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A condition known as diversion colitis frequently develops in segments of the colorectum after surgical diversion of the fecal stream; it persists indefinitely unless the excluded segment is reanastomosed. The disease is characterized by bleeding from inflamed colonic mucosa that mimics the bleeding of idiopathic inflammatory bowel disease, and it may culminate in stricture formation. We hypothesized that this condition is caused by the absence of luminal short-chain fatty acids, the preferred metabolic substrates of colonic epithelium. We studied four patients with diversion colitis, none of whom had evidence of Crohn's, idiopathic ulcerative, or infectious colitis. The excluded segment of the rectosigmoid contained negligible concentrations of short-chain fatty acids. When D-glucose was instilled, it did not undergo appreciable anaerobic fermentation. Instillation of a solution containing short-chain fatty acids twice daily resulted in the disappearance of symptoms and the inflammatory changes observed at endoscopy, over a period of four to six weeks. Remission has been maintained for up to 14 months (in one patient) by instillation daily to twice weekly. Administering enemas containing isotonic saline, or omitting treatment for periods of two to four weeks during the regimen, by contrast, did not produce any improvement or rapid relapse of the colitis. Histologic observation revealed a distinctive type of mucosal inflammation that resolved more slowly and less completely than the gross appearance of the inflamed mucosa. From these preliminary studies we infer that diversion colitis may represent an inflammatory state resulting from a nutritional deficiency in the lumen of the colonic epithelium, which is effectively treated by local application of short-chain fatty acids, the missing nutrients.

We report a case of diversion rectocolitis, an inflammatory process that frequently develops in the distal blind colorectum, after surgical diversion of the fecal stream. Since the endoscopic and histologic findings closely resemble those of inflammatory bowel disease, the differential diagnosis can be difficult. However, the inflammation permanently resolves after surgical reanastomosis. Because diversion colitis can also be treated effectively by local application of short-chain fatty acids, it has been postulated that a local nutritional deficiency, resulting from the absence of these acids, triggers the inflammation.

Nonspecific colitis, histologically similar to ulcerative colitis, may be seen in the defunctionalized colon of patients who have undergone fecal diversion for indications other than inflammatory bowel disease. Little is known about this entity, which may have important diagnostic and therapeutic implications in any patient who undergoes fecal diversion. A case of symptomatic diversion colitis is presented. A review of the records of all patients who underwent fecal diversion in our hospital between 1978 and 1983 yielded one additional patient with asymptomatic colitis in the defunctionalized rectum. Further review of the literature produced only two articles pertaining to diversion colitis, underscoring the lack of recognition of this entity in this group of patients.

We compared the rectal microflora of 16 patients with surgically excluded colorectum with 16 healthy controls. The cause of diversion was inflammatory bowel disease (n = 10), colon cancer (n = 3), miscellaneous (n = 3). Six patients had a diversion colitis. In the excluded colorectum, the total bacterial count was only slightly lower than controls but the variety of the flora was significantly reduced. This reduction was confined to strict anaerobes, mainly the genus Eubacterium and Bifidobacterium. Among aerobes, enterobacteria were more often isolated than in controls. This altered microflora of excluded colorectum could be involved in the mucosal damage observed in some cases.

The dependence of cells of the colonic epithelium upon lumenal short-chain fatty acids (SCFA) for some of their energy supply is well known. SCFA (mainly acetic, propionic, and n-butyric acids) comprise the predominant solutes in the aqueous phase of colonic contents and are produced by anaerobic bacterial fermentation of polysaccharides. Acetic acid is the principal fatty acid, but n-butyric acid is the preferred energy source for colonocytes, both in normal human colon and in colons of patients with ulcerative colitis. Four patients with diversion colitis, an inflammatory process in surgically excluded colon and rectum, were successfully treated by colonic instillation of a solution of mixed SCFA. This review examines the evidence that diversion colitis may be a new type of nutritional-deficiency syndrome based upon a local mucosal requirement for SCFA.

Background Diversion colitis (DC) seems to be common in stoma patients, and the restoration of the continuity of the digestive tract is crucial for relief from the inflammatory process. No prospective studies of the late effects of DC on the lower gastrointestinal (GI) tract mucosa and the clinical condition of patients have been reported. Methods Data from 23 patients who underwent stoma creation were analysed during the reversal period (A) and at an average of 3 months (B1) and 5.6 years (B2) after restoration of GI tract continuity. Every monitoring visit included endoscopy, histology and assessment of the clinical condition of patients. Results Shortly after GI tract restoration (B1), a significant decrease in inflammation was observed. The Ki67 positivity percentage increased, but this was not significant. At an average of 5.6 years after restoration (group B2), the clinical symptoms were mild. More patients presented with endoscopically detected inflammation of the mucosa, but its severity was not significantly higher than that at 3 months after reversal. Histological inflammation was more common, and its severity was significantly higher than that shortly after reversal but similar to that before reversal. The Ki67 positivity percentage decreased at the last examination (B2). Conclusions The results of this study show a complex recurrence of histological inflammation several years after GI tract restoration but without clinical and endoscopic inflammation and with good clinical condition. DC can potentially have a late influence on the rectal mucosa, even after stoma closure.

Diversion colitis (DC) involves nonspecific colonic inflammation following surgical diversion of the fecal stream away from the upstream colon. Although most patients are asymptomatic, endoscopic evidence of DC can be found in the majority of patients after diversion. Clinical symptoms include abdominal pain or discomfort, tenemus, and rectal bleeding and discharge. Endoscopically, mucosal edema, erythema, friability, erosions or ulcerations, exudates, and mucosal nodularity can be observed. Histopathologically, diffuse inflammation, crypt architectural abnormalities, crypt abscesses or atrophy, and lymphoid follicular hyperplasia can be seen. The colonic inflammation is generally mild and limited to the mucosa. The pathogenesis of DC is unclear. Restoring the fecal stream to the affected colon segment reverses DC. Conservative treatment options, such as enemas, may offer symptomatic improvement. In this video presentation, the endoscopic and pathological findings associated with DC are described. This article is part of an expert video encyclopedia.