completion proctectomy was uneventful and from which the patient made an unremarkable recovery.
19	Haugen et al[49]	36	F	The water and vinegar solution enema, steroid enema, bismuth subsalicylate (standard treatment SCFA enmas was not option due to insurance and spina bifida)	Antegrade irrigations of her distal bowel with tap water	Weekly to twice weekly irrigations completely stopped the malodorous and troublesome discharge.
20	Talisetti et al[50]	19	F	SCFA enema, steroids, metronidazole	Colectomy(entire colon was ultimately resected, Since only 15 cm of jejunum appeared healthy, her mid and distal small bowel was also resected up to 15 cm from the ligament of Treitz)	N/A
21	Kominami et al[51]	84	M	Short-chain fatty acid enema	5-aminosalicylic acid enemas	Undergoing 5-aminosalicylic acid enemas maintenance therapy.
22	Watanabe et al[44]	76	F	Oral mesalazine, corticosteroid, metronidazole, and ciprofloxacin	Leukocytapheresis, following low dose of metronidazole and ciprofloxacin	After 18 mo, her condition remains stable without the need for medication.
23	Gundling et al[45]	75	F	Enemas containing 5-aminosalicylic acid and steroids and antibiotic therapy	Autologous fecal transplantation	All symptoms improved dramatically within 5 d after the first treatment. Colonoscopy 28 d after the first treatment showed no major signs of inflammation in the colonic stump.
24	Matsumoto et al[52]	65	M	Corticosteroid and mesalazine enemas, prednisolone injections.	A combined mesalazine plus corticosteroid enema	Finally proctectomy and ileal pouch-anal anastomosis were successfully performed.
25	Custon et al[29]	44	M	-	Dextrose( hypertonic glucose ) spray endoscopically	The patient did not experience further episodes of recurrent bleeding during the 6-mo follow-up. No prescribed medicines were given after the endoscopic therapy.

Table 3 Summary of pharmacologic treatments

Treatment	Ref.	Procedure/standard dosage	Efficacy	Complications/main side effects
Surgical anastomosis	[2,3,10,21,25,39,42]	Mobilization of both ends of the bowel with either sutured or stapled anastomosis.	The most effective method of eliminating the signs and symptoms	Bleeding, infection, anastomotic leak, anastomotic stricture, anesthetic risks
Corticosteroids	[2,32,33]	Hydrocortisone (100 mg per 60 mL bottle) enema is administered once daily for up to 3 wk.	Response to treatment is generally seen in 3 to 5 d.	Local pain and burning, occasionally rectal bleeding.
		Occasional treatment may be given for 2 to 3 mo depending on clinical response.		Prolonged treatment may result in systemic absorption, causing systemic side effects.
5-aminosalicylic acid (5-ASA) enemas	[31,43,63,64]	4 g of mesalazine in 60 mL suspensions, administered rectally once-daily dose for 4 to 5 wk.	Varying effect	Occasionally produces acute intolerance manifested by cramping, acute abdominal pain, bloody diarrhea, fever, headache, and rash.
Short-chain-fatty acid (SCFA)	[5,10,13,18,19,26,27,61,62]	SCFA enema rectally twice a day for 2 wk, and then tapered according to response over 2 to 4 wk.	Varying effect	None
Irrigation with Fibers	[65,66]	Solution containing 5% fibers (10 g/d) for 7 d.	The endoscopic score which is used to quantify the intensity of the inflammation at the mucosa at the diverted colon diminished after treatment.	Probably none
Leukocytapheresis	[44]	Leukocytapheresis, at flow rate of 40 mL/min for 60 min, once weekly for 5 wk, following low dose of metronidazole and ciprofloxacin, another set of weekly leukocytapheresis was added.	Significant improvement in her pouchitis disease activity index (PDAI) from 14 to 1.	The common side effects were nausea, vomiting, fever, chills, and nasal obstruction.
Autologous fecal transplantation	[45]	Feces were collected from the colostomy bag, diluted with 600 ml of sterile saline (0.9 %), stirred and filtered three times using an ordinary coffee filter, irrigation endoscopically. This procedure was repeated 3 times within 4 wk (on day 0, day 10 and day 28).	All symptoms improved dramatically within 5 d after the first treatment. Colonoscopy 28 d after the first treatment showed no major signs of inflammation in the colonic stump	None, patient's tolerance required.
Dextrose spray (hypertonic glucose)	[29]	Endoscopically sprayed with 150 mL 50% dextrose via a catheter.	Follow-up pouchoscopy 2 wk after the dextrose spray showed normal pouch mucosa with no evidence of bleeding or mucosal friability.	It has a very low chance of causing transient hyperglycemia because there is no direct injection of the hypertonic solution into blood vessels.

SCFA: Short chain fatty acids; 5-ASA: 5-aminosalicylic acid.