Perspectives in clinical gastroenterology and hepatology
Microscopic Colitis: Clinical and Pathologic Perspectives

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Microscopic colitis is a chronic inflammatory bowel disease characterized by chronic nonbloody diarrhea and specific histopathology features. Active disease, defined as 3 or more stools or 1 or more watery stools per day, significantly reduces quality of life. Epidemiologic studies have found the incidence and prevalence of microscopic colitis to be comparable with those of Crohn's disease and ulcerative colitis. Nevertheless, microscopic colitis is still under-recognized in clinical practice—most health care workers know little about its etiology and pathophysiology. Furthermore, there are many challenges to the diagnosis and treatment of patients. We review the epidemiologic and clinical features of this disorder and discuss its pathogenesis. We also outline the criteria for histopathologic evaluation of microscopic colitis, recently published by the European Consensus on Inflammatory Bowel Disease, and discuss a treatment algorithm created by the European Microscopic Colitis Group. Treatment options for patients with budesonide-refractory disease are discussed.

Section snippets

Epidemiology

Epidemiologic studies have been performed mainly in Europe, North America, and Canada. However, reports on cases and smaller cohorts from Africa, Asia, Latin America, and Australia have indicated that MC is a worldwide disease.1 The most comprehensive population-based studies have been performed in Olmsted County, Minnesota, and in Örebro, Sweden. Since 1984, continuous epidemiologic follow-up evaluation in both centers has shown a parallel trend with an initial increase in incidence that has

Clinical Presentation

Regarding symptoms and clinical presentation, LC and CC are not distinguishable from each other. The key clinical feature is chronic nonbloody diarrhea, which is typically watery, leading to urgency (70% of patients) and, ultimately, fecal incontinence (40% of patients).10 In severe cases, bowel movements can exceed 15 per day and nocturnal diarrhea is common (50%).10 Despite considerable fluid loss, serious dehydration, electrolyte changes, or other complications are rare. The natural course

Histopathology

MC remains a histologic diagnosis, but only in patients with chronic diarrhea. This clinical information always should be provided to the pathologist. A recent large retrospective analysis showed that history of diarrhea per se does not identify patients at higher risk of abnormal histology, but those older than age 60 had a markedly increased likelihood of a specific histologic abnormality, and MC was the most common diagnosis.17 Histology is necessary not only to make the diagnosis,

Pathophysiology

The etiology and pathophysiology of MC is not well understood but is likely to be multifactorial, involving mucosal immune responses to luminal factors in a genetically predisposed individual. This theory is best supported by observations made in patients undergoing surgery with ileostomy. In these patients, fecal stream diversion leads to regression of intestinal inflammation and mucosal barrier dysfunction and, in turn, reconstruction of bowel continuity leads to reappearance of the classic

Drugs

Drug intake has been suggested to act as an environmental risk factor in causing or triggering MC.48 Beaugerie and Pardi49 proposed a scoring system with varying grades of certainty, and drugs with a high likelihood to cause MC were acarbose, aspirin, cyclo3 fort, lansoprazole, nonsteroidal anti-inflammatory drugs, ranitidine, sertraline, and ticlopidine. In a recently published systematic review, nonsteroidal anti-inflammatory drugs and proton pump inhibitors were identified as the 2 drugs

Treatment

The primary aim of therapy is to achieve clinical remission and to improve the patient’s QoL.13 Whether or not histologic remission is an important goal is currently unknown. Before embarking on medical therapy, the possibility of drug-induced MC always should be taken into account, and the patient’s medication should be reviewed carefully for drugs with high likelihood to cause MC.49 Discontinuation of such drugs, if possible, may lead to resolution of symptoms. Smoking cessation can be

Future Considerations

Epidemiologic data clearly show that MC has become a common gastrointestinal disorder and physicians and pathologists should be aware of the disease. All patients, especially elderly patients with chronic diarrhea, should be referred for colonoscopy and biopsy specimens should be obtained to confirm or rule out MC. On a practical level, patients should be asked to use a diary to monitor symptoms. The criteria for disease activity presented by Hjortswang et al13 are recommended for treatment

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    Conflicts of interest This author discloses the following: Andreas Münch received a research grant from Abbvie and has received lecture fees/honoraria from Dr Falk Pharma. The remaining author discloses no conflicts.

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