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Saturday, 26 October 2013

Colitis

Colitis is defined as a condition of inflammation of the large intestine, including the colon, caecum and rectum.

I. Types of Colitis
According to the study by Catholic University of the Sacred Heart, types of colitis include
microscopic colitis, ischemic colitis, segmental colitis associated with diverticula, radiation colitis, diversion colitis, eosinophilic colitis and Behcet's colitis(a).

II. Symptoms
1. Adnomial pain and Diarrhea
There is a report of a 25-year-old Iranian gentleman was admitted to hospital with severe bloody diarrhoea and abdominal pain as a result of herbal induced weight loss adversed effects. On flexible sigmoidoscopy, a continuous length of congested mucosa with multiple small ulcers was seen extending up to the mid-transverse colon, in keeping with ulcerative colitis, according to the study by
Homerton University Hospital NHS Foundation Trust(1)

2. Bleeding per rectum
Acute ischaemic colitis (AIC) is being increasingly recognised as an uncommon cause of abdominal pain associated with fresh bleeding per rectum and and diarrhoea,  according to the study by University Central Hospital(2).

3.  Distention with bloody diarrhea
The typical clinical presentation is acute sudden abdominal pain and distention with bloody diarrhea(3).

4. Abdominal bloating and flatulence
In the study to estimate the prevalence of microscopic colitis and SIBO in patients with IBS, to evaluate the symptoms and the efficacy of treatment found that out of the 132 patients initially diagnosed with IBS 3% (n=4) had microscopic colitis and 43.9% (n=58) had SIBO. Diarrhea was the main symptom in patients with microscopic colitis and SIBO (p=0.041), while abdominal painabdominal bloating and flatulence were prominent in IBS patients (p=0.042; p=0.039; p=0.048)(4).

5. Changes in bowel habits
Abdominal pain, bloating, early satiety, and changes in bowel habits are common presenting symptoms in individuals with functional GI disorders(5).

6. Fever and severe dehidration
There is a report of a 19-year-old man with a 1-year history of ulcerative colitis presented with fever, bloody diarrhea and severe dehidration. He was on po.48 mg methylprednisolon and 3 g mesalazine daily, and has recently finished taking chlarythromycin for Campylobacter jejuni infection(6).

7. Urgency
In the study to examine the differing perspectives and perceptual gaps relating to ulcerative colitis (UC) symptoms and their management between patients and healthcare professionals (HCPs), indicated that fifty-five percent of patients stated that UC symptoms over the past year had affected their quality of life, while physicians and nurses estimated that 35% to 37% of patients would have a reduced quality of life over the same period. Patients ranked urgency and pain as the most bothersome symptoms(7)

8. Other symptoms
There is a report of a case of a 51-year-old Caucasian male who was evaluated for abdominal pain, elevated liver enzymes, leukopenia, thrombocytopenia, severe peripheral arthralgias, and chronic watery diarrhea as result of granulomatous enterocolitis. due to Sarcoidosis(8). Other study conducted by Anhui University of Traditional Chinese Medicine, with rats in the model group showed lethargy, poor appetite, loss of energy, diarrhea and bloody stool(9).

III. Causes and Risk factors
A.1. Causes The causes of colitis as a result of types
A.1.1. Inflammatory bowel disease (IBD)(Ulcerative colitis and Crohn's disease)
1. Ulcerative colitis
The pathogenesis of inflammatory bowel disease (IBD) is multifactorial, with some patients presenting additional autoimmune symptoms.. In the study to describe these features, in order to differentiate a subgroup of colitis associated with autoimmunity (CAI) from CUC and  28 consecutive children with inflammatory colitis associated with primary sclerosing cholangitis (PSC), celiac disease, or AI hepatitis were compared with a matched control group of 27 children with isolated UC., by the Hôpital Necker-Enfants Malades, Service de Gastroentérologie pédiatrique, showed that in CAI the main digestive symptoms at disease onset were abdominal pain (12/28) and bloody strings in the stool (12/28), along with a high prevalence of autoimmune diseases in relatives, as compared with bloody diarrhea in the ulcerative colitis (CUC) group (26/27)(9a).

2. Crohn's disease
Crohn's disease and ulcerative colitis evolve with a relapsing and remitting course. In the study of included 63 ulcerative colitis (UC) and 41 Crohn's disease (CD) patients. Forty-seven healthy patients were included as the control group for the determination of the frequency and factors of prolonged QT dispersion that may lead to severe ventricular arrhythmias in patients with inflammatory bowel disease (IBD), indicated that  prolonged QTcd was found in 12.2% of UC patients, and in 14.5% of CD patients compared with the control group (P < 0.05). A significant difference was found between the insulin values (CD: 10.95 ± 6.10 vs 6.44 ± 3.28, P < 0.05; UC: 10.88 ± 7.19 vs 7.20 ± 4.54, P < 0.05) and HOMA (CD: 2.56 ± 1.43 vs 1.42 ± 0.75, P < 0.05; UC: 2.94 ± 1.88 vs 1.90 ± 1.09, P < 0.05) in UC and CD patients with and without prolonged QTcd(9b).

A.1.2. Microscopic colitis (Collagenous and lymphocytic colitis)
Microscopic colitis may be defined as a clinical syndrome, of unknown etiology, consisting of chronic watery diarrhea, with no alterations in the large bowel at the endoscopic and radiologic evaluation. According to the study by University of Sacred Heart, the epidemiological impact of this disease has become increasingly clear in the last years, with most data coming from Western countries. Microscopic colitis includes two histological subtypes [collagenous colitis (CC) and lymphocytic colitis (LC)] with no differences in clinical presentation and management(10).
Other researchers indicated that Collagenous and lymphocytic colitis are well-described conditions causing chronic watery diarrhoea. A peak incidence from 60 to 70 years of age with a female predominance mainly in collagenous colitis is observed. Both conditions are characterised by a (near) normal colonoscopy, but with specific histologic findings on colonic biopsies. Histopathologically, both conditions are characterised by distinct epithelial abnormalities and a dense lymphoplasmocytic infiltrate. Distinct features consist of a characteristic collagen band deposition in the subepithelial layer in collagenous colitis and a markedly increased number of intra-epithelial lymphocytes in lymphocytic colitis(10a)
a. Collagenous colitis (CC)
Collagenous colitis (CC), a form of microscopic colitis, is characterized by a thick subepithelial collagen layer in the colon in the presence of chronic nonbloody watery diarrhoea and macroscopically normal-appearing colonic mucosa. According to the Hepatology and Nutrition, The Hospital for Sick Children, typically affecting elderly adults, CC is rare in children with only 12 cases previously reported in the literature, but we report a case of a 4-year-old girl with CC associated with eosinophilic gastritis(10b).

b. Lymphocytic colitis
In the study to evaluate the biopsy specimens from the terminal ileum of 32 patients with the histopathological diagnosis of lymphocytic colitis or collagenous colitis and 11 control individuals  for the presence or absence of ileal mucosal abnormalities and for the number of intraepithelial lymphocytes, assessed by immunohistochemical stains for the pan T-cell marker, CD3, showed that the mean CD3 counts in patients with lymphocytic/collagenous colitis were significantly higher than those in the control group. Seven of 14 patients with collagenous colitis and 14 of 18 patients with lymphocytic colitis revealed an increase in intraepithelial T lymphocytes when compared with the control group (P =.001). Other notable changes included ileal villous atrophy in one case of lymphocytic colitis and in three cases of collagenous colitis and epithelial damage with thickened subepithelial collagen in two cases of collagenous colitis(10c).

A.1.3. Iatrogenesis
May be as a result of chance, medical error, negligence, social control, unexamined instrument design, etc.
1. Diversion colitis
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. 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,  according to the study by Department of Medicine, Medical College of Wisconsin(10d)

2. Chemical colitis
Chemical colitis can occur as a result of accidental contamination of endoscopes or by intentional or accidental administration of enemas containing various chemicals. Most cases have occurred after accidental contamination of endoscopes with glutaraldehyde and/or hydrogen peroxide. There have been multiple case reports of chemical colitis resulting from unintentional administration of caustic chemicals. Intentional administration of corrosive enemas has been implicated in sexual practices, bowel cleansing, or in suicide attempts. Patients present with nonspecific symptoms including abdominal pain, rectal bleeding, and/or diarrhea, according to the study byStanford University School of Medicine, Stanford(10e).

A.1.4. Ischemic colitis
Ischemic colitis is the most common form of ischemic injury of the gastrointestinal tract and can present either as an occlusive or a non-occlusive form. It accounts for 1 in 1000 hospitalizations but its incidence is underestimated because it often has a mild and transient nature. The etiology of ischemic colitis is multifactorial and the clinical presentation variable, according to the study by
Gastroenterology Unit Venizelion General Hospital of Heraklion(10f). Other study indicated that ischemic colitis is the most common manifestation of gastrointestinal ischemia. The presumed etiologies are numerous; however, it typically develops spontaneously. It is classified into the transient type, stricture type, and gangrenous type. The majority of patients with ischemic colitis, excluding the gangrenous type, follow a benign clinical course in the absence of major vasculature occlusion. It usually presents as an acute abdominal illness with bloody diarrhea(10g).

A.1.5. Infectious colitis (Clostridium difficile colitis)
In the study of diagnosis of Clostridium difficile colitis is increasing in frequency, with worsening patient outcomes of the data of one hundred fifty-seven patients diagnosed with C difficile colitis between 1994-2000., conducted by University of Washington, showed that the frequency of C difficile colitis remains high and seems to be associated with increasing mortality. Among patients with positive C difficile toxin assay results, immunocompromise and delayed diagnosis no longer seem to be associated with higher risk for death. All patients taking antibiotics are at risk and require early recognition and aggressive medical intervention(10h). Also according to the study by Baylor College of Medicine and Kelsey Research Foundation,  infectious colitis is diagnosed in someone with diarrhea and one or more of the following: fever and/or dysentery, stools containing inflammatory markers such as leukocytes, lactoferrin, or calprotectin, or positive stool culture for an invasive or inflammatory bacterial enteropathogen including Shigella, Salmonella, Campylobacter, Shiga toxin-producing Escherichia coli (STEC) or Clostridium difficile, or colonic inflammation by endoscopy(10i).

A.1.6. Indeterminate colitis and Atypical colitis
1. Indeterminate colitis(IC)
The term indeterminate colitis (IC) is an interim, or preliminary, descriptive term used by pathologists for cases of inflammatory bowel disease (IBD) in which a definite diagnosis of ulcerative colitis (UC) or Crohn's disease (CD) cannot be established based on the information available at the time of surgical sign-out. Most cases are due to fulminant ulcerative colitis, a condition in which the classic pathologic features of UC are often obscured and may overlap with CD. For instance, fulminant UC may show early superficial fissuring ulceration, transmural lymphoid aggregates and relative rectal sparing, simulating CD. Other common causes for establishing a diagnosis of IC include confusion of backwash ileitis in UC for terminal ileal involvement in CD, failure to accept hard criteria, such as granulomas, or segmental disease, as representative of CD, and failure to recognize unusual variants of UC that can cause CD-like patchiness of disease(10k).
Approximately 4% to 5% of all patients with inflammatory bowel disease will be left with the diagnosis of IC. 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. Population-based studies have demonstrated that the average annual incidence of IC ranges 1.6 to 2.4/100,000 versus 7.3 to 13.6/100,000 for UC. At the time of initial diagnosis of inflammatory bowel disease, up to 10% to 15% of patients will be diagnosed as having IC, according to the study by Brigham and Women's Hospital(10j).

2. Atypical colitis
Atypical colitis is a phrase used to define  a colitis that does not conform to criteria for accepted types of colitis. 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, according to the study by St. Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust(10l).

A.1.7. Fulminant colitis
Fulminant colitis is defined as any colitis that has become worse rapidly.
There is a report of a  33-yr-old white male presented with bloody diarrhea, leukocytosis, and left lower quadrant direct and rebound tenderness after a self-administered concentrated hydrofluoric acid enema while intoxicated from intranasal cocaine administration. Intraoperative flexible sigmoidoscopy and a gastrografin enema revealed severe mucosal ulceration and edema in the rectum and sigmoid colon. Laparotomy revealed an ulcerated, necrotic, and purulent sigmoid colon and intraperitoneal pus(10m).
Other in the review of the records of 4796 inpatients diagnosed as having C difficile colitis from January 1, 1996, to December 31, 2007, and identified 199 (4.1%) with fulminant C difficile colitis, as defined by the need for colectomy or admission to the intensive care unit for C difficile colitis, showed that the inhospital mortality rate for fulminant C difficile colitis was 34.7%. Independent predictors of mortality included the following: (1) age of 70 years or older, (2) severe leukocytosis or leukopenia (white blood cell count, >or=35 000/microL or <4000/microL) or bandemia (neutrophil bands, >or=10%), and (3) cardiorespiratory failure (intubation or vasopressors). When all 3 factors were present, the mortality rate was 57.1%; when all 3 were absent, the mortality rate was 0%. Patients who underwent colectomy had a trend toward decreased mortality rates (odds ratio, 0.49; 95% confidence interval, 0.21-1.1; P = .08). Among patients admitted primarily for fulminant C difficile colitis, care in the surgical department compared with the nonsurgical department resulted in a higher rate of operation (85.1% vs 11.2%; P < .001) and lower mortality rates (12.8% vs 39.3%; P = .001). Patients admitted directly to the surgical department had a shorter mean (SD) interval from admission to operation (0 vs 1.7 [2.8] days; P = .001)(10n).

A.2. Other causes
2. Sarcoidosis
Although clinically recognizable gastrointestinal (GI) system involvement with sarcoidosis is extremely rare, we report a case of a 51-year-old Caucasian male granulomatous as a result of Sarcoidosis. Enterocolitis Colonoscopy showed scattered right colon ulcerations and erythema. The terminal ileum appeared normal. Biopsies from the duodenum, terminal ileum, and colon showed intramucosal non-caseating granulomas with focal multinucleate giant cell formation in a background of chronic active duodenitis, ileitis, and colitis. Liver biopsy showed moderate non-specific chronic hepatitis with non-caseating granulomas present within portal and lobular parenchyma. The clinical presentations, along with biopsy results were suggestive of sarcoidosis(11).

3. Low level of both serum and tissue PON1
PON1 is known as an HDL-associated antioxidant enzyme that inhibits the oxidative modification of LDL and oxidative stress plays a role in the pathogenesis of mesenteric ischemia. According to the study to investigate the changes in PON1 activity and lipid profile in an experimental ischemic colitis model of 45male Wistar albino rats, showed that there was a significant decrease in both serum and tissue PON1 activity in ischemic colitis group (P < 0.01, for each). Similarly, arylesterase levels showed a parallel decrease in both tissue and serum of the experimental group (P < 0.01 and P < 0.001, retrospectively). MDA, an oxidative stress marker, was seen to increase in the experimental group (P < 0.01, tissue; P < 0.05, serum). In experimental group, there was a significant rise in serum total cholesterol and LDL levels (P < 0.001, for each). However, HDL level decreased significantly (P < 0.001). Triglycerides did not show any change between the groups (P > 0.05)(12).

4. Smoking, dehydration, NSAID (non-steroidal anti-inflammatory drugs) use, constipation and contraceptive use
Pathophysiology of ischemic colitis in young people is in most cases unknown. Possible contributing factors in our study were smoking, dehydration, NSAID (non-steroidal anti-inflammatory drugs) use, constipation and contraceptive use. (13a). But epidemiologic data suggest that smoking increases the risk and the severity of Crohn's disease (CD), although it may protect patients with ulcerative colitis (UC)(13), but others found no detrimental effects of smoking on the disease course of CD and no clear beneficial effects on the course of UC(14).

5. Anemia
Sickle cell-induced ischemic colitis is a rare yet potentially fatal complication of sickle cell anemia. there is a report of a 29-year-old female with sickle cell disease who was admitted with left lower quadrant abdominal pain. A diagnostic workup, including chemistries, complete blood count, blood cultures, chest x-ray, computerized tomography scanning, and colonoscopy, was performed to identify the etiology of her symptoms. This case highlights the importance of differentiating simple pain crisis from more serious and life-threatening ischemic bowel(15).

6.  Etc.

B. Risk factor
1. Medical conditions
a. Ischemic colitis is the most common type of intestinal ischemia and has a clinical spectrum of injury that ranges from mild and transient ischemia to acute fulminant colitis. Patients with medicals condition such as hypertension, diabetes, hyperlipidemia, and atrial fibrillation are associated with increased risk to develop ischemic colitis(IC), according to the study by Beijing Hospital, Ministry of Health(16)

b.. Ischemic colitis is one of the most often seen disorders of the large intestine in the elderly. Common predisposing factors are atherosclerosis, shock, and congestive heart failure, but often, elderly patients have no obvious predisposing or precipitating factors(17).

2. Age
If you are over 50, you are at increased to develop colitis. According to the study of  the records of 81 patients with colitis whose symptoms began after the age of 50 years, ischemia is the most common cause of colitis beginning in patients older than 50 years of age. Moreover, the incorrect diagnosis of idiopathic inflammatory bowel disease in a large proportion of these patients may explain why colitis has been reported to behave differently in the elderly than in the young(18).

3. Depression and psychosocial stress
In the study to analyze the data from 152,461 women (aged 29-72 years) enrolled since 1992-1993 in the Nurses' Health Study cohorts I and II, conducted by Massachusetts General Hospital and Harvard Medical School, found that On the basis of data from the Nurses' Health Study, depressive symptoms increase the risk for CD, but not UC, among women. Psychological factors might therefore contribute to development of CD(19).

4. Gender and smoking
In the study of the medical charts of 1784 adult consecutive patients (978 patients, ulcerative colitis; 118 patients, indeterminate colitis; and 688 patients, Crohn's colitis), whose smoking habits were specified by direct interview, showed that The proportion of ever smokers was 42% in ulcerative colitis, 43% in indeterminate colitis, and 61% in Crohn's colitis. Smoking cessation preceded the onset of colitis in 279 patients with ulcerative colitis or indeterminate colitis (61%) and only 52 patients (12%) with Crohn's colitis. In ulcerative colitis and indeterminate colitis, current smoking delayed mean age at disease onset in men (from 32 to 41 yr; P < 0.001), but not women (from 33 to 33 yr), and decreased the need for immunosuppressants in men (10-yr cumulative risk, 26% +/- 4% in nonsmokers vs. 8% +/- 4% in smokers; P < 0.01), but not significantly in women. Conversely, in Crohn's colitis, current smoking hastened disease onset in women (from 35 to 29 yr; P < 0.001), but not men (from 32 to 31 yr), and increased the need for immunosuppressants in women (10-yr cumulative risk, 48% +/- 5% in nonsmokers vs. 58% +/- 4% in smokers; P < 0.01), but not men(20).

5. Family history
Approximately 5 to 10 percent of patients undergoing ileal pouch-anal anastomosis with a diagnosis of ulcerative colitis are subsequently diagnosed with Crohn's disease. Acoording to the study by Cedars-Sinai Medical Center, Los Angeles, patients with ulcerative colitis and indeterminate colitis with a family history of Crohn's disease or preoperative anti-Saccharomyces cerevisiae immunoglobulin-A seropositivity are more likely to be diagnosed with Crohn's disease after ileal pouch-anal anastomosis(21).

6. Other risk factors
According to the study by, in a multivariate model, familial history of inflammatory bowel disease (odds ratio (OR) 4.3 (95% confidence interval 2.3-8)), breast feeding (OR 2.1 (1.3-3.4)), bacille Calmette-Guerin vaccination (OR 3.6 (1.1-11.9)), and history of eczema (OR 2.1 (1-4.5)) were significant risk factors for Crohn's disease whereas regular drinking of tap water was a protective factor (OR 0.56 (0.3-1)). Familial history of inflammatory bowel disease (OR 12.5 (2.2-71.4)), disease during pregnancy (OR 8.9 (1.5-52)), and bedroom sharing (OR 7.1 (1.9-27.4)) were risk factors for ulcerative colitis whereas appendicectomy was a protective factor (OR 0.06 (0.01-0.36))(21a). Also in the study by University Hospital of Heraklion, found that the logistic regression analysis showed that appendectomy and tonsillectomy have no independent association with the risk of developing ulcerative colitis, whereas in Crohn's disease both appendectomy and tonsillectomy have positive associations. Well-established risk factors, such as family history and smoking status(21b). Appendicectomy is also an environmental factors that are known to influence ulcerative colitis (UC)(21c).

IV, Complications
1. Congenital abnormalities
Women who are pregnant with Ulcerative colitis are associated with significantly increased risk of some selected congenital abnormalities (limb deficiencies, obstructive urinary and multiple congenital abnormalities) according to the birth outcomes in women with ulcerative colitis  examined in a nationwide, Danish, cohort of women based on data from the Danish National Hospital Discharge Registry and the Danish Medical Birth Registry, and within a Hungarian case-control data set(22).

2. Nutritional deficiency
It is reported that malnutrition is not a feature of Ulcerative Colitis (UC), but according to the study by the Institute of Drug Research, Faculty of Medicine, University of Toronto, ulcerative colitis and Crohn's disease are the two main entities of inflammatory bowel disease (IBD). There is an intricate relationship between IBD features in human patients, in vitro and animal colitis models, mechanisms and possible therapeutic approaches in these models, and strategies that can be extrapolated and applied in humans. Malnutrition, particularly protein-energy malnutrition and vitamin and micronutrient deficiencies, as well as dysregulation of the intestinal microbiota, are common features of IBD(23).

3. Rectovaginal fistulas
Patients with Crohn's disease are at increased risk to develop fistulas
According to the study by Kaiser Permanente Medical Center, during a 9-year period, six women with ulcerative colitis (UC) and rectovaginal fistulas were surgically treated. Three underwent ileoanal pull-through procedures with simultaneous repair of the rectovaginal fistulas. Two patients had Kock pouches, and one had a Brooke ileostomy because extensive destruction of the rectal sphincter prohibited ileoanal procedures. The three patients who had ileoanal procedures all had excellent functional results. There has been no evidence of Crohn's disease or fistula recurrence(24)

3. Other complications
Microscopic forms of colitis have been described, including collagenous colitis, a possibly heterogeneous disorder. Collagenous colitis most often appears to have an entirely benign clinical course that usually responds to limited treatment. Acording to the study by University of British Columbia, significant extracolonic disorders, especially arthritis, spondylitis, thyroiditis and skin disorders, such as pyoderma gangrenosum, dominate the clinical course and influence the treatment strategy. Colitis and toxic megacolon may develop. Concomitant gastric and small intestinal inflammatory disorders have been described including celiac disease and more extensive collagenous inflammatory disease. Colonic ulceration has been associated with the use of nonsteroidal anti-inflammatory drugs, while other forms of inflammatory bowel disease, including ulcerative colitis and Crohn disease, may evolve directly from collagenous colitis. Submucosal 'dissection', colonic fractures, or mucosal tears and perforation, possibly from air insufflation during colonoscopy, have been reported. Similar changes may result from increased intraluminal pressures that may occur during radiological imaging of the colon. Neoplastic disorders of the colon may also occur during the course of collagenous colitis, including colon carcinoma and neuroendocrine tumours (ie, carcinoids). Finally, lymphoproliferative disease has been reported(25).

4. Etc.

V. Misdiagnosis and delay diagnosis and diseases associated with colitis
A. Misdiagnosis and delay diagnosis
1. Delay diagnosis
According to the study by University Central Hospital, patients with ischaemic colitis often delay from admission to the correct diagnosis in 8 days on the average (range 2-15 days). The reasons for delayed diagnosis included suspicion of diverticulitis, Crohn's disease and bowel obstruction as well as poor general condition in one case because of which early colonoscopy was not done. It is concluded that in patients with abdominal pain, rectal bleeding and diarrhoea associated with typical clinical findings, ischaemic colitis should be suspected. This suspicion should be followed by early colonoscopy to detect the gangrenous form of the disease as early as possible(26).

2. Takayasu arteritis
Takayasu arteritis is a chronic inflammatory disease that primarily affects large arteries such as the aorta and its proximal branches. The association between Takayasu arteritis and ulcerative colitis is an extremely rare condition. Herein we report a case of Takayasu arteritis who had been misdiagnosed and treated as ulcera, according to the study by Ankara Education and Research Hospital, Department of Nephrology(27). Other study also report a case of  a 17-year-old Chinese male developed upper limb sourness and a sensation of fatigue, and his upper limb pulses were absent. He was diagnosed with TA and underwent an axillary artery bypass with autologous great saphenous vein on the left subclavian artery. After the surgery, he regained the normal blood pressure. This patient also had years of diarrhea and developed an anal canal ulcer, and was diagnosed with inflammatory bowel disease and ulcerative colitis before. Five months after the TA surgery, he was hospitalized for severe stomachache and diarrhea and was finally diagnosed with Crohn's disease(28).

3. Schistosoma-related colitis
Schaumann bodies are inclusion bodies, first described by Schaumann in 1941, typically seen in granulomatous diseases such as tuberculosis, sarcoidosis and chronic beryllium diseases. Williams WJ, in 1964, reported Schaumann bodies to occur in 10% of Crohn's disease (CD). There is a report of a case of Crohn's disease, initially misdiagnosed as a schistosoma-related colitis for the presence of numerous calcified bodies resembling calcified ova and scattered granulomas. Subsequent biopsies showed more typical histological features and, in combination with a more complete clinical history, diagnosis of Crohn's disease was made, according to the study by A.O. Spedali Civili di Brescia, Brescia(29).

4. Others
Clinical parameters helpful in differentiating intestinal tuberculosis from Crohn's disease included chest radiographic features of tuberculosis (56% v 0%), perianal fistulae (0% v 40%) and extraintestinal manifestations of Crohn's disease (0% v 40%). Histopathological features that seemed to reliably differentiate between intestinal tuberculosis and Crohn's disease included confluent granulomas, > or =10 granulomas per biopsy site and caseous necrosis (in biopsy samples of 50%, 33% and 22% of patients with intestinal tuberculosis, respectively, v 0% of patients with Crohn's disease). Features that were observed more often in patients with intestinal tuberculosis than in those with Crohn's disease included granulomas exceeding 0.05 mm(2) (67% v 8%), ulcers lined by conglomerate epithelioid histiocytes (61% v 8%) and disproportionate submucosal inflammation (67% v 10%), according to the study by University of Cape Town(30).


B. Diseases associated with colitis
1. Cholelithiasis (gallstone disease)
Cholelithiasis is considered an extraintestinal manifestation of Crohn's ileitis but has not been associated with ulcerative colitis. In the study to evaluate if an increased risk of cholelithiasis exists in patients with ulcerative colitis, biliary ultrasonography was performed on 159 patients with inflammatory bowel disease, 114 patients with ulcerative colitis, and 45 patients with Crohn's disease, indicated that there is an increased risk of gallstones in both patients with Crohn's disease (odds ratio = 3.6; 95 percent confidence limits = 1.2 - 10.4; P = 0.02) and patients with ulcerative colitis (odds ratio = 2.5; 95 percent confidence limits = 1.2 - 5.2; P = 0.01). The risk was highest in patients with Crohn's disease involving the distal ileum (odds ratio = 4.5; 95 percent confidence limits = 1.5 - 14.1; P = 0.009) and in patients with total ulcerative colitis extending to the cecum (odds ratio = 3.3; 95 percent confidence limits = 1.3 - 8.6; P = 0.01). These results confirm that there is an increased risk of gallstones in Crohn's ileitis but they show that there also exists an increased risk in patients with total ulcerative colitis(31).

2. Liver disorders
Disorders of the hepatobiliary system are relatively common extraintestinal manifestations of inflammatory bowel disease (IBD). According to the study by Department of Pediatric Gastroenterology and Hepatology, these disorders are sometimes due to a shared pathogenesis with IBD as seen in primary sclerosing cholangitis (PSC) and small-duct primary sclerosing cholangitis (small-duct PSC). There are also hepatobiliary manifestations such as cholelithiasis and portal vein thrombosis that occur due to the effects of chronic inflammation and the severity of bowel disease. Lastly, medications used in IBD such as sulfasalazine, thiopurines, and methotrexate can adversely affect the liver(32).

3. Primary sclerosing cholangitis
Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease that is associated with inflammatory bowel disease (IBD), particularly chronic ulcerative colitis and, to a lesser degree, Crohn's disease. But according to the study by Hacettepe University, in contrast to findings in Western Europe and the USA, in Turkey: 1) PSC is not regularly associated with idiopathic IBD; 2) most patients with PSC are female; 3) PSC accounts for only 18% of patients with a primary disorder of the biliary tree; 4) the incidence of small-duct primary sclerosing cholangitis is greater than that reported in the literature; and, 5) the incidence of IBD and PSC in Turkey is relatively lower than in other countries(33).

4. Eczema
In the study of nineteen mothers and babies took part in a double blind crossover trial of exclusion of egg and cows' milk, and 18 took part in open exclusion of 11 foods followed by double blind challenge to those mothers whose infants seemed to respond, indicated that the eczema improved in six infants when their mothers avoided egg and cows' milk and worsened again when these were reintroduced. Two infants suffered gastrointestinal reactions after maternal ingestion of egg and cows' milk, one developing colitis. Maternal dietary exclusion seems to benefit some breast fed babies with eczema(34).

5. Chronic polyarthritis and collagenous colitis
There is a report of a 26-year-old woman simultaneously developed chronic seronegative non-destructive polyarthritis and chronic watery diarrhoea. Biopsies from the colorectal mucosa showed a thickened subepithelial collagen layer consistent with collagenous colitis(35).

6. Atopic disease 
In the study of three hundred patients with ulcerative colitis, 200 with Crohn's disease and matched control subjects completed questionnaires about atopic disease, indicated that in ulcerative colitis asthma, hay fever, allergic rhinitis or eczema; occurred with twice the frequency, but in Crohn's disease only eczema was more common than in controls(36).

7. Asthma
Recent attention has been devoted to the respiratory manifestations that may be associated with diseases of distant organs. According to the study by Osaka City University, showed that airway microvascular hyper-permeability induced by VEGF may have a profound effect on airway function and can explain the heightened airway hyper-responsiveness characteristic of asthma associated with ulcerative colitis (UC)(37).

8. Thyroid diseases
In the study to assess the prevalence of abnormalities in the structure of the thyroid gland in IBD patients and to compare it to the control group, found that in patients with inflammatory bowel diseases focal lesions relating to tumors of the thyroid gland are more common than in the control group. In patients with ulcerative colitis enlargement of the thyroid gland is more frequent than in the control group. Initial assessments of IBD patients should include ultrasound examinations of the thyroid gland(38).

9. Psoriasis
Numerous reports have demonstrated the epidemiological, pathogenic, and genetic association between psoriasis and Crohn's disease. According to the study by Clalit Health Services, Tel Aviv, Hod Hasharon, indicated that psoriasis is associated both with Crohn's disease and ulcerative colitis. Future studies on comorbidities in patients with psoriasis should focus on ulcerative colitis(39).

10. Etc.

VI. Diagnosis
After recording family history and a complete physical examination to determine potential symptoms of colitis, if you are suspect to have developed colitis, the tests which your doctor orders may include
1. Blood tests 
The aim of the test is to read the red and white blood cell count for the possibility of bleeding causes of anemia and the sign of infection. The study of patient's Blood chemistries may ne helpful to rule other causes of symptoms, such as serious diarrhea or loss of fluid as a result of  abnormal sodium and potassium levels.

2. Stool sample
The aim of the test is to look for possibility of bacterial and parasitic infections causes of colitis. According to the study by Ghent University, patients with inflammatory bowel disease have lower numbers of Butyricicoccus bacteria in their stools. Administration of B pullicaecorum attenuates TNBS-induced colitis in rats and supernatant of B pullicaecorum cultures strengthens the epithelial barrier function by increasing the TER(40).

3. Colonoscopy 
Colonoscopy is a test with the use of a thin, flexible tube with camera attached to one end to allow your doctor to look at the inside of the colon, searching for the cause of the colitis and tumors and polyps. The instrument also can remove a sample from the mucosal lining for evaluation of the presence or cause of colitis. In the study  to compare colon capsule endoscopy (CCE) with standard colonoscopy (SC) in the assessment of mucosal disease activity and localization of inflammatory colonic mucosa in patients with known ulcerative colitis (UC), found that in considering the significantly different assessment of disease activity and significantly more appropriate assignment of the horizontal spread of inflammation by SC versus CCE, we recommend the preferential use of SC in the assessment of inflammation in UC patients(41).

4. Fecal calprotectin (FC) measurement
Faecal calprotectin proved to be an even stronger predictor of clinical relapse in UC than in CD, which makes the test a promising non-invasive tool for monitoring and optimising therapy. Increased excretion of faecal calprotectin are Crohn's disease, ulcerative colitis  and normal levels of faecal calprotectin in patients with irritable bowel syndrome (IBS) (41a).
In the study to to assess the usefulness of the FC measurement in children with various types of IBD and relation to the disease activity, by Medical University of Silesia, Medykow, found that the FC concentrations can be a useful, safe, and noninvasive test in children suspected for IBD, since FC concentration is higher in children with CD and UC than in patients with other inflammatory diseases(42).

In the study to evaluate the correlation between endoscopic activity and fecal calprotectin (FC), C-reactive protein (CRP), hemoglobin, platelets, blood leukocytes, and the Lichtiger Index (clinical score) in patients with ulcerative colitis (UC), as UC patients undergoing complete colonoscopy were prospectively enrolled and scored clinically and endoscopically. Samples from feces and blood were analyzed in UC patients and controls, showed that endoscopic disease activity correlated best with FC (Spearman's rank correlation coefficient r = 0.821), followed by the Lichtiger Index (r = 0.682), CRP (r = 0.556), platelets (r = 0.488), blood leukocytes (r = 0.401), and hemoglobin (r = -0.388). FC was the only marker that could discriminate between different grades of endoscopic activity (grade 0, 16 [10-30] μg/g; grade 1, 35 [25-48] μg/g; grade 2, 102 [44-159] μg/g; grade 3, 235 [176-319] μg/g; grade 4, 611 [406-868] μg/g; P < 0.001 for discriminating the different grades). FC with a cutoff of 57 μg/g had a sensitivity of 91% and a specificity of 90% to detect endoscopically active disease (modified Baron Index ≥2). FC correlated better with endoscopic disease activity than clinical activity, CRP, platelets, hemoglobin, and blood leukocytes. The strong correlation with endoscopic disease activity suggests that FC represents a useful biomarker for noninvasive monitoring of disease activity in UC patients(43).

VII. Preventions
A. The do and do not's list
1. Although infect millioms people every day, Infectious colitis as a result of bacterial and viral infection are difficault to inthird world due poor sanitation, poor hand washing and poor kitchen hygiene. Wash your hands before handle food.

2. Enhance your inmmune system
Excercise, proper diet, eating foods contain high amounts of antioxidant can be helpful.

3. Quit smoking
Although the incidence and severity of ulcerative colitis (UC) are higher in nonsmokers than in smokers(44), it is a remarkable risk factor for inflammatory bowel disease (IBD), aggravating Crohn's disease (CD)(45). Smoking can suppress the inmune system and enhance the production of free radicals of that can lead to infectous causes of colitis.

4. Although inflammatory bowel disease (IBD),  in most case as a result of heredity. According to the study by Vanderbilt University Medical Center, intake of semi-essential amino acid, L-arginine (L-Arg), a complementary medicine purported to be an enhancer of immunity may improves responses to injury and inflammation in dextran sulfate sodium colitis(46).

5. Protect youself from chronic diseases such as high blood pressure, high cholesterol levels, and diabetes(47)(48) as tthey increase the risk of reducing blood circulation, cauisng ischemic colitis by eating plenty fruits and vegetibles and reducing intake of fat and transfat.

6. Take your herbs with care
there is a severe, progressive case of acute ischaemic colitis related temporally to the recent ingestion of a sibutramine-containing herbal slimming agent procured on-line without prescription or medical indication in a young female that ultimately required emergency laparoscopic total colectomy with end ileostomy to prevent end organ failure(49).

7. Protect your arteries
Narrowing of the blood vessels to the bowel can increase the risk of venous thrombosis and colitis. There is a report of case of  a 22-year-old woman is reported who presented with an exacerbation of ulcerative colitis and developed extensive arterial and venous thrombosis. Good clinical improvement was achieved after treatment with steroids, sulfasalazine, and anticoagulation with enoxaparin followed by long-term warfarin(50).

8. Others
According to the study by Ninewells Hospital and Medical School, high FSS foods were characterized by high levels of the anti-thiamin additive sulfite (Mann-Whitney, p < 0.001), i.e. bitter, white wine, burgers, soft drinks from concentrates, sausages, lager and red wine. Caffeine also has anti-thiamin properties and decaffeinated coffee was associated with a better clinical state than the caffeine containing version. Beneficial foods (average intake per week) included pork (210 g), breakfast cereals (200 g), lettuce (110 g), apples and pears (390 g), milk (1250 ml), melon (350 g), bananas (350 g), bacon (120 g), beef and beef products (500 g), tomatoes (240 g), soup (700 g), citrus fruits (300 g), fish (290 g), yogurt (410 g), cheese (110 g), potatoes (710 g) and legumes (120 g)(51).

8. Etc.

B. Diet to prevent colitis
1. Glutamine, dietary fiber, and Oligosaccharide (GFO)
According to the study to whether GFO has suppressive effects on mucosal damage in ulcerative colitis in an experimental mouse model, showed that intestinal inflammation was significantly attenuated in mice treated with GFO. Furthermore, treatment with GFO significantly inhibited the dextran sulfate sodium-induced increase in the mRNA expression of interleukin-1β. As GFO may have a potential therapeutic value as an adjunct therapy for ulcerative colitis(52).

2. Low-fat diets, medium-chain triglycerides, and perhaps omega-3 fatty acids and Fermentable fiber
According to the study by , in regarding the possible therapeutic role of some dietary components in IBD, low-fat diets seem to be particularly useful. Also, some lipid sources, such as olive oil, medium-chain triglycerides, and perhaps omega-3 fatty acids, might have a therapeutic effect. Fermentable fiber may have a role in preventing relapses in inactive UC(53).

3. Avoid Zinc deficiency
Zinc deficiency may cause a modulation of TNFα production of that can influence disease activity in DSS-induced colitis(54). Other study indicated that DSS induces colonic inflammation which is modulated by the administration of anti-TNFα. Combining anti-TNFα with Zn acetate offers marginal benefit in colitis severity(55).

4. Glutamine
In the study to investigate the role of L-glutamine and short-chain fatty acids, both via enema and oral administration, on mucosal healing in experimental colitis by Uludağ University, School of Medicine, Bursa, showed that L-glutamine enema can accelerate mucosal healing and regeneration in experimentally induced colitis in rats. When compared to glutamine in this study, short-chain fatty acids showed no beneficial effect on colitis(56).

5. Soybean and fish oil mixture
Soybean and fish oil mixture may be effective in improving colonic injury and DNA damage, and it could be an important complementary therapy in UC to reduce the use of anti-inflammatory drugs and prevent colorectal cancer, according to the study by the Universidade Federal de São Paulo(57). Other suggested that the soybean and fish oil mixture, more than the fish oil alone, could be a complementary therapy to achieve a cytokine balance in UC(58).

6. Nutritional and probiotic supplementation
 Dietary supplementation with essential nutrients known to be in short supply in the diet in IBD patients and with other molecules believed to provide beneficial anti-inflammatory effects, as well as with probiotic organisms that stimulate immune functions and resistance to infection has been tested in colitis models(59).

7.  Risk of colitis in Monotonous dietary intake
The relapsing nature and varying geographical prevalence of ulcerative colitis (UC) implicates environmental factors such as diet in its aetiology study showed that
monotonous dietary intake may decrease mammalian vulnerability against colitis in association with microbiota separation(60).

8. Blueberry husks, rye bran and multi-strain probiotics
Acombination of probiotics and blueberry husks or rye bran enhanced the anti-inflammatory effects compared with probiotics or dietary fibres alone. These combinations can be used as a preventive or therapeutic approach to dietary amelioration of intestinal inflammation(61).

In summerization, we would like to quote the study by Medical Department, Viborg Regional Hospital, "Established non-diet risk factors include family predisposition, smoking, appendectomy, and antibiotics. Retrospective case-control studies are encumbered with methodological problems. Prospective studies on European cohorts, mainly including middle-aged adults, suggest that a diet high in protein from meat and fish is associated with a higher risk of inflammatory bowel disease. Intake of the n-6 polyunsaturated fatty acid linoleic acid may confer risk of ulcerative colitis, whereas n-3 polyunsaturated fatty acids may be protective. No effect was found of intake of dietary fibres, sugar, macronutrients, total energy, vitamin C, D, E, Carotene, or Retinol (vitamin A) on risk of ulcerative colitis. No prospective data was found on risk related to intake of fruits, vegetables or food microparticles (titanium dioxide and aluminium silicate)"(61a).

8. Etc.

C. Phytochemicals to prevent colitis
1. Anthocyanins (Green tea)
Sunrouge, an anthocyanin-rich tea, has similar levels of catechins as "Yabukita," the most popular green tea cultivar consumed in Japan. In the study  to determine the inhibitory effects of Sunrouge on colitis in dextran sodium sulfate (DSS)-treated and untreated control mice, conducted by Graduate School of Agriculture, Kyoto University, found that  Sunrouge improved these DSS-induced symptoms, at least in part, whereas Yabukita showed either no effect or adverse effects in regard to some those parameters. It is suggested that the differences between Yabukita and Sunrouge on DSS-induced colitis might be due to the high levels of anthocyanins found in Sunrouge tea(62).

2. Epigallocatechin-3-gallate (Green tea)
According to the study by Münster University Hospital, Albert-Schweitzer-Campus 1, the concept of anti-inflammatory properties of EGCG being generally beneficial in the DSS-model of colitis, an effect that may be mediated by its strong antioxidative potential(63).

3. Green tea extarct
Inflammatory bowel disease (IBD) is characterised by oxidative and nitrosative stress, leukocyte infiltration, and up-regulation of intercellular adhesion molecule 1 (ICAM-1) expression in the colon. According to the study to examine the effects of green tea extract in rats subjected to experimental colitis induced by intracolonic instillation of dinitrobenzene sulphonic acid (DNBS), found that treatment with green tea extract significantly attenuated diarrhoea and loss of body weight. This was associated with a remarkable amelioration of the disruption of the colonic architecture, significant reduction of colonic myeloperoxidase (MPO) and tumor necrosis factor-alpha (TNF-alpha) production. Green tea extract also reduced the appearance of nitrotyrosine immunoreactivity in the colon and reduced the up-regulation of ICAM-1(64).

4. Procyanidins (Grpae seed)
Grape seed extract (GSE) constitutes a rich source of procyanidins. GSE has been demonstrated to exert encouraging anti-inflammatory and anti-ulcer properties in experimental settings. In the study to determine the effects of GSE in a rat model of dextran sulphate sodium (DSS) for ulcerative colitis, showed that GSE decreased the severity of selected markers of DSS-induced colitis in the distal ileum and proximal colon, suggesting the potential as an adjuvant therapy for the treatment of ulcerative colitis(65).

5. Curcumin (Turmuric)
Curcumin is a widely used spice with anti-inflammatory and anticancer properties. It has been reported to have beneficial effects in experimental colitis. According to the study by The Western Hospital, First Affiliated Hospital of Guangxi Medical University, curcumin shows significant therapeutic effects on 2,4,6-trinitrobenzene sulfonic acid-induced colitis that are comparable to sulfasalazine. The anti-inflammatory actions of curcumin on colitis may involve inhibition of the TLR4/NF-κB signaling pathway and of IL-27 expression(66). Other study also indicatred that curcumin may be a safe and effective therapy for maintenance of remission in quiescent UC when given as adjunctive therapy along with mesalamine or sulfasalazine(67).

6. Resveratrol (Grape skin and seed)
According to the study by Cairo University, the anti-ulcerative effect of resveratrol in TNBS-induced experimental colitis via reduction of neutrophil infiltration, inhibition of adhesive molecules, and restoration of the nitric oxide level, as well as the redox status(68). Other study found that resveratrol effectively attenuated overall clinical scores as well as various pathological markers of colitis in IL-10(-/-) mice by down regulating Th1 responses. Resveratrol lessened the colitis-associated decrease in body weight and increased levels of serum amyloid A (SAA), CXCL10 and colon TNF-α, IL-6, RANTES, IL-12 and IL-1β concentrations(69).

7. Etc.

D. Antioxidants to prevent colitis
1. Selenium
Selenium deficiency may be implicated in the pathogenesis of some human diseases, including colon cancer. According to the study by Katedry i Zakładu Biochemii i Chemii AM, Katowicach-Ligocie, the inverse correlation between serum selenium concentration and the extension of the disease may be caused by a decreased absorption of selenium from the diseased colon in ulcerative colitis(70).

2. Tomato lycopene
In the study to investigate the effect of TLE on lipopolysaccharide (LPS)-induced innate signaling and experimental colitis, indicate that TLE prevents LPS-induced proinflammatory gene expression by blocking of NF-kappaB signaling, but aggravates DSS-induced colitis by enhancing epithelial cell apoptosis(71).

3. Myricetin
In the study to assess the protective effect of myricetin administered orally at 200, 100 or 50 mg/kg for 10 days in a murine model of acute experimental colitis induced by dextran sulphate sodium (DSS), showed that treatment with myricetin ameliorated body weight loss in a dose-dependent manner and significantly reduced histology scores. Myricetin decreased the production of nitric oxide (NO), myeloperoxidase (MPO) and malondialdehyde (MDA), while increasing the activity of superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px).  As it suggested that the anticolitis effects of myricetin may be attributed to anti-inflammatory and antioxidant actions(72).

4. Vitamin E
As  a vitamin, vitamin E is a powerful antioxidant and a scavenger of hydroxyl radicals, and it has been shown to have anti-inflammatory activities in tissues. According to the study by Istanbul University Cerrahpasa Medical Faculty, vitamin E administration suppressed these changes in the AA-induced colitis group (p < 0.001). Administration of AA resulted in increased levels of tumour necrosis factor-α, interleukin-1β, interleukin-6, myeloperoxidase and malondialdehyde, and decreased levels of glutathione and superoxide dismutase; vitamin E reversed these effects (all p < 0.001)(73).

5. Melatonin (N-acetylcysteine)
In the study to  investigate the effects of melatonin (MT) on the expression of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) in rat models of colitis, found that melatonin has a protective effect on colonic injury induced by both acetic acid and TNBS enemas, which is probably via a mechanism of local inhibition of iNOS and COX-2 expression in colonic mucosa(74). Other study also found that melatonin reduces colonic inflammatory injury through downregulating proinflammatory molecule mediated by NF-kappaB inhibition and blockade of IkappaBalpha degradation in rats with colitis(75).

6. N-acetyl-L-cysteine combined with mesalamine
According to the study by Universidad de Alcala, in the evaluation of the effectiveness and safety of oral N-acetyl-L-cysteine (NAC) co-administration with mesalamine in ulcerative colitis (UC) patients, found that Analysis per-protocol criteria showed clinical remission rates of 63% and 50% after 4 wk treatment with mesalamine plus N-acetyl-L-cysteine (group A) and mesalamine plus placebo (group B) respectively (OR = 1.71; 95% CI: 0.46 to 6.36; P = 0.19; NNT = 7.7). Oral NAC combined with mesalamine contrarily to group B (mesalamine alone), the clinical improvement correlates with a decrease of chemokines such as MCP-1 and IL-8. NAC addition not produced any side effects(76).

7. Etc.

VIII. Treatments
A. In conventional medicine perspective
Treatments in the conventional medicine is depending to the types of colitis.
A.1. Inflammatory bowel disease (IBD)
A.1.1. Non surgical therapy
1. Self care at home
a. Through home telemanagement
In a a randomized, controlled trial to evaluate a home telemanagement system for UC (UC HAT) on disease activity, quality of life (QoL), and adherence compared to best available care (BAC), showed that UC HAT did not improve disease activity, QoL, or adherence compared to BAC after 1 year,  but after adjustment for baseline disease knowledge, UC HAT trial completers experienced significant gains in disease-specific QoL from baseline compared to BAC trial completers. The results suggested a potential benefit of UC HAT. Further research is indicated to determine if telemedicine improves outcomes in patients with IBD(77).

b. Web-guided therapy
In the study to test the thesis: 1) In a European evidence based consensus to assess the IBD patients' need for Quality of Health Care (QoHC); 2) To validate the influence of a Patient Educational Center (PEC) and a web-based treatment solution program, www.constant-care.dk, on patients' disease self-management, adherence, Quality of Life, and disease course after 1 year of self-initiated 5-ASA treatment. UC patients in a conventional out-patient setting were used as controls; 3) To validate two new quantitative rapid tests (RT scanning and HT photo) for Faecal Calprotectin (FC) measurement, and to assess whether HT photo can be useful as a home test to help the patients deciding on self-initiated treatment, found that the new rapid home test (HT photo) was accurate and comparable with the Enzyme-Linked Immunosorbent Assay (ELISA) with a 90% specificity and a 96% sensitivity. The rapid test can be useful in clinical settings concerning disease self-monitoring at home, which would decrease the use of endoscopy in some cases. The findings corresponded well with action plan for a European e-Health Area and could be a helpful tool to provide more efficient health care for UC patients. Widespread implementation of the "Constant-Care" is possible, but it may require a reshaping of the current health care for IBD patients both legally and economically. It may also empower patients in disease self-management and reduce dependency on doctors(78).

3. Pain management
Abdominal pain is a common symptom in patients with inflammatory bowel disease (IBD) and has a profound negative impact on patients' lives. According to the study byUniversity Clinic of Essen, University of Duisburg-Essen,  there is growing evidence linking peripheral and mucosal immune changes and abdominal pain in IBS, supporting disturbed peripheral pain signalling. Findings in post-infectious IBS emphasize the interaction between centrally-mediated psychosocial risk factors and local inflammation in predicting long-term IBS symptoms. Investigating afferent immune-to-brain communication in visceral hyperalgesia as a component of the sickness response constitutes a promising future research goal(78a).

4. Biological therapy, including aminosalicylates, corticosteroids, immune modifiers, anti-tumor necrosis factor (TNF) agents, antibiotics, etc.
a. According to the study conducted by Helsinki University Central Hospital, with questionnaire rerponse including demographic questions and questions about IBD patients' use of biological medications, indicated that the use of antidepressants (OR: 1.44, 95% CI: 1.28-1.61), anxiolytics (OR: 1.52, 95% CI: 1.31-1.78), oral bisphosphonates (OR: 6.08, 95% CI: 4.56-8.11), cardiovascular medications (OR: 1.38, 95% CI: 1.24-1.54), antibiotics (OR: 4.01, 95% CI: 3.57-4.51), proton pump inhibitors (OR: 3.90, 95% CI: 3.48-4.36), and nonsteroidal anti-inflammatory analgesics (OR: 1.17, 95% CI: 1.07-1.28) was significantly more common in IBD than among the controls. The study also said that those who used antidepressants, anxiolytics, or analgesics had significantly impaired HRQoL (p < 0.001)(79a). 
Also in the study of one hundred and twenty-five patients fulfilled the inclusion criteria who were issued questionnaires, of these 78 questionnaires were returned (62 percent response), showed that  33 patients (42 percent) preferred infliximab and 19 patients (24 percent) preferred adalimumab (p = 0.07). Twenty-six patients (33 percent) did not indicate a preference for either biological therapy and were not included in the final analysis. The commonest reason cited for those who chose infliximab (iv) was: "I do not like the idea of self-injecting," (67 percent). For those patients who preferred adalimumab (sc) the commonest reason cited was: "I prefer the convenience of injecting at home," (79 percent). Of those patients who had previously been treated with an anti-TNF therapy (n = 10, all infliximab) six patients stated that they would prefer infliximab if given the choice in the future (p = 0.75)(79). Other study indiacted that the anti-TNFα inhibitors represent a momentous advance in the treatment of Crohn's disease and ulcerative colitis refractory to conventional treatments. They offer significant benefits in quality of life and mucosal healing, and may have the potential to change the evolution of the disease when given early(80).
Treatment with anti-TNF antibodies is accompanied by sexual dimorphic profile of ADR with female patients being more at risk for allergic reactions and subsequent discontinuation of the treatment, according to the department of Gastroenterology and Hepatology, Erasmus MC University Medical Center(81).

b. Side effects
Side of below medication are not limit to
b.1. Aminosalicylates
Side effects include Trouble breathing, Hives, Swelling of your face, lips, tongue, or throat, etc.

b.2. Corticosteroids
According to the study by, Short-term corticosteroid use is associated with generally mild side effects, including cutaneous effects, electrolyte abnormalities, hypertension, hyperglycemia, pancreatitis, hematologic, immunologic, and neuropsychologic effects, although occasionally, clinically significant side effects may occur. Long-term corticosteroid use may be associated with more serious sequel, including osteoporosis, aseptic joint necrosis, adrenal insufficiency, gastrointestinal, hepatic, and ophthalmologic effects, hyperlipidemia, growth suppression, and possible congenital malformations(81a).

b.3. Immune modifiers
Side effects include flu-like symptoms including fever, chills, nausea, appetite loss, etc.

b.4. Anti-tumor necrosis factor (TNF) agents
b.4.1. Infliximab-induced or-exacerbated psoriatic lesions(82)
b.4.2. A rare cancer of white blood cells
b.4.3. Risk of opportunistic infections
b.4.4. TB and fungal infection

b.5. Antibiotics
Side effects include dry eyes, mouth and skin,  ringing in his ears,  delayed urination, uncontrollable shaking, etc.

5. Probiotics
According to the study by the University of Washington, Seattle, in a an altered or pathogenic microbiota causes inflammation in a genetically susceptible individual, indicated that Probiotics have some efficacy in the treatment of ulcerative colitis (UC), but our current repertoire is limited in potency. Fecal microbiota therapy (FMT) is an emerging treatment for several gastrointestinal and metabolic disorders. It has demonstrated efficacy in treating refractory Clostridium difficile infection, and there are case reports of FMT successfully treating UC(82).

6. Etc.

A.1.2. Surgical treatments
In certain cases, surgical treatment may be necessary depending to type of colitis and patient's condition.
1. Colectomy
Colectomy  is a surgical treatment in removing the colon. In the study using the University of Manitoba Inflammatory Bowel Disease Epidemiology Database, a population-based data set including UC patients with up to 25 years of post diagnosis follow-up, found that the cumulative incidence of colectomy in UC is lower than previously reported, and appears to be decreasing further among more recently diagnosed cohorts of patients. Male sex and hospitalization at the time of diagnosis are major risk factors for EC and LC(83)
But according to the study by Division of Gastroenterology and Hepatology, Mayo Clinic, patients with moderately to severely active ulcerative colitis treated with infliximab were less likely to undergo colectomy through 54 weeks than those receiving placebo(84).

2. Proctocolectomy and Ileostomy
Proctocolectomy is a surgical procedure to remove the entire colon and rectum. Ileostomy is a surgical opening constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin(85). According to the study by the University of Chicago Medical Center, totally laparoscopic total proctocolectomy is therefore considered a safe alternative to open surgery for selected IBD patients not candidates for a restorative procedure(86).

A.2. Microscopic colitis
Since certain medication such as nonsteroidal, anti-inflammatory drugs such as ibuprofen (Advil, Motrin, others) or naproxen (Aleve) may induced the diseases, it is the best of the aptients to exclude them before taking any medicine.
A.2.1. Non surdical treatments
1.  Corticosteroids
The incidence of microscopic colitis and its disease burden are increasing, according to the study by the University of Calgary, both short- and long-term treatment with budesonide is effective and well-tolerated for microscopic colitis. However, the rate of symptom relapse once budesonide is discontinued is high(87). Othe rrecent study indicated that a strong evidence has added new pharmacological options for the treatment of microscopic colitis: the role of steroidal therapy, especially oral budesonide, has gained relevance, as well as immunosuppressive agents such as azathioprine and 6-mercaptopurine(89).

2. Antacids and adsorbents
In the study of thirteen patients with microscopic colitis (7 with subepithelial collagen deposition and 6 without) treated with eight chewable 262-mg bismuth subsalicylate tablets per day for 8 weeks, conducted by Baylor University Medical Center, found that Bismuth subsalicylate treatment for 8 weeks is safe and well tolerated. This regimen appears to be efficacious for the treatment of microscopic colitis and is worthy of further study in a controlled trial(88).

3. Anti-tumor necrosis factor (TNF) agents
The use of anti-tumor necrosis factor-α agents, infliximab and adalimumab, constitutes a new, interesting tool for the treatment of microscopic colitis, but larger, adequately designed studies are needed to confirm existing data(89).

4. Side effects are not limit to
a.  Corticosteroids
According to the study by, Short-term corticosteroid use is associated with generally mild side effects, including cutaneous effects, electrolyte abnormalities, hypertension, hyperglycemia, pancreatitis, hematologic, immunologic, and neuropsychologic effects, although occasionally, clinically significant side effects may occur. Long-term corticosteroid use may be associated with more serious sequel, including osteoporosis, aseptic joint necrosis, adrenal insufficiency, gastrointestinal, hepatic, and ophthalmologic effects, hyperlipidemia, growth suppression, and possible congenital malformations(81a).

b. Anti-tumor necrosis factor (TNF) agents
b.4.1. Infliximab-induced or-exacerbated psoriatic lesions(82)
b.4.2. A rare cancer of white blood cells
b.4.3. Risk of opportunistic infections
b.4.4. TB and fungal infection

c. Antacids and adsorbents
Side effects include a chalky taste, mild constipation or diarrhea, thirst, stomach cramps, etc.

A.2.2. Surgical treatment
In rare case, sugical treatment may be necessary for patients with microscopic colitis if patients are not respond to medication treatment, depending to the patients conditions. Proctocolectomy is a surgical procedure to remove the entire colon and rectum. Ileostomy is a surgical opening constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin(85). According to the study by the University of Chicago Medical Center, totally laparoscopic total proctocolectomy is therefore considered a safe alternative to open surgery for selected IBD patients not candidates for a restorative procedure(86).

A.3. Iatrogenic colitis
A.3.1. Diversion colitis 
1. Short-chain-fatty acid irrigation
A condition known as diversion colitis frequently develops in segments of the colorectum after surgical diversion of the fecal stream. In the study of four patients with diversion colitis, none of whom had evidence of Crohn's, idiopathic ulcerative, or infectious colitis, found 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(86a).


2.  5-aminosalicylic acid (Rowasa) enemas
a. There is a report of an 85-yr-old female presented with diversion colitis after surgery with a resultant colostomy and excluded rectal segment. Treatment with 5-aminosalicylic acid (Rowasa) enemas resulted in both endoscopic and histological resolution. This is the first case of diversion colitis treated with 5-aminosalicylic acid enemas, according to the study by Winthrop University Hospital(86b).

b.  Side effects are not limit to severe stomach pain, cramping, fever, headache, and bloody diarrhea

3. Corticosteroids
a. According to the study by, Short-term corticosteroid use is associated with generally mild side effects, including cutaneous effects, electrolyte abnormalities, hypertension, hyperglycemia, pancreatitis, hematologic, immunologic, and neuropsychologic effects, although occasionally, clinically significant side effects may occur. Long-term corticosteroid use may be associated with more serious sequel, including osteoporosis, aseptic joint necrosis, adrenal insufficiency, gastrointestinal, hepatic, and ophthalmologic effects, hyperlipidemia, growth suppression, and possible congenital malformations(81a).
b. Side effects, According to the study by, Short-term corticosteroid use is associated with generally mild side effects, including cutaneous effects, electrolyte abnormalities, hypertension, hyperglycemia, pancreatitis, hematologic, immunologic, and neuropsychologic effects, although occasionally, clinically significant side effects may occur. Long-term corticosteroid use may be associated with more serious sequel, including osteoporosis, aseptic joint necrosis, adrenal insufficiency, gastrointestinal, hepatic, and ophthalmologic effects, hyperlipidemia, growth suppression, and possible congenital malformations(81a)

4. Surgery
a. Colectomy
Colectomy  is a surgical treatment in removing the colon. In the study using the University of Manitoba Inflammatory Bowel Disease Epidemiology Database, a population-based data set including UC patients with up to 25 years of post diagnosis follow-up, found that the cumulative incidence of colectomy in UC is lower than previously reported, and appears to be decreasing further among more recently diagnosed cohorts of patients. Male sex and hospitalization at the time of diagnosis are major risk factors for EC and LC(83)
But according to the study by Division of Gastroenterology and Hepatology, Mayo Clinic, patients with moderately to severely active ulcerative colitis treated with infliximab were less likely to undergo colectomy through 54 weeks than those receiving placebo(84).

b. Proctocolectomy and Ileostomy
Proctocolectomy is a surgical procedure to remove the entire colon and rectum. Ileostomy is a surgical opening constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin(85).

A.3.2. Chemical colitis
1. Glutaraldehyde induced colitis presents clinically with severe abdominal pain, bloody and mucoid diarrhea, rectal bleeding, and tenesmus 48-72 h after colonoscopy. Endoscopic findings are nonspecific and mimic ischemic colitis, inflammatory bowel disease, and infectious colitis. According to the study by. the treatment is mainly supportive but sometimes necessitates mesalamine, prednisolone, or metronidazole and the resolution is rapid. In endoscopy units, strict adherence to published disinfection protocols is very important and the cleaning, rinsing and drying protocols also deserve the same attention
a. Mesalamine
Mesalazine (INN, BAN), also known as mesalamine (USAN) or 5-aminosalicylic
acid (5-ASA). In the study to assess the experimental colitis induced by rectal instillation of 2,4,6-trinitrobenzene sulfonic acid (TNBS) into male Wistar rats, found that the loading of 5-ASA into SucCH polymer markedly improved efficacy in the healing of induced colitis in rats(90).

b. Prednisolone and Metronidazole 
Prednisolone is a synthetic form of lucocorticoid,  used to treat a variety of inflammatory and auto-immune conditions and Metronidazole is an antibiotic used to treat bacterial cause of infection in your body.. According to the study by, the treatment is mainly supportive but sometimes necessitates mesalamine, prednisolone, or metronidazole and the resolution is rapid. In endoscopy units, strict adherence to published disinfection protocols is very important and the cleaning, rinsing and drying protocols also deserve the same attention(91).

c. Pregnane X Receptor (PXR)
Pregnane X Receptor (PXR), a master regulator of drug metabolism and inflammation, is abundantly expressed in the gastrointestinal tract. In the study by Albert Einstein College of Medicine,  to investigate the role these flavonoids play in inhibiting gut inflammation by an axis involving PXR and other potential factors, found that Baicalein, but not its glucuronidated metabolite baicalin, activates PXR in a Cdx2-dependent manner in vitro, in human colon carcinoma LS174T cells, and in the murine colon in vivo. While both flavonoids abrogate dextran sodium sulfate (DSS)-mediated colon inflammation in vivo, oral delivery of a potent bacterial β-glucuronidase inhibitor eliminates baicalin's effect on gastrointestinal inflammation by preventing the microbial conversion of baicalin to baicalien(92).

2. Certain chemicals such as TUDCA and PBA alleviate different forms of colitis in mice(93), including inflammatory bowel diseases, Ischemic colitis(94), etc. Treatment of such diseases depending to the development of types of colitis.

A.4. Ischemic colitis
Ischemic colitis is the most common type of intestinal ischemia
 A.4.1. Non surgical treatments
Supportive care with intravenous fluids, optimization of hemodynamic status, avoidance of vasoconstrictive drugs, bowel rest, and empiric antibiotics will produce clinical improvement within 1 to 2 days in most patients, according to the study by Duke University Medical Center(95).

A.4.2. Surgical treatments
1. Colectomy
According to the study by , although conservative therapy is effective in most cases, surgery still plays a key role in the treatment of ischemic colitis. Here, we describe a case of a 73-year-old man in whom laparoscopy-assisted left colectomy was performed 80 d after the onset of ischemic colitis. He recovered completely after surgery, and the pathological findings were consistent with ischemic colitis(96).

2. Colonoscopy
In the study of 15 patients with ischemia of the colon, researchers found that rigid proctoscopy was normal or demonstrated nonspecific proctitis in 12 of 15 patients studied. Colonoscopic biopsies demonstrated superficial inflammatory changes in all patients. Thirteen patients had complete mucosal healing endoscopically in 2 weeks to 3 months with stricture developing in four patients. Because ischemic colitis is a distinct subtype of ischemic bowel disease most often limited to the superficial mucosa, colonoscopy is an alternative and usually safe modality in the diagnosis of this entity and proved more accurate that conventional x-ray and proctoscopy(97).

A.5. Infectious colitis
Clostridium difficile, atypes of infectous colitis, has become an increasingly important nosocomial pathogen and is one of the most common causes of hospital-acquired diarrhea. The incidence of C difficile infection (CDI) is increasing worldwide(97a).
A.5.1. Non surgical therapy
1. Antimotility therapy
If patients are expereince with diarrhea of small bowel origin, then Antimotility therapy can be helpful. According to the study by the Service de Médecine B Centre hospitalier universitaire de l'hôpital d'adultes, although effective therapy is not available for patients with enteric viruses, Cryptosporidium, and Microsporidium, therapy is useful for children with amebiasis, antimicrobial-associated colitis, cholera, giardiasis, various forms of Escherichia coli diarrhea and Salmonella disease, isosporiasis, shigellosis, and strongyloidiasis(98).

2. Probotic
Perturbation of bacterial microflora of the gastrointestinal (GI) tract may play an important role in the pathophysiology of some GI disorders. Probiotics have been used as a treatment modality for over a century. They may restore normal bacterial microflora and effect the functioning of the GI tract by a variety of mechanisms. According to the study by Columbia University College of Physicians and Surgeons, the efficacy of probiotics, either as a single strain or a combination of probiotics, has been tested in antibiotic-associated diarrhea, Clostridium difficile colitis, infectious diarrhea, ulcerative colitis, Crohn's disease, pouchitis, and irritable bowel syndrome, among other disorders. Results of the studies are reviewed in this article and recommendations for probiotic use in these disorders are made. Although probiotics appear to be generally safe in an outpatient setting, the situation may be different in immunocompromised, hospitalized patients who may be at a greater risk of developing probiotic sepsis(99).

3. Other treatments
In the study to review and to investigate the efficacy of antibiotic therapy for C. difficile-associated diarrhea (CDAD), conducted by Northern General Hospital, indicated that the studies provide little evidence for antibiotic treatment of severe CDAD as many studies excluded these patients. A recommendation to achieve these goals cannot be made because of the small numbers of patients in the included studies and the high risk of bias in these studies, especially related to dropouts. Most of the active comparator studies found no statistically significant difference in efficacy between vancomycin and other antibiotics including metronidazole, fusidic acid, nitazoxanide or rifaximin. Teicoplanin may be an attractive choice but for its limited availability (Teicoplanin is not available in the USA) and great cost relative to the other options. More research of antibiotic treatment and other treatment modalities of CDAD is required(100).
Other researcher indicated that treatment of Clostridium difficile CDI is challenging due to the limited number of drugs that have proven to be effective, concerns about antibiotic resistance, and recurring disease. The recent approval of fidaxomicin provides a new alternative. Immune therapy will likely play a greater role in  the future(101).

A.5.2. Surgical treatment
Sugical treatment may be necessary for patients with microscopic colitis if patients are not respond to medication treatment, depending to the patients conditions.
In the study of sixty-seven patients (mean age, 69 (range, 40-86) years; 99 percent males) were identified. All 67 patients had C. difficile verified in the colectomy specimens, found that twenty-six of 67 patients (39 percent) underwent colonoscopy; all 26 were found to have severe inflammation or pseudomembranes. Fifty-three of 67 patients (80 percent) underwent total colectomy; 14 of 67 underwent segmental colonic resection. Perforation and infarction were found in 59 of 67 patients (58 percent) at surgery. Overall mortality was 48 percent (32/67). Mean hospitalization was 36 (range, 2-297) days(102). Several recent studies have elucidated factors that contribute to the unacceptably high postoperative mortality rate: Surgical intervention too late in the course of the disease, lack of clearly defined guidelines for patient selection, and difficulty in predicting the clinical course of the disease. Perforation, need for vasopressor support, and end-organ damage all affect the postoperative mortality rate negatively(103).

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.

  


A.7. Fulminant colitis
A.7.1. Non surgical therapy
1. Immunosuppressive drug 
a.  Tacrolimus (FK-506)
Immunosuppressive drugs are increasingly being used as a therapeutic alternative to colectomy in patients with ulcerative or Crohn's colitis. According to the study of Tacrolimus (FK-506) Treatment of Fulminant Colitis in a Child in Journal of Pediatric Gastroenterology & Nutrition:October 1996 - Volume 23 - Issue 3 - pp 329-333, oral tacrolimus offers a potential alternative to cyclosporine in patients with steroid-resistant fulminant colitis and offers the potential advantages of more reliable oral absorption and greater ease of administration. The side effects of tacrolimus are similar to those of cyclosporine, but some adverse effects (including hypertension, gingival hyperplasia, and coarsening of facial features)(112).

b. Cyclosporine 
The use of immunosuppressive medications such as 6-mercaptopurine in individuals with fulminant disease is often limited by its very slow onset of action, unfortunately.  According to the study by Hartford Hospital, there is cases of two adolescents with fulminant colitis who were being considered for colectomy and who were treated with oral cyclosporine. Each appeared to have a prompt response to this medication, and both entered into a complete clinical remission. A mild increase in serum creatinine and hirsutism were the only side effects noted(113).

2. Other medicines
According to the study by Hahnemann University School of Medicine, patients with fulminant disease may require intravenous steroids and antibiotic therapy. If frequent relapses prevent discontinuation or significant reduction of prednisone therapy, azathioprine or 6-mercaptopurine may offer benefit as steroid-sparing agents. Also, intravenous cyclosporine has proved useful in patients with fulminant inflammatory bowel disease that is unresponsive to other therapy(114).

A.7.2. Surgical treatment
1. Total colectomy
Although total abdominal colectomy has long been considered definitive treatment for fulminant ulcerative colitis refractory to medical management, the optimal timing of surgery remains controversial. According to the study by The Mount Sinai Medical Center, showed that prolonged duration of preoperative medical treatment correlates with poor postoperative outcomes after total abdominal colectomy for fulminant ulcerative colitis. In addition, sustaining postoperative complications did not prevent patients from eventually undergoing IPAA(115).
Also in the study to to define clinical and radiographic variables associated with postoperative mortality after urgent colectomy for fulminant Clostridium difficile colitis with data obtained regarding patients undergoing colectomy for fulminant C. difficile colitis at two institutions (1997-2005), showed that
hirty-five patients (mean age 70 years, 46% male) underwent urgent colectomy for C. difficile colitis. The 30-day mortality rate was 45.7 per cent (16/35). The only clinical variable associated with mortality was preoperative multisystem organ failure (nonsurvivors 9/16 vs survivors: 4/19; P = 0.037). None of the three patients undergoing partial colectomy survived, although the difference in survival versus those undergoing subtotal colectomy was not significant. Patients with fulminant C. difficile colitis undergoing colectomy have a high mortality rate. Preoperative presence of multisystem organ failure was independently predictive of mortality(116).

2. Laparoscopic creation of an ileostomy
Due to several recent studies have elucidated factors that contribute to the unacceptably high postoperative mortality rate of colectomy, an alternative surgical strategy for fulminant C. difficile colitis is laparoscopic creation of an ileostomy with total colonic washout(117).

C. In herbal medicine perspective
1. Ambrotose complex and Advanced Ambrotose (aloe vera gel, arabinogalactan, fucoidan, and rice starch)
In the study to test the efficacy of Plant-derived polysaccharide supplements in inhibiting dextran sulfate sodium-induced colitis in the rat, conducted by the Eurofins Product Safety Laboratories, indicated that Ambrotose complex and Advanced Ambrotose are dietary supplements that include aloe vera gel, arabinogalactan, fucoidan, and rice starch, all of which have shown anti- inflammatory activity(118).

2. Flax seed
People use flaxseed for many conditions related to the gastrointestinal (GI) tract, including ongoing constipation, colon damage due to overuse of laxatives, diarrhea, inflammation of the lining of the large intestine (diverticulitis), irritable bowel syndrome (IBS) or irritable colon, sores in the lining of the large intestine (ulcerative colitis), inflammation of the lining of the stomach (gastritis), and inflammation of the small intestine (enteritis)(119).

3. Boswellia
In the study to evaluate the antioxidant effect of an extract of the plant Boswellia serrata in an experimental model of acute ulcerative colitis induced by administration of acetic acid (AA) in rats, found that the extract of B. serrata has active antioxidant substances that exert protective effects in acute experimental colitis(120).

4. Peppermint Oil
Peppermint oil is the major constituent of several over-the-counter remedies for symptoms of irritable bowel syndrome (IBS). According to the study by Postgraduate Medical School, University of Exeter, found that 8 randomized, controlled trials were located. Collectively they indicate that peppermint oil could be efficacious for symptom relief in IBS. A metaanalysis of five placebo-controlled, double blind trials seems to support this notion(121).

5. Ginger
Ginger is a commonly used spice with anti-inflammatory potential. In the study to investigate the therapeutic effects of ginger and its component zingerone in mice with 2,4,6-trinitrobenzene sulphonic acid (TNBS)-induced colitis, showed that nuclear factor-κB (NF-κB) and interleukin-1β (IL-1β) were key molecules involved in the expression of ginger- and zingerone-affected genes. Ex vivo imaging and immunohistochemical staining further verified that ginger and zingerone suppressed TNBS-induced NF-κB activation and IL-1β protein level in the colon. In conclusion, ginger improved TNBS-induced colitis via modulation of NF-κB activity and IL-1β signalling pathway. Moreover, zingerone might be the active component of ginger responsible for the amelioration of colitis induced by TNBS(122).



6. Etc.

D.  In traditional Chinese medicine perspective
According to traditonal Chinese medicine, colitis is a result of irregular functioning of the stomach and spleen systems of that enhances bleeding, mucus, and diarrhea(123).
 Also according to the article of Dr. John Zhang (MD, China), an experienced Acupuncturist and Herbal Medicine Specialist with a private practice in Toronto.
1.  In case study of involved a 50-year-old male 
Colitis can be result of the accumulation of damp-heat in the patient’s body of that prevented the stomach and spleen systems from working to their full potential with symptoms of frequented bowel movements (over 20 time a day), along with plenty of mucus and bleeding.

2.  In case study of involved a a 34-year-old female
Or  as the result of a spleen and stomach deficiency due to a prolong period of illness with symptoms of mucus in the stool, and constant rectal bleeding resulting in significant blood loss every day.
During the courses of treatment with above differentiation, Dr. Chang also indicated that Dietary therapy is an important part of treatment. Patients should avoid or limit mucous-forming foods such as dairy (milk, cheese, ice cream), as well as cold (raw) foods and spicy/greasy deep fried foods. Easily digested, bland, and cooked foods are recommended. If you want do know more of above article, please visit(123).

Other study in using TCM herbal extract ((Forsythia koreana, Corydalis saxicola, Semiaquilegia adoxoides, Taraxacum officinale, Chrysanthemum coronarium, Glycyrrhiza inflate, and Lonicera japonica) ) in treating Inflammatory bowel disease (IBD) in Female Swiss-Webster mice, showed that treatment with the combination of medicinal herbs decreases leukocyte infiltration and mucosal ulceration, ameliorating the course of acute colonic inflammation. This herbal remedy may prove to be a novel and safe therapeutic alternative in the treatment of IBD(124).

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