Collagenous colitis in setting of nonsteroidal antiinflammatory drugs and antibiotics

Microscopic colitis: lymphocytic colitis, collagenous colitis, and beyond

Microscopic colitis (MC) is a chronic inflammatory disease of colon with clinical presentations of chronic, watery, nonbloody diarrhea, and normal or almost normal endoscopic findings. Confirmation of a diagnosis of MC requires microscopic examination on colon biopsy to identify characteristic morphological features, in which 2 main subtypes of MC, lymphocytic colitis (LC) and collagenous colitis (CC), have been described. Although the pathogenesis of MC is still unclear, studies have revealed associations of MC with many risk factors and other diseases such as celiac disease, inflammatory bowel disease, and medication use. Meanwhile, variants of MC, MC incomplete, or MC-like changes in other conditions are still diagnostic dilemmas for pathologists. The goal of this paper is to systemically introduce the clinicopathologic features of MC and focus on unusual features of MC and its associations with other conditions.

Nonsteroidal anti-inflammatory drug exposure and the risk of microscopic colitis

BACKGROUND

Medication consumption has been suggested as a risk factor for microscopic colitis (MC), but studies of varying design have yielded inconsistent results. Our aim was to evaluate the association between medications and MC.

METHODS

A hybrid cohort of prospectively identified patients undergoing colonoscopy with biopsies for suspicion of MC (N = 144) and patients with MC enrolled within three months of diagnosis into an MC registry (N = 59) were surveyed on medication use. Medication use was compared between patients with and without diagnosis of MC by chi-squared test and binomial logistic regression adjusted for known risk factors of MC: age and gender.

RESULTS

In total, 80 patients with MC (21 new, 59 registry) were enrolled. Patients with MC were more likely to be older (p = 0.03) and female (p = 0.01) compared to those without MC. Aspirin and other non-steroidal anti-inflammatory drugs were more commonly used among patients who developed MC (p < 0.01). After controlling for age and gender, these medications remained independent predictors of MC with odds ratio for any non-steroidal anti-inflammatory drug use of 3.04 (95% CI: 1.65-5.69). No association between MC and other previously implicated medications including proton pump inhibitors and selective serotonin reuptake inhibitors was found.

CONCLUSIONS

In this cohort of patients with chronic diarrhea, we found use of aspirin and non-steroidal anti-inflammatory drugs, but not other implicated medications to be associated with the development of MC. Whether these drugs trigger colonic inflammation in predisposed hosts or worsen diarrhea in undiagnosed patients is unclear. However, we feel that these findings are sufficient to discuss potential non-steroidal anti-inflammatory drug cessation in patients newly diagnosed with MC.

European guidelines on microscopic colitis: United European Gastroenterology and European Microscopic Colitis Group statements and recommendations

INTRODUCTION

Microscopic colitis is a chronic inflammatory bowel disease characterised by normal or almost normal endoscopic appearance of the colon, chronic watery, nonbloody diarrhoea and distinct histological abnormalities, which identify three histological subtypes, the collagenous colitis, the lymphocytic colitis and the incomplete microscopic colitis. With ongoing uncertainties and new developments in the clinical management of microscopic colitis, there is a need for evidence-based guidelines to improve the medical care of patients suffering from this disorder.

METHODS

Guidelines were developed by members from the European Microscopic Colitis Group and United European Gastroenterology in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. Following a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the certainty of the evidence. Statements and recommendations were developed by working groups consisting of gastroenterologists, pathologists and basic scientists, and voted upon using the Delphi method.

RESULTS

These guidelines provide information on epidemiology and risk factors of microscopic colitis, as well as evidence-based statements and recommendations on diagnostic criteria and treatment options, including oral budesonide, bile acid binders, immunomodulators and biologics. Recommendations on the clinical management of microscopic colitis are provided based on evidence, expert opinion and best clinical practice.

CONCLUSION

These guidelines may support clinicians worldwide to improve the clinical management of patients with microscopic colitis.

Les colites microscopiques

Microscopic colitis is frequently found as a cause of chronic watery diarrhea in women after menopause. The disease can be associated with a medication side effect in half of the patients (non-steroidal anti-inflammatory drugs or proton pump inhibitors for instance). Colonic biopsies are mandatory for the diagnosis of microscopic colitis and should be performed in several locations of the colon. Management of microscopic colitis is first based on avoiding iatrogenic factors and smoking together with symptomatic treatment of diarrhea (loperamide, cholestyramine). In case of failure or severe symptoms, budesonide is the key treatment. The aim of the treatment is to achieve clinical remission, defined as less than 3 liquid stools per day, to improve quality of life. After a first course of budesonide, recurrence of diarrhea is frequent and a maintenance therapy can be prescribed for several months. In case of intolerance or refractoriness, second-line therapy (immunosuppressants, biological therapy, surgery) should be discussed in multidisciplinary team meeting.

Microscopic colitis impacts quality of life in older people

This report describes a frail 92-year-old woman with dementia who presented with a year's history of chronic watery non-bloody diarrhoea. She had abdominal bloating, weight loss, faecal urgency, nocturnal stools and developed faecal incontinence. Her serum C reactive peptide and faecal calprotectin were elevated. Flexible sigmoidoscopy was macroscopically normal, but demonstrated histological features of microscopic colitis (MC) in sigmoid colon and rectal biopsies. Polypharmacy was reviewed for possible medication-induced MC. Ranitidine, donepezil and simvastatin were discontinued. She was started on oral budesonide with improvement in the abdominal and bowel symptoms. Stool frequency and consistency normalised, and the faecal incontinence resolved with treatment. The outcomes were an improved quality of life, reduced functional dependency, reduced carer strain and avoidance of premature transition from her home into a long-term/institutional care setting. We briefly review terminology, basic epidemiology, notable associations, the importance of establishing a diagnosis and some treatment considerations for MC.

Review of Drug-induced Injury in Mucosal Biopsies From the Tubular Gastrointestinal Tract

The use of prescription and over-the-counter medications is on the rise in the US population, especially among those aged 65 and over, with over 46% of the population taking at least 1 prescription medication. Given the frequency of medication use, and that the majority of these medications are taken orally, it has become increasingly relevant for pathologist examining endoscopically obtained gastrointestinal tract mucosal biopsies to consider and recognize patterns of mucosal injury associated with various drugs. Reports on injuries associated with certain classes of drugs can be scattered among different sources, making a comprehensive view of various injury patterns and the drugs known to cause them difficult to obtain. Herein, we provide a comprehensive overview of the drugs known to cause mucosal injuries in the tubular gastrointestinal tract organized by the organ involved and the prominent pattern of injury.

Drug Exposure and the Risk of Microscopic Colitis: A Critical Update

A variety of luminal antigens, including a wide range of drugs, have been associated with the still little-known pathophysiology of microscopic colitis (MC), with variable evidence suggesting causality. This article aims to review the aspects related to drugs as potential triggers of MC; to discuss the most commonly identified associations between drugs and MC; and to analyze the limitations of the studies currently available. A literature search was performed in PubMed combining the search terms 'drug exposure', 'drug consumption', and 'risk factors' with 'microscopic colitis', 'lymphocytic colitis', and 'collagenous colitis', with no language restrictions. Reference lists of retrieved documents were also reviewed. A handful of case-control studies have demonstrated significant associations between some commonly used drugs and a higher risk of developing MC. No universally accepted criteria for establishing cause-effect relationships in adverse reactions to drugs are available, but several methods that can be applied to MC, can provide degrees of the likelihood of an association. A high probability imputation in the development of MC as a drug adverse effect has only been demonstrated for individual cases by applying chronological (challenge, de-challenge, and relapse with re-challenge) and semiological criteria. Several case-control studies have shown significant associations between exposure to drugs and MC, but the variability in their design, the reference populations used, and the definitions for drug exposure considered require specific analyses. It can be concluded that drug exposure and MC as a likely cause-effect relationship has only been described for a handful of drugs and in individual cases.

Spectrum of Drug-induced Chronic Diarrhea

The evaluation of a patient with chronic diarrhea can be quite frustrating, as it is expensive and involves multiple diagnostic studies. Moreover, identification of a drug as a cause of chronic diarrhea is a challenge in patients taking multiple medications. The disease may either be associated with intestinal mucosal changes, mimicking diseases such as celiac disease, or purely functional, with no histopathologic change. Drug-induced diarrhea may or may not be associated with malabsorption of nutrients, and a clinical improvement may occur within days of discontinuation of the drug, or may take longer when associated with mucosal injury. Diarrhea in diabetics, often attributed to poor management and lack of control, may be due to oral hypoglycaemic agents. Chemotherapy can result in diffuse or segmental colitis, whereas olmesartan and a few other medications infrequently induce a disease that mimics celiac disease, but is not associated with gluten intolerance. In short, increased awareness of a drug, as a cause for diarrhea and a clear understanding of the clinical manifestations will help clinicians to solve this challenging problem. This article aims to review drug-induced diarrhea to (a) understand known pathophysiological mechanisms; (b) assess the risk associated with frequently prescribed medications, and discuss the pathogenesis; and

Comparison of clinical features, treatment, and outcomes of collagenous sprue, celiac disease, and collagenous colitis

BACKGROUND

Collagenous sprue (CS) is a rare form of enteropathy that had been reported to be associated with celiac disease (CD) and collagenous colitis (CC). The aim of our study was to compare the clinical features, treatments, and outcomes of CS, CD, and CC.

METHODS

All patients with histologic diagnosis of CS, CD, or CC with complete clinical data were extracted from our pathology database between 1990 and 2015. Demographic and clinical features were recorded along with treatments and outcomes.

RESULTS

A total of 21 patients with CS were included. Overall CS patients were more symptomatic with 17 (81.0%) patients with diarrhea and 15 (71.4%) with unintentional weight loss. Positive celiac serology was noted in 5 (23.8%) CS patients. CS patients had higher rates for disease-related temporary total parenteral nutrition (TPN) use (38.1% vs. 1.1% vs. 1.0%, P < 0.0001) and disease-related hospitalization (52.4% vs. 3.3% vs. 8.2%, P < 0.0001) than that in CD and CC patients. Twenty CS patients received treatments, including the combination of gluten-free diet (GFD) and corticosteroids (n = 12), GFD only (n = 2), and corticosteroids only (n = 6). All CS patients showed symptomatic reliefs with treatment. Although CS patients had a higher rate for hospitalization and TPN use, disease-related death was not observed in all three groups.

CONCLUSIONS

Collagenous sprue patients had more severe clinical presentation than patients with CD and CC and therefore had higher demand for temporary TPN and hospitalization. Nevertheless, a prompt use of steroids and/or GFD upon histologic diagnosis of CS may have contributed to an overall excellent prognosis.

Diagnosis and Management of Microscopic Colitis

Microscopic colitis (MC) is a relatively common cause of chronic watery diarrhea, especially in older persons. Associated symptoms, including abdominal pain and arthralgias, are common. The diagnosis is based upon characteristic histological findings in the presence of diarrhea. The two types of MC, collagenous and lymphocytic colitis, share similar clinical features, with the main difference being the presence or absence of a thickened subepithelial collagen band. There are several treatment options for patients with MC, although only budesonide has been well studied in multiple controlled clinical trials. This review will describe the clinical features, epidemiology, pathophysiology, diagnostic criteria, and treatment of patients with MC.

The Watery Diarrhea-Colitis Syndrome

Collagenous and lymphocytic/microscopic colitis represent a distinct histopathologic spectrum of findings, with occasional transition, observed in patients with normal or near-normal colonoscopic findings and chronic watery diarrhea (watery diarrhea- colitis syndrome). Biopsies are characterized by surface epithelial damage, an increased number of chronic inflamatory cells in the lamina propria, intraepithelial lymphocyto sis, intact crypt architecture, and in the cases of collagenous colitis, a thickened subepi thelial collagen layer (SCL). While their precise interrelationship is unclear, as their clinicopathologic similarities far outweigh their differences, it appears reasonable for pathologists and clinicians to consider them conceptually together as part of a syn drome of chronic watery diarrhea and colitis distinct from other forms of chronic inflammatory bowel disease. The etiology and pathogenesis of this syndrome are un clear. Colorectal surface epithelial damage appears to be for the most part responsible for the secretory diarrhea, while the thickened SCL appears to be a variable response to the surface epithelial damage. Why the thickened SCL occurs only in some cases, why it does not occur in other forms of colitis, and whether it functions as a diffusion barrier are unknown. The propensity of the watery diarrhea-colitis syndrome to pref erentially affect middle-aged and elderly women, an association with autoimmune disorders, and clinicopathologic similarities to celiac disease suggest that host immune factors are important. Other dietary factors, medications, or other agents may also play a role, and this is currently under investigation. Small bowel villous atrophy appears to account for the presence of steatorrhea noted in some reports. Definitive diagnosis is facilitated by the procurement of multiple, well-oriented biopsies, prefera bly extending at least into the proximal left colon. A thickened SCL occasionally can only be demonstrated in biopsies from the right colon. An appreciation of the normal variation found in colorectal biopsies and recognition of artifactual thickening of the subepithelial basement membrane in maloriented sections and in relation to bowel preparation will eliminate overdiagnosis of normal biopsies, while the absence of fea tures typical for other forms of inflammatory bowel disease facilitates differential diag nosis. Patients may respond dramatically to therapeutic intervention with drugs often used for ulcerative colitis and Crohn's disease, however, spontaneous remissions are well documented. A colitis-dysplasia-carcinoma sequence has not as yet been docu mented to occur in this patient population. In just over one decade the morphologic features of the watery diarrhea-colitis syndrome have come to be recognized. Hope fully, the next decade of observation and investigation will help to clarify the precise relationship between cases with and without a thickened SCL, as well as the etiology and pathogenesis of the secretory diarrhea. Int J Surg Pathol 1 (1): 65-82, 1993

High risk of drug-induced microscopic colitis with concomitant use of NSAIDs and proton pump inhibitors

BACKGROUND

Microscopic colitis (MC) is a chronic bowel disorder characterised by watery diarrhoea. Nonsteroidal anti-inflammatory drugs (NSAIDs), proton pump inhibitors (PPIs), selective serotonin reuptake inhibitors (SSRIs) and statins have been associated with MC. However, underlying mechanisms remain unclear.

AIM

To study the association between exposure to these drugs and MC, with attention to time of exposure, duration, dosage and combined exposure, and to test hypotheses on underlying pharmacological mechanisms.

METHODS

A case-control study was conducted using the British Clinical Practice Research Datalink. MC cases (1992-2013) were matched to MC-naive controls on age, sex and GP practice. Drug exposure was stratified according to time of exposure, duration of exposure or dosage. Conditional logistic regression analysis was applied to calculate adjusted odds ratios (AORs).

RESULTS

In total, 1211 cases with MC were matched to 6041 controls. Mean age was 63.4 years, with 73.2% being female. Current use of NSAIDs (AOR 1.86, 95% CI 1.39-2.49), PPIs (AOR 3.37, 95% CI 2.77-4.09) or SSRIs (AOR 2.03, 95% CI 1.58-2.61) was associated with MC compared to never or past use. Continuous use for 4-12 months further increased the risk of MC. Strongest associations (fivefold increased risk) were observed for concomitant use of PPIs and NSAIDs. Statins were not associated with MC.

CONCLUSIONS

Current exposure to NSAIDs, PPIs or SSRIs and prolonged use for 4-12 months increased the risk of MC. Concomitant use of NSAIDs and PPIs showed the highest risk of MC. Acid suppression related dysbiosis may contribute to the PPI effect, which may be exacerbated by NSAID-related side-effects.

Current concepts on microscopic colitis: evidence-based statements and recommendations of the Spanish Microscopic Colitis Group

BACKGROUND

Microscopic colitis (MC) is an underdiagnosed inflammatory bowel disease.

AIM

To develop an evidence-based clinical practice guide on MC current concepts.

METHODS

Literature search was done on the Cochrane Library, EMBASE and MEDLINE electronic databases, which were consulted covering the period up until March 2015. Work groups were selected for each of the reviewed topics, with the purpose of drafting the initial statements and recommendations. They subsequently underwent a voting process based on the Delphi method. Each statement/recommendation was accompanied by the result of the vote the level of evidence, and discussion of the corresponding evidence. The grade of recommendation (GR) using the GRADE approach was established for diagnosis and treatment recommendations.

RESULTS

Some key statements and recommendations are: advancing age increases the risk of developing MC, mainly in females. The symptoms of MC and IBS-D may be similar. If MC is suspected, colonoscopy taking biopsies is mandatory. Treatment with oral budesonide is recommended to induce clinical remission in patients with MC. Oral mesalazine is not recommended in patients with collagenous colitis for the induction of clinical remission. The use of anti-TNF-alpha drugs (infliximab, adalimumab) is recommended for the induction of remission in severe cases of MC that fail to respond to corticosteroids or immunomodulators, as an alternative to colectomy.

CONCLUSIONS

This is the first consensus paper on MC based on GRADE methodology. This initiative may help physicians involved in care of these patients in taking decisions based on evidence.

Lymphocytic colitis associated with lansoprazole treatment

INTRODUCTION

There have been several reported cases of lansoprazole-associated collagenous colitis (CC) reported in the literature but only 1 reported case of lansoprazole-associated lymphocytic colitis (LC) in the literature. Both CC and LC are considered inflammatory bowel diseases, but they are distinctly classified based on the condition of the colon, which is typically confirmed through biopsy.

CASE SUMMARIES

A 52-year-old white male (Patient 1), with a height of 178 cm and weight of 75 kg, presented to Gazi University Hospital, Ankara, Turkey, with a 3-month history of abdominal pain and nonbloody, watery diarrhea. The patient reported receiving PO lansoprazole 30 mg/d to treat heartburn ~1 week prior to the onset of diarrhea. The patient's medical history revealed that he did not have any preexisting conditions, other than gastroesophageal reflux disease (GERD) for which lansoprazole was prescribed. The medical history report also revealed that the patient was not receiving any concomitant medications or treatments at the time. A colon biopsy confirmed LC. Additionally, a 43-year-old white female (Patient 2), with a height of 168 cm and weight of 61 kg, presented to the same facility with a 6-month history of nonbloody, watery diarrhea and mild lower abdominal cramping. The patient reported that initial onset began ~2 months after receiving a 10-day Helicobacter pylori eradication combination treatment regimen that included lansoprazole, amoxicillin, and clarithromycin, followed by lansoprazole monotherapy to treat GERD. The patient's medical history revealed no other concomitant medications were being adminstered at the time. A colon biopsy confirmed LC.

DISCUSSION

A search of the literature using the MEDLINE database and all relevant English-language articles with key words lansoprazole and lymphocytic colitis, found that there were several cases of lansoprazole-associated CC reported and 1 reported case of lansoprazole-associated LC. Histologic findings from laboratory tests and colon biopsies confirmed diagnoses of LC in both patients in this case report. Patient 1 presented with diarrhea and cramping, which the patient reported had been ongoing for ~3 months, following lansoprazole administration. However, after lansoprazole was discontinued, the symptoms completely resolved within 7 days. Patient 2 presented with diarrhea and cramping, which had been occurring for ~6 months. That patient reported that initial onset commenced ~2 months after a 10-day H pylori eradication combination treatment regimen that included lansoprazole, amoxicillin, and clarithromycin, followed by lansoprazole monotherapy to treat GERD. However, after sulfasalazine (3 g/d) was prescribed for 2 months immediately upon diagnosis of LC, there was little improvement in the effort to control the diarrhea in this patient. After omeprazole 20 mg/d was substituted for lansoprazole, the patient's diarrhea ceased. Follow-up sigmoidoscopy 2 months later revealed normal mucosa and complete normalization of histologic findings. The patient remains diarrhea-free while on omeprazole. A causality assessment using the Naranjo adverse reaction algorithm produced scores of 6 for both patients, suggesting that LC was probably associated with lansoprazole treatment.

CONCLUSIONS

Here we report 2 cases of LC in patients probably associated with the administration of lansoprazole treatment. Complete remission occurred after lansoprazole was discontinued.

Microscopic colitis: Common cause of unexplained nonbloody diarrhea

Microscopic colitis (MC) is characterized by chronic, watery, secretory diarrhea, with a normal or near normal gross appearance of the colonic mucosa. Biopsy is diagnostic and usually reveals either lymphocytic colitis or collagenous colitis. The symptoms of collagenous colitis appear most commonly in the sixth decade. Patients report watery, nonbloody diarrhea of a chronic, intermittent or chronic recurrent course. With collagenous colitis, the major microscopic characteristic is a thickened collagen layer beneath the colonic mucosa, and with lymphocytic colitis, an increased number of intraepithelial lymphocytes. Histological workup can confirm a diagnosis of MC and distinguish the two distinct histological forms, namely, collagenous and lymphocytic colitis. Presently, both forms are diagnosed and treated in the same way; thus, the description of the two forms is not of clinical value although this may change in the future. Since microscopic colitis was first described in 1976 and only recently recognized as a common cause of diarrhea, many practicing physicians may not be aware of this entity. In this review, we outline the epidemiology, risk factors associated with MC, its etiopathogenesis, the approach to diagnosis and the management of these individuals.

Clinical characteristics of collagenous colitis with linear ulcerations

BACKGROUND

The relationship between the thickness of subepithelial collagen bands (CB) and the development of linear ulcerations (LU) in collagenous colitis (CC) remains unclear. The aim of the present study was to compare the clinical and pathological features, including the thickness of CB, in CC patients with and without LU.

PATIENTS AND METHODS

Twenty-five patients with CC diagnosed by pathological examination of biopsy specimens were analyzed. Eleven patients with LU (LU group) and 14 patients without LU (non-LU group) were compared.

RESULTS

Ten patients in the LU group and seven in the non-LU group were taking lansoprazole (P = 0.038). Seven patients in the LU group and one in the non-LU group were taking non-steroidal anti-inflammatory drugs (NSAIDs) (P = 0.004). All LU were locatedin the transverse or left colon. Patients in the LU group were older than those in the non-LU group (P = 0.015). CB were significantly thicker in the LU group than in the non-LU group (mean ± SD, 40 ± 21 μm vs 20 ± 11 μm, P = 0.004). Multivariate analysis showed that NSAIDs use (odds ratio, 19.236; 95% confidence interval, 1.341-275.869) and CB thickness (odds ratio, 0.893; 95% confidence interval, 0.804-0.999) were independently associated with the development of LU.

CONCLUSION

Use of lansoprazole and NSAIDs, thick CB, and advanced age are associated with the development of LU in CC patients.

Microscopic colitis in Uppsala health region, a population-based prospective study 2005-2009

OBJECTIVE

The aim of this study is to report on the incidence of microscopic colitis (MC), any possible relation with inflammatory bowel disease (IBD), concomitant drug consumption, related diseases and the clinical course of the diseases.

METHODS

Both new cases of IBD and MC were registered at the same time in the same geographical area. The study started in the county of Uppsala 2005-2006, and other parts of the surrounding health region were included 2007-2009. Established morphological criteria were used, i.e. a layer of subepithelial collagen band ≥ 10 μm in collagenous colitis (CC) with concomitant inflammation and at least 20 lymphocytes per 100 epithelial cells in lymphocytic colitis (LC).

RESULTS

The authors found 272 new cases of MC, 154 with CC and 118 with LC. The mean age-adjusted incidence was 7.0/1,000,000 for CC and 4.8/100,000 for LC. The clinical course was dominated by single episodes with diarrhea or intermittent symptoms, but 14% suffered from chronic diarrhea. In 10% of the cases, diagnosis was made in individuals without chronic watery diarrhea. Although not systematically tested, concomitant celiac disease was found in approximately 5% of the patients.

CONCLUSIONS

The incidence of MC in Uppsala health region is similar to other studied areas. The majority of patients had a self-limiting or easily treated condition, but 14% need a more or less continuous medication. Ten percent of the patients demonstrate other symptoms than chronic watery diarrhea. The possibility of concomitant celiac disease should be considered in new cases of MC.

Collagenous colitis in children and adolescents: study of 7 cases and literature review

The aim of this study is to examine the clinical and pathologic characteristics of collagenous colitis (CC) in children and adolescents. Seven patients (five females and two males, median age: 13 years, ranging from 4 to 16) were included. Four (of 7, 57%) patients presented with non-bloody watery diarrhea, one with alternating constipation and diarrhea with rectal prolapse, one with constipation, and one with normal bowel movement. Abdominal pain and weight loss were manifested in 80 and 40% patients, respectively. Two patients had celiac disease in remission. None of the patients took non-steroidal antiinflammatory agents. All patients had normal colonoscopy, but had typical histologic features of CC in colon biopsies. Four patients had clinical follow-up (24-75 months duration, median 54 months): three patients had no gastrointestinal symptoms upon follow-up, but one patient had continued symptoms of alternating diarrhea and constipation. Two patients had follow-up biopsies: one showed persistence of CC, and one had complete histologic resolution. We conclude that while CC is rare in children and adolescents, the clinical presentation is similar to adults, with a female preponderance, presentation with diarrhea and abdominal pain, and an association with celiac disease and other autoimmune disorders. However, compared with adults, children and adolescents are more likely to have weight loss and an atypical presentation including alternating constipation and diarrhea, constipation alone or normal bowel movements. Treatment is less standardized in children and adolescents with CC.

Pseudomembranous collagenous colitis with superimposed drug damage

Pseudomembranous collagenous colitis is a rare pathological condition, not related to infectious agents, and characterized by thickening of the subepithelial collagen and formation of pseudomembranes. We report one such case, which responded to budesonide treatment after failures of previous approaches given, being unaware of the correct diagnosis.

Microscopic colitis: epidemiology, pathophysiology, diagnosis and current management-an update 2013

Microscopic colitis is a common cause of chronic diarrhea. Over the last years the incidence and the prevalence of microscopic colitis are rising and this rise is largely attributed to a rising awareness, and concomitantly an increasing number of diagnoses are made. Patients with microscopic colitis report watery, nonbloody diarrhea of chronic, intermittent, or chronic recurrent course. Following an unremarkable physical examination the diagnosis of microscopic colitis is made by colonoscopy, which shows essentially a normal colonic mucosa. Biopsies taken during the colonoscopy procedure will then finally establish the correct diagnosis. Histological workup can then confirm a diagnosis of microscopic colitis and can distinguish the two distinct histological forms, namely, collagenous colitis and lymphocytic colitis. Presently both forms are diagnosed and treated in the same way; thus the description of the two forms is not of clinical value, though this may change in future. Depending on the patients age and gender 10-30% of patients investigated for chronic diarrhea will be diagnosed with microscopic colitis if biopsies are taken. Microscopic colitis is most common in older patients, especially in female patients and is frequently associated with autoimmune disorders and the consumption of several drugs. This review summarizes the present knowledge of the epidemiology, the pathophysiology, and the diagnosis of microscopic colitis and discusses the former and the present treatment options.

Microscopic colitis

Microscopic colitis may be defined as a clinical syndrome, of unknown etiology, consisting of chronic watery diarrhea, with no alterations in the large bowel at the endoscopic and radiologic evaluation. Therefore, a definitive diagnosis is only possible by histological analysis. The epidemiological impact of this disease has become increasingly clear in the last years, with most data coming from Western countries. Microscopic colitis includes two histological subtypes [collagenous colitis (CC) and lymphocytic colitis (LC)] with no differences in clinical presentation and management. Collagenous colitis is characterized by a thickening of the subepithelial collagen layer that is absent in LC. The main feature of LC is an increase of the density of intra-epithelial lymphocytes in the surface epithelium. A number of pathogenetic theories have been proposed over the years, involving the role of luminal agents, autoimmunity, eosinophils, genetics (human leukocyte antigen), biliary acids, infections, alterations of pericryptal fibroblasts, and drug intake; drugs like ticlopidine, carbamazepine or ranitidine are especially associated with the development of LC, while CC is more frequently linked to cimetidine, non-steroidal antiinflammatory drugs and lansoprazole. Microscopic colitis typically presents as chronic or intermittent watery diarrhea, that may be accompanied by symptoms such as abdominal pain, weight loss and incontinence. Recent evidence has added new pharmacological options for the treatment of microscopic colitis: the role of steroidal therapy, especially oral budesonide, has gained relevance, as well as immunosuppressive agents such as azathioprine and 6-mercaptopurine. The use of anti-tumor necrosis factor-α agents, infliximab and adalimumab, constitutes a new, interesting tool for the treatment of microscopic colitis, but larger, adequately designed studies are needed to confirm existing data.

Non-IBD colitides (eosinophilic, microscopic)

Microscopic colitis includes the terms lymphocytic colitis and collagenous colitis, and is a common cause of chronic diarrhoea in older adults. The incidence of microscopic colitis has increased over time and has reached levels comparable to other forms of inflammatory bowel disease. In this chapter, an updated review on the epidemiology, diagnosis and treatment of microscopic colitis has been provided. There is limited data available about eosinophilic colitis, which is the least common of the eosinophilic GI disorders. It is important to rule out the secondary causes of colonic eosinophilia in patients with suspected eosinophilic colitis.

Reactive gastropathy is associated with inflammatory conditions throughout the gastrointestinal tract

BACKGROUND

The epidemiology of reactive gastropathy and its relationship with other conditions of the gastrointestinal tract associated with NSAID use have not been evaluated.

AIMS

To test the hypothesis that if reactive gastropathy shares common aetiological factors with these conditions, the analysis of a large cohort would unveil associations.

METHODS

We queried a national pathology database for subjects with a diagnosis of reactive gastropathy; controls were patients with normal gastric biopsies. We also extracted diagnoses of H. pylori infection, intestinal metaplasia, duodenal lymphocytosis, duodenitis, ileitis, microscopic colitis and focal colitis.

RESULTS

Of 504 011 patients with gastric biopsies, 69 101 had oesophageal, 166 134 duodenal, 13 010 ileal and 83 334 colonic biopsies. Reactive gastropathy was diagnosed in 15.6% of patients, H. pylori infection in 10.3% and normal gastric mucosa in 16.3%. Reactive gastropathy was evenly distributed across the US and increased from 2.0% in the first decade of life to >20% in octogenarians. Compared with controls, reactive gastropathy was significantly associated with Barrett's mucosa (OR 1.21 95% CI 1.16-129); duodenitis (OR 1.36; 95% CI 1.28-1.44); duodenal intraepithelial lymphocytosis (OR 1.25; 95% CI 1.13-1.39); active ileitis (OR 1.88; 95% CI 1.47-2.40); focal active colitis (OR 1.57; 95% CI 1.33-1.86); and collagenous colitis (OR 1.50; 95% CI 1.12-2.03).

CONCLUSIONS

Reactive gastropathy, a common histopathological feature of the stomach, shows an age-dependent rise and is associated with changes of the digestive tract believed to be caused by NSAID use or duodenogastric reflux. However, a large fraction of reactive gastropathy remains unexplained; its frequent occurrence merits further efforts at elucidating its aetiology.

An epidemiological study of collagenous colitis in southern Sweden from 2001-2010

AIM: To estimate the incidence of collagenous colitis (CC) in southern Sweden during 2001-2010.

METHODS: Cases were identified by searching for CC in the diagnostic registers at the Pathology Departments in the county of Skåne. The catchment area comprised the south-west part of the county (394 307 inhabitants in 2010) and is a mixed urban and rural type with limited migration. CC patients that had undergone colonoscopy during the defined period and were living in this area were included in the study regardless of where in Skåne they had been diagnosed. Medical records were scrutinized and uncertain cases were reassessed to ensure that only newly diagnosed CC cases were included. The diagnosis of CC was based on both clinical and histopathological criteria. The clinical criterion was non-bloody watery diarrhoea. The histopathological criteria were a chronic inflammatory infiltrate in the lamina propria, a thickened subepithelial collagen layer ≥ 10 micrometers (μm) and epithelial damage such as flattening and detachment.

RESULTS: During the ten year period from 2001-2010, 198 CC patients in the south-west part of the county of Skåne in southern Sweden were newly diagnosed. Of these, 146 were women and 52 were men, i.e., a female: male ratio of 2.8:1. The median age at diagnosis was 71 years (range 28-95/inter-quartile range 59-81); for women median age was 71 (range 28-95) years and was 73 (range 48-92) years for men. The mean annual incidence was 5.4/10⁵ inhabitants. During the time periods 2001-2005 and 2006-2010, the mean annual incidence rates were 5.4/10⁵ for both periods [95% confidence interval (CI): 4.3-6.5 in 2001-2005 and 4.4-6.4 in 2006-2010, respectively, and 4.7-6.2 for the whole period]. Although the incidence varied over the years (minimum 3.7 to maximum 6.7/10⁵) no increase or decrease in the incidence could be identified. The odds ratio (OR) for CC in women compared to men was estimated to be 2.8 (95% CI: 2.0-3.7). The OR for women 65 years of age or above compared to below 65 years of age was 6.9 (95% CI: 5.0-9.7), and for women 65 years of age or above compared to the whole group the OR was 4.7 (95% CI: 3.6-6.0). The OR for age in general, i.e., above or 65 years of age compared to those younger than 65 was 8.3 (95% CI: 6.2-11.1). During the last decade incidence figures for CC have also been reported from Calgary, Canada during 2002-2004 (4.6/10⁵) and from Terrassa, Spain during 2004-2008 (2.6/10⁵). Our incidence figures from southern Sweden during 2001-2010 (5.4/10⁵) as well as the incidence figures presented in the studies during the 1990s (Terrassa, Spain during 1993-1997 (2.3/10⁵), Olmsted, United States during 1985-2001 (3.1/10⁵), Örebro, Sweden during 1993-1998 (4.9/10⁵), and Iceland during 1995-1999 (5.2/10⁵) are all in line with a north-south gradient, something that has been suggested before both for CC and inflammatory bowel disease.

CONCLUSION: The observed incidence of CC is comparable with previous reports from northern Europe and America. The incidence is stable but the female: male ratio seems to be decreasing.

Lymphocytic colitis and collagenous colitis: a review of clinicopathologic features and immunologic abnormalities

Lymphocytic colitis (LC) and collagenous colitis (CC), 2 histologic forms of microscopic colitis, were recognized as rare disease entities 4 decades ago. An increasing body of evidence accumulated in the past 40 years reveals increasing incidence and prevalence rates, a wide spectrum of clinical presentations, and several histologic variants. Although several recent randomized clinical trials confirmed the efficacy of oral budesonide in treating LC and CC, disease relapse after a short-duration treatment is common. Despite their common clinical presentations and well-defined histologic diagnostic criteria, there are only few studies on the immunologic abnormalities in colonic tissue. The aim of this review is to (1) familiarize the pathologists in general practice with histomorphology of LC and CC, including the rare histologic variants and the clinical implication associated with these 2 diagnoses, (2) summarize the data from recent randomized clinical trials of oral budesonide, and (3) review immunological studies on colonic tissue. Overall, immunologic abnormalities of colonic tissue seem to explain for the histomorphologic features and the clinical symptomatology of LC and CC. Advances in the understanding of the underlying immunologic abnormalities in the colonic tissue may help develop novel and effective therapies for these 2 diseases.

Distinct colonoscopy findings of microscopic colitis: Not so microscopic after all?

Microscopic colitis (MC) is considered an “umbrella term”, comprising two subtypes, i.e., collagenous colitis (CC) and lymphocytic colitis (LC). They are classically associated with normal or unremarkable colonoscopy. In the last few years, reports have been published revealing findings that are thought to be characteristic or pathognomonic of MC, especially CC. A systematic electronic and manual search of PubMed and EMBASE (to December 2010), for publications on distinct endoscopic findings in MC, resulted in 42 relevant reports for inclusion in this review. Eighty eight patients with collagenous colitis were presented. Only one publication describing a distinct endoscopic pattern in LC was found. Typical findings in CC are alteration of the vascular mucosal pattern, mucosal nodularity, a sequence of change from mucosal defects to mucosal cicatricial lesions, and perhaps (although of doubtful relevance) mucosal pseudomembranes. A causal connection of mucosal defects with the use of lansoprazole seems to exist. Adoption of the proposed lesion description herein is recommended in order to improve homogeneity of future reports.

Review article: Microscopic colitis--lymphocytic, collagenous and 'mast cell' colitis

BACKGROUND

Microscopic colitis is a relatively common cause of chronic diarrhoea in predominantly older adults, traditionally termed lymphocytic colitis and collagenous colitis. Increased mast cells found in the colonic biopsies of some patients with chronic diarrhoea may represent a distinct type of microscopic colitis.

AIM

To provide an updated review of the epidemiology, diagnosis and treatment of microscopic colitis, and to discuss the role of mast cells in the gastrointestinal tract and their potential role in cases of functional diarrhoea.

METHOD

A MEDLINE literature search was performed to identify pertinent articles. Relevant clinical abstracts were also reviewed.

RESULTS

Incidence rates of microscopic colitis (lymphocytic and collagenous colitis) have increased over time, to levels comparable with other forms of inflammatory bowel disease. The possibility of drug-induced microscopic colitis and concomitant coeliac sprue are important considerations when evaluating these patients. There are few controlled treatment trials in microscopic colitis, with much of the data on treatment coming from retrospective studies. Mast cells have been implicated in functional bowel disorders, with increased mast cells possibly contributing to cases of otherwise unexplained chronic diarrhoea, although this concept requires further investigation.

CONCLUSIONS

In patients with microscopic colitis, a systematic approach to therapy often leads to satisfactory control of symptoms. The role of mast cells in chronic diarrhoea represents an evolving field, with the potential to offer alternative treatment pathways in patients with otherwise unexplained functional diarrhoea.

Low bone mass in microscopic colitis

Background

Microscopic colitis presents with similar symptoms to classic inflammatory bowel diseases. Osteoporosis is a common complication of Crohn's disease but there are no data concerning bone metabolism in microscopic colitis.

Aims

The aim of the present study was to evaluate bone density and metabolism in patients with microscopic colitis.

Methods

Fourteen patients microscopic colitis were included in the study, and 28 healthy persons and 28 age and gender matched Crohn's disease patients were enrolled as controls. Bone mineral density was measured using dual x-ray absorptiometry at the lumbar spine, femoral neck and the radius. Serum bone formation and bone resorption markers (osteocalcin and beta-crosslaps, respectively) were measured using immunoassays.

Results

Low bone mass was measured in 57.14% patients with microscopic colitis. Bone mineral density at the femoral neck in patients suffering from microscopic colitis and Crohn's disease was lower than in healthy controls (0.852 ± 0.165 and 0.807 ± 0.136 vs. 1.056 ± 0.126 g/cm²; p < 0.01). Bone mineral density at the non-dominant radius was decreased in microscopic colitis patients (0.565 ± 0.093 vs. 0.667 ± 0.072 g/cm²; p < 0.05) but unaffected in Crohn's disease patients (0.672 ± 0.056 g/cm²). Mean beta-crosslaps concentration was higher in microscopic colitis and Crohn's disease patients than controls (417.714 ± 250.37 and 466.071 ± 249.96 vs. 264.75 ± 138.65 pg/ml; p < 0.05). A negative correlation between beta-crosslaps concentration and the femoral and radius t-scores was evident in microscopic colitis patients.

Conclusions

Low bone mass is frequent in microscopic colitis, and alterations to bone metabolism are similar to those present in Crohn's disease. Therefore, microscopic colitis-associated osteopenia could be a significant problem in such patients.

Microscopic colitis

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.

A colorectal mosaic pattern might be an endoscopic feature of collagenous colitis

BACKGROUND AND AIMS

The endoscopic aspect of the colorectal mucosa in those patients with collagenous colitis is usually normal, or with non-specific changes. Until now it had never been related to a mucosal pattern of mosaic type. Our aim was to determine the diagnostic accuracy of the presence of mosaic pattern in the colorectal mucosa for collagenous colitis.

METHODS

Patients who had undergone a colonoscopy with random biopsies performed in the diagnostic evaluation of chronic diarrhea between 2004 and 2008 were studied. We defined patients with chronic diarrhea and mosaic mucosal pattern as "cases", and patients with chronic diarrhea without mosaic pattern as "controls". The odds ratio (OR) of finding a collagenous colitis in view of a mosaic pattern in colon was determined; as well as sensitivity and specificity; positive and negative likelihood ratios (LR+, LR-), considering this finding as a diagnostic instrument for collagenous colitis.

RESULTS

252 patients who had undergone colonoscopy with biopsy due to chronic diarrhea were analyzed. In 6 patients, a mosaic pattern was identified in the colorectal mucosa. The histological diagnose of 36 of the 252 patients (14%) was microscopic colitis, 27 of which (11%) had collagenous colitis. The colonoscopy was found normal in 21 of these 27 patients; in 2 patients, congestion or petechiae was found in the rectum; and in 4 patients (15%), all women, a mosaic pattern was found in the rectosigmoid mucosa. The OR of this finding was 19.4 (CI 95% 3.9-95.4) for collagenous colitis. It had a sensitivity of 14.8% (CI 95% 6.8-20), a specificity of 99.1% (CI 95% 98.2-99.7), LR+ of 16.6 (CI 95% 3.7-76.4), and LR- of 0.86 (CI 95% 0.80-0.95) for a collagenous colitis.

CONCLUSION

The mosaic pattern in the colorectal mucosa of patients studied due to chronic diarrhea could be a distinguishing feature of collagenous colitis.

Microscopic colitis -- a common cause of diarrhoea in older adults

Diarrhoeal diseases are common in older populations and often markedly affect their quality of life. Although there are numerous potential causes, microscopic colitis (MC) is increasingly recognised as a major diagnostic entity in older individuals. MC is comprised of two distinct histological forms - collagenous colitis and lymphocytic colitis, both of which frequently occur in older populations. Recent studies suggest that between 10 and 30% of older patients investigated for chronic diarrhoea with an endoscopically normal appearing colon will have MC. It is unclear why MC is more common in older populations, but it is associated with both autoimmune disorders and several drugs that are commonly used by seniors. A definitive diagnosis can only be made with colonic biopsies. Since MC was first described in 1976 and only recently recognised as a common cause of diarrhoea, many practising physicians may not be aware of this entity. In this review, we outline the epidemiology, risk factors associated with MC, its pathophysiology, the approach to diagnosis and the management of these individuals.

Colonic left-side increase of eosinophils: a clue to drug-related colitis in adults

BACKGROUND

The colon shows frequent eosinophilic infiltration in allergic proctocolitis of infants, whereas in adults, eosinophilic infiltration of the colon is less defined and may be found in different conditions including drug-induced colitis, even though the pathological findings are often inconsistent.

AIM

To quantify eosinophils in the mucosa of normal controls and to compare them with those of patients with abdominal symptoms related to 'drug colitis'.

METHODS

Mucosal biopsies were obtained during colonoscopy in 15 controls and in 27 patients with abdominal symptoms, a history of probable 'drug-related colitis' and without obvious causes of eosinophilia.

RESULTS

The drugs related to the patient symptoms were nonsteroidal anti-inflammatory drugs (70%), antiplatelet agents (19%) and oestroprogestinic agents (11%). Colonoscopy was normal in 30% of patients and abnormal in 70%. Histology showed low content of inflammatory cells and normal crypt architecture in-patients with endoscopy similar to inflammatory bowel diseases. The eosinophil score was significantly higher in the left side of the colon in the patient group compared with controls.

CONCLUSIONS

The finding of an increased eosinophil count limited to the left (descending and sigmoid) colon is an important clue towards a diagnosis of drug-related colitis.

Microscopic colitis with giant cells: a clinico-pathological review of 11 cases and comparison with microscopic colitis without giant cells

AIM

To document clinical and pathological features of microscopic colitis with giant cells (MCGC) which is one of a number of atypical variants of microscopic colitis.

METHODS

Cases of microscopic colitis were assessed for giant cells during routine reporting and retrieved from the slide file at a private laboratory. The histological features and clinical data were assessed. Histochemistry (trichome and haematoxylin van Gieson) and immunohistochemistry (CD68) was performed to characterise the nature of the giant cells.

RESULTS

Giant cells were identified in 11 cases of microscopic colitis. The histological features of MCGC are not significantly different from usual MC except for the presence of multinucleated giant cells in the superficial lamina propria. Apart from the common but not unexpected association with autoimmune disease, no unique clinical features of the MCGC group were identified versus those described in the literature for ordinary MC. Immune disorders included gluten-sensitive enteropathy, systemic lupus erythematosus and raised titres of antinuclear antibodies.

CONCLUSIONS

The giant cells have the same immunohistochemical characteristics as histiocytes and appear to form through histiocyte fusion. The presence of giant cells does not appear to confer any further clinical significance and remains a histological curiosity.

Clinical significance of colonic intraepithelial lymphocytosis in a pediatric population

The significance of colonic intraepithelial lymphocytosis has been well described in adults, and is associated with lymphocytic colitis, untreated celiac disease, and medications, among others. Little is known about the meaning of colonic intraepithelial lymphocytosis in the pediatric population; this study examines this finding in a cohort of children. Twenty patients in whom colonic intraepithelial lymphocytosis was a prominent feature were identified from 1999 to 2005. Colonic intraepithelial lymphocytosis was defined as 20 or more intraepithelial lymphocytes per 100 colonocytes present in at least one colonic mucosal biopsy. Each biopsy was examined for numbers of intraepithelial lymphocytes per 100 surface and crypt colonocytes; various architectural, inflammatory, and metaplastic changes were also noted. When available, concurrent duodenal and/or ileal biopsies were examined. Studied clinical parameters included indications for biopsy, clinical follow-up, final diagnosis, comorbidities, autoimmune serologies, and medications. A total of 121 colonic mucosal biopsies were examined in 20 patients who ranged from 1 to 17 years (mean 10.2 years; 40% male). Common indications for endoscopy included diarrhea and abdominal pain. A mean of 29 (+/-22) intraepithelial lymphocytes per 100 enterocytes were seen. Seven patients had colonic intraepithelial lymphocytosis as the only histologic finding. The remaining 13 patients had additional architectural, inflammatory, and metaplastic changes. The mean follow-up period was 14 months (range 1-48 months). Inflammatory bowel disease was diagnosed in 4 of 20 patients and was seen chiefly in biopsies in which colonic intraepithelial lymphocytosis was associated with architectural or inflammatory changes. Common disease associations include celiac disease, lymphocytic colitis, and autoimmune enteropathy. Pediatric colonic intraepithelial lymphocytosis, in the absence of other histologic findings, is associated with various diseases, including celiac disease, lymphocytic colitis, and autoimmune enteropathy. Colonic intraepithelial lymphocytosis in the presence of other inflammatory changes indicates the possibility of idiopathic inflammatory bowel disease. These findings are similar to those seen in adults, with the exception of autoimmune enteropathy.

Clinical features of microscopic colitis in a nation-wide follow-up study in Iceland

OBJECTIVE

The long-term natural history of collagenous colitis (CC) and lymphocytic colitis (LC) is not well known. The few reports available that address these issues have a limited follow-up. The aims of this study were to evaluate the natural history of microscopic colitis (MC), to describe the treatment medications prescribed and to assess the use of non-steroidal anti-inflammatory drugs (NSAIDs) in MC.

MATERIAL AND METHODS

This study is based on an earlier epidemiological study conducted in Iceland where 125 patients with MC (71 with CC and 54 with LC) were diagnosed in the period 1995-99. All patients still alive and available were questioned about symptoms, treatment and NSAID use in the 3 months preceding the interview.

RESULTS

In a mean follow-up time of 6.4 years from diagnosis, 15% of the patients had diarrhoeal symptoms more than once a week, 30% less than once a week and 55% had no diarrhoea. Abdominal pain was reported in 18% of the patients. There was no statistically significant difference in symptoms of CC and LC patients. Forty-eight patients (50%) were receiving medication for MC, 16% used aminosalicylates and 14% corticosteroids. Patients using medication for MC had significantly more diarrhoeal symptoms compared with those who did not (p = 0.002). Patients using NSAIDs regularly or as required, statistically did not have more symptoms related to MC than non-NSAID users.

CONCLUSIONS

Only a minority of patients with MC had diarrhoea more than once a week in a long-term follow-up and the symptom pattern was similar between CC and LC patients. The use of NSAIDs was not associated with more diarrhoeal symptoms.

Linear mucosal defect may be characteristic of lansoprazole-associated collagenous colitis

BACKGROUND

Although some cases of collagenous colitis have been induced by lansoprazole (LPZ), the clinicopathologic features of LPZ-associated collagenous colitis have not been elucidated.

OBJECTIVE

To elucidate the clinical, endoscopic, and histopathologic features of LPZ-associated collagenous colitis.

DESIGN

Retrospective case study.

PATIENTS

The subjects were 13 patients with collagenous colitis diagnosed during a period from 2002 to 2007.

MAIN OUTCOME MEASUREMENTS

The colonoscopic and histopathologic findings were compared retrospectively between 9 cases of LPZ use (LPZ group) and 4 cases without the use of LPZ (non-LPZ group).

RESULTS

A colonoscopy revealed a linear mucosal defect more frequently in the LPZ group (7 of 9 cases [78%]) than in the non-LPZ group (0 of 4 cases [0%], P = .02). Friable mucosa was also noted in 4 patients (44%) in the LPZ group but none in the non-LPZ group. The colonoscopic finding in the non-LPZ group was either normal mucosa or nonspecific minimal abnormalities, whereas patients in the LPZ group had either a linear mucosal defect, mucosal bleeding, or both (P = .001). On histologic examination, the subepithelial collagen band was thicker in patients in the LPZ group than in those in the non-LPZ group (median 45 vs 26.3 mum). All patients in the LPZ group recovered from diarrhea after discontinuance of LPZ.

LIMITATION

A small number of patients.

CONCLUSIONS

Linear mucosal defects and friable mucosa may be characteristic colonoscopic findings in cases of LPZ-associated collagenous colitis.

Gastrointestinal tract pathology in patients with common variable immunodeficiency (CVID): a clinicopathologic study and review

BACKGROUND

Common variable immunodeficiency (CVID) is characterized by a host of gastrointestinal (GI) lesions that can mimic other conditions.

METHODS

We reviewed clinical documentation and samples from 132 separate GI biopsy or resection sites on 20 CVID patients obtained over a 26-year period, including biopsies from the colon (34), esophagus (19), small intestine (38), and stomach (35), a partial gastrectomy, small bowel resection, colectomy, 2 cholecystectomies, and 1 appendectomy.

RESULTS

There were 13 males and 7 females. Nine patients were children (10 y and younger) and 11 were adults. Age at diagnosis ranged from 6 months to 62 years (median, 35.5 y), and age at biopsy ranged from 10 months to 67 years (median, 38 y). Esophageal samples often showed intraepithelial neutrophils, accompanied by candida. Half of patients' esophageal biopsies had prominent intraepithelial lymphocytosis, one of which also had prominent apoptosis. The stomachs of 67% of patients lacked plasma cells. Most showed lymphoid aggregates. An increase in apoptosis was detected in biopsies from a third. About 20% had a lymphocytic gastritis pattern. Intraepithelial neutrophils were found in a subset, accompanied by various infections [cytomegalovirus (CMV), Helicobacter pylori, and Cryptosporidium]. Granulomas were found in 1 patient. Gastric adenocarcinoma was identified in one patient. There was a paucity of small bowel plasma cells in the majority of patients (68%). The small bowel showed prominent lymphoid aggregates in about half (47%). An increase in apoptosis was detected in specimens from about 20%. Increased intraepithelial lymphocytes (IELs) were found in samples from over half of patients (63%), most of whom (83%) also had villous blunting, mimicking celiac disease. Intraepithelial neutrophils were found in a subset (32%) and correlated with CMV and Cryptosporidium infections. Granulomas were seen in biopsies from 2 patients (11%). One patient had a collagenous enteritis pattern (accompanied by a collagenous colitis pattern). One patient had autoimmune enteritis; biopsies from this patient were initially relatively normal but later displayed prominent crypt apoptosis and loss of goblet cells. In colon samples, a paucity of plasma cells was seen in 10 patients (63%). The colon showed lymphoid aggregates in most patients (81%). Apoptosis was prominent in samples from half of the patients (50%). Biopsies from 6 patients had a lymphocytic colitis pattern (38%) and 2 patients had a collagenous colitis pattern. Intraepithelial neutrophils were found in samples from most patients (88%). Crypt distortion was seen in 6 of these patients (43%), thereby mimicking ulcerative or Crohn colitis. Granulomas were found in 3 patients (19%). CMV was detected in 1 patient. The appendix from 1 patient showed Cryptosporidium and acute serositis with a paucity of plasma cells and an increase in apoptosis. The gallbladder from 1 patient showed acute cholecystitis, and another patient's gallbladder lacked plasma cells.

CONCLUSIONS

GI tract CVID displays a wide spectrum of histologic patterns. Its features can mimic lymphocytic colitis, collagenous enterocolitis, celiac disease, lymphocytic gastritis, granulomatous disease, acute graft-versus-host disease, and inflammatory bowel disease. In fact, in our series, we found patients with a prior diagnosis of celiac disease (25%) and inflammatory bowel disease (35%), including Crohn disease (15%). The diagnosis of CVID may be suspected on the basis of the lack of plasma cells in a GI biopsy, but because this feature is only present in about two-thirds of patients, the diagnosis cannot always be suggested in isolation of other clinical and laboratory findings.

The risk of microscopic colitis in solid-organ transplantation patients: a population-based study

BACKGROUND

Microscopic colitis (MC) has not been recognized as a complication of transplantation because patients are on immunosuppressant medications. The objective of this work was to describe the risk of developing MC after solid-organ transplantation.

METHODS

This population-based cohort study identified all cases of MC diagnosed after kidney, kidney and pancreas, or liver transplantation using pathology and transplantation databases. The annual incidence and point prevalence of MC after transplantation was calculated. The incidence rate of MC among transplantation patients was compared with the general population and presented as a Standardized Incidence Ratio (SIR) with 95% confidence intervals.

RESULTS

Seven cases (0.9%) of MC were diagnosed in kidney (n=2), kidney and pancreas (n=1), and liver (n=4) transplantation recipients. The point prevalence of MC was 8.8 per 1000 transplantation recipients. The annual incidence rate of MC in solid-organ transplantation patients was 5.0 cases per 1000 person-years. The SIR of developing MC after transplantation was 50.5 (95% confidence interval 13.6-131.8). The average age of diagnosis of MC was 49.4+/-5.3 years, average time of onset from transplantation was 67.4+/-27.0 months, and the average latency period was 30.1+/-9.0 months. Once diagnosed, all patients responded to MC-specific therapy.

CONCLUSION

Physicians should have a low threshold to investigate for MC in solid-organ transplantation recipients who present with chronic diarrhea because this population is at an increased risk of developing MC.

Low-dose aspirin-induced gastrointestinal diseases: past, present, and future

Meta-analyses of randomized, placebo-controlled trials of low-dose aspirin indicate that aspirin approximately doubles the risk of major GI bleeding compared with placebo. The risk in Japanese may possibly be higher compared to Western populations, although the evidence is still lacking and prospective studies are required. Prior GI events, older age, and use of other injurious medicines such as NSAIDs, anticoagulants, and corticosteroids seem to be factors associated with an increased risk for upper GI bleeding among aspirin users. Prospective studies are needed to identify specific risk factors for upper GI bleeding in Japanese patients taking low-dose aspirin. There are many potential gastroprotective drugs available in Japan, and studies are needed to assess the relative effectiveness of various strategies including PPI use for the prevention of aspirin-related upper GI ulcer complications and whether any of these other agents also provide protection against small bowel or colonic damage. Aspirin-induced enteropathy is now increasingly being recognized and is presumably not uncommon, and the availability of new imaging techniques for the small intestine and noninvasive tests such as fecal calprotectin should allow rapid progress in this important area.

Clozapine-induced microscopic colitis: a case report and review of the literature

Both diarrhea and colitis associated with clozapine have been reported. In this article, the authors present a case of clozapine-induced microscopic colitis (MC)-the first reported in the literature. The definitive diagnosis was suggested on colon biopsy, which showed an intraepithelial lymphocytosis (with >20 lymphocytes for every 100 epithelial cells) more striking in the surface epithelium than in the crypts. In addition, there were a mixed inflammatory infiltrate in the lamina propria (with lymphocytes predominating over eosinophils and neutrophils), an architecturally preserved colonic mucosa (particularly in the crypts), and a subepithelial collagen band normally thickened (<10 microm). Clozapine was thought to be the culprit and discontinued. After some days, the patient gradually improved. Diarrhea and spiking fever disappeared within 72 hours. Multiple colon biopsies taken after 7 days from the discontinuation of the clozapine revealed no abnormal histological findings. It is important to clarify the issue of clozapine-induced MC because MC may require the use of expensive or potentially toxic treatments and can occasionally be life-threatening (eg, hypokalemia). Thus, any case of MC that can be cured by withdrawal of the clozapine must be investigated and identified.

Collagenous colitis: oral low-dose methotrexate for patients with difficult symptoms: long-term outcomes

AIM

To perform a qualitative retrospective review of identified cases of collagenous colitis within the patient databases of local clinicians, with particular attention to the use and effectiveness of oral low-dose methotrexate.

METHODS

Gastroenterologists in the referral area were invited to identify collagenous colitis cases from their own databases for inclusion in the study. Patients were considered eligible if they had a symptom history and colonic mucosal histology consistent with collagenous colitis. The retrospective analysis identified age at diagnosis, previous therapies, date of commencement and duration and effectiveness of methotrexate, side-effects, and repeat colonic mucosal histology (if available) after a period of treatment.

RESULTS

Between 1986 and 2003, 43 eligible patients were identified, ranging in age from 32 years to 88 years at the time of diagnosis. Nineteen of the 43 received methotrexate over varying periods, and in 16 of these the clinical response was considered either 'Good' (14) or 'Partial' (2). In the methotrexate group 10 of the 19 underwent repeat colonoscopy and mucosal biopsy at some stage after commencing methotrexate. Of these, five had normal histology in comparison with pretreatment abnormal histology, two had improvement but not normalization of histology, and three had unchanged abnormal histology.

CONCLUSION

The data from this retrospective review suggest that methotrexate may have a beneficial effect on symptoms of collagenous colitis and may improve the underlying histological abnormality. A controlled trial of adequate power and duration is needed to further clarify the usefulness of methotrexate in this condition.

Drug-induced injury in the gastrointestinal tract: clinical and pathologic considerations

Drug toxicity in the gastrointestinal tract is a common and serious medical problem; the number of drugs that can harm the gastrointestinal tract is impressive. The morbidity, mortality, and medical costs associated with drug toxicity, even when restricted to the gastrointestinal tract, are probably underestimated. Drug-induced gastrointestinal tract pathology is very diverse and can mimic many non-drug-related conditions. Drug toxicity, whether direct or indirect, can be restricted to a segment of the gastrointestinal tract or affect the entire gastrointestinal tract. The consequences of drug toxicity are also quite variable and can range from unimportant pathology (e.g. the relatively common and usually benign drug-induced diarrhea) at one end of the spectrum, to fatal gastrointestinal tract hemorrhage or perforation at the other end of the spectrum. Better awareness of the possibility of drug-induced gastrointestinal tract pathology, by both gastroenterologists and pathologists, and better communication between gastroenterologists, pathologists and other specialists will improve the recognition of drug-induced gastrointestinal tract pathology, and, ultimately, improve patient care. This Review focuses on the most common and well-described drug-related clinicopathologic conditions of the gastrointestinal tract. Much discussion is, therefore, dedicated to NSAIDs--the most commonly prescribed drugs and consequently the drugs most commonly associated with gastrointestinal tract toxicity.

Pathological effects of drugs on the gastrointestinal tract: a review

Drug-induced injury of the gastrointestinal (GI) tract is increasingly common but generally under-recognized. Although there is an overwhelming number of drugs that are associated with adverse GI effects, there is a limited number of characteristic injury patterns that should prompt consideration of drug-induced GI pathology. These include the following: erosions, ulcers, and strictures; crystal deposition; parietal cell changes; reactive gastropathy; pseudodysplastic changes; microscopic colitis; infectious or necrotizing enterocolitis; ischemic colitis; focal active colitis; and increased epithelial apoptosis. This article reviews morphological and pathophysiological features of some of the more common and pathologically recognizable drug-related injury patterns and provides a practical guide for the recognition and diagnosis of drug-induced pathology in the upper and lower GI tract.