Diagnóstico y manejo de la colitis microscópica / Diagnosis and management of microscopic colitis

Microscopic colitis (MC) is a clinical condition characterized by chronic watery diarrhea, normal colonic mucosa and characteristic histological findings. It is composed of two main entities: collagenous colitis (CC) and lymphocytic colitis (LC). Its incidence has been increasing, currently accounting for between 8 to 16% of studies for chronic diarrhea. It is more frequent in elderly women and is strongly associated with other autoimmune disorders. Its pathogenesis is not very well understood, but it supposes the immune activation secondary to the exposure of the colonic mucosa to different luminal antigens, mainly drugs. Management includes suspension of the potential causative agent and the use of anti-diarrheal medications. Oral budesonide has proven to be effective in induction and maintenance of remission, but with a high rate of recurrence upon discontinuation. Immune-modulators drugs such as azatioprine and metrotrexate have been tested in patients dependent to corticoids with variable results. Antibodies against tumor necrosis factors (TNF) are under studies, with promising results.

La colitis microscópica (CM) es una condición clínica caracterizada por diarrea crónica acuosa con mucosa colónica normal y hallazgos histológicos característicos. Está compuesta por dos entidades principales: la colitis colágena (CC) y la colitis linfocítica (CL). Su incidencia ha ido en aumento, siendo en la actualidad la responsable del 8 a 16% de los casos por diarrea crónica. Es más frecuente en mujeres de edad avanzada con una fuerte asociación a otras enfermedades autoinmunes. Su etiopatogenia no es del todo conocida, pero se cree juega un rol la activación inmune secundaria a la exposición de la mucosa colónica a diferentes antígenos luminales, principalmente fármacos. Dentro del manejo se incluye la suspensión del potencial agente causal y el uso de fármacos antidiarreicos. La budesonida oral ha demostrado alta efectividad en la inducción y mantención de la remisión, pero con una alta tasa de recurrencia al suspenderla. Fármacos inmunomoduladores como azatioprina y metrotrexato se han probado en pacientes corticodependendientes con resultados variables. El uso de anticuerpos monoclonales anti factor de necrosis tumoral (TNF) se encuentra en estudio, con resultados prometedores.

Hiperplasia neuroendocrina en colitis linfocitica y colitis ulcerativa / Neuroendocrine hiperplasia in linfocitic and ulcerative colitis

Introducción: Algunos autores han demostrado incremento de células neuroendócrinas en colitis microscópica y colitis ulcerativa. Objetivo: El objetivo del presente estudio fue evaluar la presencia de células neuroendócrinas en colitis linfocítica, colitis colagenosa y colitis ulcerativa en comparación a controles. Materiales y métodos: Se usó inmunohistoquímica para identificar a las células neuroendócrinas a través del marcador cromogranina A. El estudio incluyó 10 casos de cada diagnóstico de colitis linfocítica, colitis colagenosa y colitis ulcerativa. Resultados: Se encontró diferencia estadísticamente significativa en el conteo de células neuroendocrinas en colitis linfocítica (p=0,019104) y colitis ulcerativa en comparación con los controles (p=0,0077). En colitis colagenosa, se encontró un incremento de células neuroendocrinas pero no pudimos demostrar diferencias estadísticamente significativa. Conclusión: Se demostró hiperplasia de células neuroendocrinas en colitis linfocítica y colitis ulcerativa, lo que confirma lo reportado por los pocos estudios anteriores realizados sobre el tema.

Introduction: Some authors have found increase of neuroendocrine cells in microscopic colitis and ulcerative colitis. Objective: The aim of this study is to evaluate the presence of neuroendocrine cells in ulcerative colitis and lymphocytic colitis and collagenous colitis. Materials and methods: Immunohistochemistry was performed to identify neuroendocrine cells through marker chromogranin A (CgA). The study included 10 cases of each diagnosis of Lymphocytic colitis, collagenous colitis and ulcerative colitis. Results: There was statistically significant difference in the count of neuroendocrine cells, between lymphocytic colitis and control (p=0.019104), and between ulcerative colitis and controls (p=0.0077). In collagenous colitis there was an increase in neuroendocrine cells but we failed to find statistical differences. Conclusion: We could observe neuroendocrine cell hyperplasia in lymphocytic colitis and ulcerative colitis compared with controls, which confirm previous studies.

Prevalence, Pathogenesis, Diagnosis, and Management of Microscopic Colitis

Microscopic colitis (MC), which is comprised of lymphocytic colitis and collagenous colitis, is a clinicopathological diagnosis that is commonly encountered in clinical practice during the evaluation and management of chronic diarrhea. With an incidence approaching the incidence of inflammatory bowel disease, physician awareness is necessary, as diagnostic delays result in a poor quality of life and increased health care costs. The physician faces multiple challenges in the diagnosis and management of MC, as these patients frequently relapse after successful treatment. This review article outlines the risk factors associated with MC, the clinical presentation, diagnosis and histologic findings, as well as a proposed treatment algorithm. Prospective studies are required to better understand the natural history and to develop validated histologic endpoints that may be used as end points in future clinical trials and serve to guide patient management.

"Cat Scratch Colon" in a Patient with Ischemic Colitis

"Cat scratch colon" is a gross finding characterized by hemorrhagic mucosal scratches on colonoscopy. It is usually associated with a normal colon and is rarely associated with collagenous colitis. In a previous report, cat scratch colon was noted in the cecum and ascending colon, but has also been observed in the distal transverse colon. The patient in this study was also diagnosed with ischemic colitis that may have played a role in the development of cat scratch colon.

Pharmacologic Agents for Chronic Diarrhea

Chronic diarrhea is usually associated with a number of non-infectious causes. When definitive treatment is unavailable, symptomatic drug therapy is indicated. Pharmacologic agents for chronic diarrhea include loperamide, 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists, diosmectite, cholestyramine, probiotics, antispasmodics, rifaximin, and anti-inflammatory agents. Loperamide, a synthetic opiate agonist, decreases peristaltic activity and inhibits secretion, resulting in the reduction of fluid and electrolyte loss and an increase in stool consistency. Cholestyramine is a bile acid sequestrant that is generally considered as the first-line treatment for bile acid diarrhea. 5-HT3 receptor antagonists have significant benefits in patients with irritable bowel syndrome (IBS) with diarrhea. Ramosetron improves stool consistency as well as global IBS symptoms. Probiotics may have a role in the prevention of antibiotic-associated diarrhea. However, data on the role of probiotics in the treatment of chronic diarrhea are lacking. Diosmectite, an absorbent, can be used for the treatment of chronic functional diarrhea, radiation-induced diarrhea, and chemotherapy-induced diarrhea. Antispasmodics including alverine citrate, mebeverine, otilonium bromide, and pinaverium bromide are used for relieving diarrheal symptoms and abdominal pain. Rifaximin can be effective for chronic diarrhea associated with IBS and small intestinal bacterial overgrowth. Budesonide is effective in both lymphocytic colitis and collagenous colitis. The efficacy of mesalazine in microscopic colitis is weak or remains uncertain. Considering their mechanisms of action, these agents should be prescribed properly.

Microscopic Colitis / 대한내과학회지

Microscopic colitis (MC) is a chronic idiopathic inflammatory bowel disease presenting with chronic watery diarrhea. Epidemiologic studies from Western countries have demonstrated that it is almost as common as other classic inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis. Histological examination can confirm the diagnosis and differentiate between the two main subtypes of MC: collagenous colitis and lymphocytic colitis. The pathophysiology of MC remains unknown; however, possible etiologies include genetic predispositions, autoimmunity, inflammatory responses to luminal factors such as certain drugs or bacteria, and myofibroblast dysregulations. The aim of MC therapy should take into account the severity of symptoms, impact on quality of life, and evidence from clinical trials of available medical treatments.

Is Microscopic Colitis Really Microscopic?

No abstract available.

Is Microscopic Colitis Really Microscopic?

No abstract available.

Does Lymphocytic Colitis Always Present with Normal Endoscopic Findings?

BACKGROUND/AIMS: Although normal endoscopic findings are, as a rule, part of the diagnosis of microscopic colitis, several cases of macroscopic lesions (MLs) have been reported in collagenous colitis, but hardly in lymphocytic colitis (LC). The aim of this study was to investigate the endoscopic, clinical, and histopathologic features of LC with MLs. METHODS: A total of 14 patients with LC who were diagnosed between 2005 and 2010 were enrolled in the study. Endoscopic, clinical, and histopathologic findings were compared retrospectively according to the presence or absence of MLs. RESULTS: MLs were observed in seven of the 14 LC cases. Six of the MLs exhibited hypervascularity, three exhibited exudative bleeding and one exhibited edema. The patients with MLs had more severe diarrhea and were taking aspirin or proton pump inhibitors. More intraepithelial lymphocytes were observed during histologic examination in the patients with MLs compared to the patients without MLs, although this difference was not significant. The numbers of mononuclear cells and neutrophils in the lamina propria were independent of the presence or absence of MLs. CONCLUSIONS: LC does not always present with normal endoscopic findings. Hypervascularity and exudative bleeding are frequent endoscopic findings in patients with MLs.

Does Lymphocytic Colitis Always Present with Normal Endoscopic Findings?

BACKGROUND/AIMS: Although normal endoscopic findings are, as a rule, part of the diagnosis of microscopic colitis, several cases of macroscopic lesions (MLs) have been reported in collagenous colitis, but hardly in lymphocytic colitis (LC). The aim of this study was to investigate the endoscopic, clinical, and histopathologic features of LC with MLs. METHODS: A total of 14 patients with LC who were diagnosed between 2005 and 2010 were enrolled in the study. Endoscopic, clinical, and histopathologic findings were compared retrospectively according to the presence or absence of MLs. RESULTS: MLs were observed in seven of the 14 LC cases. Six of the MLs exhibited hypervascularity, three exhibited exudative bleeding and one exhibited edema. The patients with MLs had more severe diarrhea and were taking aspirin or proton pump inhibitors. More intraepithelial lymphocytes were observed during histologic examination in the patients with MLs compared to the patients without MLs, although this difference was not significant. The numbers of mononuclear cells and neutrophils in the lamina propria were independent of the presence or absence of MLs. CONCLUSIONS: LC does not always present with normal endoscopic findings. Hypervascularity and exudative bleeding are frequent endoscopic findings in patients with MLs.

Diagnóstico histopatológico de colitis microscópica: enfoque práctico / A practical approach to histopathologic diagnosis of microscopic colitis

La colitis linfocítica y la colitis colagenosa son las dos formas histológicas de la colitis microscópica (CM), condición médica reconocida hace más de 30 años, habitual en pacientes adultos con diarrea crónica acuosa, sin cambios endoscópicos en la mucosa del colon y cuyo diagnóstico se establece exclusivamente en el examenhistopatológico de las biopsias de colon. El objetivo de la presente revisión es familiarizar a los médicos patólogos quirúrgicos en práctica general con la morfología de la colitis linfocítica y la colitis colagenosa, así como con la importancia de los informes de patología y la de una buena comunicación con el médico endoscopista para el correcto diagnóstico de estas entidades, y brindar a estos pacientes el tratamiento adecuado.

Lymphocytic colitis and collagenous colitis are two histologic forms of microscopic colitis, a condition whichwas first recognized over 30 years ago. It is often found in adults with chronic, watery diarrhea although endoscopic examination of the colon is frequently normal. The diagnosis is based on microscopic examination of colonic biopsies. The aim of this review is to familiarize general surgical pathologists with the morphologic features of lymphocytic and collagenous colitis. In additional, this review emphasizes good communication with the endoscopist to allow correct recognition and ensure appropriate treatment.

Two Cases of Pediatric Collagenous Gastritis Each Presenting with Refractory Iron Deficiency Anemia and Chronic Diarrhea / 대한소아소화기영양학회지

Collagenous gastritis (CG) is a rare disorder that is characterized by the presence of a thick subepithelial collagen band with multiple infiltrated inflammatory cells of the gastric mucosa. CG is divided into two major subsets: first, in children and young adults presenting with severe anemia and abdominal colic pain (pediatric-type CG); and second, in adult patients with chronic watery diarrhea associated with collagenous colitis (adult-type CG). We report two cases of pediatric-type CG, each presenting with refractory anemia and chronic diarrhea.

Clinical Characteristics of Microscopic Colitis in Korea: Prospective Multicenter Study by KASID

BACKGROUND/AIMS: Microscopic colitis (MC) encompasses collagenous and lymphocytic colitis and is characterized by chronic diarrhea. In cases of MC, colonic mucosae are macroscopically normal, and diagnostic histopathological features are observed only upon microscopic examination. We designed a prospective multicenter study to determine the clinical features, pathological distribution in the colon and prevalence of MC in Korea. METHODS: We prospectively enrolled patients having watery diarrhea no more than 3 times a day between March 2008 and February 2009. We obtained patient histories and performed colonoscopies with random biopsies at each colon segment. RESULTS: A total of 100 patients with chronic diarrhea were enrolled for a normal colonoscopy and stool exam. MC was observed in 22 patients (22%) (M:F 1.2:1; mean age, 47.5 years). Of those 22 patients, 18 had lymphocytic colitis and 4 had collagenous colitis. The entire colon was affected in only 3 cases (13.6%), the ascending colon in 6 cases (27.2%), the transverse colon in 3 cases (13.6%), and the left colon in 3 cases (13.6%). More than 2 segments were affected in 7 cases (31.8%). Nonsteroidal anti-inflammatory drug-associated MCs were observed in 4 cases (18.2%), 3 of which showed improved diarrhea symptoms following discontinuation of the medication. Frequently associated symptoms were abdominal pain and weight loss. Autoimmune diseases were observed in 4 cases (18.2%). Half of the 22 patients with MC improved with conservative care by loperamide or probiotics. CONCLUSIONS: In a prospective multicenter study of Korean patients with chronic diarrhea, the frequency of MC was found to be approximately 20%, similar to the percentage observed in Western countries. Therefore, the identification of MC is important for the adequate management of Korean patients with chronic diarrhea.

Gastritis colágena: presentación de un caso clínico y revisión de la literatura / Collagenous gastritis: presentation of a clinical case and review of the literature

Collagenous gastritis (CG) is an exceptional disease characterized by the deposition of subepithelial collagen band thicker than 10 tm in association with increased inflammatory cell infiltrate of the lamina propria. These histological features seem to overlap with other "collagenous enterocolitides". The pathogenesis and prognosis of CG still remains unclear. CG presentation is seen completely different in two major subsets of patients, children and adults. We report a 38 year-old man with abdominal pain and chronic diarrhea. The upper endoscopy showed a severe gastritis with biopsies that revealed CG, and the colonoscopy was normal with biopsies indicative of collagenous colitis. This characteristic form of clinical presentation in adult patients suggests that subepithelial collagen deposition may be a generalized disease affecting different areas of the gastrointestinal tract. The patient was treated with proton-pump-inhibitors and budesonide, with clinical improvement.

La gastritis colágena (GC) es una enfermedad poco frecuente caracterizada por el depósito subepitelial de colágeno de grosor mayor de 10 um asociado a infiltrado inflamatorio en la lámina propia. Estos hallazgos histológicos son similares a los encontrados en la enterocolitis colágena. La patogénesis y pronóstico de la GC permanece aún desconocida. La presentación clínica de la GC se observa de manera diferente en dos subgrupos de pacientes, niños y adultos. Se presenta el caso de un hombre de 38 años con dolor abdominal y diarrea crónica. La endoscopia digestiva alta mostró una gastritis severa con biopsias que revelaron la presencia de GC y la colonoscopia fue normal con biopsias que mostraron una colitis colágena. Esta forma de presentación clínica en el paciente adulto sugiere que el depósito de colágena subepitelial corresponde a una enfermedad generalizada que puede afectar a diferentes áreas del tracto gastrointestinal. El paciente fue tratado con inhibidores de la bomba de protones y budesonida con mejoría clínica.

Use of budesonide in the treatment of microscopic colitis

Collagenous colitis and lymphocytic colitis, the two types of microscopic colitis, cause watery diarrhea. Budesonide, a glucocorticoid medication with limited systemic availability, is commonly used to treat these illnesses. Budesonide has proven efficacy in the induction of clinical remission in both collagenous colitis and lymphocytic colitis. Budesonide is effective as a maintenance drug for patients with collagenous colitis, but has not been studied for this indication in patients with lymphocytic colitis. This drug improves quality of life in patients while causing few mild adverse events. Budesonide is an effective treatment of microscopic colitis that is safe and well tolerated

Microscopic Colitis: The Pathologic Features of 24 Korean Patients

BACKGROUND: The clinical presentation of microscopic colitis (MC) consists of chronic non-bloody watery diarrhea for weeks or months at a time, abdominal pain, and changes in bowel habits with a normal mucosal appearance upon performing colonoscopy. MC includes two relatively well established histopathologic entities: collagenous colitis (CC) and lymphocytic colitis (LC) as well as atypical forms. The recognition of the microscopic findings of this heterogeneous entity is very important for making the correct diagnosis and providing proper treatment. METHODS: We studied the colonoscopic biopsy specimens that were obtained from 26 patients who had clinical findings that were suggestive of MC. RESULTS: Fifteen patients (M:F=9:6) and 9 patients (M:F=5:4) showed the microscopic features of LC and MC, not otherwise specified, respectively. CONCLUSIONS: The clinicopathologic findings (the incidence of the subtypes, the patients' ages and the male/female ratio) of the 24 cases of MC in this study showed differences from the previously reported findings from other countries. Further studies with a sufficient number of patients from multi-centers would be necessary to confirm the regional or ethnic influence.

Microscopic colitis in a single center study: clinical feature & characteristics / 대한내과학회지

BACKGROUND/AIMS: Collagenous colitis (CC) and lymphocytic colitis (LC) are characterized by chronic diarrhea and normal radiologic and endoscopic findings. These are currently not uncommon entities whose incidence in increasing as more clinicians take biopsies from macroscopically normal colons. The purpose of this study was to examine the clinical features and characteristics in microscopic colitis. METHODS: From January 2003 to December 2006, medical records were reviewed from 80 patients with chronic diarrhea, who had normal colonoscopic findings but underwent biopsy. Patients with microscopic colitis were identified by reviewing the pathology databases and by reviewing biopsies. RESULTS: Microscopic colitis was diagnosed in 12 patients (15%). Six patients with CC (Male:Female=2:4, mean age 54+/-20.1 years) and 6 patients with LC (Male:Female=5:1, mean age 51.2+/-21.4 years) were identified. Autoimmune disease was diagnosed in 4 patients (33%). Drug-induced disease was suspected in 3 patients (25%). The inciting drugs were NSAIDs, ticlopidine, ranitidine, and acarbose. Complete or partial resolution of diarrhea was achieved in all patients, including spontaneous resolution in 2 patients. Antidiarrheal drugs, mesalazine, and cholestylamine were highly effective in both diseases. Recurrence of symptoms occurred in 2 patients (17%). They are taking medicine at present. CONCLUSIONS: Microscopic colitis is a relatively common cause of chronic diarrhea that appears to be increasing in incidence. We reported clinical features, characteristics, treatment, and response of microscopic colitis in our experience.

A case of collagenous colitis presented with chronic diarrhea and hypokalemia / 대한내과학회지

Collagenous colitis is recognized as one of the causes of chronic diarrhea accompanied with autoimmune diseases. It is a disease associated with chronic watery diarrhea and typical histologic findings of a thick subepithelial collagenous deposit on biopsy. We experienced a 75-year-old man patient with chronic watery diarrhea and mild abdominal pain for 7 years. Physical examination, laboratory and radiologic studies were unremarkable except hypokalemia. Colonoscopy disclosed mucosal atrophy, loss of submucosal vessel and altered vascularity of terminal ileum, ascending colon. Colonoscopic biopsy revealed homogenous hyaline layered collagen deposition beneath the surface epithelium and Masson's trichrome stain showed collagen deposition. We report the case of collagenous colitis with a review of literature.

[Prevalence of the microscopic colitis to the course of the chronic diarrhea: about 150 cases]

The goal of our survey is to value the microscopic colitis frequency at 150 patients, colliged on a period of 6 years [1997-2003], that have a chronic diarrhea with a normal total coloscopy and that benefitted of systematic biopsies. The microscopic colitis has been recovered at 44 patients on 150 either 29,3%. 16 of our patients [37%] are put on Salazopyrine, they answered well to the treatment with a receding of 3 years. The microscopic colitis is a pathology whose frequency seems under valued, it is certainly benign but can give a frequent diarrhea requiring a curative treatment