Microscopic colitis

1. MICROSCOPIC COLITIS

Michael Libes, MD
Senior Physician, Carmel Medical Center,
Haifa

2. MICROSCOPIC COLITIS

O Clinical Definition: chronic, non bloody, watery
diarrhea
O Occurrence: Middle aged adult
O Clinical findings: Normal colonic mucosa on
endoscopy or with barium study
O Diagnosis made pathologically by biopsy appearance:
inflammation but not ulceration

3. MICROSCOPIC COLITIS TWO MAIN TYPES

LYMPHOCYTIC
O Seen microscopically
as subepithelial
lymphocytic
infiltrates and no
widening of the
normal collagen
band.
COLLAGENOUS
O First described in
1976
O Thickened sub
epithelial bank of
collagen 7- 100
micrometers thick
(normal is 1-7 micro
meters)

4. MICROSCOPIC COLITIS

EPIDEMIOLOGY
O Largest U.S. based study from 1985 - 2001:
O Incidence is increased with age
O Collagenous colitis much more prevalent in
women
O Overall prevalence: 103/100,000 persons

5. MICROSCOPIC COLITIS

EPIDEMIOLOGY
Barcelona, Spain
O Both diseases are more common in women
O Mean age at onset:
O Collagenous 53 years
O Lymphocytic 64 years
Other studies performed in Sweden and Iceland
have demonstrated an even higher incidence

6. MICROSCOPIC COLITIS

Generally speaking:
O Laboratory findings are nonspecific
O Mild anemia, slightly increased ESR in 1/3
of patients
O Various antibodies may be found in 50% of
patients – RF, ANA, AMA, ANCA, ASCA, AntiThyroid Peroxidase

7. MICROSCOPIC COLITIS

Generally speaking:
Stool studies
O Inflammatory markers may be increased:
Eosinophil Protein X
Myeloperoxidase
Tryptase
Calprotectin

8. MICROSCOPIC COLITIS

HOW DO WE DIAGNOSIS???
O Based on biopsy and histology
O Severity changes most pronounced in right
and transverse colon
O Biopsies from the rectosigmoid could miss
40% of cases

9. MICROSCOPIC COLITIS

O May be associated with small bowel disease
as well:
O Celiac disease
O HLA-DR3-DQ2 more frequent in microscopic
colitis (predisposes to celiac disease)

10. MICROSCOPIC COLITIS

O May be a systemic disease that is
concomitant with autoimmune disorders
more common in collagenous (53%) vs.
lymphocytic (26%) colitis
O Non-erosive arthritis, thyroiditis

11. MICROSCOPIC COLITIS

Clinical Manifestations and Natural
History
Collagenous colitis
vs
Lymphocytic colitis

12. COLLAGENOUS COLITIS

drugs reported as possible etiology:
Simvastatin
Lansoprazole
Omeprazole
Esomeprazole
Ticlopidine

13. COLLAGENOUS COLITIS-

COLLAGENOUS COLITISO Typical presentation is female in their 6th decade;
BUT has been reported in children
O Onset: Insidious in 58%, sudden 42%
O Stool Frequency:
4-9 bowel movements/day in 66%
More than 10/day in 22%
Nocturnal stooling 27%

14. COLLAGENOUS COLITIS

O
O
O
O
O
O
Variable Associated Symptoms
Nausea
Vague abdominal pain
Fecal urgency
Associated Symptoms
Weight loss – 42%
Abdominal pain – 41%
Fatigue – 24%

15. COLLAGENOUS COLITIS

Course:
O Chronic intermittent- 85%
O Chronic continuous- 13%
O Single episode- 2%
Long term effects:
O General health and lab studies are unaffected
O After 10 yearsresolution of diarrhea in 50% pts with antiinflammatory treatments
persistent symptoms in about 1/3 pts

16. LYMPHOCYTIC COLITIS

Reported Drug Associations
Ticlopidine
Flutamide
Gold Salts
Lansoprazole
Omeprazole
Esomeprazole
Sertraline

17. LYMPHOCYTIC COLITIS CLINICAL COURSE

Long term prognosis: may be more favorable than
Collagenous Colitis
After 38 months in a study with 27 patients:
Diarrhea resolved in 93%
Histology normalized in 82%
No progression to collagenous colitis

18. MICROSCOPIC COLITIS TREATMENT

Budosenide
O Only drug to have proven efficacy (a matter
of degree?)
O Few studies available with limited number of
patients
O Probably efficacious at least for short-term

19. MICROSCOPIC COLITIS OTHER TREATMENTS

O Aminosalicylates/ Sulfasalazine
O Cholestyramine
O Glucocorticoids (?Lower response rate than
budesonide?)
O Bismuth subsalicylate: One small study reported
with substantial benefits

20. MICROSCOPIC COLITIS OTHER THERAPIES

O Can try gluten-free diet in “refractory” cases (BUT not
necessarily celiac disease)
O Metronidazole, octreotide, MTX, 6-MP, Verapamil,
Anti-TNFs, Probiotics – some reports, but not enough
data to recommend

21. MICROSCOPIC COLITIS

O Natural history
O Again few studies available
O Roughly, 70% improve/resolve, 25-30%
relapse or refractory
O No identified increased risk of colorectal
cancer

22. MICROSCOPIC COLITIS SUMMARY

O Chronic, non bloody diarrhea in middle-aged
O
O
O
O
adults
Diagnosis established by biopsy
Low morbidity, no mortality, but can be very
frustrating for patients!
Treatments effective in many, and natural
history is favorable in most
Underlying cause(s) remain undetermined,