Colitis is swelling (inflammation) of the large intestine (colon).
Colitis can have many different causes, including:
Viruses and bacteria can cause colon infections. Most are food-borne illnesses or "food poisoning." Common bacterial causes include Shigella, E Coli, Salmonellaand Campylobacter. These infections may cause bloody diarrhea and can result in significant dehydration.
Parasites such as giardia can cause significant diarrhea. The parasite can enter the body when infected water is swallowed. The source may be from recreational water such as rivers, lakes, and swimming pools. It may also be contaminated from a water well or cistern.
Pseudomembranous colitis is caused by the bacteria Clostridium difficile (C. difficile). This disorder is often seen in patients who have recently been taking antibiotics for an infection. The antibiotic alters the normal bacteria present in the colon and allows an overgrowth of the Clostridium bacteria. Clostridium bacteria produce a toxin that causes diarrhea. This is an infection, and often there is a fever present. The diarrhea is usually not bloody.
The arteries that supply blood to the colon are like any other artery in the body. They have the potential to become narrow due to atherosclerosis (just like blood vessels in the heart, which can cause angina, or narrowed vessels in the brain can cause a stroke). When these arteries become narrow, the colon may lose its blood supply and become inflamed.
The colon can also lose its blood supply for mechanical reasons. A couple of examples include volvulus, where the bowel twists on itself, or an incarcerated hernia, where a portion of the colon gets trapped in an outpouching of the abdominal wall, which prevents blood from flowing to the affected portion.
In individuals who are at risk for decreased blood flow to the colon, ischemic colitis can occur if the blood pressure falls. This may occur with dehydration, anemia, orshock.
Ischemia or lack of blood supply causes significant pain, fever, and bloody bowel movements.
Inflammatory Bowel Disease
There are two types of inflammatory bowel disease, ulcerative colitis, and Crohn's disease.
Ulcerative colitis is thought to be an autoimmune illness in which the body's immune system attacks the colon and causes inflammation. Ulcerative colitis begins in the rectum and may gradually spread throughout the colon. The signs and symptoms include abdominal pain and bloody bowel movements.
Crohn's disease may involve any part of the digestive tract from the esophagus and stomach, through to the small and large intestine all the way to the rectum. It often has skip lesions, that is diseased areas are interspersed with healthy areas of tissue.
Two diseases make up this group of colon inflammation, collagenous colitis and lymphocytic colitis. In these diseases, the inflammation is caused when the colon wall becomes engorged with either collagen or lymphocytes. Watery, non-bloody diarrhea is the most common symptom.
This is an uncommon illness that is seen more frequently in older women. The cause is unknown but an autoimmune potential may exist.
If chemicals are instilled into the colon, inflammation and damage can occur. One of the complications of an enema is inflammation of the mucosal lining of the colon caused by harsh chemicals.
Symptoms of colitis will depend upon the type of colitis that is present, but in general, colitis most often is associated with abdominal pain and diarrhea.
Other symptoms of colitis that may or may not be present include:
Symptoms suggestive of colitis are worked-up by obtaining the medical history, a physical examination and laboratory tests (CBC, electrolytes, stool culture and sensitivity, stool ova and parasites et cetera). Additional tests may include medical imaging (e.g. abdominal computed tomography,abdominal X-rays) and an examination with a camera inserted into the rectum (sigmoidoscopy, colonoscopy).
Colitis Medical Treatment
The definitive treatment of colitis is dependent upon the cause. Many cases require little more than symptomatic care, including clear fluids to rest the bowel and medications to control pain. Some patients become acutely ill and will need intravenous (IV) fluids and other interventions to treat their illness.
Infections: Infections that cause diarrhea and colitis may or may not require antibiotics, depending upon the cause. Viral infections resolve with the supportive care of fluids and time. Some bacterial infections like Salmonella also do not need antibiotic therapy; the body is able to get rid of the infection on its own. Other bacterial infections like Clostridium difficile always require treatment with antibiotics.
IBD: Inflammatory bowel diseases (IBDs) like ulcerative colitis and Crohn's disease, are often controlled by a combination of medications that are used in a step-wise approach. Initially, anti-inflammatory medications are used, and if these are less than successful, medications that suppress the immune system can be added. In the most severe cases, surgery may be required to remove all or parts of the colon and small intestine.
Ischemic colitis: Treatment of ischemic colitis is initially supportive, using intravenous fluids to rest the bowel and prevent dehydration. If adequate blood supply to the bowel is not restored, surgery may be required to remove parts of the bowel that have lost blood supply.
Diarrhea and abdominal pain: Most causes of colitis present with diarrhea and crampy abdominal pain. These symptoms are also found with mild illnesses like viral enteritis (inflammation of the colon). Initial treatment at home may include a clear fluid diet for 24 hours, rest, and acetaminophen(Tylenol) as needed for pain. Often symptoms resolve quickly and no further care is needed.
Medical care should be accessed if any of the following conditions exist:
Colitis over-the-counter (OTC) medications may be used for diarrhea and crampy abdominal pain; however, medical advice should be obtained if there is blood in the stool or the pain is intense. Loperamide (Imodium) is an effective medicine to control diarrhea. Acetaminophen or ibuprofen can be used for pain control.
Depending upon the cause of the colitis, medication may be prescribed to control or cure symptoms. Antibiotics may be helpful in colitis caused by some infections. Anti-inflammatory and immune suppression drugs can be used to control the symptoms of inflammatory bowel disease.
Surgery may be required for ischemic colitis, Crohn's disease, or ulcerative colitis, depending upon the severity of the illness and the response to more conservative non-surgical treatments.
In ulcerative colitis, removal of the colon cures the disease.
For other illnesses, usually the part of the colon that is at risk or damaged is removed.
Colitis Other Therapy
• Diet: A clear fluid/liquid diet allows the colon to rest, since the fluid is absorbed in the stomach and none is passed into the colon to be processed as stool.
• Hydration: Adequate hydration is important because an individual can lose a significant amount of fluid with each diarrheal bowel movement. Aside from the daily fluid requirements, this excess loss needs to be replaced, otherwise dehydration will occur and potentially worsen the symptoms of abdominal pain and cramping.
• IV fluids: Intravenous (IV) fluid may be required, especially if the patient cannot drink enough fluids by mouth. For some illnesses like ischemic colitis, in which blood flow to the bowel is already compromised, adequate hydration is a key element in treatment. Electrolyte replacement may be required in some patients who have significant dehydration.
Infectious colitis remains a common ailment worldwide, affecting millions daily. The lack of clean drinking water and adequate sanitation are the main causes, leading to thousands of potentially preventable deaths each day. In developed countries, poor hand washing and poor kitchen hygiene allow the potential for infectious colitis. Prevention lies in cleanliness.
Inflammatory bowel diseases are difficult to prevent at the present time. The likely causes are heredity and perhaps an abnormal auto-immune response to an unknown stimulus in the body.
Since ischemic colitis is caused by narrowing of the blood vessels to the bowel, decreasing the risks for other types of circulatory problems such as peripheral vascular disease, heart attack, and stroke will also decrease the risk for ischemic colitis. The common risk factors are smoking and poor control of high blood pressure, high cholesterol levels, and diabetes.
Ulcerative colitis is a chronic (ongoing) disease of the colon, or large intestine. The disease is marked by inflammation and ulceration of the colon mucosa, or innermost lining. Tiny open sores, or ulcers, form on the surface of the lining, where they bleed and produce pus and mucus. Because the inflammation makes the colon empty frequently, symptoms typically include diarrhea (sometimes bloody) and often crampy abdominal pain.
The inflammation usually begins in the rectum and lower colon, but it may also involve the entire colon. When ulcerative colitis affects only the lowest part of the colon -- the rectum -- it is called ulcerative proctitis. If the disease affects only the left side of the colon, it is called limited or distal colitis. If it involves the entire colon, it is termed pancolitis.
Ulcerative colitis differs from another inflammatory bowel disease (IBD), Crohn's disease. Crohn's can affect any area of the gastrointestinal (GI) tract, including the small intestine and colon. Ulcerative colitis, on the other hand, affects only the colon. The inflammation involves the entire rectum and extends up the colon in a continuous manner. There are no areas of normal intestine between the areas of diseased intestine. In contrast, such so-called "skip" areas may occur in Crohn's disease. Ulcerative colitis affects only the innermost lining of the colon, whereas Crohn's disease can affect the entire thickness of the bowel wall.
Both illnesses do have one strong feature in common. They are marked by an abnormal response by the body's immune system. The immune system is composed of various cells and proteins. Normally, these protect the body from infection. In people with IBD, however, the immune system reacts inappropriately. Mistaking food, bacteria, and other materials in the intestine for foreign or invading substances, it launches an attack. In the process, the body sends white blood cells into the lining of the intestines, where they produce chronic inflammation. These cells then generate harmful products that ultimately lead to ulcerations and bowel injury. When this happens, the patient experiences the symptoms of IBD.
Neither ulcerative colitis nor Crohn's disease should be confused with irritable bowel syndrome (IBS), a disorder that affects the motility (muscle contractions) of the colon. Sometimes called "spastic colon" or "nervous colitis," IBS is not characterized by intestinal inflammation. It is, therefore, a much less serious disease than ulcerative colitis. IBS bears no direct relationship to either ulcerative colitis or Crohn's disease.
What Causes Ulcerative Colitis?
Although considerable progress has been made in IBD research, investigators do not yet know what causes this disease. Studies indicate that the inflammation in IBD involves a complex interaction of factors: the genes the person has inherited, the immune system, and something in the environment. Foreign substances (antigens) in the environment may be the direct cause of the inflammation, or they may stimulate the body's defenses to produce an inflammation that continues without control. Researchers believe that once the IBD patient's immune system is "turned on," it does not know how to properly "turn off" at the right time. As a result, inflammation damages the intestine and causes the symptoms of IBD. That is why the main goal of medical therapy is to help patients regulate their immune system better.
Many scientists now believe that the interaction of an outside agent (such as a virus or bacterium) with the body's immune system may trigger the disease, or that such an agent may cause damage to the intestinal wall, initiating or accelerating the disease process.
How Common are IBD and Ulcerative Colitis?
It is estimated that as many as 1.4 million Americans have IBD, with that number evenly split between Crohn's disease and ulcerative colitis. Males and females appear to be affected equally.
On average, people are diagnosed with ulcerative colitis in their mid-30s, although the disease can occur at any age. Men are more likely than women to be diagnosed with ulcerative colitis in their 50s and 60s. There is a greater incidence of ulcerative colitis among whites than in non-whites, and a higher incidence in Jews than in non-Jews.
Is Ulcerative Colitis Inherited?
We know that ulcerative colitis can tend to run in families. Studies have shown that up to 20 percent of people with ulcerative colitis will have a close relative with either ulcerative colitis or Crohn's disease. Most often, the affected relative of the colitis patient will also have ulcerative colitis. However, based on current research, there does not appear to be a clear-cut pattern to this inheritance. Researchers continue to seek specific genes involved in the cause of the diseases.
Symptoms of Ulcerative Colitis?
The first symptom of ulcerative colitis is a progressive loosening of the stool. The stool is generally bloody and may be associated with crampy abdominal pain and severe urgency to have a bowel movement. The diarrhea may begin slowly or quite suddenly. Loss of appetite and subsequent weight loss are common, as is fatigue. In cases of severe bleeding, anemia may also occur. In addition, there may be skin lesions, joint pain, eye inflammation, and liver disorders. Children with ulcerative colitis may fail to develop or grow properly.
Approximately half of all patients with ulcerative colitis have relatively mild symptoms. However, others may suffer from severe abdominal cramping, bloody diarrhea, nausea, and fever. The symptoms of ulcerative colitis do tend to come and go, with fairly long periods in between flare-ups in which patients may experience no distress at all. These periods of remission can span months or even years, although symptoms do eventually return. The unpredictable course of ulcerative colitis may make it difficult for physicians to evaluate whether a particular course of treatment has been effective or not.
Types of Ulcerative Colitis and Their Associated Symptoms
The symptoms of ulcerative colitis, as well as possible complications, will vary depending on the extent of inflammation in the rectum and the colon. Because of this, it is very important for you to know which part of your intestine the disease affects.
One common subcategory of ulcerative colitis is ulcerative proctitis. For approximately 30% of all patients with ulcerative colitis, the illness begins as ulcerative proctitis. In this form of the disease, bowel inflammation is limited to the rectum . Because of its limited extent (usually less than the six inches of the rectum), ulcerative proctitis tends to be a milder form of ulcerative colitis. It is associated with fewer complications and offers a better outlook than more widespread disease.
In addition to ulcerative proctitis, there are several other types of ulcerative colitis. The following is a description of each type, together with some commonly associated symptoms and potential intestinal complications:
Proctosigmoiditis: Colitis affecting the rectum and the sigmoid colon (the lower segment of colon located right above the rectum). Symptoms include bloody diarrhea, cramps, and tenesmus. Moderate pain on the lower left side of the abdomen may occur in active disease.
Left-sided colitis: Continuous inflammation that begins at the rectum and extends as far as the splenic flexure (a bend in the colon, near the spleen). Symptoms include loss of appetite, weight loss, diarrhea, severe pain on the left side of the abdomen, and bleeding.
Pan-ulcerative (total) colitis: Affects the entire colon. Symptoms include diarrhea, severe abdominal pain, cramps, and extensive weight loss. Potentially serious complications include massive bleeding and acute dilation of the colon (toxic megacolon), which may lead to perforation (an opening in the bowel wall). Serious complications may require surgery.
How is Ulcerative Colitis Diagnosed?
Physicians make the diagnosis of ulcerative colitis based on the patient's clinical history, a physical examination, and a series of tests. The first goal of these tests is to differentiate ulcerative colitis from infectious causes of diarrhea. Accordingly, stool specimens are obtained and analyzed to eliminate the possibility of bacterial, viral, or parasitic causes of diarrhea. Blood tests can check for signs of infection as well as for anemia, which may indicate bleeding in the colon or rectum. Following this, the patient generally undergoes an evaluation of the colon, using one of two tests -- a sigmoidoscopy or total colonoscopy.
Another diagnostic procedure that may be used is a barium enema X-ray of the colon. After the colon is filled with barium, a chalky white solution, an X-ray is taken. The barium shows up white on the X-ray, providing a detailed picture of the colon and any signs of disease.
What Medications are Used to Treat Ulcerative Colitis?
Currently, there is no medical cure for ulcerative colitis. However, effective medical treatment can suppress the inflammatory process. This accomplishes two important goals: It permits the colon to heal and it also relieves the symptoms of diarrhea, rectal bleeding, and abdominal pain. As such, the treatment of ulcerative colitis involves medications that decrease the abnormal inflammation in the colon lining and thereby control the symptoms.
Five major classes of medication are used today to treat ulcerative colitis:
3. Immune Modifiers
5. Biologic Therapies
Complications of Ulcerative Colitis
Complications are by no means an inevitable or even a frequent consequence of ulcerative colitis, especially in appropriately treated patients. But they are sufficiently common and cover such a wide range of manifestations that it is important for patients and physicians to be acquainted with them. Early recognition often means more effective treatment.
Local complications of ulcerative colitis include profuse bleeding from deep ulcerations, perforation (rupture) of the bowel, or simply failure of the patient to respond appropriately to the usual medical treatments.
Another complication is severe abdominal distension. A mild degree of distention is common in individuals without any intestinal disease and is somewhat more common in people with ulcerative colitis. However, if the distention is severe or of sudden onset, and if it is associated with active colitis, fever, and constipation, your physician may suspect a serious complication of colitis, called toxic megacolon. Fortunately, this is a rare development. I t is produced by severe inflammation of the entire thickness of the colon, with weakening and ballooning of its wall. The dilated colon is then at risk of rupturing. Treatment is aimed at controlling the inflammatory reaction and restoring losses of fluid, salts, and blood. If there is no rapid improvement, surgery may become necessary to avoid rupture of the bowel..
Surgery and Ulcerative Colitis
In one-quarter to one-third of patients with ulcerative colitis, medical therapy is not completely successful or complications arise. Under these circumstances, surgery may be considered. This operation involves the removal of the colon (colectomy). Unlike Crohn's disease, which can recur after surgery, ulcerative colitis is "cured" once the colon is removed.
There is no evidence that any particular foods cause or contribute to ulcerative colitis or other types of IBD. Once the disease has developed, however, paying special attention to diet may help reduce symptoms, replace lost nutrients, and promote healing.
Maintaining proper nutrition is important in the medical management of ulcerative colitis. Good nutrition is essential in any chronic disease but especially in this illness, because diarrhea and rectal bleeding can rob the body of fluids, electrolytes, and nutrients.
Emotional Stress and Coping With Ulcerative Colitis
Because body and mind are so closely interrelated, emotional stress can influence the course of ulcerative colitis -- or, for that matter, any other chronic illness. Although people occasionally experience emotional problems before a flare-up of their disease, this does not imply that emotional stress causes the illness. There is no evidence to show that stress, anxiety, or tension is responsible for ulcerative colitis. No single personality type is more prone to develop ulcerative colitis than others, and no one "brings on" the disease by poor emotional control.
It is much more likely that the emotional distress that patients sometimes feel is a reaction to the symptoms of the disease itself.
"Cannabinoids cool the intestine"
George Kunos and Pál Pacher are at the National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland 20892-8115, USA. e-mail: email@example.com or e-mail: firstname.lastname@example.org
Cannabinoids inhibit motility and secretion in the intestine. They are now assigned the additional task of curbing excessive inflammation, suggesting that drugs targeting the endogenous cannabinoid system could be exploited for inflammatory bowel disease.
Inflammatory bowel diseases (IBDs) such as ulcerative colitis and Crohn's disease affects over a million people in the United States1, with an estimated indirect cost from work loss of $3.6 billion annually2.
"Cannabinoid-based drugs as anti-inflammatory therapeutics"
Thomas W. Klein
In the nineteenth century, marijuana was prescribed by physicians for maladies ranging from eating disorders to rabies. However, as newer, more effective drugs were discovered and as the potential for abuse of marijuana was recognized, its use as a therapeutic became restricted, and only recently has its therapeutic potential been re-evaluated. Recent studies in animal models and in humans have produced promising results for the treatment of various disorders — such as obesity, cancer, and spasticity and tremor due to neuropathology — with drugs based on marijuana-derived cannabinoids. Moreover, as I discuss here, a wealth of information also indicates that these drugs have immunosuppressive and anti-inflammatory properties; therefore, on the basis of this mode of action, the therapeutic usefulness of these drugs in chronic inflammatory diseases is now being reassessed.
"Activation of the cannabinoid 2 receptor (CB2) protects against experimental colitis."
Storr MA, Keenan CM, Zhang H, Patel KD, Makriyannis A, Sharkey KA.
Division of Gastroenterology, Department of Medicine and Snyder Institute of Infection, Immunity & Inflammation, University Calgary, Calgary, Alberta, Canada.
Activation of cannabinoid (CB)(1) receptors results in attenuation of experimental colitis. Our aim was to examine the role of CB(2) receptors in experimental colitis using agonists (JWH133, AM1241) and an antagonist (AM630) in trinitrobenzene sulfonic acid (TNBS)-induced colitis in wildtype and CB(2) receptor-deficient (CB(2) (-/-)) mice.
Mice were treated with TNBS to induce colitis and then given intraperitoneal injections of the CB(2) receptor agonists JWH133, AM1241, or the CB(2) receptor antagonist AM630. Additionally, CB(2) (-/-) mice were treated with TNBS and injected with JWH133 or AM1241. Animals were examined 3 days after the induction of colitis. The colons were removed for macroscopic and microscopic evaluation, as well as the determination of myeloperoxidase activity. Quantitative reverse-transcriptase polymerase chain reaction (RT-PCR) for CB(2) receptor was also performed in animals with TNBS and dextran sodium sulfate colitis.
Intracolonic installation of TNBS caused severe colitis. CB(2) mRNA expression was significantly increased during the course of experimental colitis. Three-day treatment with JWH133 or AM1241 significantly reduced colitis; AM630 exacerbated colitis. The effect of JWH133 was abolished when animals were pretreated with AM630. Neither JWH133 nor AM1241 had effects in CB(2) (-/-) mice.
We show that activation of the CB(2) receptor protects against experimental colitis in mice. Increased expression of CB(2) receptor mRNA and aggravation of colitis by AM630 suggests a role for this receptor in normally limiting the development of colitis. These results support the idea that the CB(2) receptor may be a possible novel therapeutic target in inflammatory bowel disease.
"The atypical cannabinoid O-1602 protects against experimental colitis and inhibits neutrophil recruitment
Our data demonstrate that O-1602 is protective against experimentally induced colitis and inhibits neutrophil recruitment independently of CB1, CB2, and GPR55 receptors. Thus, atypical cannabinoids represent a novel class of therapeutics that may be useful for the treatment of inflammatory bowel diseases. (Inflamm Bowel Dis 2010;)
Cannabinoids are known to reduce intestinal inflammation. Atypical cannabinoids produce pharmacological effects via unidentified targets. We were interested in whether the atypical cannabinoid O-1602, reportedly an agonist of the putative cannabinoid receptor GPR55, reduces disease severity of dextran sulfate sodium (DSS) and trinitrobenzene sulfonic acid (TNBS)-induced colitis in C57BL/6N and CD1 mice.
"Potential of cannabinoids to modulate the inflammatory response in colitis"
Violeta Zaric,1Brandon Busbee,1Prakash Nagarkatti,1 and Mitzi Nagarkatti1
1Department of Pathology, Microbiology and Immunology, School of Medicine, University of South Carolina, Columbia, SC
Recent studies have suggested the role for cannabinoid (CB) type 1 and CB2 receptors in modulating gastrointestinal inflammation in animal models of experimental colitis. However, the immunosuppressive effect of the cannabinoid system has not been fully investigated. Our preliminary studies using delta-9-tetrahydrocannabinol (THC) showed promising results in a 2,4,6-trinitrobenzene sulfonic acid TNBS-induced colitis. 50mg/kg body weight of TNBS/ethanol was administered in 10 female BALB/c mice. Each group received intraperitoneal injections of vehicle or THC (10 mg/kg) once every other day. At day 6, mice were sacrificed and cells from spleen and MLN were analyzed for the expression of surface markers for T-cells, myeloid-derived suppressor cells (MDSC) and regulatory T-cells (Treg) by flow cytometry. The body weight increased in TNBS-treated mice administered THC when compared to vehicle. THC improved the survival up to 60% of mice in TNBS-induced colitis when compared to vehicle treated mice (30%). In the spleen and MLN, the ratio of T-cells is lower in THC-treated mice compared to vehicle-treated group whereas the ratio of Treg is increased in THC-treated mice. THC also reduced the ratio of MDSCs in TNBS-treated mice. THC treatment ameliorated colitis by modulating the immune response towards Treg and altering the T-cells and their subsets. Future experiments will address the potential of other cannabinoids in modulating the inflammatory response in colitis.
Recommendation: Use Medical Marijuana as adjunct treatment for control of symptoms. You will probably find you do not need to take pharmaceuticals or over the counter medications. Just one medicine with little or no side effects.
1. to relax the smooth muscles (slow or stop diarrhea) and prevent hemorrhoids and nutrient loss.
2. relieve vomitting
3. analgesic effects to relieve abdominal pain (spasms)
4. anti-inflammation (by suppressing certain parts of immune system)
5. anti-bacterial properties to fight infections
6. immunosuppressive properties to relieve IBD symptoms
Use whole plant extracts of Indica x Sativa hybrid: you want cannabis that has as many of the cannabinoids in it as possible: cannabigerol, caryophyllene, cannabidiol, THC (8 and 9), cannabinol and cannabichromene. (just a few)
Make your own tincture, oil, decoction, infused oils. These extracts are more potent if taken orally (under the tongue).
A vaporizor is very fast acting i.e. the cannabinoids get into your system very quickly. Edibles take quite a bit longer and must pass through the liver. However the effects last much longer.
1. ^ "Clostridium Difficile Colitis - Overview". WebMD, LLC. Retrieved 2006-09-15.
2. ^ Beutin L (2006). "Emerging enterohaemorrhagic Escherichia coli, causes and effects of the rise of a human pathogen". J Vet Med B Infect Dis Vet Public Health 53 (7): 299–305. doi:10.1111/j.1439-0450.2006.00968.x. PMID 16930272.
3. ^ Romano, C.; Famiani, A.; Gallizzi, R.; Comito, D.; Ferrau', V.; Rossi, P. (Dec 2008). "Indeterminate colitis: a distinctive clinical pattern of inflammatory bowel disease in children.". Pediatrics 122 (6): e1278–81. doi:10.1542/peds.2008-2306. PMID 19047226.
4. ^ Melton, GB.; Kiran, RP.; Fazio, VW.; He, J.; Shen, B.; Goldblum, JR.; Achkar, JP.; Lavery, IC. et al. (Jul 2009). "Do preoperative factors predict subsequent diagnosis of Crohn's disease after ileal pouch-anal anastomosis for ulcerative or indeterminate colitis?". Colorectal Dis 12: 1026. doi:10.1111/j.1463-1318.2009.02014.x. PMID 19624520.