Copyright ©The Author(s) 2018.
World J Gastroenterol. Apr 28, 2018; 24(16): 1734-1747
Published online Apr 28, 2018. doi: 10.3748/wjg.v24.i16.1734
Table 1 Clinical characteristics of case report
Case (No)ReferenceReporting yrCountryAge (yr)Gender(male/female)Primary illness(reason for diversion)Type of diversion (surgical procedure)Period of up to diagnosis from operationSymptomsEndoscopy findingsPathological findingsDiagnosis
1Glotzer et al[2]1981United States49MFree perforation sigmoid diverticulumLoop sigmoid colostomy2.5 moNo symptomsErythema, friability, petechiae, atrophyCrypt abscess, surface epithelial cell degeneration, acute inflammation, chronic inflammation, regenerationDiversion colitis
56FAdenocarcinoma. Protect low anastomosisLoop transverse colostomy3 moNo symptomsErythema, friability, petechiaeNormalDiversion colitis
78MSigmoid diverticulitis with perforationLoop sigmoid colostomy6 moNo symptomsErythema, friability, granularityNo biopsyDiversion colitis
70FSigmoid diverticulitis found at pelvic operationLoop sigmoid colostomy3 moNo symptomsErythema, friability, nodularityRegenerationDiversion colitis
43FSigmoid diverticulitis with perforationLoop sigmoid colostomy8 moNo symptomsErythema, friabilityCrypt abscess, acute inflammation.Diversion colitis
41FFecal incontinence secondary to cordotomy for painLoop sigmoid colostomy18 moNo symptomsErythema, friability, petechiaeNo biopsyDiversion colitis
65MSigmoid diverticulitis with perforationLoop transverse colostomy3 yrNo symptomsErythema, friability, granularity, petechiae, inflammatory polypCrypt abscess, surface epithelial cell degeneration, chronic inflammation, regeneration.Diversion colitis
83MSigmoid diverticulitis with perforationLoop transverse colostomy6 moNo symptomsErythema, friability, granularityCrypt abscessDiversion colitis
26MFecal incontinence after T9-10 cord transectionLoop transverse colostomy7 yrRectal dischargeErythema, friability, petechiaeSurface epithelial cell degeneration, chronic inflammation.Diversion colitis
70MColonic ileus secondary to anticholinergics for Parkinson's diseaseLoop transverse colostomy4 moNo symptomsErythema, friability, petechiae, inflammatory polypCrypt abscessDiversion colitis
2lusk et al[39]1984United States28MPerforated sigmoid colon for gunshotLoop sigmoid colostomy6 wkNo symptomsRed granular rectum with aphthous ulcersModerate loss of goblet cells with focal edema and lymphocytosis of the lamina propria.Diversion colitis
68MSigmoid carcinomaLoop transverse colostomy6 wkNo symptomsMultiple aphthaeNot obtainedDiversion colitis
3Scott et al[46]1984United States21MGunshotLoop transverse colostomy2 moNo symptomsMultiple, small, polypoid lesions in the rectum and sigmoid colon up to the cutaneous part of the mucous fistula.Mucosal biopsies of the rectal lesions were interpreted as “chronic nonspecific colitis with pseudopolyps, probably from diversion colitis”.Diversion colitis
4Korelitz et al[42]1984United States22FCrohn's DiseaseIleostomy and subtotal colectomy2 yrNo symptomsFriable, nodularNot obtainedDiversion colitis
34FCrohn's ileitisIleocolic anastomosis and Loop ileostomy2 yrNo symptomsExudateFocal chronic inflammation, edema, erosions, and an increased number of lymphoid follicles.Diversion colitis
31MCrohn's ileitisIleocolic anastomosis and Loop ileostomy1 yrNo symptomsAphthous lesionsChronic inflammationDiversion colitis
32MCrohn's ileitisIleocolic anastomosis and Loop ileostomy1 yrNo symptomsFriable, exudateNot obtainedPerforation due to complication of barium enema and diversion colitis
5Fernand et al[40]1985United States67FPerforated sigmoid diverticulumLoop sigmoid colostomy22 yrRectal bleedingN/ADiffuse multiple superficial ulcerations and intense inflammatory infiltrates composed mainly of plasma cells, lymphocytes, and some eosinophils.Diversion colitis
6Frank et al[13]1987United States38MPerineal laceration as result of a motor vehicle accidentEnd sigmoid colostomy1 yrRectal bleedingDiffuse nodularity and ulcerationModerate to severe nonspecific inflammation.Diversion colitis
7Harig et al[5]1989United States63MNeurogenic fecal incontinenceMucus fistula13 moBloody dischargeEndoscopic index of 10Inflammatory infiltrate of both acute and chronic cells in the lamina propria and the crypt abscess. Lining epithelial cells show decreased mucin secretion.Diversion colitis
63FIrradiation of rectumMucus fistula2 wkBloody dischargeEndoscopic index of 10Erosions, surface exudate, crypt abscesses, edema.Diversion colitis
54MPerianal fistulasRectosigmoid pouch35 moBloody dischargeEndoscopic index of 9Lymph folliclesDiversion colitis
56MDiverticulitisMucus fistulaN/AN/AEndoscopic index of 8N/ADiversion colitis
8Triantafillidis et al[31]1991Greece64FDiverticula with perforationHartman's type of operation laparotomy16 moBloody rectal dischargeEndoscopic index of 9 (quite inflamed with friability and erythema)Severe inflammatory infiltration, formation of lymph follicles, surface erosions, edema, and crypt abnormalities.Diversion colitis
9Tripodi et al[43]1992United States85FSmall bowel perforation with a ruptured chronic pelvic abscess secondary to diverticular diseaseEnd transverse colostomy10 wkBloody rectal dischargeErythematous and friable, with diffuse exudation, petechiae, and ulcerationAcute and chronic inflammation with cryptitis.Diversion colitis
10Lu et al[38]1995United States45FChronic constipationLoop transverse colostomy25 yrSepsis(no symptoms such as rectal bleeding)Large ulcers with overlying pseudomembraneInfiltration primarily with plasma cells and lymphocytes was noted, as well as a moderate numbers of polymorphonuclear cells, large lymphoid aggregates were seen in the lamina propriaDiversion colitis
11Lai et al[47]1997United States49MIntractable ileus,C6 ASIAB tetraplegicColostomy10 yrRectal pain and bleeding.Partial stricture 70 cm proximally to the rectum. The colonic mucosa appeared granular and friable with evidence of linear ulceration.Extravasation of erythrocytes, lymphocytic and neutrophilic cells infiltrates, and edema were present within the lamina pro-pria. No evidence of malignancy and glandular dysplasia was found. Pathologic report was consistent with chronic colitis.Diversion colitis
12Lim et al[32]1999United Kingdom60FFaecal incontinence for DMEnd sigmoid colostomy6 moBlood and mucus per rectumEdematous mucosa with bloodstained mucopurulent exudateActive chronic colitis with focal cryptitis and crypt abscesses.Diversion colitis → UC
16MImperforate anusIleostomy and colostomy6 moBlood and mucus per rectumGranular, erythematous mucosa with contact bleedingActive inflammation with polymorphs infiltrating crypts and a diffuse increase in lymphocytes and plasma cells in the lamina propria.Diversion colitis → UC
13Jowett et al[33]2000United Kingdom75FFaecal incontinenceEnd colostomy8 moBlood and mucus per rectumGranular, congested, and oedematous mucosa with contact bleedingMixed inflammatory cell infiltrate with distortion of the crypt architecture and cryptitis.Diversion colitis (→ UC)
14Lim et al[35]2000United Kingdom66MSigmoid carcinomaHartmann’s procedure with colostomy.18 moNo symptomsMildly inflamedActive colitisDiversion colitis (→ UC)
15Kiely et al[36]2001United Kingdom6MUlcerative colitisTotal colectomy and ileostomy9 moRectal bleedingEndoscopic index of 8Lymphoid hyperplasia, lymphoplasmacytosis, crypt abscesses and moderate mucosal architectural disruption.Diversion proctocolitis
3MPerforated typhoid diseaseSubtotal colectomy and ileostomy5 moRectal bleeding and abdominal painsEndoscopic index of 8Lymphoplasmacytic infiltration of lamina propria, and architectural disruption.Diversion proctocolitis
8FAplastic anemia, a large solitary rectal ulcerLoop sigmoid colostomy4 moRectal dischargeEndoscopic index of 9Lymphoplasmacytic and neurophilic infiltrate in the lamina propria, mucin depletion, and Paneth cell metaplasia.Diversion proctocolitis
3MHirschsprung's diseaseileostomyN/ARectal bleedingFlorid colitisLymphoid hyperplasia, lymphoplasmacytosis and mucin depletion,Diversion proctocolitis
10MRectovesical fistulaLoop sigmoid colostomyN/ARectal dischargeFlorid colitisLymphoid hyperplasia, lymphoplasmacytosis.Diversion proctocolitis
16Komuro et al[41]2003Japan46MAscending colon diverticular perforation (systemic lupus erythematosus and chronic renal failure)Loop transverse colostomyN/A ( On surveillance colonoscopy)No symptomsMild colitis with a decreased vascular pattern, oedema and mucosal tearN/ADiversion colitis
17Tsironi et al[48]2006United Kingdom40MUC pancolitis-typeRectal stump and ileostomy, subtotal colectomy and ileostomy5 moBlood and mucus per rectumSevere chronic inflammation with ulceration and numerous inflammatory polypsDiffuse chronic inflammation with patchy cryptitisDivesion collitis with caused by clostridium difficile infection.
18Boyce et al[37]2008United Kingdom29MLife-long constipationSubtotal colectomy15 yrRectal bleeding and anal painThe mucosa of the rectal stump was found to be chronically inflamed and ulcerated.Inflammatory changeDiversion pouchitis
19Haugen et al[49]2008United States36FFaecal incontinence due to spina bifidaLaparoscopic sigmoid colostomy and creation of a Hartmann's pouchN/ARectal dischargeN/AN/ADiversion colitis
20Talisetti et al[50]2009United States19FMegacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS)Gastrostomy and ileostomy4 yrAbdominal pain and rectal bleedingFriable mucosa with areas of pinpoint hemorrhage from the anal verge to 30 cm proximallyAcute cryptitis and scattered crypt abscesses, consistent with diversion colitis.Diversion colitis
21Kominami et al[51]2013Japan84MAngiodysplasia S/OSubtotal colectomy and ileostomy5 yrBlood in the stoolGranular, edematous mucosa with contact bleedingLymphoplasmacytic and neurophilic infiltrate in the lamina propria.Diversion colitis
22Watanabe et al[44]2014Japan76FUC3-stage pancolectomy with construction of an IPAA13 yrBloody purulent rectal dischargeSeverely active pouchitis with large erosionsN/ADiversion pouchitis
23Gundling et al[45]2015Germany75FChronic constipationPermanent end-colostomyN/ATenesmus and severe rectal painSevere DC was seen on colonoscopyConfirmed histologicallyDiversion colitis
24Matsumoto et al[52]2016Japan65MUC pancolitis-typeSubtotal colectomy and ileostomy4 moRectal bleedingModerate mucosal inflammationUlcer, granulation tissue and epithelial defectDiversion colitis or exacerbation of UC was suspected.
25Custon et al[29]2017United States44MUC complicated by colitis-associated low-grade dysplasiaTotal proctocolectomy with 2-stage IPAA7 yrBlood in the stoolEdematous and coated with old and fresh bloodN/ASevere diversion pouchitis
Table 2 Clinical course of case reports
Case (No)Ref.Age (yr)Gender(male/female)Ineffective treatmentEffective treatmentPrognosis
1Glotzer et al[2]49MN/AClosure 4 mo post-diversionAsymptomatic. Proctoscopy and biopsy normal 2.5 and 30 mo postclosure.
56FN/AClosure 3 mo post-diversionRecurrent Ca. Mucosa not inflamed grossly or microscopically 18 mo post closure.
78MN/AClosure 6 mo post-diversionAsymptomatic 1 yr postclosure.
70FN/AClosure 5 mo post-diversionAsymptomatic. Normal sigmoidoscopy 2 mo postclosure.
43FN/AClosure 2 yr post-diversionAsymptomatic. Normal sigmoidoscopy 3 yr postclosure.
41FN/ANoneAsymptomatic 2 yr after ileostomy.
65MN/ANoneAbdominal cramps purulent rectal discharge. Continued inflammation 8 yr after colostomy.
83MN/ANoneAsymptomatic. Continued mild inflammation 4.5 yr after colostomy.
26MN/ASteroid enemasInproved. Continued 8 yr after colostomy.
70MN/ASteroid enemasTenesmus, discharge and fever 4 yr after colostomy. Resolved with steroid enemas. Continued inflammation at 8 yr.
2Lusk et al[39]28M-Colostomy closureNormal at 16 mo follow-up.
68M-Colostomy closureNormal at 7 wk after clousure.
3Scott et al[46]21M-Colostomy closureOne month later, the patient was examined by flexible sigmoidoscopy, which demonstrated normal mucosa throughout with no sign of pseudopolyps.
4Korelitz et al[42]22FSteroid enemasIleocolic reanastomosis (ileostomy closure)3 mo (interval from reanastomosis to normal sigmoidoscopy), 7 yr (duration normal).
34F-Ileostomy closure1 mo (interval from reanastomosis to normal sigmoidoscopy), 2 yr (duration normal).
31M-Ileostomy closure3 mo (interval from reanastomosis to normal sigmoidoscopy), 18 mo (duration normal).
32M-Ileostomy closure2 mo (interval from reanastomosis to normal sigmoidoscopy), 14 mo (duration normal).
5Fernand et al[40]67F-Left hemicolectomy and left salpingo-oophorectomyShe recoverd well and discharged 9 d later.
6Frank et al[13]38MOral and topical steroidsAbdominoperineal resection of the diverted loop and permanent colostomyNo evidence of inflammatory bowel disease has developed. Barium study of the small bowel was normal 1 yr after surgery.
7Harig et al[5]63MN/AShort-chain-fatty acid irrigationN/A
63FN/AShort-chain-fatty acid irrigationN/A
54MN/AShort-chain-fatty acid irrigationN/A
56MN/AShort-chain-fatty acid irrigationN/A
8Triantafillidis et al[31]64F-5 aminosalicylic acid enemas comparison with Betamethasone enemasThere were no differences in the degree of clinical improvement, or in the endoscopic and histologic scores seen at the end of the trials, between betamethasone and 5-ASA.
9Tripodi et al[43]85F-5-aminosalicylic acid enemasClinically asymptomatic at a 6-mo follow-up.
10Lu et al[38]45FIntravenous metronidazoleColectomy of the diverted segmentWithout complications and has been doing well postoeratively.
11Lai et al[47]49M-Daily 5-ASA suppository and total parenteral nutrition6 wk of treatment with 5-ASA, the patient had decreased rectal pain and bleeding.
12Lim et al[32]60F-Oral prednisolone, oral mesalazine, and mesalazine enemasPSL was tapered off over four months and she remained well.
0MClosure of the loop ileostomy→oral prednisolone, oral olsalazine and oral metronidazole→sigmoid loop colostomyThe defunctioned rectosigmoid was partially removed, leaving the lower rectum and anal canal; the loop colostomy was refashioned into an end colostomy→colectomy and removal of residual rectal stump and anal canal was performed and an end ileostomy fashionedHe subsequently made a good recovery and steroid therapy was discontinued.
13Jowett et al[33]75F-Topical steroid enemas.UC
14Lim et al[35]66M-Steroid enemas6 mo later he developed ulcerative colitis.
15Kiely et al[36]6MPSL and AZASCFAOral PSL was continued at the reduced rate of 5mg on alternate days until he underwent an uneventful rectal excision and J-pouch anal anastomosis 1 mo later. Two months after this, his ileostomy was closed.
3MSalazopyrineSCFAHis ileostomy was closed 3 mo later, and he was remained symptom free.
8F-SCFAHer ulceration was virtually healed and showed a reduction in endoscopic index from 9 to 3. Treatment was maintained until her colostomy was reversed a month later. After stoma closure, SCFAs were discontinued with no further recurrence of symptoms.
3MN/ASCFAFor redo pull-through
10MN/ASCFARectal excision
16Komuro et al[41]46M--The post endoscopic course was uneventful without any treatment.
17Tsironi et al[48]40MMesalazine suppository and steroid enemasMetronidazole suppositoryImproved quickly and remains well and asymptomatic 12 wk after treatment.
18Boyce et al[37]29M-Completion proctectomyCompletion proctectomy was uneventful and from which the patient made an unremarkable recovery.
19Haugen et al[49]36FThe water and vinegar solution enema, steroid enema, bismuth subsalicylate (standard treatment SCFA enmas was not option due to insurance and spina bifida)Antegrade irrigations of her distal bowel with tap waterWeekly to twice weekly irrigations completely stopped the malodorous and troublesome discharge.
20Talisetti et al[50]19FSCFA enema, steroids, metronidazoleColectomy(entire colon was ultimately resected, Since only 15 cm of jejunum appeared healthy, her mid and distal small bowel was also resected up to 15 cm from the ligament of Treitz)N/A
21Kominami et al[51]84MShort-chain fatty acid enema5-aminosalicylic acid enemasUndergoing 5-aminosalicylic acid enemas maintenance therapy.
22Watanabe et al[44]76FOral mesalazine, corticosteroid, metronidazole, and ciprofloxacinLeukocytapheresis, following low dose of metronidazole and ciprofloxacinAfter 18 mo, her condition remains stable without the need for medication.
23Gundling et al[45]75FEnemas containing 5-aminosalicylic acid and steroids and antibiotic therapyAutologous fecal transplantationAll symptoms improved dramatically within 5 d after the first treatment. Colonoscopy 28 d after the first treatment showed no major signs of inflammation in the colonic stump.
24Matsumoto et al[52]65MCorticosteroid and mesalazine enemas, prednisolone injections.A combined mesalazine plus corticosteroid enemaFinally proctectomy and ileal pouch-anal anastomosis were successfully performed.
25Custon et al[29]44M-Dextrose( hypertonic glucose ) spray endoscopicallyThe patient did not experience further episodes of recurrent bleeding during the 6-mo follow-up. No prescribed medicines were given after the endoscopic therapy.
Table 3 Summary of pharmacologic treatments
TreatmentRef.Procedure/standard dosageEfficacyComplications/main side effects
Surgical anastomosis[2,3,10,21,25,39,42]Mobilization of both ends of the bowel with either sutured or stapled anastomosis.The most effective method of eliminating the signs and symptomsBleeding, infection, anastomotic leak, anastomotic stricture, anesthetic risks
Corticosteroids[2,32,33]Hydrocortisone (100 mg per 60 mL bottle) enema is administered once daily for up to 3 wk.Response to treatment is generally seen in 3 to 5 d.Local pain and burning, occasionally rectal bleeding.
Occasional treatment may be given for 2 to 3 mo depending on clinical response.Prolonged treatment may result in systemic absorption, causing systemic side effects.
5-aminosalicylic acid (5-ASA) enemas[31,43,63,64]4 g of mesalazine in 60 mL suspensions, administered rectally once-daily dose for 4 to 5 wk.Varying effectOccasionally produces acute intolerance manifested by cramping, acute abdominal pain, bloody diarrhea, fever, headache, and rash.
Short-chain-fatty acid (SCFA)[5,10,13,18,19,26,27,61,62]SCFA enema rectally twice a day for 2 wk, and then tapered according to response over 2 to 4 wk.Varying effectNone
Irrigation with Fibers[65,66]Solution containing 5% fibers (10 g/d) for 7 d.The endoscopic score which is used to quantify the intensity of the inflammation at the mucosa at the diverted colon diminished after treatment.Probably none
Leukocytapheresis[44]Leukocytapheresis, at flow rate of 40 mL/min for 60 min, once weekly for 5 wk, following low dose of metronidazole and ciprofloxacin, another set of weekly leukocytapheresis was added.Significant improvement in her pouchitis disease activity index (PDAI) from 14 to 1.The common side effects were nausea, vomiting, fever, chills, and nasal obstruction.
Autologous fecal transplantation[45]Feces were collected from the colostomy bag, diluted with 600 ml of sterile saline (0.9 %), stirred and filtered three times using an ordinary coffee filter, irrigation endoscopically. This procedure was repeated 3 times within 4 wk (on day 0, day 10 and day 28).All symptoms improved dramatically within 5 d after the first treatment. Colonoscopy 28 d after the first treatment showed no major signs of inflammation in the colonic stumpNone, patient's tolerance required.
Dextrose spray (hypertonic glucose)[29]Endoscopically sprayed with 150 mL 50% dextrose via a catheter.Follow-up pouchoscopy 2 wk after the dextrose spray showed normal pouch mucosa with no evidence of bleeding or mucosal friability.It has a very low chance of causing transient hyperglycemia because there is no direct injection of the hypertonic solution into blood vessels.