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PubMed2001

Celiac disease is highly prevalent in lymphocytic colitis.

A high frequency of celiac disease is reported in patients with collagenous colitis. Limited information is available on the frequency of celiac disease in lymphocytic colitis. The aim of our study was to determine the prevalence of celiac disease in microscopic colitis (collagenous and lymphocytic colitis). Patients were identified from a pathology registry of microscopic colitis from 1987 to 1999. Pathology reports and medical records were reviewed for previous small bowel biopsies and/or celiac serology. We identified 113 patients with microscopic colitis, and 46 patients underwent a small bowel biopsy and/or celiac serology. Of these, 27 patients had lymphocytic colitis (63% female; age, 58.6 +/- 16.2 years) and 19 patients had collagenous colitis (79% female; age, 61.8 +/- 13.6 years). Small bowel biopsy alone was performed in 28 of 46 patients, celiac serology alone was performed in 10, and both small bowel biopsy and celiac serology were performed in 8. Celiac disease was identified in 4 patients by small bowel histology; all had lymphocytic colitis (4 of 27 patients, 15%). This frequency of celiac disease is significantly higher than the highest reported U.S. prevalence of celiac disease (4/1,000 individuals; p < 0.01). There is a high frequency of celiac disease in patients with lymphocytic colitis. Given the importance of the early detection of celiac disease, it should be excluded in all patients with lymphocytic colitis, particularly if diarrhea does not respond to conventional treatment.

Celiac Disease↗
PubMed2004

Clinical characteristics of collagenous and lymphocytic colitis.

BACKGROUND: Microscopic colitides (MC), collagenous colitis (CC) and lymphocytic colitis (LC) share clinical features, but their mutual relationship is unclear, and clinical comparative studies are rare. We aimed to examine the clinical features in CC and LC by focusing on concomitant diseases. METHODS: Patients with MC (30 with CC, 54 with LC) were identified in the pathology databases and by reviewing biopsies. Controls included 84 age- and sex-matched persons. The clinical data collected from patient records were prospectively completed by interviews. RESULTS: The female:male ratio was 2:1 in CC and 5.75:1 in LC. Mean age at diagnosis was 53 in CC and 55.4 years in LC. There were no differences in the pattern of symptoms. Concomitant autoimmune diseases were more common in CC (53.3%) than in LC (25.9%; P = 0.017). Celiac disease was common in both CC (20%) and LC (14.8%). Bronchial asthma was associated with LC (25.9%), but not with CC (6.7%; P = 0.042). Colon diverticulosis was rare in MC (16%) compared with the controls (39%; P = 0.001). Hypolactasia was common in MC (45%; 76% in CC, 54% in LC) compared to its prevalence in the Finnish general population (17%). CONCLUSIONS: CC and LC are largely similar clinically, but the differences in the occurrence of autoimmune conditions and bronchial asthma suggest that they differ in immunopathogenesis. MC is associated with reduced lactose tolerance and shows a negative association with diverticular disease, possibly related to the small intestinal pathology and abnormal stool consistency.

Age Distribution↗
PubMed1995

Microscopic colitis syndrome.

The colorectal biopsy specimens from 30 patients with chronic watery diarrhoea but normal endoscopic and radiographic findings were studied by light microscopy, morphometry, immunohistochemistry, and two patients with electron microscopy. The histological changes in the colorectum were originally diagnosed in six patients as lymphocytic colitis and in 24 patients as collagenous colitis. The analysis of the specimens for this study could delineate three distinct groups of microscopic colitis: lymphocytic colitis (six patients), collagenous colitis without lymphocytic attack on the surface epithelium (seven patients), and a mixed form presenting with both thickening of the collagen plate and increased number of intraepithelial lymphocytes (17 patients). No transformation was seen from one type to another during follow up of six patients for four to seven years. Increased numbers of active pericryptal myofibroblasts were found with the electron microscope in one patient with mixed microscopic colitis showing also myofibroblasts entrapped within the collagen layer. Hitherto undescribed flat mucosa of the ileum was found in one patient with lymphocytic colitis and both flat mucosa and thickening of the collagen plate in the ileum were seen in one patient with the mixed form of the disease. In another patient with mixed microscopic colitis, normalisation of the colorectal morphology occurred after temporary loop ileostomy, followed by the reappearance of both diarrhoea, inflammation, and thickening of the collagen plate after the ileostomy was reversed. No association was found between non-steroid anti-inflammatory drug (NSAID) consumption and collagenous or mixed microscopic colitis. The primary cause of microscopic colitis is probably an immunological reaction to luminal antigen/s, perhaps of ileal origin. The engagement of the pericryptal myofibroblasts in the disease process might result in the development of the various forms of microscopic colitis. An inverse relation between intraepithelial lymphocyte count and collagen thickness may indicate that microscopic colitis is a spectral disease.

Adult↗
PubMedDate not supplied

Microscopic colitis: a missed diagnosis?

CONTEXT: Collagenous colitis and lymphocytic colitis, collectively designated microscopic colitis, have until recently been considered as rare gastrointestinal disorders. New data suggest, however, that these disorders are relatively common, and to reach the correct diagnosis both the gastroenterologist and the pathologist must be aware of these diagnoses when evaluating patients with persistent watery non-bloody diarrhoea. STARTING POINT: In an epidemiological study of a well-defined Swedish population, Martin Olesen and colleagues show that microscopic colitis needs to be considered as a common gastrointestinal disorder (Gut 2004; 53: 346-50). In colonic biopsy specimens from 1018 patients who had a colonoscopy because of non-bloody diarrhoea in 1993-98, 97 patients (9.5%) were found to have microscopic colitis. In about a third of these cases, the diagnosis was missed in the primary histological evaluation. Median age at diagnosis was 64 years for collagenous colitis and 59 years for lymphocytic colitis. The annual incidence of the diseases was higher than previously considered and matched the incidence of Crohn's disease, and in combination they approached the incidence of ulcerative colitis. WHERE NEXT: The high regional incidence of microscopic colitis means that both clinicians and pathologists need to be more aware of the diagnosis, especially in the elderly female population with a clinical picture of watery non-bloody diarrhoea. Because of the potentially disabling symptoms, clinicians need to develop and evaluate new therapies.

Colitis, Microscopic↗
PubMed1992

Collagenous enterocolitis: a manifestation of gluten-sensitive enteropathy.

We report coexistent collagenous colitis and collagenous sprue in a 62-year-old woman with diarrhea. Investigations suggested malabsorption, and small intestinal biopsies demonstrated a flattened mucosa with subepithelial collagen deposition. Colonic biopsies also showed a thickened subepithelial collagen band as well as a striking lamina propria inflammatory cell infiltrate. Symptomatic remission was induced with a gluten/lactose-free diet, oral prednisone, and sulfasalazine and has been maintained with gluten restriction alone. Repeat biopsies after 2 months demonstrated restoration of normal small intestinal and colonic collagen bands; only a chronic inflammatory cell infiltrate (consistent with microscopic/lymphocytic colitis) persisted in colonic biopsies. We propose that, in this instance, collagenous enterocolitis represented a diffuse manifestation of gluten sensitivity.

Celiac Disease↗
PubMedDate not supplied

Role of bile acids in lymphocytic colitis.

BACKGROUND/AIMS: A high prevalence of bile acid malabsorption and a high response rate to bile acid binders are seen in collagenous colitis. Our aim was to explore if bile acids play a role in lymphocytic colitis, which is unknown. METHODOLOGY: Patients with lymphocytic colitis completed a diagnostic program, including the 75SeHCAT (75Se-labelled homocholic acid-taurine) test and registration of symptoms. Prevalence of bile acid malabsorption, response to bile acid binders, correlation between 75SeHCAT and histopathology were determined. The 75SeHCAT values were compared with 29 controls. RESULTS: Two out of 23 with lymphocytic colitis had a 75SeHCAT retention < or = 10%. The median 75SeHCAT value in lymphocytic colitis, 24% (range: 1.7-53), was lower than in the control group, 38% (range: 8-91) (P < 0.02). Forty-six per cent (6/13) responded to bile acid binders. No correlation was found between the 75SeHCAT values and degree of colonic inflammation. Two patients developed collagenous colitis. CONCLUSIONS: Bile acid malabsorption is more uncommon in lymphocytic colitis than in collagenous colitis. The 75SeHCAT values, however, suggest a role of bile acids in lymphocytic colitis. The conversion of 2 patients to collagenous colitis and disturbed absorption of bile acids also in lymphocytic colitis is consistent with the idea that the two forms represent variants of the same disease.

Adult↗
PubMedDate not supplied

Subepithelial collagen thickening in the colon: report on a series of 23 patients.

BACKGROUND: To investigate the prevalence of collagenous colitis in patients presenting with diarrhoea. METHODS: Descriptive retrospective study in consecutive patients under study because of chronic diarrhoea. RESULTS: In a 4.5-year period 23 consecutive patients had histological signs of thickening of the subepithelial collagen band in the colon. There was a female predominance: 19 women versus 4 men, mean age 60 years (range 33-83). The stool frequency was 1-13 stools daily. Indicanuria was present in 9 patients. The patients were divided into 3 groups: those with definite collagenous colitis (n = 11; thickness of the collagen band of more than 10 micrometer); those with indefinite collagenous colitis (n = 8; thickness between 3 and 10 micrometer), and those with a collagen band between 1 and 3 micrometer (n = 4). During a mean follow-up of 20 months (range 13-36), 7 patients had waxing and waning episodes of diarrhoea, 11 showed spontaneous waning of complaints and a lower stool frequency. The 9 patients with indicanuria did well after a course of tetracyclin 250 mg t.i.d., but all cases relapsed during follow-up. CONCLUSION: It is concluded that thickening of the collagen band and collagenous colitis are not as unusual as usually thought.

Adult↗
PubMedDate not supplied

Chronic colitis in baboons: similarities with chronic colitis in humans.

In recent years, a substantial number of baboons died at the Southwest Foundation for Biomedical Research following protracted intractable diarrheas. The histopathologic diagnosis at autopsy was chronic colitis. The diarrhea could last for more than one year and occurred in infants, juveniles or young adult baboons, i.e. < or = 8 years of age (a healthy baboon may live up to 27 years). The aim was to assess the histopathologic subtype of chronic colitis in a relatively large number of colonic specimens obtained at autopsy (n = 132). In 88 out of 132 baboons with chronic diarrhea, the colonic mucosa was well preserved for histological examination. At review, various histological phenotypes of chronic colitis were disclosed in 86 of the 88 baboons. Chronic lymphocytic-plasmacytic colitis was found in 54.6% (47 out of 86), chronic ulcerative colitis in 15.1% (13 out of 86), Crohn's colitis in 12.8% (11 out of 86), superficial lymphocytic colitis in 10.5% (9 out of 86), cryptal lymphocytic colitis in 5.8% (5 out of 86) and collagenous colitis in 1.2% (1 out of 86). Chronic ulcerative colitis, Crohn's colitis, superficial lymphocytic colitis and collagenous colitis in baboons closely mimic corresponding histological phenotypes of chronic colitis in humans. Recently, cryptal lymphocytic colitis has also been found in humans. The awareness that chronic colitis in baboons is not one disease but a series oi chronic inflammatory changes, having common clinical symptoms and similar gross appearance, may lead to the correct diagnosis of the subtype of the disease. Only then would it be feasible to systematically initiate the search for the corresponding etiologic agent(s), aiming to tailor specific therapeutic strategies in those animals.

Animals↗
PubMedDate not supplied

Prevalence of microscopic colitis in patients with symptoms suggesting irritable bowel syndrome.

GOALS/BACKGROUND: Irritable bowel syndrome is a common disorder affecting 20% of the general population. It shows certain characteristics with organic bowel diseases. Definition of lymphocytic and collagenous colitis has created a new approach towards chronic idiopathic diarrheas. We searched for the frequency of lymphocytic and collagenous colitis in patients with irritable bowel syndrome. STUDY: The study group consisted of 30 irritable bowel patients and 20 controls. Multiple biopsies from cecum; ascendant, transverse and descendent colon; sigmoid and rectum were taken sequentially in all patients. RESULTS: We diagnosed 7 out of 30 irritable bowel patients as having lymphocytic colitis (23.3%) but none as having collagenous colitis. In the control group 1 out of 20 patients had lymphocytic colitis (5%) and none had collagenous colitis. Irritable bowel patients had higher rate of lymphocytic colitis association (p < 0.05). CONCLUSIONS: Functional disorders of the bowel should be searched for possible lymphocytic colitis, especially in cases refractory to classical therapies.

Adult↗
PubMedDate not supplied

Perinuclear antineutrophil cytoplasmic antibodies in collagenous or lymphocytic colitis with or without celiac disease.

Microscopic forms of colitis, including lymphocytic and collagenous colitis, have been observed in both those with and without celiac disease. Although perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) occur in most patients with ulcerative colitis, investigations in microscopic, particularly lymphocytic, colitis are still needed. In this study atypical p-ANCA was evaluated in 55 patients, including 27 with celiac disease alone, 13 with celiac disease and concomitant lymphocytic colitis, and 15 with microscopic forms of colitis, including lymphocytic and collagenous colitis. Nine patients (16.3%) had atypical p-ANCA, including six with celiac disease and three with a microscopic form of colitis alone. Although five of the six positive celiac disease patients had lymphocytic colitis, all three celiac disease patients with associated primary sclerosing cholangitis--a separate risk factor for a positive assay result--were serologically positive for atypical p-ANCA. These results indicate for the first time that this serological marker may occur in histologically defined celiac disease with or without concomitant lymphocytic colitis. Furthermore, these results suggest that the pathogenesis of ulcerative colitis differs from that of lymphocytic colitis and further emphasizes the heterogeneous nature of these newly recognized types of colonic inflammatory mucosal disorders.

Adolescent↗
PubMed2004

[Chronic diarrhea in adults: diagnostic strategies].

The presence of chronic diarrhea requires a prompt diagnostic strategy in order to avoid risks of malnutrition and electrolytic disturbances. Two different clinical situations, i.e. collagen colitis and secretory diarrhea, exemplify the diagnostic evaluation of a single symptom. This non exhaustive review should lead to a diagnostic strategy of chronic diarrhea.

Aged↗
PubMed2002

Increased colonic intraepithelial lymphocytes in patients with Hashimoto's thyroiditis.

BACKGROUND: Hashimoto's thyroiditis is an autoimmune thyroid disorder. Lymphocytic colitis and collagenous colitis are characterized by diarrhea with normal endoscopic findings. Autoimmune disorders are common in Hashimoto's thyroiditis and lymphocytic colitis. The aim of this study was to investigate the incidence of lymphocytic colitis in patients with Hashimoto's thyroiditis. STUDY: Fifty patients with well-documented Hashimoto's thyroiditis were included. Twenty patients with nonulcer dyspepsia served as a control group. Five of 50 patients with Hashimoto's thyroiditis reported intermittent diarrhea, whereas no patients had diarrhea in the control group. All patients and the control group underwent total colonoscopy, and multiple colonoscopic biopsies were performed. RESULTS: We found that 40% (20 of 50) of Patients with Hashimoto's thyroiditis had histologic findings consistent with lymphocytic colitis, and one patient in the control group had lymphocytic colitis (p < 0.01). The mean number of intraepithelial lymphocytes was 34.4/100 epithelial cells in these 20 patients, whereas the mean number of intraepithelial lymphocytes was 12.3/100 epithelial cells in the other 30 patients with Hashimoto's thyroiditis (p < 0.05). CONCLUSIONS: There was a higher incidence of histologic findings of lymphocytic colitis in patients with Hashimoto's thyroiditis, although most of the patients were clinically asymptomatic. This finding suggests that lymphocytic colitis may have an asymptomatic clinical course and should encourage further clinical investigations to better anticipate the relationship between autoimmune disorders.

Adult↗
PubMed2006

Microscopic colitis is not associated with cholecystectomy or appendectomy.

BACKGROUND: Microscopic colitis is a common cause of chronic watery diarrhea of unknown origin. Some patients develop diarrhea after cholecystectomy, and some patients with microscopic colitis have evidence of bile acid malabsorption. However, the association between cholecystectomy and microscopic colitis has not been studied. A protective effect of appendectomy on the development of ulcerative colitis also has been reported, but its relationship with microscopic colitis has not been studied. The aim of this study was to assess cholecystectomy and appendectomy as potential risk factors for the development of microscopic colitis in a nested case-control study. MATERIALS AND METHODS: Using the Rochester Epidemiology Project, we identified all Olmsted County (Minnesota) residents with an initial diagnosis of microscopic colitis between January 1, 1985, and December 31, 2001. Rates of antecedent cholecystectomy or appendectomy in patients with microscopic colitis were compared with age-, gender-, and calendar year-matched community controls through conditional logistic regression. RESULTS: Microscopic colitis was identified in 130 cases. Cholecystectomy preceded the diagnosis of microscopic colitis in 12 cases (9%) compared with 17 (13%) in the control group (odds ratio [OR] 0.7; 95% CI 0.3-1.5). Appendectomy preceded the diagnosis of microscopic colitis in 39 subjects (30%) compared with 28 (22%) in the control group (OR 1.6; 95% CI 0.9-2.7). Similar results were obtained when the analysis was restricted to microscopic colitis subtype (lymphocytic colitis or collagenous colitis). CONCLUSIONS: In this population-based nested case-control study, no significant association was seen between cholecystectomy or appendectomy and the development of microscopic colitis or its subtypes.

Adult↗
PubMedDate not supplied

Diagnosis and management of microscopic colitis syndrome.

Microscopic colitis syndrome consists of chronic watery diarrhea, a normal or near-normal gross appearance of the colonic mucosa, and a specific histologic picture described as either lymphocytic colitis or collagenous colitis. The cause of microscopic colitis is unknown, but recent work suggests some immunologic similarities to celiac disease, suggesting that luminal antigens may be important in its pathogenesis. Diarrhea in microscopic colitis seems to be directly related to the extent of inflammation, suggesting that inflammatory mediators are responsible for reduced water absorption by the colon. Microscopic colitis is a frequent diagnosis in patients with chronic diarrhea seen at referral centers. It is often associated with other immune-mediated conditions and frequently is complicated by fecal incontinence. The differential diagnosis is broad, comprising all causes of watery diarrhea. Evaluation is straightforward with the key aspect being review of colon biopsy specimens by an experienced pathologist. Treatment is still being defined: symptomatic management with antidiarrheal agents, 5-aminosalicylate drugs, corticosteroids, especially budesonide, bile acid-binding resins, and bismuth subsalicylate all can be effective. The prognosis is good with no evidence of conversion to classic inflammatory bowel disease or of development of neoplasia over time.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2001

Usefulness of colonoscopy with biopsy in the evaluation of patients with chronic diarrhea.

OBJECTIVE: Patients referred for chronic diarrhea frequently undergo endoscopic evaluation. There are limited data on the role for colonoscopy with biopsy and ileoscopy for patients with chronic diarrhea. METHODS: We reviewed the charts of 228 patients with chronic diarrhea evaluated by colonoscopy between November 1995 and March 1998. Chronic diarrhea was defined as loose, frequent bowel movements for a minimum of 4 wk. Patients were excluded if biopsies were not performed in normal colons, if they had undergone previous bowel surgery, a history of inflammatory bowel disease, HIV, or an inadequate colonoscopy. RESULTS: One hundred sixty-eight patients were included in the analysis, of whom 142 (85%) had ileoscopy. Colonoscopy and biopsy yielded a specific histological diagnosis in 52 (31%) patients. These included Crohn's disease (9), ulcerative colitis (7), lymphocytic colitis (10), collagenous colitis (3), ischemic colitis (3), infectious colitis (6), and miscellaneous diseases (14). Ileoscopy yielded significant findings in 3% of patients (four with Crohn's disease and one with infection). CONCLUSIONS: Colonoscopy and biopsy is useful in the investigation of patients with chronic diarrhea yielding a histological diagnosis in 31% of patients without a previous diagnosis. Ileoscopy complemented colonoscopy findings in a minority of patients with chronic diarrhea and was essential for a diagnosis in only two patients.

Adult↗
PubMed1998

Lymphocytic colitis: clinical presentation and long term course.

BACKGROUND: Lymphocytic colitis is characterised by chronic watery diarrhoea with normal endoscopic or radiological findings and microscopic evidence of pronounced infiltration of the colonic mucosa with lymphocytes. AIM: To investigate the long term clinical and histological evolution of the disease in a large group of patients with well characterised lymphocytic colitis. METHODS: Between 1986 and 1995 the histological diagnosis of lymphocytic colitis was obtained in 35 patients; 27 of these agreed to a follow up examination. All clinical, endoscopic, and histopathological records were reviewed at that time and the patients had a second endoscopic examination with follow up biopsies. RESULTS: The patients initially presented with the typical findings of lymphocytic colitis. After a mean (SD) follow up of 37.8 (27.5) months, diarrhoea subsided in 25 (93%) and histological normalisation was observed in 22 (82%) of the 27 patients. Progression from lymphocytic colitis to collagenous colitis was not observed. CONCLUSIONS: Lymphocytic colitis is characterised by a benign course with resolution of diarrhoea and normalisation of histology in over 80% of patients within 38 months. Considering the benign course of the disease, the potential benefit of any drug treatment should be carefully weighed against its potential side effects.

Adult↗
PubMedDate not supplied

Ketotifen treatment of active colitis in patients with 5-aminosalicylate intolerance.

Mast cell stabilizers are commonly used in the treatment of asthma and allergic disorders. Although the role of mucosal mast cells in the pathogenesis of inflammatory bowel disease remains uncertain, mast cell stabilizers have been shown in animal models to attenuate the severity of experimental colitis. The authors' experience with ketotifen in three patients--one each with Crohn's disease, ulcerative colitis and collagenous colitis--who had demonstrated allergy to, or intolerance of, 5-aminosalicylic acid is reported.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2005

Mechanism of diarrhea in microscopic colitis.

AIM: To search the pathophysiological mechanism of diarrhea based on daily stool weights, fecal electrolytes, osmotic gap and pH. METHODS: Seventy-six patients were included: 51 with microscopic colitis (MC) (40 with lymphocytic colitis (LC); 11 with collagenous colitis (CC)); 7 with MC without diarrhea and 18 as a control group (CG). They collected stool for 3 d. Sodium and potassium concentration were determined by flame photometry and chloride concentration by titration method of Schales. Fecal osmotic gap was calculated from the difference of osmolarity of fecal fluid and double sum of sodium and potassium concentration. RESULTS: Fecal fluid sodium concentration was significantly increased in LC 58.11+/-5.38 mmol/L (P<0.01) and CC 54.14+/-8.42 mmol/L (P<0.05) than in CG 34.28+/-2.98 mmol/L. Potassium concentration in LC 74.65+/-5.29 mmol/L (P<0.01) and CC 75.53+/-8.78 mmol/L (P<0.05) was significantly less compared to CG 92.67+/-2.99 mmol/L. Chloride concentration in CC 36.07+/-7.29 mmol/L was significantly higher than in CG 24.11+/-2.05 mmol/L (P<0.05). Forty-four (86.7%) patients had a secretory diarrhea compared to fecal osmotic gap. Seven (13.3%) patients had osmotic diarrhea. CONCLUSION: Diarrhea in MC mostly belongs to the secretory type. The major pathophysiological mechanism in LC could be explained by a decrease of active sodium absorption. In CC, decreased Cl/HCO3 exchange rate and increased chloride secretion are coexistent pathways.

Case-Control Studies↗