Collagenous colitis

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Collagenous colitis
Collagenous colitis - high mag.jpg
Micrograph of collagenous colitis. H&E stain.
Specialty Gastroenterology

Collagenous colitis is an inflammatory condition of the colon. Together with the related condition lymphocytic colitis, it is a subtype of microscopic colitis, which is characterized by inflammation that specifically affects the colon (i.e. colitis), and a clinical presentation that involves watery diarrhea but a lack of rectal bleeding. Microscopic colitis does not usually cause macroscopic changes to the colon that allow a visual diagnosis during colonoscopy, instead causing microscopic changes that can be detected through histopathological examination of colonic biopsies. The nature of these microscopic changes is what differentiates collagenous from lymphocytic colitis, with the characteristic finding in collagenous colitis being depositions of collagen in the connective tissue between the colonic glands. [1] Collagenous colitis, and microscopic colitis as a whole, is sometimes considered to be an inflammatory bowel disease (IBD) along with Crohn's disease and ulcerative colitis. However, little is known about the etiology of microscopic colitis, and so the degree of similarity to the inflammatory bowel diseases is uncertain. [1] [2]

Contents

Although cases are known to occur in all age groups, the disease is most frequently diagnosed in late middle aged or elderly people, with the average person being diagnosed in their 60s. Women are more frequently affected than men, with different studies finding female-male incidence ratios of between 3 and 8. Epidemiological studies have found large increases in diagnosed cases of microscopic colitis, of which collagenous colitis cases are a majority, over the past few decades, with cases of microscopic colitis now outnumbering those of Crohn's disease and ulcerative colitis at least in some regions. [3] [4]

Signs and symptoms

In general, microscopic colitis causes chronic watery diarrhea with increased stool frequency. Some patients report nocturnal diarrhea, abdominal pain, bowel urgency, fecal incontinence, fatigue and weight loss. In severe cases, symptoms may include dehydration and electrolyte imbalances. [5] Patients report a significantly diminished quality of life. [1] [6] In a retrospective study specifically on collagenous colitis patients, all studied patients experienced chronic diarrhea, 42% experienced weight loss, 41% experienced abdominal pain, 27% of the patients experienced nocturnal diarrhea, while 14% experienced fatigue and 8% experienced meteorism. The median patent had 6 stools per day. Among the patients who experienced weight loss and whose magnitude of weight loss was recorded, the median lost weight was 6 kg. [7]

Causes

The cause of collagenous colitis is unknown. A connection with autoimmune disorders such as celiac disease is suspected, as up to 40% of patients with collagenous colitis have an autoimmune disease. Use of nonsteroidal anti-inflammatory drugs (NSAIDs), proton pump inhibitors (PPIs) and beta blockers also appear to increase the risk of collagenous colitis, but the cause of this is not known. [1]

Diagnosis

On colonoscopy, the mucosa of the colon typically looks normal, but biopsies of affected tissue usually show deposition of collagen in the lamina propria, which is the area of connective tissue between colonic glands. Radiological tests, such as a barium enema are also typically normal. [6]

Treatment

First line treatment for collagenous colitis is the use of budesonide, a steroid that works locally in the colon and is highly cleared by first pass effect. Other medications that can be used include the following: [1] [6]

Pilot-scale studies have shown some evidence of possible benefit for both Boswellia serrata extract and specific strains of probiotics in the treatment of collagenous colitis, although larger sample sizes are needed to confirm the results. [8] [9] [10]

Epidemiology

One epidemiological study reported previous incidence rates of collagenous colitis found in the literature as ranging from 0.6 cases per 100,000 person-years (based on French data from 1987–1992) to 5.2 per 100,000 person-years (from an Icelandic study based on data from 1995-1999), while the authors themselves found an incidence rate of 3.1 per 100,000 person-years in Olmsted County, Minnesota across the period 1985-2001. Based only on the subset of the data from 1998-2001, however, the authors found a higher rate of 7.1 per 100,000 person-years, an incidence rate which exceeded those of Crohn's disease and ulcerative colitis. [11] The previously mentioned Icelandic study also found increasing rates through the studied period, with the incidence rate in Iceland increasing from 2.2 in 1995 to 8.3 in 1999. [12] Women appear to be more frequently affected by collagenous colitis than men, with the Icelandic study finding a female-male ratio of 7.9 in diagnosed cases and the Olmsted County study finding a female-male ratio of 4.4. [11] [12]

An updated study on microscopic colitis in Olmsted County published in 2022 and based on data from between 2011 and 2019 found an incidence rate for collagenous colitis of 9.9 cases per 100,000 person-years, a prevalence of 100.1 per 100,000 persons and a female-male ratio of 4.7. Unlike in the previous study on data from 1995-1999, the rate of collagenous colitis in Olmsted County was found to have remained stable between 2011 and 2019. [3] Another study on rates of microscopic colitis in Denmark between 2001 and 2016 found an overall incidence rate for collagenous colitis of 12.2 per 100,000 person-years, a prevalence of 116.7 per 100,000 persons and a female-male ratio of 3.1. Like the 1995-1999 Olmsted County study and the 1995-1999 Icelandic study, this Danish study found a heavy increase in rates of collagenous colitis and microscopic colitis overall during the studied period, with the incidence rates in 2001 and 2016 for microscopic colitis found to be, respectively, 2.3 and 24.3 cases per 100,000 person-years. However, the incidence rates of collagenous colitis in this Danish data peaked in 2011 with a rate of 19.6 cases per 100,000 person-years, and rates appeared to be stable between 2012 and 2016. The average age at diagnosis was found to be 67, and the highest incidence rate was found among patients over the age of 80. The strong increase in the case rates of microscopic colitis (with collagenous colitis making up 59% of these cases) throughout the study period meant that by 2016, microscopic colitis had a greater incidence rate in Denmark than did Crohn's disease and ulcerative colitis. The authors suggest an increase in the use of colonoscopies as a possible cause of the observed change in microscopic colitis diagnoses over time. [4]

Related Research Articles

<span class="mw-page-title-main">Crohn's disease</span> Type of inflammatory bowel disease

Crohn's disease is a type of inflammatory bowel disease (IBD) that may affect any segment of the gastrointestinal tract. Symptoms often include abdominal pain, diarrhea, fever, abdominal distension, and weight loss. Complications outside of the gastrointestinal tract may include anemia, skin rashes, arthritis, inflammation of the eye, and fatigue. The skin rashes may be due to infections as well as pyoderma gangrenosum or erythema nodosum. Bowel obstruction may occur as a complication of chronic inflammation, and those with the disease are at greater risk of colon cancer and small bowel cancer.

<span class="mw-page-title-main">Ulcerative colitis</span> Inflammatory bowel disease that causes ulcers in the colon

Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD). It is a long-term condition that results in inflammation and ulcers of the colon and rectum. The primary symptoms of active disease are abdominal pain and diarrhea mixed with blood (hematochezia). Weight loss, fever, and anemia may also occur. Often, symptoms come on slowly and can range from mild to severe. Symptoms typically occur intermittently with periods of no symptoms between flares. Complications may include abnormal dilation of the colon (megacolon), inflammation of the eye, joints, or liver, and colon cancer.

<span class="mw-page-title-main">Hematochezia</span> Medical condition

Haematochezia is the passage of fresh blood through the anus path, usually in or with stools. The term is from Greek αἷμα ("blood") and χέζειν. Hematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur from a brisk upper gastrointestinal bleed. The difference between hematochezia and rectorrhagia is that, in the latter, rectal bleeding is not associated with defecation; instead, it is associated with expulsion of fresh bright red blood without stools. The phrase bright red blood per rectum is associated with hematochezia and rectorrhagia.

<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

Abdominal pain, also known as a stomach ache, Is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important.

<span class="mw-page-title-main">Inflammatory bowel disease</span> Medical condition

Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine, with Crohn's disease and ulcerative colitis (UC) being the principal types. Crohn's disease affects the small intestine and large intestine, as well as the mouth, esophagus, stomach and the anus, whereas ulcerative colitis primarily affects the colon and the rectum.

<span class="mw-page-title-main">Colitis</span> Inflammation of the colon (large intestine)

Colitis is swelling or inflammation of the large intestine (colon). Colitis may be acute and self-limited or long-term. It broadly fits into the category of digestive diseases.

<span class="mw-page-title-main">Toxic megacolon</span> Medical condition

Toxic megacolon is an acute form of colonic distension. It is characterized by a very dilated colon (megacolon), accompanied by abdominal distension (bloating), and sometimes fever, abdominal pain, or shock.

In medicine, the ileal pouch–anal anastomosis (IPAA), also known as restorative proctocolectomy (RPC), ileal-anal reservoir (IAR), an ileo-anal pouch, ileal-anal pullthrough, or sometimes referred to as a J-pouch, S-pouch, W-pouch, or a pelvic pouch, is an anastomosis of a reservoir pouch made from ileum to the anus, bypassing the former site of the colon in cases where the colon and rectum have been removed. The pouch retains and restores functionality of the anus, with stools passed under voluntary control of the person, preventing fecal incontinence and serving as an alternative to a total proctocolectomy with ileostomy.

Proctitis is an inflammation of the anus and the lining of the rectum, affecting only the last 6 inches of the rectum.

<span class="mw-page-title-main">Blood in stool</span> Medical condition

Blood in stool or rectal bleeding looks different depending on how early it enters the digestive tract—and thus how much digestive action it has been exposed to—and how much there is. The term can refer either to melena, with a black appearance, typically originating from upper gastrointestinal bleeding; or to hematochezia, with a red color, typically originating from lower gastrointestinal bleeding. Evaluation of the blood found in stool depends on its characteristics, in terms of color, quantity and other features, which can point to its source, however, more serious conditions can present with a mixed picture, or with the form of bleeding that is found in another section of the tract. The term "blood in stool" is usually only used to describe visible blood, and not fecal occult blood, which is found only after physical examination and chemical laboratory testing.

Pouchitis is an umbrella term for inflammation of the ileal pouch, an artificial rectum surgically created out of ileum in patients who have undergone a proctocolectomy or total colectomy. The ileal pouch-anal anastomosis is created in the management of patients with ulcerative colitis, indeterminate colitis, familial adenomatous polyposis, cancer, or rarely, other colitides.

<span class="mw-page-title-main">Microscopic colitis</span> Medical condition

Microscopic colitis refers to two related medical conditions which cause diarrhea: collagenous colitis and lymphocytic colitis. Both conditions are characterized by the presence of chronic non-bloody watery diarrhea, normal appearances on colonoscopy and characteristic histopathology findings of inflammatory cells.

<span class="mw-page-title-main">Lower gastrointestinal bleeding</span> Medical condition

Lower gastrointestinal bleeding, commonly abbreviated LGIB, is any form of gastrointestinal bleeding in the lower gastrointestinal tract. LGIB is a common reason for seeking medical attention at a hospital's emergency department. LGIB accounts for 30–40% of all gastrointestinal bleeding and is less common than upper gastrointestinal bleeding (UGIB). It is estimated that UGIB accounts for 100–200 per 100,000 cases versus 20–27 per 100,000 cases for LGIB. Approximately 85% of lower gastrointestinal bleeding involves the colon, 10% are from bleeds that are actually upper gastrointestinal bleeds, and 3–5% involve the small intestine.

<span class="mw-page-title-main">Descending colon</span>

In the anatomy of humans and homologous primates, the descending colon is the part of the colon extending from the left colic flexure to the level of the iliac crest. The function of the descending colon in the digestive system is to store the remains of digested food that will be emptied into the rectum.

<span class="mw-page-title-main">Lymphocytic colitis</span> Medical condition

Lymphocytic colitis is a subtype of microscopic colitis, a condition characterized by chronic non-bloody watery diarrhea.

<span class="mw-page-title-main">Pancolitis</span> Medical condition

Pancolitis, in its most general sense, refers to inflammation of the entire colon. This can be caused by a variety of things. Pancolitis or universal colitis is frequently used in a more specific fashion to denote a very severe form of ulcerative colitis. This form of ulcerative colitis is spread throughout the entire large intestine including the right colon, the left colon, the transverse colon, descending colon, and the rectum. A diagnosis can be made using a number of techniques but the most accurate method is direct visualization via a colonoscopy. Symptoms are similar to those of ulcerative colitis but more severe and affect the entire large intestine. Patients with ulcerative colitis generally exhibit symptoms including rectal bleeding as a result of ulcers, pain in the abdominal region, inflammation in varying degrees, and diarrhea. Pancolitis patients exhibit these symptoms and may also experience fatigue, fever, and night sweats. Due to the loss of function in the large intestine patients may lose large amounts of weight from being unable to procure nutrients from food. In other cases the blood loss from ulcers can result in anemia which can be treated with iron supplements. Additionally, due to the chronic nature of most cases of pancolitis, patients have a higher chance of developing colon cancer.

<span class="mw-page-title-main">Cytomegalovirus colitis</span> Medical condition

Cytomegalovirus colitis, also known as CMV colitis, is an inflammation of the colon.

<span class="mw-page-title-main">Colonic ulcer</span> Medical condition

Colonic ulcer can occur at any age, in children however they are rare. Most common symptoms are abdominal pain and hematochezia.

Checkpoint inhibitor induced colitis is an inflammatory condition affecting the colon (colitis), which is caused by cancer immunotherapy. Symptoms typically consist of diarrhea, abdominal pain and rectal bleeding. Less commonly, nausea and vomiting may occur, which may suggest the present of gastroenteritis. The severity of diarrhea and colitis are graded based on the frequency of bowel movements and symptoms of colitis, respectively.

<span class="mw-page-title-main">Segmental colitis associated with diverticulosis</span> Medical condition

Segmental colitis associated with diverticulosis (SCAD) is a condition characterized by localized inflammation in the colon, which spares the rectum and is associated with multiple sac-like protrusions or pouches in the wall of the colon (diverticulosis). Unlike diverticulitis, SCAD involves inflammation of the colon between diverticula, while sparing the diverticular orifices. SCAD may lead to abdominal pain, especially in the left lower quadrant, intermittent rectal bleeding and chronic diarrhea.

References

  1. 1 2 3 4 5 Park, Tina; Cave, David; Marshall, Christopher (2015-08-07). "Microscopic colitis: A review of etiology, treatment and refractory disease". World Journal of Gastroenterology. 21 (29): 8804–8810. doi: 10.3748/wjg.v21.i29.8804 . ISSN   1007-9327. PMC   4528022 . PMID   26269669.
  2. ↑ Jegadeesan R, Liu X, Pagadala MR, Gutierrez N, Butt M, Navaneethan U (2013). "Microscopic colitis: is it a spectrum of inflammatory bowel disease?". World J Gastroenterol. 19 (26): 4252–6. doi: 10.3748/wjg.v19.i26.4252 . PMC   3710430 . PMID   23864791.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  3. 1 2 Tome, June; Sehgal, Kanika; Kamboj, Amrit K.; Harmsen, William S.; Kammer, Patricia P.; Loftus, Edward V.; Tremaine, William J.; Khanna, Sahil; Pardi, Darrell S. (2022). "The Epidemiology of Microscopic Colitis in Olmsted County, Minnesota: Population-Based Study From 2011 to 2019". Clinical Gastroenterology and Hepatology. Elsevier BV. 20 (5): 1085–1094. doi:10.1016/j.cgh.2021.06.027. ISSN   1542-3565. PMC   8716639 . PMID   34216819.
  4. 1 2 Weimers, Petra; Ankersen, Dorit Vedel; Lophaven, Søren; Bonderup, Ole Kristian; Münch, Andreas; Løkkegaard, Ellen Christine Leth; Burisch, Johan; Munkholm, Pia (2020-06-05). "Incidence and Prevalence of Microscopic Colitis Between 2001 and 2016: A Danish Nationwide Cohort Study". Journal of Crohn's and Colitis. Oxford University Press (OUP). 14 (12): 1717–1723. doi: 10.1093/ecco-jcc/jjaa108 . ISSN   1873-9946. PMID   32502240.
  5. ↑ Tome, June; Kamboj, Amrit K.; Pardi, Darrell S. (2021). "Microscopic Colitis: A Concise Review for Clinicians". Mayo Clinic Proceedings. Elsevier BV. 96 (5): 1302–1308. doi: 10.1016/j.mayocp.2021.03.022 . ISSN   0025-6196. PMID   33958059.
  6. 1 2 3 O’Toole, Aoibhlinn (2016-02-10). "Optimal management of collagenous colitis: a review". Clinical and Experimental Gastroenterology. 9: 31–39. doi: 10.2147/CEG.S67233 . ISSN   1178-7023. PMC   4754103 . PMID   26929656.
  7. ↑ Bohr, J; Tysk, C; Eriksson, S; Abrahamsson, H; Jarnerot, G (1996-12-01). "Collagenous colitis: a retrospective study of clinical presentation and treatment in 163 patients". Gut. BMJ. 39 (6): 846–851. doi: 10.1136/gut.39.6.846 . ISSN   0017-5749. PMC   1383457 . PMID   9038667.
  8. ↑ Madisch A, Miehlke S, Eichele O, Mrwa J, Bethke B, Kuhlisch E, Bästlein E, Wilhelms G, Morgner A, Wigginghaus B, Stolte M (Dec 2007). "Boswellia serrata extract for the treatment of collagenous colitis. A double-blind, randomized, placebo-controlled, multicenter trial". International Journal of Colorectal Disease. 22 (12): 1445–51. doi:10.1007/s00384-007-0364-1. PMID   17764013. S2CID   206966118.
  9. ↑ Wildt S, Munck LK, Vinter-Jensen L, Hanse BF, Nordgaard-Lassen I, Christensen S, Avnstroem S, Rasmussen SN, Rumessen JJ (May 2006). "Probiotic treatment of collagenous colitis: a randomized, double-blind, placebo-controlled trial with Lactobacillus acidophilus and Bifidobacterium animalis subsp. lactis". Inflammatory Bowel Diseases. 12 (5): 395–401. doi: 10.1097/01.MIB.0000218763.99334.49 . PMID   16670529. S2CID   870587.
  10. ↑ Tromm A, Niewerth U, Khoury M, Baestlein E, Wilhelms G, Schulze J, Stolte M (May 2004). "The probiotic E. coli strain Nissle 1917 for the treatment of collagenous colitis: first results of an open-label trial". Zeitschrift für Gastroenterologie. 42 (5): 365–9. doi:10.1055/s-2004-812709. PMID   15136935. S2CID   3010852.
  11. 1 2 Pardi, D. S; Loftus, E. V; Smyrk, T. C; Kammer, P. P; Tremaine, W. J; Schleck, C. D; Harmsen, W S.; Zinsmeister, A. R; Melton, L J.; Sandborn, W. J (2007-04-01). "The epidemiology of microscopic colitis: a population based study in Olmsted County, Minnesota". Gut. BMJ. 56 (4): 504–508. doi:10.1136/gut.2006.105890. ISSN   0017-5749. PMC   1856874 . PMID   17135309.
  12. 1 2 Agnarsdottir, Margret; Gunnlaugsson, Olafur; Orvar, Kjartan B.; Cariglia, Nick; Birgisson, Sigurbjorn; Bjornsson, Sigurdur; Thorgeirsson, Thorgeir; Jonasson, Jon Gunnlaugur (2002). "Collagenous and lymphocytic colitis in Iceland". Digestive Diseases and Sciences. Springer Science and Business Media LLC. 47 (5): 1122–1128. doi:10.1023/a:1015058611858. ISSN   0163-2116. PMID   12018911. S2CID   24307756.
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