Chemical colitis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Qasim Salau, M.B.B.S., FMCPaed [2]

Synonyms and Keywords: Disinfectant colitis, Corrosive colitis, Iatrogenic colitis.

Overview

Chemical colitis is inflammation of the large intestine or colon, caused by the introduction of harsh chemicals to the colon by an enema or other anorectal procedures. Chemical colitis can resemble ulcerative colitis, infectious colitis and pseudomembranous colitis endoscopically. Prior to 1950, hydrogen peroxide enemas were commonly used for certain conditions. This practice will often result in chemical colitis. Soap enemas may also cause chemical colitis. Harsh chemicals, such as compounds used to clean colonoscopes, are sometimes accidentally introduced into the colon during colonoscopy or other procedures. This can also lead to chemical colitis. Chemical colitis may trigger a flare of ulcerative colitis or Crohn's disease.

Historical Perspective

  • The first description of chemical colitis was by Pinnock (1937), Murray (1937), and Gabriel (1937) when they reported deaths following use of soapsuds enemas.[1]
  • In 1945, Barker described acute colitis from soapsuds enema.[2]
  • In 1945, Bendit reported rectal gangrene following soap enema. Turrell further described that xray findings may be confusing following chemical colitis.[1]
  • Sheehan and Bryjolfsson in 1960, reported ulcerative colitis following self-administration of hydrogen peroxide enema.[3]
  • Since the earlier description, several cases of chemical colitis have been reported from glutaraldehyde or hydrogen peroxide used for cleansing endoscopes.[4][5][6]

Classification

There is no established classification system for chemical colitis. However, chemical colitis may be classified based on the mechanism or the causative chemical.

Classification based on the mechanism

Based on the mechanism, chemical colitis can be classified into:

  • Accidental (most common) or non-accidental

Classification based on the causative chemical

Chemical colitis can be classified based on the causative chemical such as:[4]

Pathophysiology

Pathogenesis

Chemical colitis usually results from accidental or intentional rectal introduction of chemicals such as endoscopy cleaning solutions (glutaraldehyde and hydrogen peroxide), radiologic contrast material, hydrogen peroxide, soaps, formalin, hydrofluoric acid, alcohol, ammonia, lye, hot water, and herbal substances. Rarely it could occur following accidental ingestion of chemicals, such as accidental swallowing of hydrogen peroxide mouthwash during oral procedures.[7][4][8][9][10][5]

  • The most common implicated chemical agents in the pathogenesis of chemical colitis are glutaraldehyde and/or hydrogen peroxide disinfectants. The improper cleaning of the endoscopes allows the disinfectants to remain on the endoscopes, subsequently causing a chemical proctocolitis when the endoscopes are used.
  • The main mechanism for developing chemical colitis is the direct contact of the chemical agent with the mucosa, subsequently causing corrosive injury to the mucosa and activation of the inflammatory pathway. Reactive oxygen formation, lipid peroxidation and vascular smooth muscle contraction also occur in hydrogen peroxide-induced chemical colitis.
  • The primary mucosa toxin in glutaraldehyde is not fully known. However, it may be related to aldehyde. In addition to direct damage, glutaraldehyde is thought to activate arachidonic acid pathway and recruitment of inflammatory cells and substances. [9]
  • The symptoms of chemical colitis typically develop within 48 hours, often less than 12 hours after introduction of the chemical, but may sometimes take days to weeks when frequent small dilute amount is ingested.[5]

Genetics

There are no identified genetic factors associated with chemical colitis.

Gross Pathology

Gross pathology findings in most cases shows predominant superficial mucosa involvement. The mucosa is erythematous, friable, edematous with areas of necrosis. Also, multiple shallow mucosal ulcers with fibrinous and/ or purulent exudate and hemorrhage are present. In addition, in hydrogen peroxide-induced colitis, gas may be seen in the colonic wall.[4][11][12]

Microscopic Histopathology

Differentiating chemical colitis from other Diseases

Chemical colitis must be differentiated from other causes of bloody diarrhea, especially acute causes and abdominal pain. Although the symptoms of chemical colitis may overlap with other causes of colitis, history of prior use of enema containing a known chemical agent shortly before onset of symptom will help in distinguishing the cause.


Diseases History and Symptoms Physical Examination Laboratory findings
Diarrhea Rectal bleeding Abdominal pain Atopy Dehydration Fever Hypotension Malnutrition Blood in stool (frank or occult) Microorganism in stool Pseudomembranes on endoscopy Lab Test 4
Allergic Colitis + ++ + ++ ++
Chemical colitis + ++ ++ + + ++ +
Infectious colitis ++ ++ ++ +++ +++ ++ + ++ ++ +
Radiation colitis + ++ + + + ++
Ischemic colitis + + ++ + + + + ++
Drug-induced colitis + + ++ + ++ +

Epidemiology and Demographics

The overall prevalence and incidence of chemical colitis is not known.[4]

Epidemiology

The overall prevalence and incidence of chemical colitis are not known. Although, most reports of chemical colitis have been related to inadvertent residual contamination of endoscopes with the disinfectants glutaraldehyde and/ or hydrogen peroxide or following radio-contrast studies.

  • The incidence of glutaraldehyde-induced colitis ranges from 0.1% to 4.7%.

Demography

Age

Patient of all age group can develop chemical colitis. However, the incidence of may be higher in elderly due to increased frequency of diagnostic and/ or therapeutic endoscopy in this age group.

Gender

The prevalence and incidence of chemical colitis does not vary by gender.

Race

There is no racial predilection to chemical colitis.

Risk Factors

The common risk factors for developing chemical colitis include:[4]

Screening

There are no established screening guidelines for chemical colitis[15]

Natural History, Complications and Prognosis

Natural History

The symptoms and course of chemical colitis is highly variable. The severity and extent chemical colitis depend on the type of chemical agent, the concentration of the chemical agent, the quantity and duration of use the chemical agent. The symptoms often develop insidiously within 48 hours of the procedure and resolve following a period of bowel rest and symptomatic treatment.[4][5][6]

Complications

Complications of chemical colitis include[4][5][6][16]

Prognosis

The prognosis of chemical colitis varies with the type of chemical. However, prognosis is generally good with resolution of symptoms following treatment. [4]

Diagnosis

Diagnostic Criteria

There is no definitive diagnostic criteria for chemical colitis. Diagnosis of chemical colitis is primarily clinical, based on detailed history, physical examination and endoscopic findings.

History and Symptoms

Obtaining a complete history including any anorectal procedure done and recent use of enemas is important in making a diagnosis of chemical colitis. Symptoms of chemical colitis are not specific, and the severity depends on the type of chemical. Therefore, diagnosis of chemical colitis should be suspected in any individual who presents acutely (typically within 12 hours) with intestinal symptoms and has a prior history of endoscopy and/ or administration of enema. Common symptoms of chemical colitis include.[4][5][6][8][17]

Physical Examination

Physical examination findings in patients with chemical colitis may reveal:[4]

  • Abdominal tenderness which may be more prominent in lower abdominal quadrants due to involvement of the distal sigmoid colon and/ or rectum
  • Signs of dehydration such as lethargy, Tachycardia and Hypotension
  • Fever due to dehydration or in individuals who have developed sepsis
  • Pallor
  • Toxic appearance in those with bowel perforation and sepsis

Laboratory Findings

There are no specific laboratory findings associated with chemical colitis. Initial investigations should include hematological, biochemistry profiles and stool examination.[4]

Hematology

Electolytes

Stool Examination

Stool analysis may show

Endoscopy

Endoscopy is required for confirmation of chemical colitis. Endoscopic features of chemical colitis include.[4][18][19]

Other Diagnostic Studies

Other diagnostic test include

CT scan

Abdominal CT scan may show characteristic homogenous thickened colonic wall (target sign) in glutaraldehyde-induced chemical colitis[4]

Xray

There is no specific Xray feature of chemical colitis. However, it may help to rule out complications such as intestinal obstruction and perforation.

Treatment

Majority of patients with chemical colitis can be managed medically.[4][18]

Medical Therapy

Medical treatment involves

Surgical Therapy

Surgical intervention may occasionally be required in chemical colitis. It is usually reserved for management of complications such as bowel perforation and stenosis.

Prevention

Primary prevention

There is presently no established method of prevention for chemical colitis. However, endoscopy probes should be properly rinsed after cleansing with disinfectant to avoid inadvertent exposure that may cause chemical colitis.

Secondary prevention

There are no secondary prevention methods for chemical colitis.

References

  1. 1.0 1.1 Smith D (1967). "Severe anaphylactic reaction after a soap enema". Br Med J. 4 (5573): 215. PMC 1748582. PMID 6053991.
  2. Barker CS (1945). "Acute Colitis Resulting from Soapsuds Enema". Can Med Assoc J. 52 (3): 285. PMC 1582117. PMID 20323382.
  3. SHEEHAN JF, BRYNJOLFSSON G (1960). "Ulcerative colitis following hydrogen peroxide enema: case report and experimental production with transient emphysema of colonic wall and gas embolism". Lab Invest. 9: 150–68. PMID 14445720.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 Sheibani S, Gerson LB (2008). "Chemical colitis". J Clin Gastroenterol. 42 (2): 115–21. doi:10.1097/MCG.0b013e318151470e. PMID 18209577.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 Zanelli M, Ragazzi M, De Marco L (2016). "Chemical gastritis and colitis related to hydrogen peroxide mouthwash". Br J Clin Pharmacol. doi:10.1111/bcp.13100. PMID 27696496.
  6. 6.0 6.1 6.2 6.3 Love BL, Siddiqui S, McCallum BJ, Helman RM (2012). "Severe chemical colitis due to hydrogen peroxide enema". J Clin Gastroenterol. 46 (1): 87. doi:10.1097/MCG.0b013e31822a288d. PMID 21857533.
  7. Tortora A, Purchiaroni F, Scarpellini E, Ojetti V, Gabrielli M, Vitale G; et al. (2012). "Colitides". Eur Rev Med Pharmacol Sci. 16 (13): 1795–805. PMID 23208963.
  8. 8.0 8.1 Lim CH, Lee HY, Kim WC, Cho SH, Jeong HS, Jeon YJ; et al. (2011). "[A case of chemical colitis caused by hydrogen peroxide enema]". Korean J Gastroenterol. 58 (2): 100–2. PMID 21873825.
  9. 9.0 9.1 West AB, Kuan SF, Bennick M, Lagarde S (1995). "Glutaraldehyde colitis following endoscopy: clinical and pathological features and investigation of an outbreak". Gastroenterology. 108 (4): 1250–5. PMID 7698592.
  10. Shih HY, Wu DC, Huang WT, Chang YY, Yu FJ (2011). "Glutaraldehyde-induced colitis: case reports and literature review". Kaohsiung J Med Sci. 27 (12): 577–80. doi:10.1016/j.kjms.2011.06.036. PMID 22208542.
  11. 11.0 11.1 Kara M, Turan I, Polat Z, Dogru T, Bagci S (2010). "Chemical colitis caused by peracetic acid or hydrogen peroxide: a challenging dilemma". Endoscopy. 42 Suppl 2: E3–4. doi:10.1055/s-0029-1215260. PMID 20066605.
  12. 12.0 12.1 Morini S, Campo SM, Zullo A, Guarini A, Ridola L, Hassan C (2009). "Chemical colitis induced by peracetic acid: further evidence". Endoscopy. 41 (4): 383. doi:10.1055/s-0029-1214493. PMID 19340747.
  13. Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.
  14. Khan AM, Faruque AS, Hossain MS, Sattar S, Fuchs GJ, Salam MA (2004). "Plesiomonas shigelloides-associated diarrhoea in Bangladeshi children: a hospital-based surveillance study". J Trop Pediatr. 50 (6): 354–6. doi:10.1093/tropej/50.6.354. PMID 15537721.
  15. US preventive service task force.chemical colitis. http://www.uspreventiveservicestaskforce.org/accessed on December 5, 2016
  16. Pietsch JB, Shizgal HM, Meakins JL (1977). "Injury by hypertonic phosphate enema". Can Med Assoc J. 116 (10): 1169–70. PMC 1879475. PMID 861870.
  17. Desai Y, Orledge J (2010). "Chemical colitis from a hydrogen peroxide enema". J Miss State Med Assoc. 51 (11): 314–6. PMID 21365964.
  18. 18.0 18.1 Stein BL, Lamoureux E, Miller M, Vasilevsky CA, Julien L, Gordon PH (2001). "Glutaraldehyde-induced colitis". Can J Surg. 44 (2): 113–6. PMC 3695104. PMID 11308232.
  19. Bilotta JJ, Waye JD (1989). "Hydrogen peroxide enteritis: the "snow white" sign". Gastrointest Endosc. 35 (5): 428–30. PMID 2792676.



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