Tuesday, 3 December 2013

Indeterminate colitis and Atypical colitis - Treatments in Conventional medicine

Colitis is defined as a condition of inflammation of the large intestine, including the colon, caecum and rectum.
A. In conventional medicine perspective

A.6. Indeterminate colitis and Atypical colitis
A.6.1. Indeterminate colitis
Indeterminate colitis (IC) originally referred to those 10–15% of cases of inflammatory bowel disease (IBD) in which there was difficulty distinguishing between ulcerative colitis (UC) and Crohn’s disease (CD) in the colectomy specimen(104). Other researchers defined that a diagnosis of indeterminate colitis (IC) is based on endoscopic, histologic, and radiologic findings when the criteria for either Crohn's colitis or ulcerative colitis (UC) cannot be definitively established(105). Others indicated that most cases of IC represent UC upon long-term clinical follow-up. Although, in some instances, serologic testing for ANCA or ASCA may be helpful in separating UC from CD in patients with IC, there is much overlap in the results of these assays for cases in which CD involves the colon in a UC-like pattern. Approximately 20% of IC patients develop severe pouch complications, which is intermediate in frequency between that seen in ulcerative colitis (UC) or CD. The risk of pouch complications, such as perianal fistulas or abscesses, and the risk of pouch breakdown is, overall, quite similar between IC and UC patients, supporting the notion that most patients with IC probably have UC and can safely undergo an ileal pouch-anal anastomosis (a procedure involves the creation of a pouch of small intestine to recreate the removed rectum) procedure and have a reasonably good chance of having a good outcome(106).
According to the study by Center for Crohn's and Colitis, Brigham and Women's Hospital, no studies have been undertaken to determine the optimum treatment regimen for IC. Recent studies have shown that patients with IC are still appropriate candidates for ileal pouch anal anastomosis. In conclusion, the current data support the premise that IC may be a separate entity, but future studies will have to focus on the genotypic and phenotypic characterization of these patients(107).
1. Medical therapy
Medication used to  treatment commonly in treating IBD,  is also being used in IC.
2. Surgical therapy
Total proctocolectomy and ileal pouch-anal anastomosis (IPAA) has become the surgical treatment of choice for a large number of patients with UC(108).

A.6.2. Atypical colitis
Treatment of atypical colitis is dependence to the differentiation
1. C. difficile colitis
According to the study by St. Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, in patients with cystic fibrosis, imaging findings of a pancolitis should raise the possibility of C. difficile colitis despite the lack of watery diarrhea. Anticlostridial treatment can be initiated before bacteriologic confirmation is obtained(109).

2. Atypical forms of microscopic colitis
Microscopic colitis is defined as a syndrome of chronic watery diarrhea with a chronic inflammatory cell infiltrate in the colonic mucosa but without significant abnormalities at colonoscopy. According to the study by St. Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, by considering the clinical history and symptoms, the pathologist should be able to reach the correct diagnosis in most cases. However, the spectrum of morphologic changes associated with watery diarrhea syndrome appears to be broader than originally thought. Morphologic changes more often associated with chronic inflammatory bowel disease or even chronic ischemic or infectious colitis have been noted in patients with clinically established microscopic colitis. The data presented in this article suggest that microscopic colitis is a heterogeneous entity, which includes both classic and "atypical" forms(110).

3. Atypical allergic colitis
There is a report of  2 atypical cases of colitis due to cow's milk protein intolerance (CMPI) are reported, affecting preterm infants. One developed a toxic dilatation of the colon and responded well to a casein hydrolysate based feed. The second presented insidiously and failed to tolerate a casein hydrolysate, but responded well to a chicken-based modular feed(111)

4. Etc.
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(107) http://www.ncbi.nlm.nih.gov/pubmed/15115931
(108) www.annalsgastro.gr/index.php/annalsgastro/article/download/681/497 
(109) http://www.ncbi.nlm.nih.gov/pubmed/9930816
(110) http://www.ncbi.nlm.nih.gov/pubmed/16096382 
(111) http://www.ncbi.nlm.nih.gov/pubmed/1750352

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