Coexistencia de colitis linfocítica y enteritis microscópica en pacientes con diarrea crónica / Concurrent lymphocytic colitis and microscopic enteritis in patients with chronic diarrhea

Introducción: Colitis linfocítica y enteritis microscópica son causas relativamente comunes de diarrea crónica y ambas se caracterizan por un infiltrado linfocitico intraepitelial. No existen reportes previos de la coexistencia de ambas entidades. Objetivo: Describir las características clínicas e histológicas de los pacientes que presentan este diagnóstico simultáneamente. Material y métodos: Se seleccionaron pacientes adultos con diarrea crónica que tuvieran biopsia simultánea de colon y duodeno tomados el mismo día, durante los años 2010-2016, en el Servicio de Gastroenterología del Hospital Nacional Daniel Alcides Carrión. Se recopiló información clínica del archivo de historias. Las láminas fueron reevaluadas histológicamente por 3 patólogos. Se realizó estudio inmunohistoquímico de linfocitos intraepiteliales para CD8 y CD3 en 6 casos. Resultados: De 63 pacientes con diarrea crónica y biopsia simultánea de duodeno y colon, se identificó un total de 35 pacientes (55,5%) con diagnóstico simultáneo de enteritis microscópica y colitis linfocítica, 80% fueron mujeres. Se identificó anemia en 28,5% de los pacientes e infestación por Blastocystis hominis en el 31,8.%. En enteritis microscópica, el promedio de linfocitos intraepiteliales con CD8 y CD3 fue 40%, mientras que, en colitis linfocítica, el promedio fue de 37,2% para CD3 y 29,2% para CD8. En 11 de los 35 casos, se pudo obtener biopsias de íleon que fueron diagnosticadas como ileitis linfocítica. En 9 casos se diagnosticó colitis eosinofílica asociada a colitis linfocítica. Conclusión: Se encontró coexistencia de colitis linfocítica, enteritis microscópica y en algunos de ileitis linfocítica en un 55,5% pacientes con diarrea crónica con biopsia duodenal y colónica. Estos resultados abren la interrogante sobre si colitis linfocítica y enteritis microscópica son entidades diferentes o constituyen una sola patología que en algunos pacientes afecta varios segmentos del tubo digestivo.

Introduction: Lymphocytic colitis and microscopic enteritis are relatively common causes of chronic diarrhea and it is characterized by an intraepithelial lymphocytic infiltrate. There have been no previous reports of coexistence between these 2 pathologies. Objective: To describe histological and clinical characteristic in patients with coexistence of lymphocytic colitis and microscopic enteritis. Material and methods: All cases with simultaneous diagnosis of lymphocytic duodenosis and lymphocytic colitis were reevaluated during lapse time 2010-2016 in hospital Daniel Carrion. The slides were reviewed by 3 pathologists and clinical information was obtained from clinical records. Expression of CD3 and CD8 was detected in 6 cases by immunohistochemical assays. Results: A total of 35 patients with coexistence of lymphocytic duodenitis and lymphocytic colitis were selected of the pathology archives, 80% were females, Anemia was identified in 28.5% of patients. Blastocysitis hominis infestation was identified in 31.8%. The mean intraepithelial lymphocyte CD8 and CD3 positive was 40% in microscopic enteritis, while the mean intraepithelial lymphocyte CD3 positive was 37.2% and CD8 positive was 29.2% Additionally, lymphocytic ileitis was diagnosed in 11 of our cases. Eosinophilic colitis was diagnosed in 9 cases of lymphocytic colitis Conclusion: We found that lymphocytic colitis, microscopic enteritis and even lymphocytic ileitis can coexist in a group of patients with chronic diarrhea. These findings bring the question if this concurrence of both pathologies constituted a more generalized gastrointestinal disorder, involving both the large and the small intestines.

Microscopic colitis: A literature review / Colite microscópica: uma revisão da literatura

SUMMARY 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.

RESUMO Colite microscópica (CM) corresponde à inflamação crônica do cólon que se manifesta por modificações histológicas em nível de uma mucosa radiológica e endoscopicamente normal. É uma causa comum de diarreia crônica não sanguinolenta que ocorre principalmente em indivíduos idosos; porém, há poucos trabalhos na literatura com forte evidência científica quando comparada à de outras doenças inflamatórias intestinais (DII), o que limita seu conhecimento por médicos e patologistas. Este artigo tem como objetivo revisar as informações referentes à CM descrevendo os meios diagnósticos e os medicamentos disponíveis para o tratamento. Foi realizada uma pesquisa na base de dados Pubmed e no Portal da CAPES entre 1996 e 2015 utilizando as palavras-chave “colite microscópica”, “colite colagenosa”, “colite linfocítica” e “revisão” para seleção de artigos relacionados ao tema. Diante dos trabalhos analisados, conclui-se que a CM é uma desordem gastrointestinal relativamente nova, a maioria dos estudos são incipientes, principalmente quanto à imunologia e fisiopatologia, e a budesonida é o tratamento em curto prazo mais bem documentado. Todavia são necessários novos estudos para elucidar qual é a melhor estratégia em longo prazo.

Colitis microscópica: Patogénesis / Microscopic colitis: Pathogenesis

Introducción: Colitis microscópica (CM) es el proceso inflamatorio crónico observado en biopsias del colon de pacientes con diarrea crónica acuosa. Se denomina microscópica porque el diagnóstico es histológico ya que las características microscópicas de la endoscopía del colon son normales. Incluye 2 patrones: Colitis microscópica Linfocítica y la Colítis microscópica Colagenosa. La causa es desconocida y los mecanismos patógenos propuestos señalan un fenómeno inmunológico; de acuerdo a este concepto los autores del presente estudio suponemos que la infiltración linfocítica en la lámina propia podrían corresponder a linfocitos citotóxicos CD8 como ejecutores del daño tisular colónico. Objetivos: Probar la hipótesis de la patogénesis inmunológica de la CM. Material y Método: 38 pacientes con diagnóstico de CM reclutados durante los 4 últimos años en el laboratorio de patología Clínica Ricardo Palma. Se seleccionaron 22 biopsias de colon con lesiones histológicas más severas, correspondientes a 17 pacientes, 5 de ellos tuvieron 2 biopsias en 2 sesiones colonoscópicas, las biopsias fueron fijadas en formol neutro. Y procesadas por el método de inclusión en parafina, tenidas con hematoxilina y eosina y tricrómica de Masson para tejido colágeno. La inmunohistoquímica se hizo en secciones histológicas de 4 y 5 micras de espesor precesadas por el método de la Inmunopereoxidasa. Resultados: 19 biopsias correspondieron a CM Linfocítica y 3 a CM Colagenosa. El CM Linfocítica mostró linfocitosis intraepitelial, daño epitelial distrófico en las áreas de infiltración linfocítica, inflamación de la lámina propia con linfocitos y célula plasmática, membrana basal normal. La CM Colagenosa mostró membrana basal engrosada por la presencia de una banda colágena, linfocitos Intra epiteal leve a moderado vacuolización y frecuente desprendimiento del epitelio cobertor. Los estudios de Inmunohistoquímica fueron positivos en las 22 biopsias estudiadas.

Introduction: Microscopic colitis (MC) is a chronic inflammatory process observed in colon biopsies of patients with chronic aqueous diarrhea. It is called microscopic because diagnosis is determined by histological studies since the microscopic characteristics of the colon endoscopy are normal. Two patterns exist: Lymphocytic Microscopic Colitis and Collagenous Microscopic Colitis. Etiology is unknown, and the proposed pathogenic mechanisms indicate an immunological phenomenon. Based on this, the authors of this study hypothesize that lymphocytic infiltration of the lamina propria could be related to cytotoxic lymphocytes CD8 as causative agents of colon tissue damage. OBJECTIVES: Prove hypothesis of immunological pathogenesis of MC. Apparatus and Methods: Thirty eight (38) patients with diagnosed MC were recruited for the last four years in the Pathology Laboratory at Ricardo Palma University. Twenty two (22) colon biopsies with the most severe histological lesions were selected. Thesebiopsies were obtained from 17 patients: 5 patients had 2 biopsies in 2 colonoscopy sessions. Biopsies were fixed in neutral formaldehyde, processed through the paraffin inclusion method, and stained with hematoxiline-eosine and Masson trichromic to distinguish collagenous tissue. Immunohistochemistry was conducted in 4- or 5-micron-thick histological sectionsprocessed through the immunoperoxidase method. RESULTS: Nineteen (19) biopsies corresponded to Lymphocytic MC and 3 to Collagenous MC. Lymphocytic MC showed intraepithelial lymphocytosis, dystrophic epithelial damage in the areas of lymphocytic infiltration, lamina propria inflammation with lymphocytesand plasma cells, and normal basement membrane. Collagenous MC showed thickened basement membrane due to the presence of a collagenous band, mild to moderate intraepithelial lymphocytosis, vacuolization, and frequent detachment of protective epithelium. Twenty two (22) biopsies were positive in the immunohistochemical...