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Westbrook KE, Garber A. Microscopic colitis: What is it, and what are the treatment options? Cleve Clin J Med 2024; 91:215-216. [PMID: 38561206 DOI: 10.3949/ccjm.91a.23057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
| | - Ari Garber
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, OH
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Kotze LMDS, Kotze LR, Souza RCAD, Kotze PG, Nisihara R. WARNING TO DELAY IN DIAGNOSING MICROSCOPIC COLITIS IN OLDER ADULTS. A SERIES OF CASES. Arq Gastroenterol 2024; 61:e23114. [PMID: 38451666 DOI: 10.1590/s0004-2803.24612023-114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/28/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Microscopic colitis (MC) is a chronic inflammatory bowel disease causing non-bloody diarrhea, and several cases are undiagnosed as a hidden cause of chronic diarrhea. OBJECTIVE We aimed to report the symptoms, delay diagnosis and the treatment of MC in a case series. METHODS All patients were treated at a Gastroenterology reference office from May 2022 to June 2023. Personal history including preexisting disorders, use of medications and smoking habits were collected. The delay between the onset of symptoms and the correct diagnosis was informed. All patients consented to use budesonide MMX (Corament®) off label. RESULTS During the study period, six Caucasoid patients were diagnosed with MC, five females and one male, between the ages of 65 and 74. All patients had comorbities and were taking multiple prescription drugs. Laboratory findings showed negative serology for celiac disease for all patients, normal levels of albumin and vitamin B12. The delay between the symptoms and the MC diagnosis varied from 2 months to 6 years. All patients had a previous diagnosis of irritable bowel syndrome. All patients were in complete clinical remission during the treatment and referred no side effects of the drug. CONCLUSION Older females using high-risk medications are suggestive of MC. Preventing delay in the diagnosis of MC is crucial to improvement in patients´ quality of life. Budesonide MMX appears to be effective, safe and well-tolerated. BACKGROUND • Microscopic Colitis is a chronic inflammatory bowel disease causing non-bloody diarrhea. BACKGROUND • Several cases are undiagnosed and can be a hidden cause of chronic diarrhea. BACKGROUND • Treatment with budesonide MMX (Corament®, off label) was effective and safe.
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Affiliation(s)
| | | | | | | | - Renato Nisihara
- Universidade Federal do Paraná, Curitiba, PR, Brasil
- Universidade Positivo, Curitiba, PR, Brasil
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Enwerem NY, Yen EF. The colitis may be microscopic, but the diarrhea is not: update on the treatment of microscopic colitis and immune checkpoint inhibitor colitis. Curr Opin Gastroenterol 2024; 40:50-59. [PMID: 37874119 DOI: 10.1097/mog.0000000000000986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
PURPOSE OF REVIEW Microscopic colitis is an inflammatory disease of the colon that presents as watery diarrhea with minimal to normal endoscopic changes on colonoscopy. It encompasses two common subtypes, lymphocytic colitis and collagenous colitis, which are both treated similarly.Immune checkpoint inhibitor colitis is among the most common immune-related adverse events. Endoscopic and histological findings range from normal colonic mucosa to inflammatory bowel like changes. This review article provides update in treatment and management of microscopic colitis and immune checkpoint inhibitor colitis (ICPi colitis). RECENT FINDINGS Recent studies on microscopic colitis have focused on the successful use of immunomodulators such as biologics for treatment of budesonide refractory microscopic colitis cases. Microscopic colitis does not confer an added risk for colorectal cancer.With the increasing usage of immunotherapy agents, immune checkpoint inhibitor colitis is becoming more common. ICPi colitis can be successfully managed with steroids, with treatment stepped up to biologics for moderate to severe cases or for mild cases that do not respond to steroids. Immunotherapy agents can be carefully re-introduced in mild cases, after treatment of ICPi colitis. SUMMARY Biologics can be used to treat budesonide refractory microscopic colitis. ICPi colitis can be managed with steroids and biologics in moderate to severe cases.
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Affiliation(s)
- Ngozi Y Enwerem
- University of Texas Southwestern Medical Center, Division of Digestive and Liver Diseases
- VA Medical Center, Dallas, Texas
| | - Eugene F Yen
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Osadchuk AM, Fadeeva NA, Dashkina NA, Loranskaya ID, Khomeriki SG. [Clinical cases of microscopic colitis: Diagnosis and treatment issues. Case report]. TERAPEVT ARKH 2023; 95:985-990. [PMID: 38158957 DOI: 10.26442/00403660.2023.11.202468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 01/03/2024]
Abstract
Currently, there is an increase in the incidence of microscopic colitis. There are difficulties in diagnosing this disease due to the variability of histological signs, variability of morphological changes in the mucous membrane of the colon in different parts of the colon, and the combination in one patient of not only various forms of microscopic colitis, but also other intestinal diseases. The article describes the differential diagnosis, an example of its staging and successful treatment of various forms of microscopic colitis with budesonide (two clinical cases presented).
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Affiliation(s)
- A M Osadchuk
- Russian Medical Academy of Continuous Professional Education
| | - N A Fadeeva
- Loginov Moscow Clinical Scientific and Practical Center
- Research Institute of Health Organization and Medical Management
| | - N A Dashkina
- Loginov Moscow Clinical Scientific and Practical Center
| | - I D Loranskaya
- Russian Medical Academy of Continuous Professional Education
| | - S G Khomeriki
- Loginov Moscow Clinical Scientific and Practical Center
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6
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Tome J, Sehgal K, Kamboj AK, Harmsen WS, Khanna S, Pardi DS. Bile Acid Sequestrants in Microscopic Colitis: Clinical Outcomes and Utility of Bile Acid Testing. Clin Gastroenterol Hepatol 2023; 21:3125-3131.e2. [PMID: 37172800 DOI: 10.1016/j.cgh.2023.04.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/18/2023] [Accepted: 04/22/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND & AIMS Bile acid sequestrants (BAS) may be a treatment in microscopic colitis (MC), but efficacy data are limited. We evaluated the effectiveness of BAS in MC and assessed the utility of bile acid testing to predict response. METHODS Adults with MC treated with BAS (2010-2020) at Mayo Clinic were identified. Bile acid malabsorption was defined by elevated serum 7⍺-hydroxy-4-cholesten-3-one or by fecal testing using previously validated cutoffs. Response was defined at 12 ± 4 weeks after BAS initiation as: complete (resolution of diarrhea), partial (≥50% improvement in diarrhea), nonresponse (<50% improvement), and intolerance (discontinuation due to side effects). Logistic regression was used to identify predictors of response to BAS. RESULTS We identified 282 patients (median age, 59 years [range, 20-87 years]; 88.3% women) with median follow-up of 4.5 years (range, 0.4-9.1 years). Patients were treated with the following BAS: 64.9% cholestyramine, 21.6% colesevelam, and 13.5% colestipol. Clinical outcomes were: 49.3% complete response, 16.3% partial response, 24.8% nonresponse, and 9.6% intolerance. There were no differences in outcomes between those on BAS alone or BAS combined with other medications (P = .98). The dose of BAS was not associated with response (P = .51). Bile acid testing was done in 31.9% of patients, and 56.7% were positive. No predictors of response to BAS were identified. After BAS discontinuation, 41.6% had recurrence at a median of 21 weeks (range, 1-172 weeks). CONCLUSION In one of the largest cohorts evaluating BAS treatment in MC, nearly two-thirds had a partial or complete response. Additional research is needed to determine the role of BAS and bile acid malabsorption in MC.
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Affiliation(s)
- June Tome
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kanika Sehgal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Amrit K Kamboj
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Djembissi Fotso A, Arvanitakis M, Salame M, Gallez J, Lakis A. What do we know today about drug-induced microscopic colitis? A case of lymphocytic colitis on olmesartan. Acta Gastroenterol Belg 2023; 86:474-480. [PMID: 37814563 DOI: 10.51821/86.3.11361] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Microscopic colitis is part of the differential diagnosis of chronic watery diarrhea. Colonoscopy discloses a normal looking mucosa, therefore its diagnosis is based on histology of colonic biopsies. Two main phenotypes are distinguished: collagenous colitis and lymphocytic colitis. A third entity, incomplete microscopic colitis or unspecified microscopic colitis has been reported in the literature. It affects preferentially women over 60 years of age and its association with certain drugs is increasingly established. In case of suspected drug-induced microscopic colitis, identification of the responsible drug is a key to management. After discontinuation of the suspected drug, the gold standard of treatment is budesonide both for induction and for maintenance in case of clinical relapse, as is often the case after discontinuation. Therapy with immunomodulators, biologics, or surgery is reserved for refractory forms of microscopic colitis after multidisciplinary consultation. Through the clinical case of colitis on olmesartan, we will review the latest recommendations on drug-induced microscopic colitis.
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Affiliation(s)
- A Djembissi Fotso
- Department of Gastroenterology, Centre Hospitalier Régional de la Haute Senne, Soignies, Belgium
- Department of Gastroenterology, Erasme Hospital, Université Libres de Bruxelles (ULB), Brussels, Belgium
| | - M Arvanitakis
- Department of Gastroenterology, Erasme Hospital, Université Libres de Bruxelles (ULB), Brussels, Belgium
| | - M Salame
- Department of Gastroenterology, Centre Hospitalier Régional de la Haute Senne, Soignies, Belgium
| | - J Gallez
- Department of Gastroenterology, Centre Hospitalier Régional de la Haute Senne, Soignies, Belgium
| | - A Lakis
- Department of Gastroenterology, Centre Hospitalier Régional de la Haute Senne, Soignies, Belgium
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Lenfant M, De Hertogh G, Verstockt B. Tofacitinib for celiac disease and microscopic colitis: killing two birds with one stone. Acta Gastroenterol Belg 2023; 86:374-376. [PMID: 37428175 DOI: 10.51821/86.2.11639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Microscopic colitis is a chronic inflammatory condition of the colon. Firstline treatment consists of budesonide, with the consideration of biological agents in refractory cases. Celiac disease is a chronic immune mediated and gluten-induced enteropathy, with treatment consisting of a gluten-free diet. There is an association between microscopic colitis and instead of xand celiac disease, especially in refractory cases they can coincide. In this manuscript, we report for the first time the efficacy of tofacitinib, a pan Janus kinase inhibitor, in the treatment of concomitant microscopic colitis and celiac disease, resulting in persistent clinical and histological remission.
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Affiliation(s)
- M Lenfant
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - G De Hertogh
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - B Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
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Kotze LMDS, Kotze PG, Kotze LR, Nisihara R. MICROSCOPIC COLITIS: CONSIDERATIONS FOR GASTROENTEROLOGISTS, ENDOSCOPISTS, AND PATHOLOGISTS. Arq Gastroenterol 2023; 60:188-193. [PMID: 37556744 DOI: 10.1590/s0004-2803.20230222-143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/27/2023] [Indexed: 08/11/2023]
Abstract
•Diagnosis of microscopic colitis necessitates effective communication among gastroenterologists, endoscopists, and pathologists. •The gastroenterologist should refer every patient with chronic watery diarrhea to perform a colonoscopy in spite of the benign course of the disease and the absence of alarm symptoms. •The endoscopist should take 2 or 3 biopsy samples of the colonic mucosa from the right and left colon, put in separate recipients, despite that the mucosa looked macroscopically normal. •The pathologist should be encouraged to use objective histological criteria to make the diagnosis. Microscopic colitis is a chronic inflammatory bowel disease characterized by non-bloody diarrhea that can range from mild to severe. It is difficult to attribute up to 10-20% of chronic diarrhea to microscopic colitis. The three determinants factors of the diagnosis are characteristic clinical symptoms, normal endoscopic picture of the colon, and pathognomonic histological picture. This manuscript aimed to update considerations and recommendations for professionals involved (gastroenterologist, endoscopists and pathologist) in the diagnosis of MC. In addition, a short recommendation about treatment.
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Affiliation(s)
| | - Paulo Gustavo Kotze
- Pontifícia Universidade Católica do Paraná, Programa de Pós-Graduação em Ciências da Saúde, Ambulatório de Doenças Inflamatórias Intestinais, Curitiba, PR, Brasil
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Nevalainen A, Nevalainen OPO. Autoimmune and immune-mediated inflammatory diseases after exposure to acid-suppressive medication: A systematic review and meta-analysis. Int J Risk Saf Med 2023; 34:207-225. [PMID: 36442213 DOI: 10.3233/jrs-220012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pharmacovigilance risk signals have proposed a relationship between the use of acid-suppressive medications and the development of certain autoimmune and immune-mediated inflammatory diseases. OBJECTIVE A systematic review and a meta-analysis was performed. METHODS We reviewed MEDLINE (Ovid) and Scopus for comparative observational studies between these diseases and previous exposure to proton-pump inhibitors (PPI), H2-receptor antagonists (H2RA), and antacids. The protocol was registered on the PROSPERO database (CRD42020192715). RESULTS From 3,191 citations, 25 articles were eligible and covered 16 diseases. Microscopic colitis (MC) was studied the most (7 studies). In a random-effects meta-analysis, there was low certainty evidence (GRADE approach) of a non-significant relationship between exposure to any PPIs and MC (meta-OR 3.28, 95% CI 0.98-11.0, I2 98.2%, six studies, 4,436 PPI-exposed MC patients). Moderate certainty evidence pointed towards large odds of collagenous colitis after exposure to lansoprazole (meta-OR 14.5, 95% CI 9.37-22.3, I2 10.2%, three studies, 1,725 lansoprazole-exposed patients). After PPI exposure, the risk of rheumatoid arthritis was slightly increased based on low certainty evidence from two cohort studies totaling 475 diagnoses (meta-RR 1.62, 95% CI 1.12-2.34, I2 34.5%). CONCLUSIONS In patients with MC, it would be reasonable to carefully review the indication of PPI, especially in CC patients using lansoprazole.
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Affiliation(s)
| | - Olli P O Nevalainen
- Hatanpää Health Centre, City of Tampere, Tampere, Finland
- Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
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Marigliano B, Internullo M, Scuro L, Tavanti A, Del Vecchio LR, Romagno PF, Schito MB, Pace F, Colombo GM, Guglielmelli E. Microscopic colitis, a forgotten condition: a clinical case and review of the literature. Eur Rev Med Pharmacol Sci 2022; 26:7493-7497. [PMID: 36314319 DOI: 10.26355/eurrev_202210_30019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Microscopic colitis is a not uncommon chronic inflammatory disease of the colon, characterized by watery, non-bloody diarrhea, which is often forgotten and misdiagnosed. CASE PRESENTATION In this paper, we present a puzzling case of relapsing chronic diarrhea triggered by non-steroidal anti-inflammatory drug (NSAID) abuse, smoking, inappropriate antibiotic use, and secondary Clostridium Difficilis infection. Several tests were performed during hospitalization, all of which were negative apart from fecal calprotectin (> 6,000 mg/kg, normal values < 50 mg/kg) and a positive Clostridium Difficilis toxin test. Since Vancomycin treatment did not bring about the expected response, colonoscopy was performed, which led to diagnosis, targeted therapy, and clinical resolution. Targeted therapy with budesonide and probiotics was initiated leading to resolution of the diarrhea. CONCLUSIONS This case study shows how actual diagnosis may be delayed not only due to having to perform differential diagnosis with chronic inflammatory diseases, but also because certainty can only come from histological evidence, which takes time to obtain, especially when the disease's multifactorial nature is considered (smoking, NSAID abuse, oral proton pump inhibitors, inappropriate antibiotic use, and Clostridium difficilis infection).
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Affiliation(s)
- B Marigliano
- UOC Pronto Soccorso e Medicina d'Urgenza, Azienda Ospedaliera San Camillo - Forlanini, Rome, Italy.
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12
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Abstract
GOALS There is an unmet need in investigating corticosteroid-sparing treatments for induction and maintenance of remission in microscopic colitis (MC). The authors' aim was to evaluate the outcomes of patients with MC treated with bile acid sequestrants (BAS). BACKGROUND MC is a common chronic diarrheal illness. Budesonide is effective induction therapy, but relapses are high after cessation of treatment. STUDY Our cohort consisted of patients enrolled in our institutional MC registry, a biorepository of histology-confirmed diagnoses of MC. Patients receiving BAS for the treatment of MC were reviewed at each clinical visit for efficacy or ability to decrease budesonide maintenance dosing. RESULTS The authors included 79 patients (29 collagenous colitis and 50 lymphocytic colitis) with a median follow-up period of 35 months (range, 1 to 120). Most patients were female individuals (78%) and the median age was 69 years (range, 29 to 87). BAS therapy was used in 21 patients who were budesonide-naive, with a response rate of 76% (16/21). In patients treated previously with budesonide, 46 patients were budesonide-dependent and given BAS as maintenance therapy. Of these patients, 23 (50%) were able to decrease their budesonide dosing and 9 (20%) were able to stop budesonide completely. Seven of 46 patients (15%) stopped BAS because of intolerance, perceived lack of benefit, or treatment of concomitant diarrhea illness. CONCLUSIONS BAS may be an effective corticosteroid-sparing option in the treatment of MC and should be considered after budesonide induction. Larger controlled studies are needed to confirm the efficacy for long-term maintenance and tolerability of BAS in patients with MC.
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Affiliation(s)
- Michael J Northcutt
- Division of Gastroenterology, University of Chicago Medicine, NorthShore University Health System, Evanston, IL
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Gandu SSK, Khan MH, Vasikaran A, Pandit S. Secukinumab-Induced Lymphocytic Colitis. J Investig Med High Impact Case Rep 2022; 10:23247096221110399. [PMID: 35801542 PMCID: PMC9272475 DOI: 10.1177/23247096221110399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/26/2022] [Accepted: 06/13/2022] [Indexed: 11/15/2022] Open
Abstract
Secukinumab an interleukin-17 (IL-17) monoclonal antibody inhibitor is currently approved for the treatment of rheumatological conditions, such as psoriasis and ankylosing spondylitis. Lymphocytic colitis, a phenotype of microscopic colitis, is a long-term inflammatory condition, is characterized by relapsing diarrhea. The specific entity of drug-induced lymphocytic colitis has been discussed with numerous individual cases being reported from around the world. Secukinumab has been linked with exacerbation of and de novo cases of inflammatory bowel disease. However, lymphocytic colitis in association with this drug has not been documented. The management of drug-induced lymphocytic colitis is complicated, as patients frequently exhibit spontaneous remission of symptoms. Removal of the offending agent has shown some benefit; however, some patients continue to exhibit symptoms months after drug cessation and washout. Although our patient's lymphocytic colitis was benign and responded to the cessation Secukinumab, it is an important diagnosis to consider in patients with new onset relapsing diarrhea treated with biologics.
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Affiliation(s)
| | | | - Anush Vasikaran
- Louisiana State University Health Sciences Center Shreveport, USA
| | - Sudha Pandit
- Louisiana State University Health Sciences Center Shreveport, USA
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14
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Miehlke S. [State-of-the-art management of microscopic colitis]. MMW Fortschr Med 2021; 163:70-72. [PMID: 34888808 DOI: 10.1007/s15006-021-0508-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Stephan Miehlke
- CED-Schwerpunktpraxis / Magen-Darm-Zentrum, Facharztzentrum Eppendorf, Eppendorfer Landstr. 42, 20249, Hamburg, Deutschland
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15
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Münch A, Mihaly E, Nagy F, Madisch A, Kupčinskas J, Miehlke S, Bohr J, Bouma G, Guardiola J, Belloc B, Shi C, Aust D, Mohrbacher R, Greinwald R, Munck LK. Budesonide as induction therapy for incomplete microscopic colitis: A randomised, placebo-controlled multicentre trial. United European Gastroenterol J 2021; 9:837-847. [PMID: 34414678 PMCID: PMC8435258 DOI: 10.1002/ueg2.12131] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/01/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS Incomplete microscopic colitis (MCi) is a subtype of microscopic colitis (MC). Budesonide is recommended as a first-line treatment for MC. However, randomised trials on efficacy of treatment in MCi are missing. We therefore performed a randomised, placebo-controlled trial to evaluate budesonide as induction therapy for MCi. METHODS Patients with active MCi were randomly assigned to either budesonide 9 mg once daily or placebo for 8 weeks in a double-blind, double-dummy design. The primary endpoint was clinical remission, defined as a mean of <3 stools/day and a mean of <1 watery stool/day in the 7 days before week 8. RESULTS Due to insufficient patient recruitment, the trial was discontinued prematurely. The intention-to-treat analysis included 44 patients (21 budesonide and 23 placebo). The primary endpoint of clinical remission at week 8 was obtained by 71.4% on budesonide and 43.5% on placebo (p = 0.0582). All clinical secondary endpoints were in favour of budesonide. Budesonide decreased the number of soft or watery stools (16.3 vs. 7.7, p = 0.0186) and improved health-related quality of life for all four dimensions of the short health scale. Adverse events with a suspected relation to study drug were reported in one patient in the budesonide group and two patients in the placebo group. Neither serious nor severe adverse events occurred during the double-blind phase. CONCLUSIONS Budesonide decreased the frequency of soft or watery stools and improved the patients' quality of life significantly in MCi, but the primary endpoint was not met due to the low sample size (type 2 error). Budesonide was safe and well tolerated during the 8-weeks treatment course.
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Affiliation(s)
- Andreas Münch
- Department of Gastroenterology and HepatologyLinköping University Hospital School of MedicineLinköpingSweden
| | - Emese Mihaly
- Department of Internal MedicineSemmelweis EgyetemBudapestHungary
| | - Ferenc Nagy
- First Department of MedicineSzegedi Egyetem ÁOK I sz.SzegedHungary
| | - Ahmed Madisch
- Medical Department IKRH Klinikum SiloahHannoverGermany
| | - Juozas Kupčinskas
- Department of GastroenterologyInstitute for Digestive ResearchLithuanian University of Health SciencesKaunasLithuania
| | - Stephan Miehlke
- Center for Digestive DiseasesInternal Medicine Center EppendorfHamburgGermany
- Centre for Interdisciplinary EndoscopyUniversity Hospital EppendorfHamburgGermany
| | - Johan Bohr
- Division of GastroenterologyDepartment of MedicineÖrebro University HospitalÖrebroSweden
| | - Gerd Bouma
- Department of GastroenterologyVrije Universiteit Medical CentreAmsterdamNetherlands
| | - Jordi Guardiola
- Department of Digestive DiseasesHospital Universitario de BellvitgeBarcelonaSpain
| | - Blanca Belloc
- Department of GastroenterologyHospital San Jorge – University of ZaragozaHuescaSpain
| | - Chunliang Shi
- Department of GastroenterologyNorrlands UniversitetssjukhusUmeåSweden
| | - Daniela Aust
- Institute for PathologyUniversity Hospital Carl Gustav CarusDresdenGermany
| | - Ralf Mohrbacher
- Clinical Research and Development DepartmentDr Falk Pharma GmbHFreiburgGermany
| | - Roland Greinwald
- Clinical Research and Development DepartmentDr Falk Pharma GmbHFreiburgGermany
| | - Lars Kristian Munck
- Department of GastroenterologyZealand University HospitalKøgeDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
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16
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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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17
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Abstract
Microscopic colitis (MC) is an inflammatory disease of the colon and a common cause of chronic watery diarrhea, predominantly in older patients. Microscopic colitis encompasses 2 different subtypes, lymphocytic colitis and collagenous colitis. The colon typically appears normal endoscopically in MC, and the diagnosis requires histologic evaluation. Whereas recent studies suggest that the incidence of MC has plateaued, given the aging of the population, the prevalence of MC will likely increase. Risk factors for MC include increasing age; female sex; presence of other autoimmune diseases; and possibly use of certain medications, including proton pump inhibitors, nonsteroidal anti-inflammatory drugs, selective serotonin reuptake inhibitors, and statins. The clinical presentation of MC is nonspecific and includes watery nonbloody diarrhea, nocturnal stools, fecal urgency, abdominal pain, arthralgias, and weight loss. The disease course of MC is variable; some patients experience occasional, intermittent symptoms, and others demonstrate more chronic and even progressive symptoms. The approach to treatment is similar for both lymphocytic colitis and collagenous colitis and should be guided by the severity of the patient's symptoms. Offending medications highly associated with MC should be eliminated as clinically possible. In patients with mild symptoms, antidiarrheals such as loperamide are the initial choice; for moderate-severe disease, budesonide is recommended for induction of clinical remission. In those with recurrent symptoms, low-dose budesonide may be required for maintenance therapy with close monitoring for potential adverse effects. In rare cases, immunomodulators may be required.
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Affiliation(s)
- June Tome
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Amrit K Kamboj
- 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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18
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Affiliation(s)
- Laurens Janssens
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Hyun Ji
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Sahil Khanna
- Advisor to Residents and Consultant in Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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19
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Affiliation(s)
- Bodil Ohlsson
- Department of Internal MedicineSkåne University HospitalLund UniversityMalmöSweden
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20
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Abstract
Microscopic colitis encompasses both collagenous and lymphocytic colitis and is a relatively common condition with rising incidence. Diagnosis is by colonoscopy (which is usually normal but may show some mild changes) and biopsies which reveal characteristic histological findings. Symptoms include non-bloody diarrhoea with urgency which may be associated with faecal incontinence and abdominal pain. Microscopic colitis is associated with a reduced health-related quality of life, and treatment is aimed at symptom control. Medications linked with the development of microscopic colitis, including proton pump inhibitors, non-steroidal anti-inflammatory drugs and selective serotonin-reuptake inhibitors, should be discontinued. If symptoms persist, budesonide is a licensed treatment for microscopic colitis which has been shown to be effective in clinical trials and real-world practice.
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Affiliation(s)
- Omer F Ahmad
- Department of Gastroenterology, University College Hospital, London, UK
| | - Ayesha Akbar
- Department of Gastroenterology, St Mark's Hospital, LNWH Trust, Harrow, UK
- Department of Surgery, Imperial College London, London, UK
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21
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Hughes MS, Molina GE, Chen ST, Zheng H, Deshpande V, Fadden R, Sullivan RJ, Dougan M. Budesonide treatment for microscopic colitis from immune checkpoint inhibitors. J Immunother Cancer 2019; 7:292. [PMID: 31699151 PMCID: PMC6839080 DOI: 10.1186/s40425-019-0756-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (CPIs) are effective against a variety of malignancies but can be limited by inflammatory toxicities such as enterocolitis. Enterocolitis is typically treated with systemically active glucocorticoids. Endoscopy can stratify patients by the severity of mucosal inflammation, including identifying patients with colitis in the absence of visible mucosal changes: microscopic colitis. Whether patients with CPI microscopic colitis could be managed differently from colitis with more severe mucosal involvement is unclear. The objective of this study was to describe outcomes in CPI microscopic colitis focusing on the response to first line treatment with budesonide. METHODS We evaluated data from a retrospective cohort from a single-center large academic hospital. The participants were all adult patients evaluated by endoscopy for suspected CPI enterocolitis between 3/2017 and 3/2019. The exposures were: Mayo Endoscopic Score (range 0-3). The subset was: oral budesonide, maximum dose 12 mg daily, administered minimum of 5 weeks. The main outcomes and measures were: Primary: time from first CPI exposure to first glucocorticoid use; use of systemic glucocorticoids; time from symptom onset to resolution; continuation of CPI therapy; number of additional CPI infusions received. Secondary: admissions for symptom control; novel irAE development; need for second-line immunosuppression; oncologic outcomes. RESULTS We identified 38 patients with biopsy confirmed CPI enterocolitis, 13 in the microscopic colitis cohort, and 25 in the non-microscopic colitis cohort. Budesonide use was higher in the microscopic colitis cohort (12/13 vs 3/25, p < 0.001), and systemic glucocorticoid use was higher in non-microscopic colitis (22/25 vs. 3/13, p < 0.001). Time from symptom onset to resolution did not differ. Microscopic colitis patients more frequently remained on CPI after developing (entero)colitis (76.9% vs 16.0%, p < 0.001). Microscopic colitis patients tolerating further CPI received, on average, 4.2 CPI infusions more than non-microscopic colitis patients tolerating CPI (5.8 vs 1.6, p = 0.03). Microscopic colitis was associated with increased time-to-treatment-failure (HR 0.30, 95% CI 0.14-0.66) and progression-free survival (HR 0.22, 95% CI 0.07-0.70). CONCLUSIONS Gastrointestinal mucosal inflammation without visible mucosal injury is a distinct, prevalent CPI enterocolitis subset that can be diagnosed by endoscopy. First-line budesonide appears effective in controlling "microscopic colitis" symptoms and prolonging immunotherapy duration. These findings present a compelling rationale for routine endoscopic evaluation of suspected CPI enterocolitis and suggest an alternative glucocorticoid-sparing treatment strategy for a subset of such patients.
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Affiliation(s)
- Michael S Hughes
- Harvard Medical School, Boston, MA, USA
- Present address: Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Steven T Chen
- Harvard Medical School, Boston, MA, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Vikram Deshpande
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Riley Fadden
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Ryan J Sullivan
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Dougan
- Harvard Medical School, Boston, MA, USA.
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.
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22
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Bonderup OK, Nielsen GL, Dall M, Pottegård A, Hallas J. Significant association between the use of different proton pump inhibitors and microscopic colitis: a nationwide Danish case-control study. Aliment Pharmacol Ther 2018; 48:618-625. [PMID: 30039564 DOI: 10.1111/apt.14916] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 04/30/2018] [Accepted: 07/02/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Microscopic colitis causes chronic watery diarrhoea and has previously been associated with the use of proton pump inhibitors. AIM To explore the association between proton pump inhibitor use and microscopic colitis, including its dependency on timing, dose and choice of proton pump inhibitor. METHODS Within a 10-year period, we identified 10 652 patients with a first-time diagnosis of microscopic colitis, including 6254 (59%) with collagenous colitis and 4398 (41%) with lymphocytic colitis. All microscopic colitis cases were histologically confirmed in the Danish Pathology Register. Information on proton pump inhibitor use was obtained from the Danish Prescription Register. In this case-control study, we estimated the adjusted odds ratios (aOR) for the association between proton pump inhibitor use and risk of microscopic colitis using conditional logistic regression while adjusting for potential confounders. RESULTS We found strong associations between current proton pump inhibitor use and both collagenous colitis (aOR 6.98; 95% CI: 6.45-7.55) and lymphocytic colitis (aOR 3.95; 95% CI: 3.60-4.33). This association was observed with all PPIs. The strongest association was with the current use of lansoprazole for both collagenous colitis (aOR 15.74; 95% CI: 14.12-17.55) and lymphocytic colitis (aOR 6.87; 95% CI: 6.00-7.86). When considering timing, ORs were highest for current use of proton pump inhibitor and lower for recent or past exposure. No clear dose-response pattern was observed. CONCLUSIONS We found a strong association between microscopic colitis and ongoing use of proton pump inhibitors, especially lansoprazole.
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Affiliation(s)
- Ole K Bonderup
- Diagnostic Centre, Regional Hospital Silkeborg, and University Research Clinic for Innovative Patient Pathways, Aarhus University, Aarhus, Denmark
| | - Gunnar L Nielsen
- Department of Internal Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Michael Dall
- Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense University Hospital, Odense, Denmark
- Department of Medicine, Odense University Hospital, Svendborg, Denmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense University Hospital, Odense, Denmark
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23
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Marlicz W, Skonieczna-Żydecka K, Yung DE, Loniewski I, Koulaouzidis A. Endoscopic findings and colonic perforation in microscopic colitis: A systematic review. Dig Liver Dis 2017; 49:1073-1085. [PMID: 28847471 DOI: 10.1016/j.dld.2017.07.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 07/23/2017] [Accepted: 07/25/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Microscopic colitis (MC) is a clinical syndrome of severe watery diarrhea with few or no endoscopic abnormalities. The incidence of MC is reported similar to that of other inflammatory bowel diseases. The need for histological confirmation of MC frequently guides reimbursement health policies. With the advent of high-definition (HD) coloscopes, the incidence of reporting distinct endoscopic findings in MC has risen. This has the potential to improve timely diagnosis and cost-effective MC management and diminish the workload and costs of busy modern endoscopy units. METHODS Publications on distinct endoscopic findings in MC available until March 31st, 2017 were searched systematically (electronic and manual) in PubMed database. The following search terms/descriptors were used: collagenous colitis (CC) OR lymphocytic colitis (LC) AND endoscopy, colonoscopy, findings, macroscopic, erythema, mucosa, vasculature, scars, lacerations, fractures. An additional search for MC AND perforation was made. RESULTS Eighty (n=80) articles, predominantly single case reports (n=49), were found. Overall, 1582 (1159F; 61.6±14.1 years) patients (pts) with MC and endoscopic findings were reported. The majority of articles (n=62) were on CC (pts 756; 77.5% females). We identified 16 papers comprising 779 pts (69.2% females) with LC and 7 articles describing 47 pts (72.3% females) diagnosed as MC. The youngest patient was 10 and the oldest a 97-year-old. Aside diarrhea, symptoms included abdominal pain, weight loss, bloating, flatulence, edema and others. In the study group we found 615 (38.8%) persons with macroscopic lesions in gut. Isolated linear ulcerations were identified in 7 pts (1.1%) while non-ulcerous lesions i.e. pseudomembranes, a variable degree of vasculature pruning & dwindling, mucosal lacerations and abnormalities such as erythema/edema/nodularity, or surface textural alteration in 608 pts (98.1%). The location of endoscopic findings was not reported in 27 articles. The distinct endoscopic findings were described in the left (descending, sigmoid, rectum - 10/21/11 studies), right (cecum, ascending - 7/7 studies), transverse colon (n=12), as well as duodenum (n=4), and terminal ileum (n=2). In 17 (1.1%) pts colonic perforation occurred. CONCLUSION Endoscopic findings are recognized with increased frequency in pts with MC. This could improve MC diagnosis by prompting a more extensive biopsy protocol in such cases and an earlier initiation of treatment. Procedure-related perforation has been reported in this group; therefore, cautious air insufflation is advisable when endoscopic findings are recognised.
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Affiliation(s)
- Wojciech Marlicz
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland.
| | | | - Diana E Yung
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Igor Loniewski
- Department of Biochemistry and Human Nutrition, Pomeranian Medical University, Szczecin, Poland; Sanprobi Sp. z o.o. Sp. K, Szczecin, Poland
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24
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Clara APHS, Magnago FD, Ferreira JN, Grillo TG. Microscopic colitis: A literature review. Rev Assoc Med Bras (1992) 2016; 62:895-900. [PMID: 28001266 DOI: 10.1590/1806-9282.62.09.895] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 07/06/2015] [Indexed: 12/26/2022]
Abstract
Microscopic colitis (MC) refers to chronic inflammation of the colon which is characterized by histologic changes at the level of a radiologically and endoscopically normal mucosa. It is a common cause of chronic non-bloody diarrhea that occurs primarily in older individuals; however, there are few studies in the literature with strong scientific evidence compared to other inflammatory bowel diseases (IBD), which limits the knowledge of physicians and pathologists. This article aims to review the information on MC, describing diagnostic methods and drugs available for treatment. We conducted a search of the Pubmed database and CAPES Portal using the keywords "microscopic colitis", "collagenous colitis", "lymphocytic colitis", and "review" for selection of articles published between 1996 and 2015 related to the topic. Based on the studies discussed in this review, we conclude that MC is a relatively new gastrointestinal disorder, most studies are incipient particularly with respect to pathophysiology and immunology, and budesonide is the best documented short-term treatment. However, further studies are needed to elucidate the best strategy for treatment in the long term.
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Affiliation(s)
- Ana Paula Hamer Sousa Clara
- MSc in Public Policies and Local Development from Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (Emescam). Professor of Semiology and Internal Medicine at Emescam, Vitória, ES, Brazil
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25
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Gonciarz M, Mularczyk A, Kowalik T, Kopała M. [Microscopic colitis - a frequent cause of chronic diarrhea]. Pol Merkur Lekarski 2016; 41:248-250. [PMID: 27883353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Chronic diarrhea is a very common problem in the general population. It requires a physician to differentiate its causes and depending on its etiology referring the patient to a hospital for diagnosis and subsequent treatment. One of the causes of chronic diarrhea may be microscopic colitis, which is characterized by the presence of clinical symptoms without endoscopic or radiological abnormalities. Diagnosis is based on a histopathological examination of the colon and thus clinical suspicion of the disease is so important for further diagnosis and treatment, which is primarily based on the use of topical steroids such as budesonide.
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Affiliation(s)
- Maciej Gonciarz
- Department of Gastroenterology, Main District Hospital, Sosnowiec, Poland
| | - Aldona Mularczyk
- Department of Gastroenterology, Main District Hospital, Sosnowiec, Poland
| | - Tomasz Kowalik
- Department of Gastroenterology, Main District Hospital, Sosnowiec, Poland
| | - Marek Kopała
- Corpora-Med, Medical Rehabilitation Center, Gliwice, Poland
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26
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Gonciarz M, Szkudłapski D, Eszyk J, Smagacz J, Kopała M. [Treatment of microscopic colitis - what's new?]. Pol Merkur Lekarski 2016; 41:202-204. [PMID: 27760097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Microscopic colitis (MC) is frequent, although still uncommonly diagnosed, cause of chronic diarrhea. The etiopathology of MC is unknown but this disease has strong influence on patient's quality of life (measured by health-related quality of life - HRQoL). MC is characterized by microscopic abnormalities in large bowel's mucosa whereas endoscopic and radiological examination findings are normal. The treatment of MC is an essential social and financial problem due to its frequency in society. Thanks to the results of some controlled research which judged efficiency of some medicines as well as advisory groups recommendations, the MC therapy is nowadays going from empiric to accordance with evidence based medicine.
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Affiliation(s)
- Maciej Gonciarz
- Department of Gastroenterology, Main District Hospital, Sosnowiec, Poland
| | - Dawid Szkudłapski
- Department of Gastroenterology, Main District Hospital, Sosnowiec, Poland
| | - Jerzy Eszyk
- Department of Gastroenterology, Main District Hospital, Sosnowiec, Poland
| | - Justyna Smagacz
- Department of Gastroenterology, Main District Hospital, Sosnowiec, Poland
| | - Marek Kopała
- Corpora-Med, Medical Rehabilitation Center, Gliwice, Poland
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27
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Fernández-Bañares F, Casanova MJ, Arguedas Y, Beltrán B, Busquets D, Fernández JM, Fernández-Salazar L, García-Planella E, Guagnozzi D, Lucendo AJ, Manceñido N, Marín-Jiménez I, Montoro M, Piqueras M, Robles V, Ruiz-Cerulla A, Gisbert JP. Current concepts on microscopic colitis: evidence-based statements and recommendations of the Spanish Microscopic Colitis Group. Aliment Pharmacol Ther 2016; 43:400-26. [PMID: 26597122 DOI: 10.1111/apt.13477] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/01/2015] [Accepted: 10/23/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Microscopic colitis (MC) is an underdiagnosed inflammatory bowel disease. AIM To develop an evidence-based clinical practice guide on MC current concepts. METHODS Literature search was done on the Cochrane Library, EMBASE and MEDLINE electronic databases, which were consulted covering the period up until March 2015. Work groups were selected for each of the reviewed topics, with the purpose of drafting the initial statements and recommendations. They subsequently underwent a voting process based on the Delphi method. Each statement/recommendation was accompanied by the result of the vote the level of evidence, and discussion of the corresponding evidence. The grade of recommendation (GR) using the GRADE approach was established for diagnosis and treatment recommendations. RESULTS Some key statements and recommendations are: advancing age increases the risk of developing MC, mainly in females. The symptoms of MC and IBS-D may be similar. If MC is suspected, colonoscopy taking biopsies is mandatory. Treatment with oral budesonide is recommended to induce clinical remission in patients with MC. Oral mesalazine is not recommended in patients with collagenous colitis for the induction of clinical remission. The use of anti-TNF-alpha drugs (infliximab, adalimumab) is recommended for the induction of remission in severe cases of MC that fail to respond to corticosteroids or immunomodulators, as an alternative to colectomy. CONCLUSIONS This is the first consensus paper on MC based on GRADE methodology. This initiative may help physicians involved in care of these patients in taking decisions based on evidence.
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Affiliation(s)
- F Fernández-Bañares
- Hospital Universitari Mutua Terrassa, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - M J Casanova
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | | | - B Beltrán
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- Hospital La Fe, Valencia, Spain
| | - D Busquets
- Hospital Doctor Josep Trueta, Girona, Spain
| | - J M Fernández
- Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | | | | | - A J Lucendo
- Hospital General de Tomelloso, Ciudad Real, Spain
| | - N Manceñido
- Hospital Infanta Sofía, San Sebastián de los Reyes, Spain
| | - I Marín-Jiménez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - V Robles
- Hospital Vall d'Hebron, Barcelona, Spain
| | | | - J P Gisbert
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
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28
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Abstract
Microscopic colitis is a common cause of chronic diarrhea. It is characterized by non-bloody watery diarrhea with macroscopically normal colonic mucosa. Its specific histological characteristics confirm the diagnosis. Two distinct histological forms can be identified, namely, collagenous colitis and lymphocytic colitis. In collagenous colitis, a thick colonic subepithelial collagenous deposit can be observed, whereas in lymphocytic colitis, a pronounced intraepithelial lymphocytic inflammation in the absence of a thickened collagen band can be identified. Microscopic colitis occurs more frequently in elderly females and its etiology is believed to be multifactorial, although smoking and consumption of several drugs have been identified as risks factors for the development of the disease. The treatment is based on avoiding the risks factors and administration of oral budesonide.
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Affiliation(s)
| | | | - Karel Geboes
- b 2 University Hospitals Leuven, Pathology, Leuven, Belgium
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29
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Abstract
Microscopic colitis is a chronic inflammatory bowel disease characterized by chronic nonbloody diarrhea and specific histopathology features. Active disease, defined as 3 or more stools or 1 or more watery stools per day, significantly reduces quality of life. Epidemiologic studies have found the incidence and prevalence of microscopic colitis to be comparable with those of Crohn's disease and ulcerative colitis. Nevertheless, microscopic colitis is still under-recognized in clinical practice-most health care workers know little about its etiology and pathophysiology. Furthermore, there are many challenges to the diagnosis and treatment of patients. We review the epidemiologic and clinical features of this disorder and discuss its pathogenesis. We also outline the criteria for histopathologic evaluation of microscopic colitis, recently published by the European Consensus on Inflammatory Bowel Disease, and discuss a treatment algorithm created by the European Microscopic Colitis Group. Treatment options for patients with budesonide-refractory disease are discussed.
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Affiliation(s)
- Andreas Münch
- Division of Gastroenterology and Hepatology, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköpings University, Linköping, Sweden.
| | - Cord Langner
- Institute of Pathology, Medical University of Graz, Graz, Austria
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30
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Burgmann K, Fraga M, Schoepfer AM, Yun P. [Microscopic colitis: update 2014]. Rev Med Suisse 2014; 10:1586-1590. [PMID: 25276996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Microscopic colitis, which includes lymphocytic colitis and collagenous colitis, represents a frequent cause of chronic watery diarrhea especially in the elderly population. Several medications, such as nonsteroidal antiinflammatory drugs, proton pump inhibitors or antidepressants, as well as cigarette smoking have been recognized as risk factors for microscopic colitis. The diagnosis of microscopic colitis is based on a macroscopically normal ileo-colonoscopy and several biopsies from the entire colon, which demonstrate the pathognomonic histopathologic findings. Therapy is mainly based on the use of budesonide. Other medications, such as mesalazine, cholestyramine and bismuth, have been evaluated as well but the evidence is less solid.
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31
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O'Toole A, Coss A, Holleran G, Keegan D, Doherty G, Sheahan K, Mulcahy H, O'Donoghue D. Microscopic colitis: clinical characteristics, treatment and outcomes in an Irish population. Int J Colorectal Dis 2014; 29:799-803. [PMID: 24743846 DOI: 10.1007/s00384-014-1860-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Many aspects of microscopic colitis remain poorly understood. Our aim was to report a single centre experience with this condition. METHODS Two hundred and twenty-two patients (52 male, 170 female; median age 64 years; range 32-90) diagnosed between 1993 and 2010 were studied. Medical notes were reviewed, and data on age, gender, clinical features, history of autoimmune diseases, medication use, cigarette smoking, histology and outcome were collected. RESULTS There were 99 cases of lymphocytic and 123 of collagenous colitis. Diarrhoea was almost invariably present (98 %) while abdominal pain (24 %), weight loss (10 %), faecal incontinence (8 %) and blood PR (5 %) were also described. Twenty-eight percent had concomitant autoimmune diseases, most commonly coeliac disease. Patients were taking a variety of medications at diagnosis thought to be associated with microscopic colitis including NSAIDs (22 %), aspirin (19 %), statins (15 %), proton pump inhibitors (19 %) and SSRIs (10 %) at diagnosis. Prior to the widespread use of budesonide in our institution, 33 % of patients required two or more medications during therapy compared to 15 % following the introduction of budesonide (p = 0.001). Thirty-eight percent of patients achieved spontaneous remission with either no treatment or simple anti-diarrhoeals. Using a multivariate model, the only factor associated with spontaneous remission was male gender (RR 1.9; 95 % CI 1.0-3.6; p = 0.04). Two patients had refractory microscopic colitis; one required a colectomy while a more recent case has responded to anti-TNFα therapy. CONCLUSION Microscopic colitis is predominantly a benign and self-limiting disorder. The introduction of budesonide has revolutionised treatment of this lesser studied inflammatory bowel disease.
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Affiliation(s)
- Aoibhlinn O'Toole
- Centre for Colorectal Disease, St Vincent's University Hospital/University College Dublin, Elm Park, Dublin 4, Ireland,
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Munck LK, Wildt S, Engell PJH, Bonderup OK. [Microscopic colitis is a common cause of chronic diarrhoea]. Ugeskr Laeger 2014; 176:V10130601. [PMID: 25350302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Microscopic colitis (MC) is a common cause of chronic, non-bloody diarrhoea in the elderly population. In Denmark the incidence has been rising for the last decades. Sufficient biopsy material from colon mucosa is essential for the diagnosis. Treatment is important to improve the patient's quality of life, which is significantly impaired in active MC. This paper reviews newly published data regarding epidemiology, diagnostic criteria and a new European treatment guideline and also includes updates on ongoing and future studies in MC.
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Miehlke S, Aust D, Madisch A. [Microscopic colitis--new insights relevant to clinical practice]. Z Gastroenterol 2013; 51:1389-1394. [PMID: 24146102 DOI: 10.1055/s-0033-1355518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Microscopic colitis is an increasingly recognised chronic inflammatory bowel disease associated with watery, non-bloody diarrhoea. In addition, many patients suffer from abdominal pain, nocturnal diarrhoea, urgency and incontinence. The two traditional histological subtypes are collagenous colitis and lymphocytic colitis. A novel third subgroup is the so-called incomplete microscopic colitis which is clinically indistinguishable. At present, budesonide is the only evidenced-based effective therapy, however many problems in the long-term treatment strategy are still unsolved. The present paper reviews new developments in microscopic colitis which are relevant for clinical practice.
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Affiliation(s)
- S Miehlke
- Facharztzentrum Eppendorf, Magen-Darm-Zentrum, Hamburg
| | - D Aust
- Universitätsklinikum, Institut für Pathologie, Dresden
| | - A Madisch
- Klinikum Siloah, Medizinische Klinik I, Hannover
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Roth B, Bengtsson M, Ohlsson B. Diarrhoea is not the only symptom that needs to be treated in patients with microscopic colitis. Eur J Intern Med 2013; 24:573-8. [PMID: 23561634 DOI: 10.1016/j.ejim.2013.02.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 01/21/2013] [Accepted: 02/11/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Many patients with microscopic colitis (MC) also suffer from symptoms of irritable bowel syndrome (IBS), but the only treatment given is corticosteroids for the diarrhoea. The aim of this study was to examine how social factors, life style factors and drug treatment affect symptoms and well-being in patients suffering from MC. METHODS Women, over the age of 73years, with biopsy-verified MC, at any Departments of Gastroenterology, Skåne, between 2002 and 2010 were invited. The questionnaires Gastrointestinal Symptom Rating Scale (GSRS) and Psychological General Well-being Index (PGWB) were sent by mail, along with questions about social and life style factors, and medical history. RESULTS Of 240 invited, 158 patients (66%) were included (median age 63years, range 27-73years). Only 26% had never smoked. Smoking and concomitant IBS were associated with both impaired gastrointestinal symptoms (OR=3.96, 95% CI=1.47-10.66 and OR=4.40, 95% CI=2.09-9.26, respectively) and impaired psychological well-being (OR=2.77, 95% CI=1.04-7.34 and OR=3.82, 95% CI=1.83-7.99, respectively). Treatment with proton pump inhibitors (PPI) was associated with increased gastrointestinal symptoms (OR=3.44, 95% CI=1.45-8.16). Age, social factors, and corticosteroids had no effect on symptoms or well-being. Smoking was the only risk factor associated with IBS (OR=2.68, 95% CI=1.115-6.26). CONCLUSION Smoking and IBS are associated with impaired gastrointestinal symptoms and psychological well-being in MC patients. PPI is associated with impaired gastrointestinal symptoms.
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Affiliation(s)
- Bodil Roth
- Department of Clinical Sciences, Division of Gastroenterology, Skåne University Hospital, Malmö, Lund University, Lund, Sweden
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Thörn M, Sjöberg D, Ekbom A, Holmström T, Larsson M, Nielsen AL, Holmquist L, Thelander U, Wanders A, Rönnblom A. Microscopic colitis in Uppsala health region, a population-based prospective study 2005-2009. Scand J Gastroenterol 2013; 48:825-30. [PMID: 23721118 DOI: 10.3109/00365521.2013.800993] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study is to report on the incidence of microscopic colitis (MC), any possible relation with inflammatory bowel disease (IBD), concomitant drug consumption, related diseases and the clinical course of the diseases. METHODS Both new cases of IBD and MC were registered at the same time in the same geographical area. The study started in the county of Uppsala 2005-2006, and other parts of the surrounding health region were included 2007-2009. Established morphological criteria were used, i.e. a layer of subepithelial collagen band ≥ 10 μm in collagenous colitis (CC) with concomitant inflammation and at least 20 lymphocytes per 100 epithelial cells in lymphocytic colitis (LC). RESULTS The authors found 272 new cases of MC, 154 with CC and 118 with LC. The mean age-adjusted incidence was 7.0/1,000,000 for CC and 4.8/100,000 for LC. The clinical course was dominated by single episodes with diarrhea or intermittent symptoms, but 14% suffered from chronic diarrhea. In 10% of the cases, diagnosis was made in individuals without chronic watery diarrhea. Although not systematically tested, concomitant celiac disease was found in approximately 5% of the patients. CONCLUSIONS The incidence of MC in Uppsala health region is similar to other studied areas. The majority of patients had a self-limiting or easily treated condition, but 14% need a more or less continuous medication. Ten percent of the patients demonstrate other symptoms than chronic watery diarrhea. The possibility of concomitant celiac disease should be considered in new cases of MC.
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Affiliation(s)
- Mari Thörn
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
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Umeno J, Esaki M, Nuki Y, Kim H, Kitazono T, Matsumoto T. Letter: lansoprazole consumption is more common in Japanese patients with collagenous colitis. Aliment Pharmacol Ther 2013; 38:208-9. [PMID: 23772906 DOI: 10.1111/apt.12356] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 05/09/2013] [Indexed: 12/08/2022]
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Keszthelyi D, Masclee AA. Letter: lansoprazole consumption is more common in Japanese patients with collagenous colitis--authors' reply. Aliment Pharmacol Ther 2013; 38:209-10. [PMID: 23772907 DOI: 10.1111/apt.12364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 05/14/2013] [Indexed: 12/08/2022]
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Abstract
The treatment of microscopic colitis is mainly based on the use of budesonide, the only drug found effective in controlled clinical trials. After an initial course at a dose of 9 mg daily, however, most patients relapse when the drug is discontinued, hence a maintenance therapy at doses of 6 mg daily or lower is necessary. In order to avoid steroid dependence and drug toxicity different pharmacological agents should be considered as an alternative to indefinite long-term budesonide treatment. Evidence-based guidelines are currently lacking due to the lack of conclusive data concerning the use of either immunosuppressive or anti-tumor necrosis factor agents. For the time being in clinical practice the skilled physician should therefore tailor long term management of microscopic colitis on the single patient.
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Lukáš K, Mandys V. [Microscopic colitis]. Cas Lek Cesk 2013; 152:59-66. [PMID: 23641677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Microscopic colitis is characterized by chronic or intermittent watery diarrhoea. Microscopic colitis is a common cause of chronic diarrhoea in predominantly older adults. The underlying mechanism in the pathogenesis of microscopic colitis remains unspecified. Microscopic colitis including colitis collagenous, lymphocytic, microscopic colitis with incomplete findings, minimal change colitis, eosinophilic colitis, Brainerd´s diarrhoea, graft-versus-host disease, mastocytic enterocolitis and postinfectious irritable bowel syndrome. Careful consideration of the clinical features and colonic mucosal biopsies usually lead to correct diagnosis. Treatments of microscopic colitis were based primarily on case reports and personal experience. Many medications have been proposed that either offer symptomatic relief (loperamide, cholestyramine) or had anti-inflammatory or immunosuppressive properties (aminosalicylates, steroids, adalimumab, azathioprine).
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MESH Headings
- Adalimumab
- Adrenal Cortex Hormones/therapeutic use
- Anti-Inflammatory Agents/therapeutic use
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antidiarrheals/therapeutic use
- Azathioprine/therapeutic use
- Cholestyramine Resin/therapeutic use
- Colitis/complications
- Colitis/diagnosis
- Colitis/drug therapy
- Colitis, Collagenous/complications
- Colitis, Collagenous/diagnosis
- Colitis, Collagenous/drug therapy
- Colitis, Lymphocytic/complications
- Colitis, Lymphocytic/diagnosis
- Colitis, Lymphocytic/drug therapy
- Colitis, Microscopic/complications
- Colitis, Microscopic/diagnosis
- Colitis, Microscopic/drug therapy
- Diarrhea/drug therapy
- Diarrhea/etiology
- Eosinophilia/complications
- Eosinophilia/diagnosis
- Eosinophilia/drug therapy
- Humans
- Immunosuppressive Agents/therapeutic use
- Loperamide/therapeutic use
- Mastocytosis/complications
- Mastocytosis/diagnosis
- Mastocytosis/drug therapy
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40
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Stoicescu A, Andrei M, Becheanu G, Stoicescu M, Nicolaie T, Diculescu M. Microscopic colitis and small intestinal bacterial overgrowth--diagnosis behind the irritable bowel syndrome? Rev Med Chir Soc Med Nat Iasi 2012; 116:766-772. [PMID: 23272525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
UNLABELLED Some patients previously diagnosed with irritable bowel syndrome (IBS) may develop microscopic colitis or small intestinal bacterial overgrowth (SIBO). AIM To estimate the prevalence of microscopic colitis and SIBO in patients with IBS, to evaluate the symptoms and the efficacy of treatment. MATERIAL AND METHODS We examined patients with IBS admitted in our clinic during a three-year period. We identified patients with microscopic colitis by performing total colonoscopy with multiple biopsies from normal intestinal mucosa and those with SIBO by performing a H2-breath test with glucose. We compared the symptoms and the effectiveness of the treatment. RESULTS Out of the 132 patients initially diagnosed with IBS 3% (n=4) had microscopic colitis and 43.9% (n=58) had SIBO. Diarrhea was the main symptom in patients with microscopic colitis and SIBO (p=0.041), while abdominal pain, abdominal bloating and flatulence were prominent in IBS patients (p=0.042; p=0.039; p=0.048). Specific treatment with rifaximin in SIBO patients negativated H2-breath test in 70.9% cases. CONCLUSIONS Patients suspected to have irritable bowel syndrome should be evaluated for microscopic colitis and SIBO. The proper diagnosis and the specific treatment may cure some difficult cases of the so called "irritable bowel syndrome".
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Rasmussen MA, Munck LK. Systematic review: are lymphocytic colitis and collagenous colitis two subtypes of the same disease - microscopic colitis? Aliment Pharmacol Ther 2012; 36:79-90. [PMID: 22670660 DOI: 10.1111/j.1365-2036.2012.05166.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 04/25/2012] [Accepted: 05/14/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite similar clinical symptoms, collagenous colitis (CC) and lymphocytic colitis (LC) are considered two distinct disease entities. AIM To compare pathoanatomical findings, clinical presentations, risk factors, course of diseases and response to treatment in CC and LC to establish whether they could be subtypes of the same disease, microscopic colitis (MC). METHODS The MEDLINE was searched for CC, LC and MC, and clinical studies of >20 patients were included. Pooled results with 95% confidence intervals were calculated based on the number of patients. RESULTS An abnormal number of intraepithelial lymphocytes are found in 45% (40-50%) with CC, and an abnormal subepithelial collagen band in 16% (13-20%) with LC suggesting a histological overlap. The incidence of CC and LC has increased in parallel. Mean age (CC 63 years; LC 60 years) and clinical presentation are indistinguishable, and females are predominant in CC (77%; 75-79%) as well as LC (68%; 66-70%). Risk factors such as nonsteroid anti-inflammatory drugs consumption CC 39% (36-42%); LC 32% (29-35%) are similar and prevalence of concomitant autoimmune diseases such as coeliac disease (CC 5%; CI: 4-6% and LC 7%; CI: 6-9%) do not differ. Bile acid diarrhoea is highly prevalent in CC (41%; 37-45%) and LC (29%; 24-34%). The effect of budesonide is identical. CONCLUSIONS CC and LC could be considered histological subtypes of the same disease, MC. To facilitate recruitment to clinical trials, all MC patients could be included in future trials and stratified for subtypes.
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MESH Headings
- Anti-Inflammatory Agents/therapeutic use
- Budesonide/therapeutic use
- Colitis, Collagenous/classification
- Colitis, Collagenous/drug therapy
- Colitis, Collagenous/pathology
- Colitis, Lymphocytic/classification
- Colitis, Lymphocytic/drug therapy
- Colitis, Lymphocytic/pathology
- Colitis, Microscopic/classification
- Colitis, Microscopic/drug therapy
- Colitis, Microscopic/pathology
- Diagnosis, Differential
- Humans
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Affiliation(s)
- M A Rasmussen
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Matuchansky C. Microscopic colitis and disease associations. Aliment Pharmacol Ther 2011; 34:819-20; author reply 820-1. [PMID: 21896042 DOI: 10.1111/j.1365-2036.2011.04762.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Stewart MJ, Seow CH, Storr MA. Prednisolone and budesonide for short- and long-term treatment of microscopic colitis: systematic review and meta-analysis. Clin Gastroenterol Hepatol 2011; 9:881-90. [PMID: 21699817 DOI: 10.1016/j.cgh.2011.06.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 05/18/2011] [Accepted: 06/04/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The incidence of microscopic colitis and its disease burden are increasing, yet there is limited systematic information addressing the use of conventional corticosteroids and budesonide in microscopic colitis. We performed a systematic review and meta-analysis on the short- and long-term efficacy of corticosteroids in treatment of microscopic colitis. METHODS Randomized controlled trials that met predetermined selection criteria were included. Articles were identified through MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, proceedings of major gastroenterology meetings, and reference lists of trials and review articles. RESULTS Eight randomized trials were identified. A total of 248 patients were randomized to corticosteroid versus placebo. The intervention was budesonide in 7 trials and prednisolone in 1 trial. Budesonide was significantly more effective than placebo for short-term clinical response (risk ratio [RR], 3.07; 95% confidence interval [CI], 2.06-4.57) and long-term clinical response (RR, 3.22; 95% CI, 1.05-9.89). Prednisolone was not superior to placebo for short-term clinical response (RR, 2.00; 95% CI, 0.38-10.58). Histologic improvement was seen with both short- and long-term budesonide (RR, 3.76; 95% CI, 2.00-7.06, and RR, 2.50; 95% CI, 1.25-4.98, respectively). Symptom relapse occurred in 46%-80% of patients within 6 months of treatment cessation. Withdrawal because of adverse effects occurred in 4.4% of patients, with no difference between study groups (P = .55). CONCLUSIONS Both short- and long-term treatment with budesonide is effective and well-tolerated for microscopic colitis. However, the rate of symptom relapse once budesonide is discontinued is high. Further studies are needed to determine optimal treatment duration, dose, and withdrawal procedure.
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Affiliation(s)
- Michael J Stewart
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Abstract
BACKGROUND Microscopic colitis is a relatively common cause of chronic diarrhoea in predominantly older adults, traditionally termed lymphocytic colitis and collagenous colitis. Increased mast cells found in the colonic biopsies of some patients with chronic diarrhoea may represent a distinct type of microscopic colitis. AIM To provide an updated review of the epidemiology, diagnosis and treatment of microscopic colitis, and to discuss the role of mast cells in the gastrointestinal tract and their potential role in cases of functional diarrhoea. METHOD A MEDLINE literature search was performed to identify pertinent articles. Relevant clinical abstracts were also reviewed. RESULTS Incidence rates of microscopic colitis (lymphocytic and collagenous colitis) have increased over time, to levels comparable with other forms of inflammatory bowel disease. The possibility of drug-induced microscopic colitis and concomitant coeliac sprue are important considerations when evaluating these patients. There are few controlled treatment trials in microscopic colitis, with much of the data on treatment coming from retrospective studies. Mast cells have been implicated in functional bowel disorders, with increased mast cells possibly contributing to cases of otherwise unexplained chronic diarrhoea, although this concept requires further investigation. CONCLUSIONS In patients with microscopic colitis, a systematic approach to therapy often leads to satisfactory control of symptoms. The role of mast cells in chronic diarrhoea represents an evolving field, with the potential to offer alternative treatment pathways in patients with otherwise unexplained functional diarrhoea.
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Affiliation(s)
- E F Yen
- Division of Gastroenterology, University of Chicago, Pritzker School of Medicine, NorthShore University HealthSystem, Evanston, IL, USA.
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Mahtani KR, Rose PW, van Someren N. Microscopic colitis in primary care. BMJ 2010; 340:b5520. [PMID: 20053827 DOI: 10.1136/bmj.b5520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Kamal R Mahtani
- Department of Primary Health Care, University of Oxford, Oxford OX3 7LF.
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Datta I, Brar SS, Andrews CN, Dupre M, Ball CG, Buie WD, Beck PL. Microscopic colitis: a review for the surgical endoscopist. Can J Surg 2009; 52:E167-E172. [PMID: 19865548 PMCID: PMC2769103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2008] [Indexed: 05/28/2023] Open
Abstract
Microscopic colitis (MC) is an inflammatory condition of the colon distinct from Crohn disease or ulcerative colitis that can cause chronic diarrhea as well as cramping and bloating. Although it was first described 30 years ago, awareness of this entity as a cause of diarrhea has only become more widespread recently. Up to 20% of adults with chronic diarrhea who have an endoscopically normal colonoscopy may have MC. Endoscopic and radiological examinations are usually normal, but histology reveals increased lymphocytes in the colonic mucosa, which typically cause watery nonbloody diarrhea. Treatment is initially supportive but can include corticosteroids and immunomodulatory therapy for resistant cases. Since surgeons perform a large number of colonoscopies and sigmoidoscopies to assess diarrhea, it is important to be aware of this disease and to look for it with mucosal biopsy in appropriate patients.
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Affiliation(s)
| | | | | | - Marc Dupre
- Department of Pathology, University of Calgary, Calgary, Alta., and the
| | - Chad G. Ball
- Department of Surgery, Grady Memorial Hospital, Atlanta, Ga
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Tysk C, Bohr J, Nyhlin N, Wickbom A, Eriksson S. Diagnosis and management of microscopic colitis. World J Gastroenterol 2008; 14:7280-8. [PMID: 19109861 PMCID: PMC2778111 DOI: 10.3748/wjg.14.7280] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Revised: 12/03/2008] [Accepted: 12/10/2008] [Indexed: 02/06/2023] Open
Abstract
Microscopic colitis, comprising collagenous and lymphocytic colitis, is characterized clinically by chronic watery diarrhea, and a macroscopically normal colonic mucosa where diagnostic histopathological features are seen on microscopic examination. The annual incidence of each disorder is 4-6/100,000 inhabitants, with a peak incidence in 60-70-year-old individuals and a noticeable female predominance for collagenous colitis. The etiology is unknown. Chronic diarrhea, abdominal pain, weight loss, fatigue and fecal incontinence are common symptoms, which impair the health-related quality of life of the patient. There is an association with other autoimmune disorders such as celiac disease, diabetes mellitus, thyroid disorders and arthritis. Budesonide is the best-documented short-term treatment, but the optimal long-term strategy needs further study. The long-term prognosis is good and the risk of complications including colonic cancer is low.
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48
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Madisch A. [Diagnostics and therapy of chronic diarrhea in elderly people]. MMW Fortschr Med 2008; 150:28-32. [PMID: 19130728 DOI: 10.1007/bf03365674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- A Madisch
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Dresden.
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49
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Marín-Jiménez I, Yepes Barreto I. [Locally acting corticosteroids in microscopic colitis: are they the treatment of choice? How should they be used?]. Gastroenterol Hepatol 2008; 31 Suppl 3:22-26. [PMID: 19087860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Ignacio Marín-Jiménez
- Sección de Gastroenterología, Servicio de Medicina del Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Madrid, España.
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50
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Abstract
Microscopic colitis--including collagenous colitis and lymphocytic colitis--causes chronic watery diarrhea, usually in middle-aged or elderly patients. There is an association with celiac disease and certain medications. Medical treatment includes various antidiarrheal agents, mesalamine, corticosteroids and immunosuppressant drugs. Rarely, patients require surgery for refractory disease. An evidence-based and practical approach to treatment should optimize the treatment response while minimizing potential adverse events.
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Affiliation(s)
- Nilesh Chande
- Division of Gastroenterology, The University of Western Ontario, London Health Sciences Centre-South Street Hospital, London, Ontario.
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