Gastroenterology

Gastroenterology

Volume 140, Issue 4, April 2011, Pages 1155-1165
Gastroenterology

Reviews in Basic and Clinical Gastroenterology and Hepatology
Microscopic Colitis

https://doi.org/10.1053/j.gastro.2011.02.003Get rights and content

Microscopic colitis is a common cause of chronic watery diarrhea, especially among older persons. Diagnosis requires histologic analysis of colon biopsy samples in the appropriate clinical setting. Recent studies have shown an increase in the incidence of microscopic colitis, and several have addressed potential mechanisms. We review recent findings about the clinical features, diagnosis, epidemiology, pathophysiology, and treatment of microscopic colitis.

Section snippets

Epidemiology

Population-based studies have found the incidence of microscopic colitis to vary between 1 and 12 per 100,000 persons per year.6, 15, 16, 20, 21, 22 In Europe, the incidence of collagenous colitis has been reported to vary from 1.1 to 5.2 per 100,000 persons per year and the incidence of lymphocytic colitis from 3.1 to 4.0 per 100,000 persons per year.6, 15, 16, 20 In North America, the reported incidence of collagenous colitis (3.1 and 4.6 per 100,000 per year) and of lymphocytic colitis (5.4

Mechanism of Diarrhea

A variety of mechanisms have been proposed to cause diarrhea in patients with microscopic colitis. The severity of diarrhea appears to be related to the intensity of the inflammatory response, as opposed to the thickness of the subepithelial collagen band, indicating that the diarrhea is predominantly inflammatory in origin.8, 39, 40, 41

Several studies have reported that patients with microscopic colitis have impaired electrolyte absorption or increased secretion.40, 42 Studies of epithelial

Pathogenesis

The etiology of microscopic colitis is unknown, but leading models of pathogenesis include autoimmunity, an immune or inflammatory response to luminal factors, and, for collagenous colitis, myofibroblast dysfunction.45 However, information on pathophysiology is taken from small, sometimes conflicting, studies and there is no single clear mechanism of disease.

Clinical Features

Microscopic colitis is characterized by chronic or intermittent watery diarrhea, ranging from mild and self-limited to severe, with dehydration and other metabolic abnormalities. Many patients also have abdominal pain or weight loss. The weight loss is typically mild but can be significant in some cases.26, 48 Quality of life is affected in proportion to the degree of diarrhea, abdominal pain, urgency, and incontinence.13, 97, 98 It is important to recognize that the symptoms of microscopic

Diagnosis

Endoscopic evaluation reveals that the colon is typically normal or has mild nonspecific changes such as erythema or edema. Colon ulceration is uncommon, and when it occurs it is likely to be caused by NSAIDs.118 Fecal leukocytes can be present,48 but steatorrhea, fever, or hematochezia indicate an alternate diagnosis should be made.

The hallmark histologic feature of microscopic colitis is intraepithelial lymphocytosis.2, 37 In addition, the disease is characterized by mixed infiltrate in the

Treatment

In treating patients with microscopic colitis, it is important that they first discontinue use of drugs that might have caused the disorder or other agents that might exacerbate diarrhea (eg, dairy products) if possible (Figure 6). Nonspecific antidiarrheal drugs such as loperamide or diphenoxylate/atropine can be effective15, 26, 48 and are often first prescribed for mild cases (Figure 6). If these agents are unsuccessful, or for patients with moderate symptoms, bismuth subsalicylate, at a

Summary

Microscopic colitis is a relatively common cause of chronic diarrhea, especially among the elderly, and the incidence is increasing. Biopsies of the colon are required to diagnose this disorder and should be performed for any patient undergoing sigmoidoscopy or colonoscopy to evaluate unexplained diarrhea. The 2 subtypes of microscopic colitis, collagenous and lymphocytic colitis, are similar histologically and clinically and seem to respond similarly to various medical therapies. Although

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    Conflicts of interest The authors disclose no conflicts.

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