Diagnosis and treatment of microscopic colitis

Evaluation of TNF-α and IFN-γ primed conditioned medium of mesenchymal stem cell in acetic acid-induced mouse model of acute colitis

IBD, an autoimmune-inflammatory disorder that affects people who are genetically prone to inflammation. There is a lot of interest in MSC-CM therapy, especially when primed with TNF-α + IFN-γ. Throughout the study, data were collected on the percentage of apoptotic cells, gene expression of ZO-1, Foxp3, GATA3, IDO-1, Muc2, T-bet, Notch1, TNFR2, and ROR-γt, colon weight and length, histopathological analysis, and DAI. TNF-α and IL-10 levels were assessed in addition to the NO level. The results suggest that primed MSC-CM improved DAI, mucosal deterioration, intestinal inflammation and NO concentration. The amount of TNF-α was decreased, but IL-10 and the colon's percentage of apoptotic cells was increased. The mRNA expression of ZO-1, Foxp3, GATA3, IDO-1, and Muc2 genes increased greatly in the treatment groups, while the expression of T-bet, Notch1, TNFR2, and ROR-γt genes has decreased. These studies suggest that primed MSC-CM may combine with common treatments to improve responsiveness.

Spontaneous colonic perforation with collagenous colitis in an elderly patient

Collagenous colitis (CC) is a variant of microscopic colitis that causes chronic, non-bloody, and watery diarrhea. The natural history of CC is generally benign and serious complications are rare. Perforation, especially spontaneous perforation, is a particularly rare complication. A 90-year-old woman presented with acute abdominal pain. She was diagnosed with peritonitis due to colonic perforation, and partial colectomy was performed. Macroscopic findings showed well-circumscribed longitudinal ulcer, and a pathological examination revealed descending colon perforation with CC. She had no history of examination and the case was considered to be spontaneous. The postoperative course was uneventful and she had no recurrence of CC after changing from the suspected drug (lansoprazole) to an H2-blocker. The characteristics of perforation by CC are characteristic longitudinal ulcer and micro-perforation. If it can be diagnosed accurately, conservative treatment may be an option. In spontaneous cases, the history of medication and the site of perforation may assist in this decision.

Collagenous Colitis Possibly Associated with Dipeptidyl Peptidase-4 Inhibitor

A 60-year-old man with type 2 diabetes mellitus treated with a dipeptidyl peptidase-4 (DPP-4) inhibitor was referred to our hospital because of his refractory watery diarrhea. Ileocolonoscopy revealed increased capillary growth, fine granular mucosa, and longitudinal mucosal tears mainly in the left side of the colon. A bioptic examination revealed thickened subepithelial collagen bands, thus confirming the diagnosis of collagenous colitis. Systemic steroid therapy was initiated, but his symptoms recurred when tapering the steroid. However, withdrawal of the DPP-4 inhibitor was successful even after the cessation of steroid therapy. We therefore considered his collagenous colitis to have been caused by the DPP-4 inhibitor.

Proctocolectomy and ileal pouch-anal anastomosis for the treatment of collagenous colitis

The role of surgery for collagenous colitis (CC) is unexplored. Either diverting stoma, subtotal colectomy with ileo-rectal anastomosis, and proctocolectomy with ileal pouch-anal anastomosis (IPAA) have been proposed. However, the optimal surgical strategy still needs to be defined. The aim of this short report is to report our experience with two cases of IPAA for CC. Two patients affected by histologically proven CC with watery diarrhea refractory to several lines of medical treatment underwent a laparoscopic proctocolectomy with IPAA at a tertiary referral hospital for the treatment of Inflammatory Bowel Disease in Belgium. A longer rectal cuff was left in place because of the absence of macroscopic inflammation of the rectal mucosa and the consequent negligible risk of cuffitis. No postoperative complications (90 days) occurred. Definitive pathological examination confirmed the diagnosis of CC. At six months, pouchoscopy revealed no signs of inflammation. One year after surgery, mean Öresland and Pouch Functional Score were 10.5 (8-13) and 11.5 (9-14). Functional outcomes after IPAA for CC were barely satisfactory. A high stool frequency not responding to high doses of anti-diarrheals was observed. This has also previously been reported for CC patients receiving a diverting stoma. Proctocolectomy and IPAA for medical refractory CC leads to acceptable short-term gastrointestinal functional outcomes which seems to be particularly affected by high stool frequency. For this reason, pouch surgery might not be the optimal indication for collagenous colitis.

Collagenous colitis in a child induced by chronic respiratory allergy: A case report

INTRODUCTION

Collagen colitis (CC) is a microscopic colitis diagnosed by mucosal biopsy and is extremely rare in children.

PATIENT CONCERNS

We reported a child with severe persistent diarrhea that could not be relieved with traditional diarrheal treatment. No abnormalities were found after multiple colonoscopies.

DIAGNOSES

A significant increase in total IgE levels was found in the patient's blood. He had a history of mild chronic allergic rhinitis and slightly intermittent wheezing. However, we found that the child had a hyperallergic reaction to multiple respiratory antigens and had mild pulmonary dysfunction. Finally, colonoscopy with biopsy identified the diagnosis of CC.

INTERVENTION

Considering that a respiratory allergic reaction was one of the causes of diarrhea, anti-allergic treatment was given to the child, and his severe diarrhea was soon relieved. Corticosteroid treatment was suggested to the patient, but his parents firmly refused steroid therapy. According to the patient's specific allergic reaction to mites, desensitization treatment was finally chosen for him.

OUTCOMES

After 1 year of desensitization for dust mites, the patient's respiratory symptoms improved, total IgE levels decreased, autoantibodies declined, and diarrhea did not reoccur. Colonoscopy with biopsy showed a significant improvement in pathology.

CONCLUSION

CC in children is rare, and childhood CC induced by a respiratory allergic reaction has not been previously reported. Therefore, this is a special case of CC in a patient who was cured with anti-allergy treatments and desensitization instead of steroid therapy.

Microscopic colitis: pathophysiology and clinical management

Microscopic colitis is a chronic inflammatory disease of the colon that frequently causes chronic watery diarrhoea that might be accompanied by abdominal pain, nocturnal diarrhoea, urgency, and faecal incontinence. These symptoms lead to poor quality of life and increased health-care costs. Diagnosis relies on histological examination of multiple biopsy samples from the colonic mucosa, which often show no or only few abnormalities on endoscopy. Two major histological subtypes can be distinguished-collagenous colitis and lymphocytic colitis-but incomplete and variant forms with fewer characteristic features have been reported. Here we summarise the latest evidence on epidemiology, pathogenesis, and risk factors, and discuss established and novel therapeutic options for clinical remission. Finally, we propose an updated treatment algorithm. Further prospective studies are needed to clarify the natural history of microscopic colitis, supported by validated criteria for the assessment of disease activity.

Beclomethasone dipropionate in microscopic colitis: Results of an exploratory open-label multicentre study (COLCO)

Background

Budesonide has been proven to be an effective treatment for microscopic colitis (MC). However, the two current commercially available preparations are released in the ileum. Beclomethasone dipropionate (Clipper®) is a synthetic corticosteroid with topical colonic release.

Objective

This study aimed to explore whether an open-label treatment with beclomethasone dipropionate is an effective treatment for MC.

Methods

Prospectively collected data of 30 patients from six centres were retrospectively analysed. All patients had a confirmed diagnosis of idiopathic MC (lymphocytic and collagenous colitis) and were symptomatic (i.e. ≥ 21 loose stools over a seven-day period). Treatment consisted of 10 mg beclomethasone daily for four weeks, followed by 5 mg daily for another four weeks. The primary end point was the proportion of patients in remission (i.e. a mean of < 3 stools/day and a mean of <1 watery stool per day) after an eight-week treatment period. Secondary end points were the proportion of patients responding to therapy at weeks 4 and 8, remission at weeks 4 and 12 and relapse at week 12. Reported adverse events were collected.

Results

Overall, at week 8, remission was achieved in 70%, and 77% of patients were responding to treatment. After four weeks of treatment, 80% were responding, and 67% were in remission. Four weeks after stopping treatment, 60% were still in remission.

Conclusion

This open-label study suggests that an eight-week course of beclomethasone could be a promising and relatively safe treatment for MC. A randomised controlled study is warranted.

Management of elderly ulcerative colitis in Japan

Japan has the largest aging society, where many elderly people have intractable diseases including ulcerative colitis (UC). Along with the increasing total number of UC patients, the number of elderly UC patients has also been increasing and will continue to do so in the future. Although the clinical features and natural history of UC in the elderly have many similarities with UC in the non-elderly population, age-specific concerns including comorbidities, immunological dysfunction, and polypharmacy make the diagnosis and management of elderly UC challenging compared to UC in non-elderly patients. Based on increasing data related to elderly UC patients from Japan, as well as other countries, we reviewed the epidemiology, clinical course, differential diagnosis, management of comorbidities, surveillance, medical therapy, and surgery of UC in the elderly.

Research progress and perspectives of microscopic colitis

Microscopic colitis (MC) is a common cause of chronic diarrhea. Over the past 20 years, the prevalence of MC has been increasing rapidly, which has aroused the close attention of digestive physicians. The etiology of MC is still unknown, and immune abnormalities are the main pathogenesis, followed by some drugs. MC is clinically characterized by chronic non-bloody watery diarrhea, spastic abdominal pain, weight loss, and fatigue, but colonoscopy is often normal or roughly normal. Colonic biopsy often shows mucosal inflammation or subepithelial collagen band thickening, based on which a diagnosis can be made. At present, there has been no special treatment for MC, with steroid budesonide and immunosuppressive agents being the main treatments. As a self-limiting disease, MC has a good prognosis. Studies have found that MC has a protective effect against colorectal cancer. However, it was recently found that innate immune abnormalities may have carcinogenic effects.