Microscopic colitis

Last updated
Microscopic colitis
Collagenous colitis - intermed mag.jpg
Micrograph of collagenous colitis, a type of microscopic colitis. H&E stain.
Specialty Gastroenterology
Symptoms Persistent diarrhea
Types Lymphocytic colitis, collagenous colitis
Diagnostic method Endoscopic biopsy of colonic mucosa
Differential diagnosis Bile acid diarrhea, celiac disease, lactose malabsorption, Crohn's disease, ulcerative colitis, infectious colitis [1] [2]
Medication Loperamide, Bismuth subsalicylate, Budesonide
Frequency103 cases per 100,000 persons [2]

Microscopic colitis refers to two related medical conditions which cause diarrhea: collagenous colitis and lymphocytic colitis. [2] [3] Both conditions are characterized by the presence of chronic non-bloody watery diarrhea, normal appearances on colonoscopy and characteristic histopathology findings of inflammatory cells. [1]

Contents

Signs and symptoms

The main symptom is persistent non-bloody watery diarrhea, which may be profuse. People may also experience abdominal pain, fecal incontinence, and unintentional weight loss. [1] Microscopic colitis is the diagnosis in around 10% of cases investigated for chronic non-bloody diarrhea. [2]

Associated conditions

A higher incidence of autoimmune diseases, for example arthritis, Sjögren's syndrome, thyroid disorders, and celiac disease, has been reported in people with microscopic colitis. [1] Associations with various drugs have been found, especially proton pump inhibitors, H2 blockers, selective serotonin reuptake inhibitors (SSRIs), and non-steroidal anti-inflammatory drugs (NSAIDs). [1] [2] Bile acid diarrhea is found in 41% of patients with collagenous colitis and 29% with lymphocytic colitis. [3] Additionally, cigarette smoking has been identified as a significant risk factor of microscopic colitis. [1]

Diagnosis

Colonoscopic appearances are normal or near normal. As the changes are often patchy, an examination limited to the rectum may miss cases of microscopic colitis, and so a full colonoscopy is necessary. [2] Multiple colonic biopsies are taken in order to make the diagnosis. [1] Histological features of colonic biopsies indicating microscopic colitis are: greater than 20 intraepithelial lymphocytes per 100 epithelial cells and, additionally, 10-20 μm of a thickened subepithelial collagen band in collagenous colitis. [1] Inflammation of the lamina propria, with mainly mononuclear cells, may be observed in collagenous colitis. [1]

Pathology

Microscopic colitis is characterized by an increase in inflammatory cells, particularly lymphocytes, in colonic biopsies with an otherwise normal appearance and architecture of the colon. [2] Inflammatory cells are increased both in the surface epithelium ("intraepithelial lymphocytes") and in the lamina propria. The key feature is more than 20 intra-epithelial lymphocytes per 100 epithelial cells. [2] These are the principal features of lymphocytic colitis. An additional distinguishing feature of collagenous colitis is a thickened subepithelial collagen layer, which may be up to 30 micrometres thick, that occurs in addition to the features found in lymphocytic colitis. [1] The fact that the two types of microscopic colitis share many features including epidemiology, risk factors and, response to therapy has led to the suggestion that they are actually subtypes of the same disease. [3]

Differential diagnosis

Differential diagnoses, which should be ruled out, include bile acid diarrhea, lactose malabsorption, celiac disease, Crohn's disease, ulcerative colitis, and infectious colitis. [1] [2]

Treatment

Lymphocytic and collagenous colitis have both been shown in randomized, placebo-controlled trials to respond well to budesonide, a glucocorticoid. [4] [5] Budesonide formulated to be active in the distal colon and rectum is effective for both active disease and in the prevention of relapse. [2] [6] However, relapse occurs frequently after withdrawal of therapy. [1]

Studies of a number of other agents including antidiarrheals, bismuth subsalicylate (Pepto-Bismol), mesalazine/mesalamine (alone or in combination with cholestyramine), systemic corticosteroids, cholestyramine, immunomodulators, and probiotics have shown to be less effective than budesonide for treating both forms of microscopic colitis. [1] [2] [7] [8]

Anti-TNF inhibitors. split ileostomy, diverting ileostomy, and subtotal colectomy are options for management of steroid-dependent or refractory microscopic colitis. [1] [9] Currently, the need to resort to surgery is limited considering the improvement of drug therapy options. [9] However, surgery is still considered for patients with severe, unresponsive microscopic colitis. [9]

Prognosis

The prognosis for lymphocytic colitis and collagenous colitis is good, and both conditions are considered to be benign. [10] The majority of people afflicted with the conditions recover from their diarrhea, and their histological abnormalities resolve, [5] although relapses commonly occur if maintenance treatment is not continued. [1] [2]

Epidemiology

Incidence and prevalence of microscopic colitis nears those of ulcerative colitis and Crohn's disease. [11] Studies in North America found incidence rates of 7.1 per 100,000 person-years and 12.6 per 100,000 person-years for collagenous colitis for lymphocytic colitis, respectively. [11] Prevalence has been estimated as 103 cases per 100,000 persons. [2]

People who develop microscopic colitis are characteristically, though not exclusively, middle-aged females. The average age of diagnosis is 65 but 25% of cases are diagnosed below the age of 45. [2]

History

The condition of microscopic colitis was first described as such in 1982. [12] Lymphocytic colitis was described in 1989. [13] Collagenous colitis was recognised earlier, in 1976. [14]

Related Research Articles

<span class="mw-page-title-main">Diarrhea</span> Loose or liquid bowel movements

Diarrhea, also spelled diarrhoea or diarrhœa, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin with loss of the normal stretchiness of the skin and irritable behaviour. This can progress to decreased urination, loss of skin color, a fast heart rate, and a decrease in responsiveness as it becomes more severe. Loose but non-watery stools in babies who are exclusively breastfed, however, are normal.

<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 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">Inflammatory bowel disease</span> Medical condition

Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine, 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.

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

Megacolon is an abnormal dilation of the colon. This leads to hypertrophy of the colon. The dilation is often accompanied by a paralysis of the peristaltic movements of the bowel. In more extreme cases, the feces consolidate into hard masses inside the colon, called fecalomas, which can require surgery to be removed.

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">Collagenous colitis</span> Medical condition

Collagenous colitis is an inflammatory bowel disease affecting the colon specifically with peak incidence in the 5th decade of life, affecting women more than men. Its clinical presentation involves watery diarrhea in the absence of rectal bleeding. It is often classified under the umbrella entity microscopic colitis, that it shares with a related condition, lymphocytic colitis.

Management of Crohn's disease involves first treating the acute symptoms of the disease, then maintaining remission. Since Crohn's disease is an immune system condition, it cannot be cured by medication or surgery. Treatment initially involves the use of medications to eliminate infections and reduce inflammation. Surgery may be required for complications such as obstructions, fistulae, abscesses, or if the disease does not respond to drugs within a reasonable time. However, surgery cannot cure Crohn's disease. It involves removing the diseased part of the intestine and rejoining the healthy ends, but the disease tends to recur after surgery.

Management of ulcerative colitis involves first treating the acute symptoms of the disease, then maintaining remission. Ulcerative colitis is a form of colitis, a disease of the intestine, specifically the large intestine or colon, that includes characteristic ulcers, or open sores, in the colon. The main symptom of active disease is usually diarrhea mixed with blood, of gradual onset which often leads to anaemia. Ulcerative colitis is, however, a systemic disease that affects many parts of the body outside the intestine.

<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.

Anti-Saccharomyces cerevisiae antibodies (ASCAs) are antibodies against antigens presented by the cell wall of the yeast Saccharomyces cerevisiae. These antibodies are directed against oligomannose sequences α-1,3 Man n. ASCAs and perinuclear antineutrophil cytoplasmic antibodies (pANCAs) are the two most useful and often discriminating biomarkers for colitis. ASCA tends to recognize Crohn's disease more frequently, whereas pANCA tend to recognize ulcerative colitis.

Vedolizumab, sold under the brand name Entyvio, is a monoclonal antibody medication developed by Millennium Pharmaceuticals, Inc. for the treatment of ulcerative colitis and Crohn's disease. It binds to integrin α4β7, blocking the α4β7 integrin results in gut-selective anti-inflammatory activity.

<span class="mw-page-title-main">Budesonide</span> Type of corticosteroid medication; group of stereoisomers

Budesonide, sold under the brand name Pulmicort among others, is a medication of the corticosteroid type. It is available as an inhaler, nebulization solution, pill, nasal spray, and rectal forms. The inhaled form is used in the long-term management of asthma and chronic obstructive pulmonary disease (COPD). The nasal spray is used for allergic rhinitis and nasal polyps. The pills in a delayed release form and rectal forms may be used for inflammatory bowel disease including Crohn's disease, ulcerative colitis, and microscopic colitis.

<span class="mw-page-title-main">Lloyd Mayer</span>

Lloyd Mayer was an American gastroenterologist and immunologist. He was Professor and Co-Director of the Immunology institute at the Mount Sinai Medical Center, now known as the Marc and Jennifer Lipschultz Precision Immunology Institute.

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

Lymphocytic esophagitis is a rare and poorly understood medical disorder involving inflammation in the esophagus. The disease is named from the primary inflammatory process, wherein lymphocytes are seen within the esophageal mucosa. Symptoms of the condition include difficulty swallowing, heartburn and food bolus obstruction. The condition was first described in 2006 by Rubio and colleagues. Initial reports questioned whether this was a true medical disorder, or whether the inflammation was secondary to another condition, such as gastroesophageal reflux disease.

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.

Integrin α4β7 is an integrin heterodimer composed of CD49d (alpha-4) subunit and beta-7 subunit noncovalently linked. LPAM-1 is expressed on the cell surface of leukocytes. This receptor is involved in lymphocyte trafficking pathway to site of inflammation in intestinal tissues.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Münch A, Aust D, Bohr J, Bonderup O, Fernández Bañares F, Hjortswang H, et al. (2012). "Microscopic colitis: Current status, present and future challenges: statements of the European Microscopic Colitis Group". J Crohns Colitis. 6 (9): 932–45. doi: 10.1016/j.crohns.2012.05.014 . PMID   22704658.
  3. 1 2 3 Rasmussen MA, Munck LK (2012). "Systematic review: are lymphocytic colitis and collagenous colitis two subtypes of the same disease - microscopic colitis?". Aliment Pharmacol Ther. 36 (2): 79–90. doi: 10.1111/j.1365-2036.2012.05166.x . PMID   22670660.
  4. Chande, N; Al Yatama, N; Bhanji, T; Nguyen, TM; McDonald, JW; MacDonald, JK (13 July 2017). "Interventions for treating lymphocytic colitis". Cochrane Database of Systematic Reviews. 7 (11): CD006096. doi:10.1002/14651858.CD006096.pub4. PMC   6483541 . PMID   28702956.
  5. 1 2 Fernández-Bañares F, Salas A, Esteve M, Espinós J, Forné M, Viver J (2003). "Collagenous and lymphocytic colitis. evaluation of clinical and histological features, response to treatment, and long-term follow-up". Am J Gastroenterol. 98 (2): 340–7. doi:10.1111/j.1572-0241.2003.07225.x. PMID   12591052. S2CID   1983209.
  6. O'Donnell, Sarah; O'Morain, Colm A. (2016-10-19). "Therapeutic benefits of budesonide in gastroenterology". Therapeutic Advances in Chronic Disease. 1 (4): 177–186. doi:10.1177/2040622310379293. ISSN   2040-6223. PMC   3513866 . PMID   23251737.
  7. Chande, Nilesh; Al Yatama, Noor; Bhanji, Tania; Nguyen, Tran M.; McDonald, John Wd; MacDonald, John K. (13 July 2017). "Interventions for treating lymphocytic colitis". The Cochrane Database of Systematic Reviews. 7 (11): CD006096. doi:10.1002/14651858.CD006096.pub4. ISSN   1469-493X. PMC   6483541 . PMID   28702956.
  8. Kafil, Tahir S.; Nguyen, Tran M.; Patton, Petrease H.; MacDonald, John K.; Chande, Nilesh; McDonald, John Wd (11 November 2017). "Interventions for treating collagenous colitis". The Cochrane Database of Systematic Reviews. 2017 (11): CD003575. doi:10.1002/14651858.CD003575.pub6. ISSN   1469-493X. PMC   6486307 . PMID   29127772.
  9. 1 2 3 Bohr, Johan; Wickbom, Anna; Hegedus, Agnes; Nyhlin, Nils; Hultgren Hörnquist, Elisabeth; Tysk, Curt (2014-08-21). "Diagnosis and management of microscopic colitis: current perspectives". Clinical and Experimental Gastroenterology. 7: 273–284. doi: 10.2147/CEG.S63905 . ISSN   1178-7023. PMC   4144984 . PMID   25170275.
  10. Mullhaupt B, Güller U, Anabitarte M, Güller R, Fried M (1998). "Lymphocytic colitis: clinical presentation and long term course". Gut. 43 (5): 629–33. doi:10.1136/gut.43.5.629. PMC   1727313 . PMID   9824342.
  11. 1 2 Storr, Martin Alexander (2013-04-18). "Microscopic Colitis: Epidemiology, Pathophysiology, Diagnosis and Current Management—An Update 2013". ISRN Gastroenterology. 2013: 352718. doi: 10.1155/2013/352718 . ISSN   2090-4398. PMC   3654232 . PMID   23691336.
  12. Kingham JG, Levison DA, Ball JA, Dawson AM (1982). "Microscopic colitis-a cause of chronic watery diarrhoea". Br Med J (Clin Res Ed). 285 (6355): 1601–4. doi:10.1136/bmj.285.6355.1601. PMC   1500804 . PMID   6128051.
  13. Lazenby AJ, Yardley JH, Giardiello FM, Jessurun J, Bayless TM (1989). "Lymphocytic ("microscopic") colitis: a comparative histopathologic study with particular reference to collagenous colitis". Hum. Pathol. 20 (1): 18–28. doi:10.1016/0046-8177(89)90198-6. PMID   2912870.
  14. Bogomoletz WV, Adnet JJ, Birembaut P, Feydy P, Dupont P (1980). "Collagenous colitis: an unrecognised entity". Gut. 21 (2): 164–8. doi:10.1136/gut.21.2.164. PMC   1419351 . PMID   7380341.