MICROSCOPIC COLITIS Michael Libes, MD Senior Physician, Carmel Medical Center, Haifa
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
MICROSCOPIC COLITIS TWO MAIN TYPES LYMPHOCYTIC O Seen microscopically COLLAGENOUS O First described in 1976 as subepithelial lymphocytic O Thickened sub infiltrates and no epithelial bank of collagen 7 - 100 widening of the micrometers thick normal collagen band. (normal is 1 -7 micro meters)
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
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
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, Anti. Thyroid Peroxidase
MICROSCOPIC COLITIS Generally speaking: Stool studies O Inflammatory markers may be increased: Eosinophil Protein X Myeloperoxidase Tryptase Calprotectin
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
MICROSCOPIC COLITIS O May be associated with small bowel disease as well: O Celiac disease O HLA-DR 3 -DQ 2 more frequent in microscopic colitis (predisposes to celiac disease)
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
MICROSCOPIC COLITIS Clinical Manifestations and Natural History Collagenous colitis vs Lymphocytic colitis
COLLAGENOUS COLITIS drugs reported as possible etiology: Simvastatin Lansoprazole Omeprazole Esomeprazole Ticlopidine
COLLAGENOUS COLITISO Typical presentation is female in their 6 th 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%
COLLAGENOUS COLITIS O O O Variable Associated Symptoms Nausea Vague abdominal pain Fecal urgency Associated Symptoms Weight loss – 42% Abdominal pain – 41% Fatigue – 24%
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
LYMPHOCYTIC COLITIS Reported Drug Associations Ticlopidine Flutamide Gold Salts Lansoprazole Omeprazole Esomeprazole Sertraline
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
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
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
MICROSCOPIC COLITIS OTHERAPIES 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
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
MICROSCOPIC COLITIS SUMMARY O Chronic, non bloody diarrhea in middle-aged 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,
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