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microscopic colitis

Etiology: 1) pharmaceuticals [2] a) likely - proton pump inhibitors (PPI)* [5] - lansoprazole [5] - coadministration of PPI with NSAID [8] - NSAIDs alone may not increase risk [8] - SSRI - sertraline - histamine H2-receptor antagonists - ranitidine [11] - ticlopidine - acarbose - Parkinsonian agents* [5] b) less likely - carbamazepine - flutamide - lisinopril - levodopa with benserazide - paroxetine - statins - simvastatin [11] c) unlikely - cimetidine - gold salts 2) association with celiac disease [3] * predictors of microscopic colitis vs functional diarrhea - autoimmune disease - starting a new drug < 3 months prior to diarrhea onset - age >50 - weight loss - duration of diarrhea <12 months [5] Epidemiology: - most commonly occurs in middle-age (45-60 years) & elderly women - 10-15% of patients with secretory chronic diarrhea Pathology: 1) abnormal immune reaction to luminal antigens in predisposed hosts [3] 2) infiltration of lamina propria with inflammatory cells & intraepithelial lymphocytes (> 20/100 epithelial cells) 3) subepithelial collagen band in the lamina propria > 10 mm Clinical manifestations: - presents with painless watery chronic diarrhea - non-bloody secretory diarrhea - sometimes abdominal discomfort & weight loss Laboratory: - serum tissue transglutaminase IgA to rule out celiac disease if unresponsive to therapy [2] Special laboratory: - sigmoidoscopy or colonoscopy - normal appearance of colonic mucosa [2] - colonic biopsy for diagnosis Complications: - no increased risk of colorectal cancer Management: 1) stop offending drug(s) - SSRI, proton pump inhibitors, NSAIDs 2) supportive treatment - antimotility agents - loperamide - diphenoxylate 3) budesonide first-line for symptomatic colitis - taper to lowest effective dose [6] 4) mesalamine, bismuth salicylate, or prednisone if budesonide not an option [6] 5) do not treat patients with probiotics or Boswellia serrata [6] 6) do not add cholestyramine to mesalamine monotherapy [6]

Related

diphenoxylate loperamide (Imodium)

Specific

collagenous colitis lymphocytic colitis

General

enterocolitis

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 218
  2. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Beaugerie L, Pardi DS Review article: drug-induced microscopic colitis - proposal for a scoring system and review of the literature. Aliment Pharmacol Ther. 2005 Aug 15;22(4):277-84. PMID: 16097993
  4. Williams JJ, Beck PL, Andrews CN, Hogan DB, Storr MA. Microscopic colitis - a common cause of diarrhoea in older adults. Age Ageing. 2010 Mar;39(2):162-8. PMID: 20065357
  5. Macaigne G et al. Microscopic colitis or functional bowel disease with diarrhea: A French prospective multicenter study. Am J Gastroenterol 2014 Sep; 109:1461 PMID: 25001258
  6. Nguyen GC et al. American Gastroenterological Association Institute guideline on the medical management of microscopic colitis. Gastroenterology 2015 Nov 14 PMID: 26584605
  7. Pardi DS, Kelly CP. Microscopic colitis. Gastroenterology. 2011 Apr;140(4):1155-65. Epub 2011 Feb 22. PMID: 21303675
  8. Verhaegh BP, de Vries F, Masclee AA et al. High risk of drug-induced microscopic colitis with concomitant use of NSAIDs and proton pump inhibitors. Aliment Pharmacol Ther 2016 Mar 9 PMID: 26956016
  9. Pardi DS. Diagnosis and Management of Microscopic Colitis. Am J Gastroenterol. 2017 Jan;112(1):78-85. Review. PMID: 27897155
  10. Pardi DS, Tremaine WJ, Carrasco-Labra A. American Gastroenterological Association Institute Technical Review on the Medical Management of Microscopic Colitis. Gastroenterology. 2016 Jan;150(1):247-274.e11. PMID: 26584602
  11. NEJM Knowledge+ Gastroenterology