diversion colitis typically occurs in diverted segments of the colon following surgery . while patients with diversion colitis usually are asymptomatic , a minority of patients has abdominal pain and rectal discharge of blood or mucus . effective treatments with short - chain fatty acids , mesalazine enemas [ 2 , 4 ] , and corticosteroid enemas   have been reported . herein , we present a case of successful treatment of diversion colitis developing after subtotal colectomy for ulcerative colitis ( uc ) with combined mesalazine plus corticosteroid enemas . a 65-year - old japanese man diagnosed as having uc , pancolitis - type , was started on treatment with prednisolone injections at 1.0 mg / kg daily and oral mesalazine . the symptoms failed to improve , and the patient was transferred to our hospital . on the 2nd hospital day , his abdominal pain worsened and an abdominal x - ray showed free air and distension of the entire colon . the resected specimen showed a markedly distended colon with diffuse ulcerations , and a perforation in the sigmoid colon . the postoperative clinical course was uneventful and administration of mesalazine 1 g suppositories ( pentasa suppositories , kyorin pharmaceutical co. , ltd . , japan ) was started . at 4 months after the colectomy , the patient developed rectal bleeding , and proctoscopy revealed moderate mucosal inflammation in the diverted rectum ( fig . stool cultures were negative for bacterial pathogens and clostridium difficile latex antigen and toxin assay . diversion colitis or exacerbation of uc was suspected and treatment was started with a corticosteroid enema in the morning and mesalazine enema in the evening . therefore , prednisolone injections were started again at 1.0 mg / kg daily ; however , the mucosal inflammation still failed to improve . the only symptom was bleeding from the diverted rectum , and blood test results were within normal limits . the patient was then started on treatment with a combined mesalazine 1 g ( pentasa enema , kyorin , japan ) plus prednisolone sodium phosphate 20 mg enema ( predonema , kyorin , japan ) once daily . the rectal bleeding resolved gradually and follow - up proctoscopy after 4 weeks revealed only mild mucosal inflammation ( fig . diversion colitis is a benign inflammatory condition that can occur in any colonic segment excluded from the fecal stream by a diverting colostomy . because this patient showed clinical exacerbation 4 months after subtotal colectomy for uc , we diagnosed him as having diversion colitis associated with uc . in this case , the diversion colitis seemed to occur with a longer residual rectum and sigmoid colon ( around 20 cm ) . mesalazine enema is safe and effective for the treatment of diversion colitis [ 2 , 4 ] . however , our patient failed to respond to nonsynchronous treatment with mesalazine and corticosteroid enemas . the efficacy of combined beclomethasone plus mesalazine enemas in cases of active uc has been reported . furthermore , combined beclomethasone and mesalazine treatment appears to be clearly superior to monotherapy with either drug . therefore , we attempted treatment with combined mesalazine plus corticosteroid enemas . this provided sufficient symptomatic improvement to allow the treatment to proceed to the next step . in conclusion , although we can not explain why synchronous and nonsynchronous administrations varied in effectiveness , combined mesalazine plus corticosteroid enemas may be effective in patients with diversion colitis associated with uc .
diversion colitis is a benign inflammatory process that occurs in any part of the large bowel excluded from the fecal stream by a diverting colostomy . while most of the patients with diversion colitis usually are asymptomatic , a minority has abdominal pain and rectal discharge of blood or mucus . 
 a 65-year - old japanese man was diagnosed as having diversion colitis with ulcerative colitis at 4 months after subtotal colectomy . 
 corticosteroid and mesalazine enemas were started nonsynchronously . 
 a proctoscopy after 2 months showed no response . 
 prednisolone injections were started at 1.0 mg / kg daily , but the mucosal inflammation still failed to improve . 
 a combined mesalazine 1 g plus prednisolone sodium phosphate 20 mg enema was started once daily . 
 the rectal bleeding and endoscopic findings improved . 
 finally proctectomy and ileal pouch - anal anastomosis were successfully performed . 
 a combined mesalazine plus corticosteroid enema may be effective in patients with diversion colitis associated with ulcerative colitis .