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Nielsen OH, Pardi DS. Diagnosis and Pharmacological Management of Microscopic Colitis in Geriatric Care. Drugs Aging 2024; 41:113-123. [PMID: 38231321 PMCID: PMC10869377 DOI: 10.1007/s40266-023-01094-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 01/18/2024]
Abstract
Microscopic colitis, a diagnosis under the umbrella term of inflammatory bowel disease, is a prevalent cause of watery diarrhea, often with symptoms of urgency and bloating, typically observed in older adults aged ≥ 60 years. Its incidence has been reported to exceed those of ulcerative colitis and Crohn's disease in some geographical areas. Although nonpathognomonic endoscopic abnormalities, including changes of the vascular mucosal pattern; mucosal erythema; edema; nodularity; or mucosal defects, e.g., "cat scratches" have been reported, a colonoscopy is typically macroscopically normal. As reliable biomarkers are unavailable, colonoscopy using random biopsies from various parts of the colon is compulsory. Based on the histological examination under a microscope, the disease is divided into collagenous (with a thickened subepithelial collagenous band) and lymphocytic (with intraepithelial lymphocytosis) colitis, although incomplete forms exist. In routine clinical settings, the disease has a high risk of being misdiagnosed as irritable bowel syndrome or even overlooked. Therefore, healthcare providers should be familiar with clinical features and rational management strategies. A 6-8-week oral budesonide treatment course (9 mg/day) is considered the first-line therapy, but patients often experience relapse when discontinued, or might become intolerant, dependent, or even fail to respond. Consequently, other therapeutic options (e.g., bismuth subsalicylate, biologics, loperamide, bile acid sequestrants, and thiopurines) recommended by available guidelines may be prescribed. Herein, clinically meaningful data is provided based on the latest evidence that may aid in reaching a diagnosis and establishing rational therapy in geriatric care to control symptoms and enhance the quality of life for those affected.
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology D112, Herlev Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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2
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Redd WD, Anderson C, Peery AF, Keku TO, Woosley JT, Sandler RS. Follow-Up of Microscopic Colitis Patients and Diarrhea Controls at 1 Year. GASTRO HEP ADVANCES 2023; 3:336-343. [PMID: 38681976 PMCID: PMC11052583 DOI: 10.1016/j.gastha.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
BACKGROUND AND AIMS Microscopic colitis (MC) is a common cause of chronic diarrhea; however, the clinical course of this disease is poorly understood. We aimed to investigate how patients diagnosed with MC were treated in routine clinical practice and how their symptoms compared to patients with other causes of chronic diarrhea at one year follow-up. METHODS We conducted a case-control study of patients undergoing outpatient colonoscopy to evaluate diarrhea. The study pathologist determined whether patients were classified as MC cases or non-MC controls. One year after colonoscopy, we interviewed cases (n = 74) and controls (n = 162) about their diagnosis, medications for diarrhea, and symptom burden. RESULTS At 1-year follow-up after colonoscopy, 10% of MC cases were unaware of the diagnosis, 60% had been prescribed a medication for diarrhea, 40% had fecal urgency, 32% had weight loss, and 21% had fecal incontinence. Among cases, 46% were treated with budesonide. Compared to cases, controls had worse symptoms based on the Microscopic Colitis Disease Activity Index score with a median score of 3.0 (interquartile range 1.9-4.2) vs 2.3 (interquartile range 1.4-3.2) at 1-year follow-up. Controls had more frequent stools, urgency, fecal incontinence, and abdominal pain. CONCLUSION In a cohort of patients with biopsy-confirmed MC and diarrhea controls, we found that some cases remained unaware of their diagnosis, many cases had persistent symptoms, and controls had worse symptoms than cases. These findings suggest there are opportunities to improve management of this chronic disease.
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Affiliation(s)
- Walker D. Redd
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Chelsea Anderson
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anne F. Peery
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Temitope O. Keku
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John T. Woosley
- UNC Department of Pathology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Robert S. Sandler
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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3
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Hamilton P, Buhler K, MacDonald JK, Kaplan GG, Seow CH, Lu C, Novak KL, Andrews CN, Singh S, Jairath V, Panaccione R, Ma C. Meta-analysis: Placebo rates in microscopic colitis randomised trials and applications for future drug development using a historical control arm. Aliment Pharmacol Ther 2023; 57:837-850. [PMID: 36825479 DOI: 10.1111/apt.17433] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/05/2023] [Accepted: 02/11/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Effective medical therapies for patients with microscopic colitis (MC) who fail budesonide are lacking. However, conducting randomised controlled trials (RCTs) in MC has been challenging due to small sample sizes. Understanding placebo responses can help inform more efficient future trials. AIMS The aim of this study is to estimate clinical and histologic placebo response rates and to determine factors associated with placebo response in MC. METHODS EMBASE, MEDLINE, and CENTRAL were searched until 7 January 2022, to identify placebo-controlled RCTs in adult patients with MC. Clinical and histologic response in the placebo arms were pooled using random-effects models. Stratified analyses based on disease- and trial-level characteristics, leave-one-out meta-analysis, and cumulative meta-analysis were performed. RESULTS Twelve RCTs enrolling a total of 391 patients (placebo n = 163) with MC were included. Pooled clinical and histologic placebo response rates were 24.4% (95% CI: 12.4%-38.4%), I2 = 60.8%, p < 0.01, and 19.9% (95% CI: 5.3%-39.0%), I2 = 66.4%, p = 0.01 (tests for heterogeneity), respectively. Clinical response to placebo was numerically higher in patients with lymphocytic compared to collagenous colitis (39.9% vs. 19.8%, p = 0.08). Heterogeneity in clinical response to placebo was significantly reduced when the Miehlke 2014 RCT was excluded in the leave-one-out meta-analysis or when a more stringent secondary definition of response based on the Hjortswang criteria was applied. CONCLUSIONS Approximately one-quarter of patients in MC trials respond to placebo, although with substantial heterogeneity, reflecting the need for standardised outcome definitions and study designs for MC. This analysis also serves to inform future MC trials that may consider incorporating an external, historical placebo control arm, rather than directly randomising patients to placebo.
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Affiliation(s)
- Patrick Hamilton
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Katherine Buhler
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Gilaad G Kaplan
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Lu
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher N Andrews
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Vipul Jairath
- Alimentiv Inc., London, Ontario, Canada
- Division of Gastroenterology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Remo Panaccione
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alimentiv Inc., London, Ontario, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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4
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Yu H, Zhang F, Wen Y, Zheng Z, Chen G, Pan Y, Wu P, Ye Q, Han J, Chen X, Liu C, Shen T. Mechanism of interventional effect and targets of Zhuyu pill in regulating and suppressing colitis and cholestasis. Front Pharmacol 2022; 13:1038188. [PMID: 36408242 PMCID: PMC9666482 DOI: 10.3389/fphar.2022.1038188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/24/2022] [Indexed: 11/23/2022] Open
Abstract
Zhuyu pill (ZYP) is a traditional Chinese medicine prescription composed of two drugs, Coptis chinensis Franch. and Tetradium ruticarpum (A. Jussieu) T. G. Hartley, and is commonly used in the clinical treatment of diseases of the digestive system. However, the mechanism underlying the effect of ZYP on colitis remains unclear. In this study, a colitis rat model was induced with 2,4,6-trinitro-benzenesulfonic acid (TNBS, 100 mg/kg) and treated with ZYP (low dose: 0.6 g/kg, high dose: 1.2 g/kg). Disease activity index, colonic weight index, and weight change ratio were used to evaluate the model and efficacy. LC-MS and 16S rRNA gene sequencing were used to measure differences in fecal metabolism and microorganism population among the control, model, low-dose ZYP, and high-dose ZYP groups. To elucidate the mechanism of interventional effect of ZYP, Spearman correlation analysis was used to analyze the correlation between fecal metabolism and fecal microbial number. High-dose and low-dose ZYP both exhibited significant interventional effects on colitis rat models, and high-dose ZYP produced a better interventional effect compared with low-dose ZYP. Based on a metabolomics test of fecal samples, significantly altered metabolites in the model and high-dose ZYP treatment groups were identified. In total, 492 metabolites were differentially expressed. Additionally, sequencing of the 16S rRNA gene in fecal samples revealed that the high-dose ZYP could improve TNBS-induced fecal microbiota dysbiosis. Ultimately, changes in tryptophan metabolism and Firmicutes and Gammaproteobacteria populations were detected after ZYP treatment in both colitis and cholestasis. Therefore, we conclude that tryptophan metabolism and Firmicutes and Gammaproteobacteria populations are the core targets of the anti-inflammatory effect of ZYP. These findings provide a scientific basis for further investigation of the anti-inflammatory mechanism of ZYP in the future.
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Affiliation(s)
- Han Yu
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Fenghua Zhang
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yueqiang Wen
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China,Department of Pediatrics, Guang’an Hospital of Traditional Chinese Medicine, Guang’an, China
| | - Zhili Zheng
- Department of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Gaoyang Chen
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yingying Pan
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Peijie Wu
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qiaobo Ye
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jun Han
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiaofeng Chen
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China,*Correspondence: Xiaofeng Chen, ; Chao Liu, ; Tao Shen,
| | - Chao Liu
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China,*Correspondence: Xiaofeng Chen, ; Chao Liu, ; Tao Shen,
| | - Tao Shen
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China,*Correspondence: Xiaofeng Chen, ; Chao Liu, ; Tao Shen,
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5
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Tome J, Sehgal K, Kamboj AK, Harmsen WS, Kammer PP, Loftus EV, Tremaine WJ, Khanna S, Pardi DS. The Epidemiology of Microscopic Colitis in Olmsted County, Minnesota: Population-Based Study From 2011 to 2019. Clin Gastroenterol Hepatol 2022; 20:1085-1094. [PMID: 34216819 PMCID: PMC8716639 DOI: 10.1016/j.cgh.2021.06.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 06/13/2021] [Accepted: 06/21/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Epidemiologic studies from Europe and North America have reported an increasing incidence of microscopic colitis (MC) in the late 20th century, followed by a plateau. This population-based study assessed recent incidence trends and the overall prevalence of MC over the past decade. METHODS Residents of Olmsted County, MN, diagnosed with collagenous colitis (CC) or lymphocytic colitis (LC) between January 1, 2011, and December 31, 2019 were identified using the Rochester Epidemiology Project. Clinical variables were abstracted by chart review. Incidence rates were age- and sex-adjusted to the 2010 US population. Associations between incidence and age, sex, and calendar periods were evaluated using Poisson regression analyses. RESULTS A total of 268 incident cases of MC were identified with a median age at diagnosis of 64 years (range, 19-90 y); 207 (77%) were women. The age- and sex-adjusted incidence of MC was 25.8 (95% CI, 22.7-28.9) cases per 100,000 person-years. The incidence of LC was 15.8 (95% CI, 13.4-18.2) and CC was 9.9 (95% CI, 8.1-11.9) per 100,000 person-years. A higher MC incidence was associated with increasing age and female sex (P < .01). There was no significant trend in age- and sex-adjusted incidence rate over the study period (P = .92). On December 31, 2019, the prevalence of MC, LC, and CC (including cases diagnosed before 2011) was 246.2, 146.1, and 100.1 per 100,000 persons, respectively. CONCLUSIONS The incidence of MC and its subtypes was stable between 2011 and 2019, but its prevalence was higher than in previous periods. The incidence of MC continues to be associated with increasing age and female sex.
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Affiliation(s)
- June Tome
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Kanika Sehgal
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Amrit K. Kamboj
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - William S. Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Edward V. Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Darrell S. Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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6
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Lesnovska KP, Münch A, Bonderup O, Magro F, Kupcinskas J, Zabana Y, Tontini GE, Munck LK, Guagnozzi D, Latella G, Fernandez-Banares F, Miehlke S, Madisch A, Wildt S, Hjortswang H. The Process of Developing a Disease Activity Index in Microscopic Colitis. J Crohns Colitis 2022; 16:452-459. [PMID: 34562005 DOI: 10.1093/ecco-jcc/jjab170] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Patient-reported outcome measures [PROMs] aim to measure patients' perception of how their disorder influences everyday functioning. The objective of this study was to develop a PROM to assess disease activity in microscopic colitis [MC] fulfilling the requirements of the Food and Drug Administration [FDA]. METHODS The European Microscopic Colitis Activity Index [E-MCAI] was developed in four steps. [1] A list of symptoms associated with active MC was created by a group of experts in the field. [2] Content validity of the symptoms was performed by experts [n = 14] and patients [n = 79] using the Content Validity Index. [3] Questions and response alternatives were created for each symptom, and validity of the E-MCAI was evaluated with cognitive interviews with patients [n = 7] and by the experts. [4] A pilot postal survey was performed to ensure usability. RESULTS Seven of the symptoms related to active MC fulfilled the criteria for content validity and were included in the E-MCAI: stool consistency, stool frequency, stools at night, feel a need to pass more stools shortly after a bowel movement, urgent need to empty the bowel, leakage of stool and abdominal pain. The development and validation process resulted in the current version of the E-MCAI consisting of six questions related to MC. CONCLUSIONS The E-MCAI was developed using the methods advocated by the FDA. The evaluation indicates good content validity. Further evaluation will be performed to achieve construct validity, reliability and responsiveness in future cross-sectional and longitudinal studies.
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Affiliation(s)
- Katarina Pihl Lesnovska
- Department of Gastroenterology and Hepatology in Linköping, and Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
| | - Andreas Münch
- Department of Gastroenterology and Hepatology in Linköping, and Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
| | - Ole Bonderup
- Diagnostik Center, Hospitalenhed Midt, Regionhospitalet Silkeborg, Silkeborg, Denmark
| | - Fernando Magro
- Department of Pharmacology, Hospital de Sao Joao, Porto, Portugal
| | - Juozas Kupcinskas
- Department of Gastroenterology and Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Yamile Zabana
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Barcelona, Spain.,Department of Gastroenterology, Hospital Universitari Mutua de Terrassa, University of Barcelona, Barcelona, Spain
| | - Gian Eugenio Tontini
- Department of Pathophysiology and Organ Transplantation, University of Milan and Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lars Kristian Munck
- Department of Gastroenterology, Zealand University Hospital, Koege, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Danila Guagnozzi
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Barcelona, Spain.,Neuro-Immuno-Gastroenterology Group, Digestive Physiology and Pathophysiology Unit, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Giovanni Latella
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Fernando Fernandez-Banares
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Barcelona, Spain.,Department of Gastroenterology, Hospital Universitari Mutua de Terrassa, University of Barcelona, Barcelona, Spain
| | - Stephan Miehlke
- Center for Digestive Diseases, Internal Medicine Center Eppendorf, Hamburg, Germany.,Center for Esophagal Disorder, University Hospital Eppendorf, Hamburg, Germany
| | - Ahmed Madisch
- Department of Gastroenterology, CRH Clinic Siloah, Hannover, Germany
| | - Signe Wildt
- Department of Gastroenterology, Zealand University Hospital, Koege, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Hjortswang
- Department of Gastroenterology and Hepatology in Linköping, and Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
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Kamboj AK, McGoldrick J, Voth E, Penrice D, Tome J, Gujral A, Miller K, Burke KE, Pardi DS, Khalili H. Clinical Characteristics and Treatment Response in Microscopic Colitis Based on Age at Diagnosis: A Multicenter Retrospective Study. Dig Dis Sci 2022; 67:3108-3114. [PMID: 34283360 PMCID: PMC9236988 DOI: 10.1007/s10620-021-07162-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/06/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Microscopic colitis (MC) primarily affects older adults; thus, data in younger patients are scarce. AIMS To compare clinical characteristics and treatment response by age at diagnosis. METHODS This retrospective cohort study was performed at Mayo Clinic and Massachusetts General Hospital. Patients were chosen consecutively using established databases. Patients were 'younger' if age at diagnosis was ≤ 50 years and 'older' if age > 50 years. Treatment outcomes were captured for induction (12 ± 4 weeks), based on the total number of daily stools, and defined as remission (complete resolution), response (≥ 50% improvement), non-response (< 50% improvement), and intolerance. Patients were considered 'responders' if they had remission or response and 'non-responders' if they had non-response or intolerance. RESULTS We included 295 patients (52 younger, 243 older). There were no differences in sex, race, MC subtype, and diarrhea severity between groups (all P > 0.05). Younger patients were more likely to have celiac disease (17.3% vs. 5.8%, P = 0.01), while older patients had higher BMI (mean 25.0 vs. 23.8 kg/m2, P = 0.04) were more likely smokers (53.9% vs. 34.6%, P = 0.01) and use NSAIDs (48.6% vs. 15.4%, P < 0.01) and statins (22.6% vs. 3.8%, P < 0.01). Overall treatment response was highest for budesonide (88.3%) and did not differ when comparing older to younger patients (90.6% vs. 77.8%, P = 0.12) or by MC subtype (LC, 81.5% vs. CC, 92.9%, P = 0.07). CONCLUSIONS There are no significant differences in MC treatment response based on age or disease subtype. These findings support treating patients with MC based on symptom severity rather than age.
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Affiliation(s)
- Amrit K. Kamboj
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN USA
| | - Jessica McGoldrick
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, MA USA
| | - Eli Voth
- Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Daniel Penrice
- Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - June Tome
- Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Amandeep Gujral
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, MA USA
| | - Kaia Miller
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, MA USA
| | - Kristin E. Burke
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, MA USA ,Clinical and Translational Epidemiology Unit, Mongan Institute, Massachusetts General Hospital, Boston, MA USA
| | - Darrell S. Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN USA
| | - Hamed Khalili
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, MA USA ,Clinical and Translational Epidemiology Unit, Mongan Institute, Massachusetts General Hospital, Boston, MA USA ,Cardiovascular and Nutritional Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
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8
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Sandler RS, Keku TO, Woosley JT, Galanko JA, Peery AF. Medication use and microscopic colitis. Aliment Pharmacol Ther 2021; 54:1193-1201. [PMID: 34514632 PMCID: PMC8511165 DOI: 10.1111/apt.16594] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/08/2021] [Accepted: 08/20/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Microscopic colitis is an increasingly common cause of watery diarrhoea. Several classes of medications have been associated with microscopic colitis in prior studies. AIMS To determine the association between the use of previously implicated medications and microscopic colitis. METHODS This was a case-control study of patients referred for elective, outpatient colonoscopy for diarrhoea. Patients were excluded for inflammatory bowel disease, C difficile, or other infectious diarrhoea. Colon biopsies were reviewed by the study pathologist and patients were classified as microscopic colitis cases or non-microscopic colitis controls. RESULTS The study population included 110 microscopic colitis cases and 252 controls. The cases were older, better educated and more likely to be female. Cases reported a greater number of loose, watery, or liquid stools, nocturnal stools, more urgency and weight loss compared to controls. There was no association with proton pump inhibitors (PPIs), adjusted OR (aOR) 0.66, 95% CI 0.38-1.13 or nonsteroidal anti-inflammatory drugs, aOR 0.68, 95% CI 0.40-1.17. Cholecystectomy was less common in cases, aOR 0.33, 95% CI 0.17-0.64, but microscopic colitis cases had more frequent bowel movements following cholecystectomy. CONCLUSION Compared to similar patients with diarrhoea, cases with microscopic colitis were not more likely to have taken previously implicated medications. They had more diarrhoea following cholecystectomy, suggesting that bile may play a role in symptoms or aetiology. We conclude that the appropriate choice of controls is crucial to understanding risk factors for microscopic colitis.
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Affiliation(s)
- Robert S. Sandler
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Temitope O. Keku
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill
- Department of Medicine, University of North Carolina at Chapel Hill
| | - John T. Woosley
- Department of Pathology, University of North Carolina at Chapel Hill
| | - Joseph A. Galanko
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Anne F. Peery
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill
- Department of Medicine, University of North Carolina at Chapel Hill
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9
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Mihaly E, Patai Á, Tulassay Z. Controversials of Microscopic Colitis. Front Med (Lausanne) 2021; 8:717438. [PMID: 34712675 PMCID: PMC8546222 DOI: 10.3389/fmed.2021.717438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/11/2021] [Indexed: 11/21/2022] Open
Abstract
Microscopic colitis (MC) has become a disease with increased awareness due to the availability of new data about the pathogenesis, diagnosis and therapy of this disease. The incidence of MC is increasing, reaching the incidence of the inflammatory bowel disease (IBD) in some populations. However, some aspects of MC are still controversial. It is unknown whether the changes of microbiome play a role in the pathogenesis and what is in the background of the different subtypes of disease that can transform into each other. Is there a connection between MC and IBD or why the histological changes do not follow the clinical activity? We do not know what the etiology of the incomplete MC is, and what its natural course is. The association of MC with celiac disease is well-known- is there a common pathogenesis? The MC treatment is budesonide. Its effectiveness is high, but the relapse rate is high, as well. Why would biologics be effective in these cases when budesonide is not? This mini-review makes an attempt to summarize the data about MC and highlight that there are still unanswered questions in the pathogenesis, diagnosis and therapy of the disease, which can initiate further investigations in the future.
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Affiliation(s)
- Emese Mihaly
- Gastroenterology Unit, Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
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10
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Abstract
Microscopic colitis (MC) is an inflammatory disease of the large intestine associated with urgent watery diarrhoea. MC may occur in people of all ages, although the disease primarily affects older women. Once believed to be rare, MC is now known to be a common cause of chronic watery diarrhoea in high-income countries, affecting 1 in 115 women and 1 in 286 men during their lifetime in Swedish population-based estimates. An inappropriate immune response to disturbances in the gut microenvironment is implicated in the pathogenesis of MC. Evidence also supports an underlying genetic basis for disease. The diagnosis of MC relies on clinical symptoms and microscopic assessment of colonic biopsy samples. MC is categorized histologically into collagenous colitis, lymphocytic colitis and their incomplete forms. The mainstay of treatment includes the use of budesonide, with or without adjunctive therapies, and withdrawal of offending drugs. Emerging studies suggest a role for biologicals and immunosuppressive therapies for the management of budesonide-refractory or budesonide-dependent disease. MC can have a substantial negative effect on patient quality of life. The outlook for MC includes a better understanding of the immune response, genetics and the microbiome in disease pathogenesis along with progress in disease management through robust clinical trials.
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Affiliation(s)
- Kristin E Burke
- Gastroenterology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA.
| | - Mauro D'Amato
- Gastrointestinal Genetics Lab, CIC bioGUNE, Basque Research and Technology Alliance (BRTA), Derio, Spain
- Ikerbasque, Basque Foundation for Science, Bilbao, Spain
| | - Siew C Ng
- Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, LK Institute of Health Science, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Hamed Khalili
- Gastroenterology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA.
- Institute of Environmental Medicine, Nutrition Epidemiology, Karolinska Institutet, Solna, Sweden.
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11
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Miehlke S, Guagnozzi D, Zabana Y, Tontini GE, Kanstrup Fiehn A, Wildt S, Bohr J, Bonderup O, Bouma G, D'Amato M, Heiberg Engel PJ, Fernandez‐Banares F, Macaigne G, Hjortswang H, Hultgren‐Hörnquist E, Koulaouzidis A, Kupcinskas J, Landolfi S, Latella G, Lucendo A, Lyutakov I, Madisch A, Magro F, Marlicz W, Mihaly E, Munck LK, Ostvik A, Patai ÁV, Penchev P, Skonieczna‐Żydecka K, Verhaegh B, Münch A. European guidelines on microscopic colitis: United European Gastroenterology and European Microscopic Colitis Group statements and recommendations. United European Gastroenterol J 2021; 9:13-37. [PMID: 33619914 PMCID: PMC8259259 DOI: 10.1177/2050640620951905] [Citation(s) in RCA: 110] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/27/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Microscopic colitis is a chronic inflammatory bowel disease characterised by normal or almost normal endoscopic appearance of the colon, chronic watery, nonbloody diarrhoea and distinct histological abnormalities, which identify three histological subtypes, the collagenous colitis, the lymphocytic colitis and the incomplete microscopic colitis. With ongoing uncertainties and new developments in the clinical management of microscopic colitis, there is a need for evidence-based guidelines to improve the medical care of patients suffering from this disorder. METHODS Guidelines were developed by members from the European Microscopic Colitis Group and United European Gastroenterology in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. Following a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the certainty of the evidence. Statements and recommendations were developed by working groups consisting of gastroenterologists, pathologists and basic scientists, and voted upon using the Delphi method. RESULTS These guidelines provide information on epidemiology and risk factors of microscopic colitis, as well as evidence-based statements and recommendations on diagnostic criteria and treatment options, including oral budesonide, bile acid binders, immunomodulators and biologics. Recommendations on the clinical management of microscopic colitis are provided based on evidence, expert opinion and best clinical practice. CONCLUSION These guidelines may support clinicians worldwide to improve the clinical management of patients with microscopic colitis.
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12
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Rojo E, Casanova MJ, Gisbert J. Treatment of microscopic colitis: the role of budesonide and new alternatives for refractory patients. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 112:53-58. [PMID: 31880163 DOI: 10.17235/reed.2019.6655/2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Microscopic colitis is a common cause of chronic watery diarrhea with a great impact on patient quality of life. Microscopic colitis includes two histological subtypes: collagenous colitis and lymphocytic colitis. Due to the increasing incidence and awareness of this disease over the last decades, several international guidelines have been recently published. However, there is still significant heterogeneity in the management of these patients, and treatments without solid scientific evidence support are often used in clinical practice. This article reviews the therapeutic role of budesonide in microscopic colitis and summarizes the current evidence regarding other treatments available for this disease, especially for the management of refractory patients. Finally, an updated treatment algorithm is proposed.
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Affiliation(s)
- Eukene Rojo
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, España
| | - María José Casanova
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, España
| | - Javier Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, España
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13
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Ji E, Wang T, Xu J, Fan J, Zhang Y, Guan Y, Yang H, Wei J, Zhang G, Huang L. Systematic Investigation of the Efficacy of Sinitang Decoction Against Ulcerative Colitis. Front Pharmacol 2020; 11:1337. [PMID: 32982747 PMCID: PMC7490561 DOI: 10.3389/fphar.2020.01337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/11/2020] [Indexed: 12/12/2022] Open
Abstract
The aim of this study was to investigate the precise clinical use of Sinitang decoction (SNT) in ulcerative colitis (UC). Network pharmacology-based analysis of the drug components-targets-diseases-pathways was used to predict the possible clinical applications of SNT. Next, 2,4,6-trinitrobenzenesulfonic acid (TNBS) was used to establish a rat model of UC, and the efficacy of SNT against UC was tested, followed by a proteomic analysis of the specific signatures regulated by SNT against UC. SNT was predicted to be effective in inflammatory bowel disease, UC, and several other diseases. In the rats with UC, SNT decreased the disease activity index and colon mucosal damage index compared to the untreated UC model rats. Additionally, SNT reversed the upregulated levels of serum tumor necrosis factor (TNF)-α, prostaglandin E2 (PGE2), interleukin (IL)-6, and nitric oxide (NO) in UC model rats. The proteomic analysis identified 78 proteins that were differentially regulated by SNT in the rats with UC, which were associated with the Gene Ontology terms sulfur compound binding, calcium ion binding, and Toll-like receptor (TLR)-4 binding. Among these differentially regulated proteins, C-reactive protein (CRP) and collagen alpha-1(XII) chain (COL12A1) were found to be signature proteins associated with the efficacy of SNT against UC. This study represents the first precise investigation of the efficacy and mechanisms of SNT against UC, and shows that SNT is a promising candidate for personalized management of UC.
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Affiliation(s)
- Enhui Ji
- School of Traditional Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou, China.,Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Tingting Wang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jing Xu
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jianwei Fan
- State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co., Ltd., Linyi, China
| | - Yi Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yongxia Guan
- State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co., Ltd., Linyi, China
| | - Hongjun Yang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Junying Wei
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Guimin Zhang
- State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co., Ltd., Linyi, China
| | - Luqi Huang
- School of Traditional Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou, China.,Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
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14
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Miehlke S, Verhaegh B, Tontini GE, Madisch A, Langner C, Münch A. Microscopic colitis: pathophysiology and clinical management. Lancet Gastroenterol Hepatol 2020; 4:305-314. [PMID: 30860066 DOI: 10.1016/s2468-1253(19)30048-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/18/2019] [Accepted: 01/18/2019] [Indexed: 12/12/2022]
Abstract
Microscopic colitis is a chronic inflammatory disease of the colon that frequently causes chronic watery diarrhoea that might be accompanied by abdominal pain, nocturnal diarrhoea, urgency, and faecal incontinence. These symptoms lead to poor quality of life and increased health-care costs. Diagnosis relies on histological examination of multiple biopsy samples from the colonic mucosa, which often show no or only few abnormalities on endoscopy. Two major histological subtypes can be distinguished-collagenous colitis and lymphocytic colitis-but incomplete and variant forms with fewer characteristic features have been reported. Here we summarise the latest evidence on epidemiology, pathogenesis, and risk factors, and discuss established and novel therapeutic options for clinical remission. Finally, we propose an updated treatment algorithm. Further prospective studies are needed to clarify the natural history of microscopic colitis, supported by validated criteria for the assessment of disease activity.
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Affiliation(s)
- Stephan Miehlke
- Centre for Digestive Diseases, Internal Medicine Centre Eppendorf, Hamburg, Germany; Centre for Oesophageal Disorders, University Hospital Eppendorf, Hamburg, Germany.
| | - Bas Verhaegh
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Gian Eugenio Tontini
- Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ahmed Madisch
- Department of Gastroenterology, CRH Clinic Siloah, Hannover, Germany
| | - Cord Langner
- Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Andreas Münch
- Department of Gastroenterology, Linköping University, Linköping, Sweden
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15
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Abstract
Microscopic colitis (MC), encompassing lymphocytic and collagenous colitis, is a common cause for chronic nonbloody diarrhoea, which impacts significantly on the quality of life for patients. Despite increasing awareness of the condition and its treatment, there is considerable variation in therapeutic approaches. To conduct a systematic review and meta-analysis on the efficacy and safety of budesonide in the treatment of MC. We searched Medline, Embase and Central databases using predefined search methodology for randomised trials using budesonide in the treatment of MC. We extracted data, on the efficacy and safety of budesonide, from studies identified that met the feasibility for analysis criteria. These data were pooled with a fixed effects model. Nine studies met the inclusion criteria for analysis. The pooled odds ratios (ORs) for a response to budesonide therapy at induction and maintenance were 7.34 [95% confidence interval (CI): 4.08-13.19] and 8.35 (95% CI: 4.14-16.85) respectively. Histological response rates were superior in budesonide-treated patients compared to placebo following induction (OR: 11.52; 95% CI: 5.67-23.40) and maintenance treatment (OR: 5.88; 95% CI: 1.90-18.17). There was no difference in adverse events. Significant relapse rates (>50%) were observed following treatment cessation with no difference noted between the budesonide or the placebo-treated patients. Budesonide is an effective treatment option for MC for achieving induction and maintenance of both clinical and histological response. High relapse rates on treatment cessation were observed.
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16
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Shor J, Churrango G, Hosseini N, Marshall C. Management of microscopic colitis: challenges and solutions. Clin Exp Gastroenterol 2019; 12:111-120. [PMID: 30881078 PMCID: PMC6398419 DOI: 10.2147/ceg.s165047] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Microscopic colitis (MC) is a chronic inflammatory bowel disease characterized by nonbloody diarrhea in the setting of normal appearing colonic mucosa. MC has two main subtypes based on histopathologic features, collagenous colitis and lymphocytic colitis. Management of both subtypes is the same, with treatment goal of reducing the number of bowel movements and improving consistency. First-line treatment involves counseling the patient about decreasing their risk factors, like discontinuing smoking and avoiding medications with suspected association such as NSAIDs, proton pump inhibitor, ranitidine, and sertraline. Starting loperamide for immediate symptomatic relief is used as an adjunct to therapy with glucocorticoids. Budesonide is considered first-line treatment for MC given its favorable side effect profile and good efficacy, though relapse rates are high. Systemic glucocorticoids should be reserved to patients unable to take budesonide. In glucocorticoid refractory disease, medications that have been tried include cholestyramine, bismuth salicylate, antibiotics, probiotics, aminosalicylates, immunomodulators, and anti-tumor necrosis factor-alpha inhibitors. More research is needed for the creation of a systematic stepwise approach for relapsing and refractory disease.
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Affiliation(s)
- Julia Shor
- Department of Gastroenterology, University of Massachusetts Medical School, Worcester, MA, USA,
| | - Gustavo Churrango
- Department of Gastroenterology, University of Massachusetts Medical School, Worcester, MA, USA,
| | - Nooshin Hosseini
- Department of Gastroenterology, Mount Sinai Hospital, New York, NY, USA
| | - Christopher Marshall
- Department of Gastroenterology, University of Massachusetts Medical School, Worcester, MA, USA,
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17
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Gentile N, Yen EF. Prevalence, Pathogenesis, Diagnosis, and Management of Microscopic Colitis. Gut Liver 2018; 12:227-235. [PMID: 28669150 PMCID: PMC5945253 DOI: 10.5009/gnl17061] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 03/24/2017] [Accepted: 03/24/2017] [Indexed: 12/12/2022] Open
Abstract
Microscopic colitis (MC), which is comprised of lymphocytic colitis and collagenous colitis, is a clinicopathological diagnosis that is commonly encountered in clinical practice during the evaluation and management of chronic diarrhea. With an incidence approaching the incidence of inflammatory bowel disease, physician awareness is necessary, as diagnostic delays result in a poor quality of life and increased health care costs. The physician faces multiple challenges in the diagnosis and management of MC, as these patients frequently relapse after successful treatment. This review article outlines the risk factors associated with MC, the clinical presentation, diagnosis and histologic findings, as well as a proposed treatment algorithm. Prospective studies are required to better understand the natural history and to develop validated histologic endpoints that may be used as end points in future clinical trials and serve to guide patient management.
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Affiliation(s)
- Nicole Gentile
- NorthShore University HealthSystem, University of Chicago, Evanston, IL, USA
| | - Eugene F Yen
- NorthShore University HealthSystem, University of Chicago, Evanston, IL, USA
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18
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Kane JS, Irvine AJ, Derwa Y, Ford AC. Fatigue and its associated factors in microscopic colitis. Therap Adv Gastroenterol 2018; 11:1756284818799599. [PMID: 30228831 PMCID: PMC6137548 DOI: 10.1177/1756284818799599] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/06/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Fatigue is a well-recognized symptom in patients with inflammatory bowel disease and irritable bowel syndrome (IBS), and has been associated with psychological comorbidity and impaired quality of life in both. However, features associated with fatigue in patients with microscopic colitis (MC) are less clear. MATERIALS AND METHODS We conducted a cross-sectional survey of patients with a new diagnosis of MC including levels of anxiety, depression, somatization, quality of life, and IBS-type symptoms. Levels and impact of fatigue were assessed using the Inflammatory Bowel Disease Fatigue self-assessment scale. Mean scores were compared against various patient characteristics, and were also correlated with anxiety, depression, somatization, and quality-of-life scores. RESULTS In total, 129 patients with MC diagnosed between 2010 and 2015 returned completed postal questionnaires. Common histological subtypes were collagenous colitis (53.5%, n = 69) and lymphocytic colitis (38.8%, n = 50). Higher mean fatigue severity and impact scores were associated with the presence of irritable-bowel-syndrome-type symptoms, abnormal levels of anxiety and depression, and high levels of somatization (p < 0.0001 for all), but those reporting ongoing symptoms attributable to MC did not report significantly higher scores. There were significant positive correlations between total anxiety, depression, or somatization scores and fatigue severity and impact scores, and significant negative correlations with quality-of-life measures (p < 0.001 for all). CONCLUSIONS Fatigue in MC appears to be associated with reporting IBS-type symptoms, psychological comorbidity and impaired quality of life. It may therefore represent an important target for treatment.
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Affiliation(s)
- John S. Kane
- Leeds Gastroenterology Institute, 4
Floor, Bexley Wing, St. James’s University Hospital, Beckett Street, Leeds
LS9 7TF, UK
| | - Andrew J. Irvine
- Leeds Gastroenterology Institute, St. James’s
University Hospital, Leeds, UK
| | - Yannick Derwa
- Leeds Gastroenterology Institute, St. James’s
University Hospital, Leeds, UK
| | - Alexander C. Ford
- Leeds Gastroenterology Institute, St. James’s
University Hospital, Leeds, UK Leeds Institute of Biomedical and Clinical
Sciences, University of Leeds, Leeds, UK
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Kane JS, Irvine AJ, Derwa Y, Rotimi O, Ford AC. High prevalence of irritable bowel syndrome-type symptoms in microscopic colitis: implications for treatment. Therap Adv Gastroenterol 2018; 11:1756284818783600. [PMID: 29977339 PMCID: PMC6024332 DOI: 10.1177/1756284818783600] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/21/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with microscopic colitis (MC) often present with abdominal pain and diarrhoea, and previous data suggest that there may be overlap between MC and irritable bowel syndrome (IBS). We evaluated the prevalence of IBS-type symptoms in patients with MC, and assess the impact of these symptoms on psychological health and quality of life. METHODS We conducted a cross-sectional survey of individuals with a histological diagnosis of MC, collecting demographic data, Rome III IBS-type symptoms, and mood, somatization, and quality of life data. RESULTS In total, 151 (31.6%) of 478 individuals with a new diagnosis of MC completed questionnaires, 52 (34.4%) of whom reported IBS-type symptoms. The commonest histological subtype was collagenous colitis (51.7%, n = 78), followed by lymphocytic colitis (39.1%, n = 59). Individuals with IBS-type symptoms had significantly higher levels of anxiety [Hospital Anxiety and Depression Scale (HADS) anxiety score 8.6 versus 5.1, p < 0.001], depression (HADS depression score 6.2 versus 3.6, p = 0.001), and somatoform-type behaviour (Patient Health Questionnaire 15 score 12.7 versus 8.0, p < 0.001) compared with individuals who did not. Those with IBS-type symptoms scored significantly worse across all domains of the 36-item Short Form questionnaire, except for physical functioning. CONCLUSIONS More than one third of individuals with MC reported IBS-type symptoms, although whether this is due to ongoing inflammation is unclear. These individuals had higher levels of anxiety, depression, and somatization, and impaired quality of life. Identifying concomitant IBS in individuals with MC may have important implications for management decisions.
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Affiliation(s)
- John S. Kane
- Leeds Gastroenterology Institute, 4th Floor, Bexley Wing, St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK
| | - Andrew J. Irvine
- Leeds Gastroenterology Institute, St James’s University Hospital, Leeds, UK
| | - Yannick Derwa
- Leeds Gastroenterology Institute, St James’s University Hospital, Leeds, UK
| | - Olorunda Rotimi
- Department of Histopathology, St James’s University Hospital, Leeds, UK
| | - Alexander C. Ford
- Leeds Gastroenterology Institute, St James’s University Hospital, Leeds, UK Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
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van Hemert S, Skonieczna-Żydecka K, Loniewski I, Szredzki P, Marlicz W. Microscopic colitis-microbiome, barrier function and associated diseases. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:39. [PMID: 29610731 DOI: 10.21037/atm.2017.03.83] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Microscopic colitis (MC) is a chronic inflammatory bowel disease (IBD) with little in terms of endoscopic abnormalities and is frequently associated with other autoimmune diseases. The peak incidence of the disease is in middle aged or older populations, mostly females. The pathogenesis of MC is complex, multifactorial and poorly understood. Current concepts revolve around innate immunity or microbiome alterations as well as gut barrier dysfunction, all of which lead to the development of subtle inflammatory lesions in gut mucosa. The results of numerous basic and clinical studies involving molecular techniques as well as advanced endoscopic imaging revealed the important role of both intrinsic (e.g., hormonal) as well as extrinsic (e.g., NSAIDs and PPIs) factors in the modulation of gastrointestinal microbiome and MC pathogenesis. Capsule endoscopy as well confocal endomicroscopy imaging, alongside standard endoscopic techniques offer new tools in the evaluation of MC patients and allow their better stratification for novel treatment protocols based on modulation of gut microbiome and barrier function.
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Affiliation(s)
| | | | - Igor Loniewski
- Department of Biochemistry and Human Nutrition, Pomeranian Medical University, Szczecin, Poland.,Sanprobi Sp. z o.o. Sp. K., Szczecin, Poland
| | - Piotr Szredzki
- Endoscopy Unit, Department of Surgery, Hospital Sędziszów Małopolski, Sędziszów Małopolski, Poland
| | - Wojciech Marlicz
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland
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Chojnacki C, Błasiak J, Fichna J, Chojnacki J, Popławski T. Evaluation of Melatonin Secretion and Metabolism Exponents in Patients with Ulcerative and Lymphocytic Colitis. Molecules 2018; 23:molecules23020272. [PMID: 29382152 PMCID: PMC6017024 DOI: 10.3390/molecules23020272] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 01/21/2018] [Accepted: 01/26/2018] [Indexed: 12/15/2022] Open
Abstract
Inflammatory bowel diseases, particularly ulcerative colitis (UC) and lymphocytic colitis (LC), affect many people. The role of melatonin in the pathogenesis of UC is precisely determined, whereas in LC it remains unknown. The aim of this study was to compare the expression of the melatonin-synthesizing enzymes tryptophan hydroxylase (TPH1), arylalkylamine-N-acetyltransferase (AANAT), and N-acetylserotonin methyltransferase (ASMT) in the colonic mucosa and urinary excretion of 6-sulfatoxymelatonin in patients with ulcerative and lymphocytic colitis. The study included 30 healthy subjects (group C), 30 patients with severe ulcerative colitis (group UC), and 30 patients with lymphocytic colitis (group LC). The diagnosis was based on endoscopic, histological, and laboratory examinations. Biopsy specimens were collected from right, transverse, and left parts of the colon. The levels of mRNA expression, TPH1, AANAT, and ASMT were estimated in the colonic mucosa with RT-PCR. The urine concentration of aMT6s was determined by the photometric method. The expression of TPH1, AANAT, and ASMT in colonic mucosa in UC and LC patients was significantly higher than in healthy subjects. Significant differences were found in the urinary aMT6s excretion: group C—13.4 ± 4.8 µg/24 h, group UC—7.8 ± 2.6 µg/24 h (p < 0.01), group LC—19.2 ± 6.1 µg/24 h (p < 0.01). Moreover, a negative correlation was found between fecal calprotectin and MT6s—in patients with UC − r = −0.888 and with LC − r = −0.658. These results indicate that patients with UC and those with LC may display high levels of melatonin-synthesizing enzymes in their colonic mucosa, which could possibly be related to increased melatonin synthesis as an adaptive antioxidant activity.
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Affiliation(s)
- Cezary Chojnacki
- Department of Clinical Nutrition and Gastroenterological Diagnostics, Medical University, 90-647 Lodz, Poland.
| | - Janusz Błasiak
- Department of Molecular Genetics, University of Lodz, 90-647 Lodz, Poland.
| | - Jakub Fichna
- Department of Biochemistry, Medical University of Lodz, 90-647 Lodz, Poland.
| | - Jan Chojnacki
- Department of Clinical Nutrition and Gastroenterological Diagnostics, Medical University, 90-647 Lodz, Poland.
| | - Tomasz Popławski
- Department of Molecular Genetics, University of Lodz, 90-647 Lodz, Poland.
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Abstract
PURPOSE OF REVIEW Microscopic colitis is a common cause of chronic watery diarrhea, particularly in the elderly. The accompanying symptoms, which include abdominal pain and fatigue, can markedly impair patients' quality of life. Diagnosis is based upon characteristic histologic findings of the colonic mucosa. This review focuses on the current approach to evaluation and management of patients with microscopic colitis. RECENT FINDINGS Although the incidence of microscopic colitis has been increasing over time, recent epidemiological studies show stabilization at 21.0-24.7 cases per 100,000 person-years. Recent research has further expanded our knowledge of the underlying pathophysiology and emphasized the entity of drug-induced microscopic colitis and the association with celiac disease. Two recent randomized studies have confirmed the effectiveness of oral budesonide for both induction and maintenance treatment of microscopic colitis and is now endorsed by the American Gastroenterological Association as first-line treatment. The incidence of microscopic colitis has stabilized at just over 20 cases per 100,000 person-years. Celiac disease and drug-induced microscopic colitis should be considered in all patients diagnosed with microscopic colitis. There are a number of treatments available for patients with microscopic colitis; however, budesonide is the only option well studied in controlled trials and is effective for both induction and maintenance treatment.
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