Diarrhoea is not the only symptom that needs to be treated in patients with microscopic colitis

Microscopic colitis found together with celiac disease in a female population is associated with one episode of lymphocytic colitis

BACKGROUND

Microscopic colitis (MC) is considered a chronic disease associated with autoimmune disease, smoking, and drugs. The aim was to examine the association between MC and celiac disease, adjusted for smoking, considering subtypes and clinical course of the disease in a retrospectively collected female cohort.

METHODS

Women (n = 240), ≤ 73 years, diagnosed as MC in medical records or pathological registers were invited. One hundred and fifty-eight women accepted to be included. Participants completed a study questionnaire about sociodemographic factors, lifestyle habits, and medical history; the Rome III questionnaire; and the visual analog scale for irritable bowel syndrome (VAS-IBS). Participants were categorized into collagenous colitis (CC) (n = 92) and lymphocytic colitis (LC) (n = 66) or MC with one episode of the disease (n = 70) and refractory MC (n = 88). Presence of IBS-like symptoms were noted. Blood samples were collected and analyzed for anti-transglutaminase antibodies. Differences between groups were calculated and logistic regression was adjusted for smoking habits.

RESULTS

MC and celiac disease debuted simultaneously in half of the cases. Celiac disease was most prevalent in LC (12.1% vs. 3.3%; p = 0.05) and MC with one episode (12.9% vs. 2.3%; p = 0.01). Anti-transglutaminase antibodies were found in one patient with one episode of MC. Corticosteroid use was most often found in CC (37.0% vs. 21.2%; p = 0.037) and refractory MC (38.6% vs. 20.0%; p = 0.015). Past smokers were most prevalent in patients with one episode of MC (54.3 vs. 29.5%; p = 0.007). Current smoking was the smoking habit with highest prevalence of IBS-like symptoms. When adjusted for smoking habits, celiac disease was associated with LC (OR: 4.222; 95% CI: 1.020-17.469; p = 0.047) and tended to be inversely associated with refractory MC (OR: 0.210; 95% CI: 0.042-1.506; p = 0.058).

CONCLUSION

Celiac disease is most common in patients with one episode of LC. The question remains whether LC in combination with celiac disease should be classified as celiac disease or two different entities.

Loose ends in the differential diagnosis of IBS-like symptoms

Two thirds of the patients we believed to have IBS in the 1970's have since been possible to diagnose with treatable conditions like bile acid diarrhea, inflammatory bowel disease, microscopic colitis, celiac disease, disaccharide malabsorption, exocrine pancreatic insufficiency, or rare genetic variants. Despite advances in diagnostic techniques a substantial proportion of patients continue suffering from IBS-like symptoms that cannot be explained by current knowledge. Although it is likely that further research will reveal small but important subgroups of patients with treatable mechanisms for IBS-like symptoms, we propose that only two large groups remain for being addressed in the clinic: those with connective tissue disorders such as Ehlers-Danlos syndrome or hypermobility spectrum disorders and those with autism spectrum disorders. Patients with connective tissue disorders exhibit identifiable disturbances of gut motor function and possibly increased gut permeability as underlying mechanisms for IBS-like symptoms. Autism spectrum disorders pose a much more difficult problem in the clinic. Disturbances of perception combined with anxiety and excessive worry about signals from the gut can lead to an endless but futile search for something being wrong. The search can involve large numbers of care givers, no one understanding the patient's suffering. Others may try to change their diet to lessen symptoms, only to find that almost all foods may cause worrying perceptions from the gut. Early recognition of autism spectrum disorders is essential for finding better ways to help patients with gastrointestinal and, as is often the case, extraintestinal symptoms.

OUP accepted manuscript

Microscopic colitis (MC) is a chronic inflammatory disease of the large intestine and as a relatively late recognized condition, its relationship with other disorders of the gastrointestinal tract is gradually being understood and investigated. As a multifactorial disease, MC interacts with inflammatory bowel disease, celiac disease, and irritable bowel syndrome through genetic overlap, immunological factors, and gut microflora. The risk of colorectal cancer was significantly lower in MC, gastrointestinal infections increased the risk of developing MC, and there was an inverse association between Helicobacter pylori infection and MC. A variety of associations are found between MC and other gastrointestinal disorders, where aspects such as genetic effects, resemblance of immunological profiles, and intestinal microecology are potential mechanisms behind the relationships. Clinicians should be aware of these connections to achieve a better understanding and management of MC.

Impact of tobacco and/or nicotine products on health and functioning: a scoping review and findings from the preparatory phase of the development of a new self-report measure

BACKGROUND

Measuring self-reported experience of health and functioning is important for understanding the changes in the health status of individuals switching from cigarettes to less harmful tobacco and/or nicotine products (TNP) or reduced-risk products (RRP) and for supporting tobacco harm reduction strategies.

METHODS

This paper presents insights from three research activities from the preparatory phase of the development of a new self-report health and functioning measure. A scoping literature review was conducted to identify the positive and negative impact of TNP use on health and functioning. Focus groups (n = 29) on risk perception and individual interviews (n = 40) on perceived dependence in people who use TNPs were reanalyzed in the context of health and functioning, and expert opinion was gathered from five key opinion leaders and five technical consultants.

RESULTS

Triangulating the findings of the review of 97 articles, qualitative input from people who use TNPs, and expert feedback helped generate a preliminary conceptual framework including health and functioning and conceptually-related domains impacted by TNP use. Domains related to the future health and functioning measurement model include physical health signs and symptoms, general physical appearance, functioning (physical, sexual, cognitive, emotional, and social), and general health perceptions.

CONCLUSIONS

This preliminary conceptual framework can inform future research on development and validation of new measures for assessment of overall health and functioning impact of TNPs from the consumers' perspective.

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.

Faecal microbiota transfer in patients with microscopic colitis - a pilot study in collagenous colitis

OBJECTIVES

Faecal microbiota transfer (FMT) consists of the infusion of donor faecal material into the intestine of patients with the aim to restore a disturbed gut microbiota.

METHODS

In this pilot study (NCT03275467), the effect of three repeated FMTs (day 0, two weeks, four weeks) was studied and followed up for six months in nine collagenous colitis (CC) patients, using two stool donors.

RESULTS

Five patients had an active disease at the time of baseline sampling. The primary endpoint (remission at six weeks, defined as <3 stools whereof <1 watery stool per day) was achieved by two of these patients, and by one at eight weeks. Overall, in all nine patients, FMT did not result in a significant reduction of watery stools, assessed by daily diary. However, diarrhoea (assessed by gastrointestinal symptom rating scale) was significantly improved at four (p = .038) and eight weeks (p = .038), indigestion at eight (p = .045) and 12 weeks (p = .006), disease-related worries at four (p = .027) and eight weeks (p = .027), and quality of life at six months (p = .009). FMT resulted in an increased number of lamina propria lymphocytes, possibly indicating an initial mucosal immune activation. No serious adverse events, no systemic effects, and no changes in faecal calprotectin and psychological symptoms were observed.

CONCLUSIONS

FMT is able to improve symptoms in a yet undefined subset of CC patients. Further studies could help to characterise this subset and to understand if these results can be generalised to all microscopic colitis patients.

The association between smoking and both types of microscopic colitis: A systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

It has been suggested that smoking may be associated with microscopic colitis (MC) in some studies; however, there are conflicting results in the current literature with many of these studies having significant limitations. Our study aims to offer a meta-analysis evaluating the association between MC, including both its subtypes, and smoking.

PATIENTS AND METHODS

A systemic review was conducted in PUBMED, Embase, PubMed Central, and ScienceDirect databases from inception through December 2019. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird and a pooled odds ratio (OR) was calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques.

RESULTS

Eight observation studies with a total of 1461 patients with MC were included in this study, 383 of whom were active smokers (26.2%). Current smoking was significantly associated with MC (OR 3.58, 95% CI, 2.51-5.11), lymphocytic colitis (LC) (OR 3.64, 95% CI, 2.46-5.38), and collagenous colitis (CC) (OR 4.43, 95% CI, 2.68-7.32). Gender-specific subgroup analysis showed a significant association with smoking was found for CC in men (OR 4.53, 95% CI, 1.59-12.85), CC in women (OR 3.27, 95% CI, 2.35-4.54), LC in women (OR 2.27, 95% CI, 1.27-4.06) and MC in women (OR 2.93, 95% CI, 2.09-4.10). We found no publication bias as assessed by the funnel plots and Egger's regression asymmetry test.

CONCLUSION

Our meta-analysis found a statistically significant association between smoking and both subtypes of MC.

Smoking in Irritable Bowel Syndrome: A Systematic Review

OBJECTIVE

The aim of this review was to examine (1) the prevalence of smoking in subjects with irritable bowel syndrome (IBS), (2) whether smoking prevalence significantly differs between subjects with and without IBS, and (3) whether smoking significantly predicts the presence or the development of IBS.

METHODS

Articles were retrieved by systematically searching the Scopus, Web of Science, and PubMed electronic databases from inception to July 2016, using the keywords "smoking" and "tobacco" combined with "irritable bowel syndrome." Reference lists of included articles were also searched. Articles were included if they (1) reported data on smoking prevalence in subjects with IBS and/or on the association (assessed by means of multivariate analyses) between smoking and IBS, (2) identified IBS according to Manning criteria or Rome I-III criteria, (3) were English-language articles, and (4) involved only adult subjects.

RESULTS

The electronic searches yielded a total of 1,637 records, and 42 articles met inclusion criteria. Another 13 articles were retrieved through manual search, leading to a total of 55 included articles. Smoking prevalence in subjects with IBS was assessed by 48 articles and ranged from 0% in university students to 47.1% in patients with microscopic colitis. Thirty-three articles compared smoking prevalence between subjects with and without IBS. In 25 articles no significant difference was found. In seven articles smoking was significantly more frequent in subjects with IBS compared to those without IBS, while one study found a significantly higher smoking prevalence in controls. Eighteen multivariate analyses assessing the association between smoking and IBS were presented in 16 articles. Only one study employed a prospective design. In 11 analyses, smoking was not significantly associated with IBS after adjusting for covariates. In seven studies smoking independently predicted the presence of IBS.

CONCLUSIONS

According to the selected articles, a significant association between smoking and IBS cannot be confirmed. However, different shortcomings may hinder generalizability and comparability of many studies. A dimensional assessment of smoking, a prospective design, the differentiation between IBS subgroups, and the recruitment of patients in clinical settings, especially in primary care, are necessary to clarify the role of smoking in IBS.

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.

Smoking is associated with several functional gastrointestinal symptoms

BACKGROUND

The etiology behind functional gastrointestinal symptoms is not clear. Only a few studies have examined how lifestyle factors affect these symptoms, especially in middle-aged or elder subjects. The aim of the present study was to describe the prevalence of functional gastrointestinal symptoms in a Swedish population-based cohort of middle-aged to elder subjects, and to examine associations between symptoms and smoking and alcohol use.

METHODS AND MATERIALS

This study was conducted on a web-based baseline questionnaire from a part of the EpiHealth study. The cohort included 16,840 subjects between 45 and 75 years of age. Subjects with organic gastrointestinal diseases were excluded. Gastrointestinal symptoms were defined as functional abdominal pain, functional bloating, functional constipation, and functional diarrhea. Parameters regarding age, gender, educational level, occupation, civil status, physical activity, and body mass index (BMI) were described, and association between smoking and alcohol habits were calculated, adjusted for parameters with >5 percentage difference between cases and controls.

RESULTS

An association was found between former and current smoking and functional abdominal pain (OR: 1.15, 95% CI: 1.03-1.28 vs. OR: 1.30, 95% CI: 1.08-1.57). Former smoking was associated with functional bloating (OR: 1.18, 95% CI: 1.04-1.33) and functional constipation (OR: 1.28, 95% CI: 1.06-1.56). There was a trend of decreased functional abdominal pain, functional constipation, and functional diarrhea in subjects with a moderate alcohol intake.

CONCLUSION

Smoking is associated with functional abdominal pain, functional bloating, and functional constipation. A moderate alcohol intake tends to be associated with decreased risk of functional gastrointestinal symptoms.

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.

New insights and challenges in microscopic colitis

Microscopic colitis (MC) is described as an inflammatory bowel disease characterized by chronic, bloodless diarrhea with normal or close to normal endoscopic findings. Histopathological examination reveals two subtypes: collagenous colitis (CC) and lymphocytic colitis (LC), which are indistinguishable clinically. The disease debuts typically in middle-aged patients, but can occur at all ages, including children. A female predominance is found in both CC and LC, but is not confirmed by others in LC. The etiology is unclear, but the disease has been assumed to be of autoimmune origin. However, several etiologies may render a microscopic inflammation in the mucosa; this is a common, universal reaction to a variety of irritants in contact with the intestinal lumen. Furthermore, some patients with a microscopic inflammation in their colonic mucosa have no symptoms, or are suffering from constipation or abdominal pain, rather than diarrhea. Recently, a discussion was initiated calling into question the overdiagnosing of symptoms and pointing out the danger of exacerbating people's perception of their ailments, of weakening their eligibility in health insurance, of overprescription of drugs, and thus the increasing cost to the society of health care. In the light of this discussion, this review will highlight histopathological and clinical features of MC, and discuss the diagnosis and management of this disease. Perhaps, the intestinal mucosa has no other mode by which to react than an inflammatory response, irrespective of the presence or absence of autoimmunity. Thus, to better identify and classify subgroups of MC, and to clarify and correctly handle the inflammatory changes, this field of research stands to benefit from a review of the results and experience gained to date.

Smoking- and alcohol habits in relation to the clinical picture of women with microscopic colitis compared to controls

Background

Microscopic colitis (MC) induces gastrointestinal symptoms, which are partly overlapping with irritable bowel syndrome (IBS), predominately in middle-aged and elderly women. The etiology is unknown, but association with smoking has been found. The aim of this study was to examine whether the increased risk for smokers to develop MC is a true association, or rather the result of confounding factors. Therefore, patients suffering from MC and population-based controls from the same geographic area were studied regarding smoking- and alcohol habits, and other simultaneous, lifestyle factors, concerning the clinical expression of the disease.

Methods

Women at the age of 73 years or younger, who had been treated for biopsy-verified MC at any of the Departments of Gastroenterology in Skåne, between 2002 and 2010, were invited to the study (240 patients). Women (737) from the population-based prospective cohort study, Malmö Diet and Cancer Study (MDCS), served as controls. A self-administered questionnaire about lifestyle factors, gastrointestinal symptoms, medical conditions and medication at the time for the study was sent by post.

Results

Altogether, 131 women with MC could be included after age-matching with controls (median age 56 years) and exclusion of secondary MC. Patients were divided into persistent MC (MC1) and transient MC (MC2). Past smoking was associated with increased risk to develop MC2 (OR = 2.67, 95 CI = 1.15–6.23), whereas current smoking was associated with increased risk to develop MC1 (OR = 3.18, 95 CI = 1.57–6.42). Concomitant symptoms of IBS were associated with smoking (OR = 4.24, 95 CI = 1.92–9.32). Alcohol drinking had no association with MC or IBS.

Conclusions

The results suggest that past smoking is associated with transient MC, whereas current smoking is associated with persistent MC. Smoking is associated with MC patients with concomitant IBS-like symptoms.

Microscopic colitis and reproductive factors related to exposure to estrogens and progesterone

Microscopic colitis (MC) often debuts around or after menopause and is divided into lymphocytic- and collagenous colitis. The aim of this study was to examine whether factors influencing sex hormone levels differed between subgroups of MC as well as between patients and controls. A self-administered questionnaire about parity was completed which included questions surrounding age at first childbirth, menarche and menopause, the use of oral contraceptives, and hormonal replacement therapy. Patients with lymphocytic colitis had children less often compared to those with collagenous colitis (OR = 0.20, 95% CI = 0.05-0.86), however no differences were observed between patients with persistent or transient disease. Patients were less often older than 15 years of age at menarche (OR = 0.48, 95% CI = 0.26-0.91) and were younger at menopause (OR = 0.30, 95% CI = 0.16-0.56) compared with controls. Thus, no obvious association between factors influencing sex hormone levels and presence of MC could be found.