Microscopic colitis (MC) is a name used to describe a chronic diarrheal syndrome that is caused by inflammation in the large intestine. It is called “microscopic” colitis because the inflammation can be detected only with a microscope. During an endoscope procedure (colonoscopy or sigmoidoscopy), the colon looks normal. The presence or absence of a specific feature within the colonic inflammatory process as seen under the microscope (thickened collagen under the surface of the biopsy) has led to use of two other names for this syndrome: collagenous colitis and lymphocytic colitis. The symptoms and treatment of this syndrome are identical, regardless of whether the collagen in the biopsy is thick or normal.
The typical patient is a middle-aged woman; but it is seen in men, children as young as six and older people also. Possible initial misdiagnoses include stress, gastroenteritis, celiac sprue, lupus, or irritable bowel syndrome (IBS). It’s not unusual for diagnosis to take several years, since microscopic colitis is the form of inflammatory bowel disease least familiar to doctors and often the last considered.
There does not seem to be an association with Crohn’s disease, ulcerative colitis, or cancer. It does not appear to be contagious. Some patients report a close family member with the same diagnosis or with similar intestinal symptoms, and it appears there may be a hereditary tendency to get microscopic colitis.
Certain foods, especially high fiber, fat, milk products, spices, wheat and/or uncooked fruit and vegetables, may aggravate it. But, some patients tolerate any foods — even when quite ill.
Approximately half of the patients with microscopic colitis report a sudden onset. They can pin down the exact day and location that symptoms started, often triggered by an initial bout with dysentery, giardia, or an undiagnosed intestinal illness.
One theory is that the inflammatory response is caused by a bacterium or a bacterial toxin. Another theory suggests this is an autoimmune disease, although that hasn’t been conclusively established. A third suggests that non-steroidal anti-inflammatory drugs (NSAIDs, such as aspirin or ibuprofen) might be responsible or aggravate the symptoms in individuals predisposed to the disease by another mechanism. It may well turn out to be a combination of several of these factors.
This illness can come and go, with or without treatment, making it difficult to assess the effect of any treatment plan.
Signs, symptoms & indicators of Microscopic Colitis (Collagenous Colitis / Lymphocytic Colitis)
Iritis
Itchy skin
Microscopic colitis has been associated with unexplained severe itching.
Conditions that suggest Microscopic Colitis (Collagenous Colitis / Lymphocytic Colitis)
Chronic Fatigue / Fibromyalgia Syndrome
Both fatigue and fibromyalgia have been associated with microscopic colitis.
Joint Pain, General
Patients sometimes seek treatment for an elusive form of arthritis as much as ten years prior to problems with diarrhea. This atypical arthritis can affect the back, hips and sometimes ribs. It can come and go, and can change locations.
Microscopic colitis
Counter Indicators
Absence of microscopic colitis
Risk factors for Microscopic Colitis (Collagenous Colitis / Lymphocytic Colitis)
Gluten Sensitivity / Celiac Disease
In most cases, the gene causing microscopic colitis is the same as the one known to cause celiac sprue and gluten sensitivity. It appears that colitis can cause the immune system to begin recognizing gluten as immunostimulatory and vice versa, gluten sensitivity can lead to colitis. Many have difficulty eating wheat, oats, bran and rye because they induce abdominal symptoms and diarrhea. This fact, as well as other scientific evidence, indicates that there may be clinical overlap of microscopic colitis with a disease called celiac sprue.
Research indicates that many patients who experience an early relapse after Pepto Bismol treatment may be gluten intolerant, even if they appear to test negative for celiac disease with prevailing tests. In those cases, a gluten-free diet must be followed for life, but offers dramatic improvement in many cases.
Autoimmune Tendency
Microscopic colitis appears to be in the family of autoimmune syndromes, all of which are more common in women.
Dysbiosis, Bacterial
Extensive data from animals (mainly rodents) suggest that colitis is the result of the body’s immune system setting up an unusual attack on the bacteria living in the colon. If the balance of less immunogenic bacteria (good bacteria) and more immunostimulatory bacteria (bad bacteria) favors the latter, inflammation can result.
Caucasian ethnicity
Most patients diagnosed with microscopic colitis are Caucasians living in Northern Europe, Canada, the United States, Australia and New Zealand.
History of microscopic colitis
History of iritis
Recommendations for Microscopic Colitis (Collagenous Colitis / Lymphocytic Colitis)
Conventional Drugs / Information
Conventional treatment is often started with sulfasalazine. Patients may improve with sulfasalazine, but they are not necessarily cured. For the many that don’t tolerate sulfasalazine, Asacol (one brand of mesalamine or 5-aminosalicylic acid) is typically prescribed. These medicines are thought to act as anti-inflammatory agents in the intestine.
Anti-diarrheal medications such as Imodium and Lomotil are used for temporary relief, but tend to merely delay the diarrhea.
Studies done with prednisone (a corticosteroid) do not sound very promising for long-term use. Most patients do respond quickly to this agent, so it can be useful to stop a severe attack. However, the diarrhea routinely returns when prednisone is discontinued. Long-term use of prednisone is discouraged because the side effects (formation of cataracts, bone degeneration, high blood pressure, and a tendency toward diabetes) which can eventually be worse than the benefits.
Some people report excellent short-term results with certain antibiotics; however, the results generally are not long lasting.
A cholesterol-lowering drug called cholestyramine is helpful to some. Fiber in the form of psyllium hydrophilic mucilloid (like Metamucil) also helps some patients, but not others.
Low dose tricyclic antidepressants (such as Doxepin or Elavil) can sometimes help with the joint and muscle pain.
NSAIDs
The use of NSAIDs including aspirin for those with microscopic colitis may prevent successful treatment or cause relapses following treatment.
Bismuth
Thirteen patients with microscopic colitis were treated with 8 chewable 262mg bismuth subsalicylate tablets per day for 8 weeks. Twelve patients completed the trial. Eleven patients had a resolution of their diarrhea and a reduction in fecal weight. The average time to respond was 2 weeks. In 9 patients colitis resolved. Post-treatment follow-up for 7-28 months showed that the 9 patients remained well without treatment, 2 were well but still required treatment and 1 had continued diarrhea. [Gastroenterology 1998;114(1): pp.29-36]
Key
| Weak or unproven link |
| Strong or generally accepted link |
| Proven definite or direct link |
| Very strongly or absolutely counter-indicative |
| Likely to help |
| Highly recommended |
| Reasonably likely to cause problems |
Glossary
Colitis
Inflammation of the colon.
Chronic
Usually Chronic illness: Illness extending over a long period of time.
Endoscope
Instrument for examining the interior of a hollow organ.
Colon
The part of the large intestine that extends to the rectum. The colon takes the contents of the small intestine, moving them to the rectum by contracting.
Collagen
The primary protein within white fibers of connective tissue and the organic substance found in tendons, ligaments, cartilage, skin, teeth and bone.
Biopsy
Excision of tissue from a living being for diagnosis.
Gastroenteritis
Gastrointestinal tract inflammation; characterized by abdominal pain, nausea, diarrhea, vomiting; which may be caused by bacteria, parasites or a virus.
Irritable Bowel Syndrome
(IBS) A condition that causes upset intestines for a long period of time. It is very unpleasant to the sufferer but tends to be harmless and usually does not lead to more serious complaints. The symptoms vary from person to person and from day to day. In order to be diagnosed with IBS, a person must have at least three of the following symptoms: pain in the lower abdomen; bloating; constipation; diarrhea or alternating diarrhea and constipation; nausea; loss of appetite; tummy rumbling; flatulence; mucous in stools; indigestion; constant tiredness; frequent urination; low back pain; painful intercourse for women.
Crohn's Disease
Chronic inflammatory disease of the gastrointestinal tract. The most common symptoms are abdominal pain, often in the lower right area, and diarrhea. Rectal bleeding, weight loss, and fever may also occur. Bleeding may be serious and persistent, leading to anemia.
Ulcerative Colitis
(Colitis ulcerosa): Ulceration of the colon and rectum, usually long-term and characterized by rectal bleeding or blood in the stool, frequent urgent diarrhea/bowel movements each day, abdominal pain.
Cancer
Refers to the various types of malignant neoplasms that contain cells growing out of control and invading adjacent tissues, which may metastasize to distant tissues.
Dysentery
An inflammatory disorder of the lower intestinal tract, usually caused by a bacterial, parasitic, or protozoan infection and resulting in pain, fever, and severe diarrhea, often accompanied by the passage of blood and mucous.
Autoimmune Disease
One of a large group of diseases in which the immune system turns against the body's own cells, tissues and organs, leading to chronic and often deadly conditions. Examples include multiple sclerosis, rheumatoid arthritis, systemic lupus, Bright's disease and diabetes.
Anti-inflammatory
Reducing inflammation by acting on body mechanisms, without directly acting on the cause of inflammation, e.g., glucocorticoids, aspirin.
NSAID
Non-steroidal anti-inflammatory drug.
Fibromyalgia
(FMS): Originally named fibrositis, it is a mysteriously debilitating syndrome that attacks women more often than men. It is not physically damaging to the body in any way, but is characterized by the constant presence of widespread pain that often moves about the body. Fibromyalgia can be so severe that it is often incapacitating.
Arthritis
Inflammation of a joint, usually accompanied by pain, swelling, and stiffness, and resulting from infection, trauma, degenerative changes, metabolic disturbances, or other causes. It occurs in various forms, such as bacterial arthritis, osteoarthritis, or rheumatoid arthritis. Osteoarthritis, the most common form, is characterized by a gradual loss of cartilage and often an overgrowth of bone at the joints.
Diarrhea
Excessive discharge of contents of bowel.
Celiac Disease
(Gluten sensitivity) A digestive disease that damages the small intestine and interferes with absorption of nutrients from food. People who have celiac disease cannot tolerate a protein called gluten. Common symptoms include diarrhea, increased appetite, bloating, weight loss, irritability and fatigue. Gluten is found in wheat (including spelt, triticale, and kamut), rye, barley and sometimes oats.
Immune System
A complex that protects the body from disease organisms and other foreign bodies. The system includes the humoral immune response and the cell-mediated response. The immune system also protects the body from invasion by making local barriers and inflammation.
Bacteria
Microscopic germs. Some bacteria are "harmful" and can cause disease, while other "friendly" bacteria protect the body from harmful invading organisms.