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254
D.L. Beral and J.E. Hartley
preoperative diagnosis of dysplasia or malignancy is a risk factor for pouch cancer.
The adjusted hazard ratios for subsequent pouch neoplasia were 13.43 for previous
colorectal cancer and 3.62 for prior UC-associated dysplasia [ 21 ] . The risk of
pouch neoplasia continues to accumulate up to 25 years after surgery, and the
Cleveland data also shows that the risk is not eliminated by mucosectomy.
Therefore, the recommendation must be that endoscopic surveillance should be
undertaken to detect rare pouch cancers, especially in high-risk patients with prior
dysplastic or neoplastic change. The current guidelines from the British Society of
Fig. 18.5 Stapled J-pouch ileoanal
anastomosis (From Michelassi et al. [
18 ] )
Table 18.3 Hand-sewn vs. double-stapled anastomosis
Hand-sewn Double-stapled
Accurate placement at dentate line
Anastomosis at anorectal junction
Mucosectomy No mucosectomy
Reduced risk of cuffi tis Risk of cuffi tis
Pouch neoplasia risk not abolished No increased risk of pouch neoplasia
Technically challenging Relatively easy to perform
Prolonged sphincter dilatation risks sphincter injury Probable reduced risk of sphincter injury
255
18 Surgical Options in Ulcerative Colitis
Gastroenterology and Association of Coloproctology of Great Britain and Ireland
suggest yearly surveillance for high-risk and 5-yearly for low-risk patients [ 22 ] .
The double-stapled anastomosis using a circular end-to-end staple gun does not
involve mucosectomy and therefore carries with it some risk of cuffi tis. It is possible
however to perform a mucosectomy at a later date if the patient is signifi cantly symp-
tomatic. It is easier to learn and perform than the hand-sewn anastomosis, being a
familiar technique in colorectal surgery. It also reduces the degree and duration of
anal dilatation and thus reduces the risk of sphincter damage (although this has not
been proven with statistical signifi cance in small trials). In summary, the double-sta-
pled anastomosis has not been shown to be inferior to the original hand-sewn anasto-
mosis, does not carry an increased risk of malignancy, and is simpler to perform. The
anastomosis will be at the anorectal junction, providing the bowel has been accurately
cross-stapled at this level initially, and as this is 1–2 cm more proximal than the den-
tate line, it also more easily allows the pouch to be anastomosed without tension.
18.6.8 Laparoscopic IPAA
An emerging area in pouch surgery is the use of laparoscopy. Laparoscopic IPAA
has been performed since the early 1990s and carries the same theoretical advan-
tages as laparoscopic colorectal surgery for other indications: reduced postoperative
pain, quicker recovery, and improved cosmetic appearance. Although there have
been many single-center experience papers published, there is a lack of good quality
trial evidence in the literature comparing laparoscopic to open IPAA. The recent
Cochrane collaboration systematic review [ 23 ] only had one randomized controlled
trial (RCT) out of 11 included studies. The conclusion was that laparoscopic IPAA
has been shown to be safe and feasible with no increase in mortality or complica-
tions. There were trends towards earlier fi rst bowel movement and quicker return to
normal diet, as well as shorter hospital stay and cosmesis, but statistical signifi cance
was not reached. The single RCT was unable to show benefi ts in terms of postopera-
tive morphine requirement, hospital stay, or quality of life scores, possibly because
the surgery was hand-assisted rather than totally laparoscopic [ 24 ] .
In summary, there is evidence of some advantage to performing IPAA laparo-
scopically, and the benefi ts are likely to be greatest in the typically young and active
UC patient. Surgeons should be appropriately trained and skilled in laparoscopic
colorectal surgery before undertaking these procedures.
18.6.9 Defunctioning Ileostomy
Many surgeons will routinely create a loop ileostomy at the time of pouch construc-
tion to temporarily divert the fecal stream – the “two-stage” procedure (or “three-
stage” if emergency subtotal colectomy has been carried out initially). The benefi ts
of the two-stage approach are to reduce the sequelae of an anastomotic leak and
allow the patient to recover from the major surgery and cease medications before
256
D.L. Beral and J.E. Hartley
having to deal with the functional aspects of the pouch itself after ileostomy rever-
sal. A one-stage pouch procedure without temporary ileostomy has been advocated
by some centers as it requires only one hospital admission and avoids the morbidity
associated with the ileostomy and its closure. Some centers have reported excellent
results with low rates of anastomotic leak and pouch failure, but other series’ results
are signifi cantly worse. A recent meta-analysis examined 17 studies where IPAA
with covering ileostomy was compared to IPAA without ileostomy (11 prospective
nonrandomized trials, 5 retrospective studies, and only 1 RCT) [ 25 ] . It found that
anastomotic leak was signifi cantly more likely when an ileostomy was omitted
(9.4% vs. 4.3%, odds ratio 2.37 [95% CI 1.39–4.04]; p = 0.002) and on subgroup
analysis, pouch-related sepsis was also signifi cantly more common. Perianal sepsis
rates did not differ between the two groups, and pouch failure rates were also simi-
lar. There was also no increase in small bowel obstruction rates with covering ileo-
stomy. Functional outcomes were equivalent, but omitting a stoma reduced the risk
of anastomotic stricture. The authors comment that omitting the ileostomy in patients
undergoing IPAA may be feasible, but only in a subgroup of patients, such as young
women with minimal infl ammation who are not on steroids. This defi nition of
patients at low risk for anastomotic leak is not evidence-based but is similar to the
clinical decision-making generally employed for low rectal anastomoses.
In summary, the omission of a defunctioning loop ileostomy is a balance of the
risks of anastomotic leak (which may be related to age, nutrition, anemia, general
condition, comorbidities, and level of immunosuppression) versus the known com-
plications of ileostomies and their reversal (see Table 18.4 ). The fi nal decision will
necessarily be made intraoperatively based upon any diffi culties encountered.
18.7 Total Colectomy and Ileorectal Anastomosis
With the advent of modern stoma appliances and IPAA, total colectomy and ileorec-
tal anastomosis (IRA) became largely a procedure of historical interest in UC.
However, it does offer some signifi cant advantages which bear consideration. It
avoids an ileostomy, and it is a relatively safe procedure with low morbidity and
Table 18.4 Two-stage vs. one-stage IPAA
Two-stage One-stage
Reduced risk of anastomotic leak
Increased risk of anastomotic leak
Reduces sequelae of anastomotic leak More likely to require further intervention
after leak
Reduced risk of pouch-related sepsis Increased risk of pouch-related sepsis
Allows recovery and cessation medications Avoids need for stoma and pouch utilized
immediately
Multiple hospital admissions Single hospital admission
Risk of ileostomy-related complications No ileostomy-related complications
Increased risk of pouch-anal anastomotic
stricture
Reduced risk of pouch-anal anastomotic
stricture
257
18 Surgical Options in Ulcerative Colitis
mortality. It also avoids the pelvic dissection and its possible effect on the pelvic
nerves, sexual function, and female fertility. In the typically young population of
patients requiring surgery for UC, these are important factors to be taken into account.
Functionally, IRA patients may have a better outcome than IPAA, with less frequency
and seepage and an equivalent quality of life, although greater urgency [
26 ] .
In order to be considered for IRA, it is essential that the patient have relative
sparing of a distensible and compliant rectum and good anal sphincter function.
Relatively few patients will meet all of these criteria, and therefore IRA is reserved
for a small subgroup of patients. Occasionally, a patient with UC may present with
stage IV colon cancer, and while a palliative colectomy may be considered, the
additional morbidity of the proctectomy can be avoided with IRA, as well as avoid-
ing a stoma.
After IRA, around half of patients will retain their rectum long term with the
remainder being defunctioned with an ileostomy or excised. This often occurs
because of ongoing proctitis which is unable to be controlled medically leading to
poor function. Of greater concern historically has been the signifi cant number of
cases where the rectum has been removed for dysplasia or malignancy, which has
often been advanced at the time of diagnosis [
26 ] . Annual surveillance and biopsy
of the rectum should therefore be considered mandatory in IRA patients, and if the
patient will not be compliant with surveillance, the operation should be
reconsidered.
If a patient is appropriately counseled regarding the risk of ongoing disease and
malignant change in the rectal remnant, then it is possible to view the total colec-
tomy and IRA as a viable option in selected patients. It may also be considered as a
staging post on the road to eventual IPAA or proctectomy and end ileostomy, par-
ticularly in younger patients wishing to preserve sexual function and fertility. IPAA
can be performed in the majority of patients after IRA if required [ 26 ] .
18.8 Summary
The choice of surgical procedure in UC is dependent on the indication for surgery
as well as patient-related factors including patient preference. TAC and EI is almost
universally the recommendation in the acute setting. In the elective setting, the
choice lies between proctocolectomy and end ileostomy or IPAA. It is worth rein-
forcing that the only indication for IPAA is the avoidance of permanent ileostomy
and that the procedure carries signifi cant morbidity, mortality, and the risk of pouch
failure. Patients must be fully counseled regarding these risks and the functional
outcomes of pouch surgery. Total colectomy and IRA may be considered in a few,
carefully selected younger patients who wish to avoid a stoma and to defer proctec-
tomy to preserve sexual function and fertility. Finally, although the evidence for
screening is lacking, surveillance of pouches and retained rectums for dysplasia
and malignancy is recommended: yearly in high-risk and 5-yearly in low-risk
patients.
258
D.L. Beral and J.E. Hartley
References
1. Hoie O, Wolters FL, Riis L, Bernklev T, Aamodt G, Clofent J, et al. Low colectomy rates in
ulcerative colitis in an unselected European cohort followed for 10 years. Gastroenterol.
2007;132(2):507–15.
2. Solberg IC, Lygren I, Jahnsen J, Aadland E, Hoie O, Cvancarova M, et al. Clinical course dur-
ing the fi rst 10 years of ulcerative colitis: results from a population-based inception cohort
(IBSEN Study). Scand J Gastroenterol. 2009;44(4):431–40.
3. Brady RR, Collie MH, Ho GT, Bartolo DC, Wilson RG, Dunlop MG. Outcomes of the rectal
remnant following colectomy for ulcerative colitis. Colorectal Dis. 2008;10(2):144–50.
4. Nicholls RJ, Tekkis PP. Ulcerative colitis. In: Phillips RKS, editor. Colorectal surgery. 3rd ed.
Philadelphia: Elsevier/Saunders; 2005. p. 129–62.
5. Kock NG. Intra-abdominal “reservoir” in patients with permanent ileostomy. Preliminary
observations on a procedure resulting in fecal “continence” in fi ve ileostomy patients. Arch
Surg. 1969;99(2):223–31.
6. Cohen Z, McLeod RS. Proctocolectomy with Kock pouch. In: Michelassi F, Milsom JW, edi-
tors. Operative strategies in infl ammatory bowel disease. New York: Springer; 1999. p. 215.
7. Lindsey I, George BD, Kettlewell MG, Mortensen NJ. Impotence after mesorectal and close
rectal dissection for infl ammatory bowel disease. Dis Colon Rectum. 2001;44(6):831–5.
8. Lyttle JA, Parks AG. Intersphincteric excision of the rectum. Br J Surg. 1977;64(6):413–6.
9. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J.
1978;2(6130):85–8.
10. Bach SP, Mortensen NJ. Ileal pouch surgery for ulcerative colitis. World J Gastroenterol.
2007;13(24):3288–300.
11. Ording OK, Juul S, Berndtsson I, Oresland T, Laurberg S. Ulcerative colitis: female fecundity
before diagnosis, during disease, and after surgery compared with a population sample.
Gastroenterology. 2002;122(1):15–9.
12. Farouk R, Pemberton JH, Wolff BG, Dozois RR, Browning S, Larson D. Functional outcomes
after ileal pouch-anal anastomosis for chronic ulcerative colitis. Ann Surg. 2000;231(6):
919–26.
13. Mitchell PJ, Rabau MY, Haboubi NY. Indeterminate colitis. Tech Coloproctol. 2007;11(2):
91–6.
14. Yu CS, Pemberton JH, Larson D. Ileal pouch-anal anastomosis in patients with indeterminate
colitis: long-term results. Dis Colon Rectum. 2000;43(11):1487–96.
15. Delaney CP, Remzi FH, Gramlich T, Dadvand B, Fazio VW. Equivalent function, quality of
life and pouch survival rates after ileal pouch-anal anastomosis for indeterminate and ulcer-
ative colitis. Ann Surg. 2002;236(1):43–8.
Key Points
Total abdominal colectomy and end ileostomy is the operation of choice in •
the acute situation.
Proctocolectomy and end ileostomy remains the defi nitive treatment for •
UC.
Restorative proctocolectomy and ileal pouch-anal anastomosis requires •
careful patient selection and comprehensive counselling regarding the
associated risks and functional outcomes.
Ileal pouches and retained rectums should undergo surveillance for dyspla-•
sia and malignancy.
259
18 Surgical Options in Ulcerative Colitis
16. Dayton MT, Larsen KR, Christiansen DD. Similar functional results and complications after
ileal pouch-anal anastomosis in patients with indeterminate versus ulcerative colitis. Arch
Surg. 2002;137(6):690–4.
17. Uraiqat AA, Byrne CM, Phillips RK. Gaining length in ileal-anal pouch reconstruction: a
review. Colorectal Dis. 2007;9(7):657–61.
18. Michelassi F, Takanishi D, McLeod RS, et al. Ileal reservoirs. In: Michelassi F, Milsom JW,
editors. Operative strategies in infl ammatory bowel disease. New York: Springer; 1999.
p. 186.
19. Branco BC, Sachar DB, Heimann TM, Sarpel U, Harpaz N, Greenstein AJ. Adenocarcinoma
following ileal pouch-anal anastomosis for ulcerative colitis: review of 26 cases. Infl amm
Bowel Dis. 2009;15(2):295–9.
20. Al-Sukhni W, McLeod RS, Macrae H, O’connor B, Huang H, Cohen Z. Oncologic outcome in
patients with ulcerative colitis associated with dysplasia or cancer who underwent stapled or
handsewn ileal pouch-anal anastomosis. Dis Colon Rectum. 2010;53(11):1495–500.
21. Kariv R, Remzi FH, Lian L, Bennett AE, Kiran RP, Kariv Y, et al. Preoperative colorectal
neoplasia increases risk for pouch neoplasia in patients with restorative proctocolectomy.
Gastroenterology. 2010;139(3):806–12, 812.
22. Cairns SR, Scholefi eld JH, Steele RJ, Dunlop MG, Thomas HJ, Evans GD, et al. Guidelines
for colorectal cancer screening and surveillance in moderate and high risk groups (update from
2002). Gut. 2010;59(5):666–89.
23. Ahmed AU, Keus F, Heikens JT, Bemelman WA, Berdah SV, Gooszen HG, et al. Open versus
laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial adenom-
atous polyposis. Cochrane Database Syst Rev. 2009;(1):CD006267.
24. Maartense S, Dunker MS, Slors JF, Cuesta MA, Gouma DJ, van Deventer SJ, et al. Hand-
assisted laparoscopic versus open restorative proctocolectomy with ileal pouch anal anastomo-
sis: a randomized trial. Ann Surg. 2004;240(6):984–91.
25. Weston-Petrides GK, Lovegrove RE, Tilney HS, Heriot AG, Nicholls RJ, Mortensen NJ, et al.
Comparison of outcomes after restorative proctocolectomy with or without defunctioning ileo-
stomy. Arch Surg. 2008;143(4):406–12.
26. da Luz MA, Kiran RP, Lavery I. Clinical outcomes of ileorectal anastomosis for ulcerative
colitis. Br J Surg. 2010;97(1):65–9.
261
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_19, © Springer-Verlag London Limited 2012
Fulminant colitis can be considered as an acute and progressive infl ammatory
disorder of the large bowel mucosa which has failed to respond to escalating medical
therapy and for which surgical intervention must be considered. Ulcerative colitis
(UC) remains the commonest cause of this condition, but changing patterns of dis-
ease and increasing levels of intervention mean that other causes must be frequently
considered. There are considerable and ongoing advances in medical therapy for this
condition which are infl uencing the decision to proceed to surgery. By comparison,
the surgical treatment itself has changed little over the last 30 years. Optimal man-
agement requires a multidisciplinary approach with close collaboration between the
gastroenterologist, surgeon, nutrition team, and colorectal nurse specialist. The key
to successful management of these patients is timely surgery before large bowel
perforation and before the patient is too debilitated to withstand the surgical insult.
This chapter will cover the recent changes in fulminant colitis and its management.
K. Futaba , FRCS
Department of Colorectal Surgery ,
Queen Elizabeth Hospital ,
Birmingham, West Midlands,
B15 2TH , UK
e-mail: kaorifutaba@hotmail.com
T. Mak , FRCS
Department of Surgery ,
The Chinese University of Hong Kong, Prince of Wales Hospital ,
Hong Kong , China
e-mail: tonymak@surgery.cuhk.edu.hk
D. Morton , FRCS (
*)
Academic Department of Surgery ,
Queen Elizabeth Hospital ,
Edgbaston , Birmingham,
B15 2TH , UK
e-mail: d.g.morton@bham.ac.uk
Chapter 19
Surgery for Fulminant Colitis
Kaori Futaba , Tony Mak , and Dion Morton
262
K. Futaba et al.
Case Scenario 1
A 27-year-old male presents to A&E with a 6-week history of bloody diar-
rhea. His stool frequency is 5 times/24 h; he is apyrexial, HR is 80 and CRP
25. Plain abdominal x-ray is normal. Flexible sigmoidoscopy shows mucosal
ulceration, friability, and contact bleeding as far as the middescending colon.
1. The initial management for this patient should be:
(a) Admit to hospital and commence iv hydrocortisone 100 mg qds.
(b) Admit to hospital and commence oral prednisolone 40 mg od.
(c) Allow home, commence oral prednisolone 40 mg od, and arrange early
follow up.
(d) Allow home, commence oral 5-ASA, and arrange early follow-up.
(e) Allow home, commence rectal 5-ASA, and arrange early follow-up.
2. The patient improves following initial management but subsequently
fl ares. Which one of the following is an indication for commencing
azathioprine?
(a) Following a moderate severity fl are
(b) A fl are of disease 6 months after completing the last course of
steroids
(c) Two fl ares requiring steroid treatment within a 12-month period
(d) Three fl ares requiring steroid treatment within a 12-month period
(e) For a patient on 5 mg prednisolone od, 7 weeks after commencing
steroids
3. Prior to commencing azathioprine treatment, it is recommended to check
all of the following except:
(a) Thiopurine methyltransferase (TPMT) levels
(b) Varicella zoster serology
(c) Full blood count
(d) Urea and electrolytes
(e) Hepatitis BsAg
Case Scenario 2
A patient with a preexisting diagnosis of ulcerative colitis presents with a
4-week history of progressively increasing stool frequency. She is on no treat-
ment. When seen in clinic, she has a stool frequency of eight times/24 h; her
HR is 106, and temperature is 37°C. Subsequent blood tests reveal a CRP of
110 and a hemoglobin level of 9.7 g/dL. She is admitted for treatment.
1. All of the following treatments are indicated except:
(a) Prophylactic low molecular weight heparin
(b) Oral calcium supplementation
(c) Intravenous hydrocortisone
(d) Oral 5-ASA
(e) Rectal 5-ASA
263
19 Surgery for Fulminant Colitis
19.1 Clinical Presentation
Patients with severe colitis will usually present with bloody diarrhea and urgency
associated with abdominal pain. Severe colitis is defi ned by Truelove and Witts as
six or more bloody diarrhea per day with one or more of the following: temperature
>37.5°C, tachycardia (HR > 90), anemia (Hb < 10.5), and ESR > 30 [ 1 ] . Some, on
the contrary, may present with constipation associated with abdominal distension
and pain due to progressive loss of propulsive motility of the colon or with symp-
toms of sepsis alone. It is important to take a detailed history, including past medical
history (recent illness/hospital admissions, diabetes, and ischemic heart disease),
drug history including recent immunosuppressant therapy and antibiotic usage, or
history of recent foreign travel, to obtain maximum information to fi nd the most
likely cause for their colitis.
Regular observations including stool charts are essential to assess disease pro-
gression, which will be a key determinant of the need for surgery. Careful daily
examination, if possible by the same experienced clinician, will be useful to monitor
progress and response to treatment. On abdominal examination, there may be signs
of peritoneal irritation, which represents transmural infl ammation causing serosal
irritation. One must be wary of fi nding only minimal peritoneal signs, especially in
the elderly or masked in patients on steroid therapy. If patients have signs of gener-
alized peritonitis, the cause may be colonic perforation or incipient perforation sec-
ondary to (now rare) toxic megacolon. This would be a clear indication for early
surgical intervention.
2. When assessing her response to treatment, which of the following indi-
cates an 85% likelihood of steroids failing to control the disease?
(a) Stool frequency six times/24 h at 48 h
(b) Stool frequency eight times/24 h at 72 h
(c) Stool frequency three times/24 h and CRP 20 mg/L at 72 h
(d) CRP 50 mg/L at 48 h
(e) CRP 40 mg/L at 72 h
3. She is assessed at 72 h and is deemed to have had an incomplete response
to steroids. Plain abdominal fi lm shows no evidence of toxic megacolon;
she is not tachycardic, she is apyrexial, and her abdomen is soft. She is
considered for rescue medical therapy. With regard to medical rescue ther-
apy, which of the following is true?
(a) Before giving cyclosporin A, serum cholesterol should be below
3 mmol/L.
(b) Infl iximab is superior to cyclosporin A in achieving remission.
(c) Infl iximab has a faster onset of action than cyclosporin A.
(d) Long-term colectomy free rates are around 50% with rescue therapy.
(e) Patients who do not respond to cyclosporin A should be considered for
infl iximab treatment.
264
K. Futaba et al.
19.2 Investigations
Blood test including FBC, ESR/CRP, and U&E should be performed and repeated
daily for monitoring. A falling hemoglobin and persistently raised infl ammatory
markers can be useful indicators of failing medical management. Features of severe
colitis may be seen on plain abdominal x-ray (AXR) as loss of haustration, mucosal
thumb printing, colonic deep ulcerations, or proximal colonic dilatation. A repeated
plain fi lm may also show proximal extension, a further indication of poor response
to medical therapy. In young previously healthy patients who are on high-dose ste-
roids, clinical signs can be subtle; biochemical and radiological fi ndings can pro-
vide useful corroborative evidence of active disease.
Toxic megacolon is classically defi ned as total or segmental nonobstructive
hypotonic dilatation of colon, with transverse colon measuring >5.5 cm in the mid-
line on a plain AXR in a toxic patient [
2 ] . Toxic megacolon complicates consider-
ably less than 10% of patients with fulminant colitis. The more dilated the colon is,
the higher the risk of perforation. Erect chest x-ray may show free intraperitoneal
gas as free gas under the diaphragm or as Rigler’s sign where both sides of the
bowel wall are seen (double-wall sign) on a plain AXR. Toxic megacolon and per-
foration are features of complications of fulminant ulcerative colitis. Retrospective
studies have shown that small bowel distension may precede colonic dilatation,
termed impending megacolon, and is a bad prognostic sign for this subgroup of
patients [ 3 ] . It should be recognized that the rising incidence of Crohn’s colitis and
earlier medical management of UC have combined to make this a rare presentation,
seen only a couple of times per year in major units in the UK.
CT scan of abdomen and pelvis may also be helpful when clinical picture is not
clear, particularly in Crohn’s colitis, notably in diagnosing local abscess formation
and fi stulation, which are more prevalent features of fulminant Crohn’s colitis [ 4 ] .
Target signs can often be identifi ed in areas of submucosal edema and infl ammation
from various diseases of the bowel on a CT scan. In severe fulminant colitis, severe
mucosal ulceration leads to mural thinning and pseudopolyps [ 5 ] . CT scans are also
more sensitive than plain AXR in picking up pseudopolyps, unsuspected perfora-
tions, or pneumatosis, which may expedite decision for surgical intervention
(Fig. 19.1 ).
Endoscopy can be used as a marker of disease severity but is most commonly
used if there is uncertainty over the etiology. Deep ulceration eroding into the mus-
cularis propria involving >1/3 of the circumference of a colonic segment and
mucosal detachment of the edge of ulceration in at least one colonic segment on
endoscopy is classifi ed as severe endoscopic colitis and is associated with poor
prognosis for response to medical therapy [ 6, 7 ] . Limited rectosigmoidoscopy
should be employed if it is a fi rst presentation of UC or Crohn’s disease. It is also
useful in ischemic colitis, which is often a diffi cult diagnosis to establish. Endoscopy
may be avoided initially in patients with established infective colitis. Biopsies can
however be helpful to establish viral colitis such as CMV, of particular importance
in the immunosuppressed population. Full colonoscopy and contrast enema are
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