Collagenous and lymphocytic colitis

Rheumatologic Associations of Microscopic Colitis: A Narrative Review

Extra-intestinal manifestations are frequent complications of the classical inflammatory bowel diseases, Crohn's disease and ulcerative colitis. However, in addition to the classical diseases, there is a spectrum of conditions, often termed "microscopic colitis", in which extra-intestinal manifestations are less well described. Our objective was to review the literature regarding the extra-intestinal manifestations complicating microscopic colitis and describe the association with systemic autoimmune rheumatic diseases. A comprehensive search and review of peer-reviewed English-language and international journals and reports was completed based on key terms, including "microscopic colitis", "lymphocytic colitis", "collagenous colitis", "inflammatory bowel disease", "extraintestinal manifestations", and the specific disease associations utilizing the PubMed Central database and MEDLINE. A broad spectrum of rheumatologic manifestations has been reported in patients with microscopic colitis. The identification of rheumatoid arthritis and limited scleroderma as co-morbidities with microscopic colitis was noteworthy. Inflammatory arthropathy was frequently seen in microscopic colitis, usually preceding or occurring in conjunction with the onset of gastrointestinal symptoms. A variety of presentations of associated arthritis were reported: migratory, symmetric or asymmetric, peripheral or axial, oligoarticular or polyarticular, erosive or non-erosive. There was a high incidence of autoantibodies in these patients, supporting a potential autoimmune association. On the basis of these anecdotal reports, we would suggest development of a clinical registry to help define the incidence of extra-intestinal manifestations and systemic autoimmune rheumatic diseases among microscopic colitis patients to help elucidate shared predispositions, pathogenic mechanisms and therapeutic opportunities.

Histopathology of non-IBD colitis practical recommendations from pathologists of IG-IBD Group

Pathologists are often called upon to diagnose colitides that differ from the two main forms of inflammatory bowel disease (IBD). These non-IBD colitides include infectious colitis, microscopic colitis, ischemic colitis, eosinophilic colitis, autoimmune enterocolitis, segmental colitis associated with diverticulosis, drug-induced colitis, radiation colitis and diversion colitis. The diagnosis of these different disease entities relies on the histopathological examination of endoscopic biopsies of the gastrointestinal tract. This paper reviews the main histomorphological characteristics of the various Non-IBD colitides.

Histopathology of Non-IBD Colitis. A practical approach from the Italian Group for the study of the gastrointestinal tract (GIPAD)

Non-IBD colitides (NIBDC) are intestinal diseases clinically and endoscopically overlapping with Inflammatory Bowel Diseases (IBD), sometimes with a similar histological picture. NIBDC include entities such as infectious colitis, ischemic colitis, pseudomembranous colitis, eosinophilic colitis, autoimmune enterocolitis, segmental colitis associated with diverticulosis, drug-induced colitis, radiation-induced colitis, diversion colitis, and microscopic colitis, this last including two entities: collagenous and lymphocytic colitis. The knowledge of the most useful histological features and the main clinical data for each entity is mandatory in daily clinical practice, for correct pathological diagnosis and clinical management.

Histochemistry in the diagnosis of non-neoplastic gastrointestinal disorders

The alimentary tract serves as host to a large number of diseases. In the non-neoplastic group of disorders, conventional histochemistry continues to play an important diagnostic role. It is particularly important in recognizing specific infectious diseases, such as Helicobacter gastritis, Whipple disease, intestinal tuberculosis and other forms of mycobacteriosis, malakoplakia, intestinal spirochetosis, fungal enteritides, amebiasis, cryptosporidiosis, isosporiasis, and microsporidiosis. Those conditions and their histochemical properties are discussed in this review, along with the use of histochemistry in the characterization of structural gastrointestinal disorders. The latter include mucosal metaplasias, amyloidosis, glycogenic acanthosis of the esophagus, lymphocytic-collagenous colitis, gastric neuroendocrine hyperplasia, and pill gastritis.

Colonic immune cells in irritable bowel syndrome: A systematic review and meta-analysis

BACKGROUND & AIMS

Increases in mucosal immune cells have frequently been observed in irritable bowel syndrome (IBS) patients. However, this finding is not completely consistent between studies, possibly due to a combination of methodological variability, population differences and small sample sizes. We performed a meta-analysis of case-control studies that compared immune cell counts in colonic biopsies of IBS patients and controls.

METHODS

PubMed and Embase were searched in February 2017. Results were pooled using standardized mean difference (SMD) and were considered significant when zero was not within the 95% confidence interval (CI). Heterogeneity was assessed based on I² statistics where I²  ≤ 50% and I²  > 50% indicated fixed and random effect models, respectively.

KEY RESULTS

Twenty-two studies on 706 IBS patients and 401 controls were included. Mast cells were increased in the rectosigmoid (SMD: 0.38 [95% CI: 0.06-0.71]; P = .02) and descending colon (SMD: 1.69 [95% CI: 0.65-2.73]; P = .001) of IBS patients. Increased mast cells were observed in both constipation (IBS-C) and diarrhea predominant IBS (IBS-D). CD3⁺ T cells were increased in the rectosigmoid (SMD: 0.53 [95% CI: 0.21-0.85]; P = .001) and the descending colon of the IBS patients (SMD: 0.79, 95% CI [0.28-1.30]; P = .002). This was possibly in relation to higher CD4⁺ T cells in IBS (SMD: 0.33 [95% CI: 0.01-0.65]; P = .04) as there were no differences in CD8⁺ T cells.

CONCLUSIONS & INFERENCES

Mast cells and CD3⁺ T cells are increased in colonic biopsies of patients with IBS vs non-inflamed controls. These changes are segmental and sometimes IBS-subtype dependent. The diagnostic value of the quantification of colonic mucosal cells in IBS requires further investigation.

Proton pump inhibitor induced collagen expression in colonocytes is associated with collagenous colitis

AIM

To elucidate the role of proton pump inhibitors (PPIs) in collagenous disease, direct effect of PPI on colonocytes was examined.

METHODS

Collagenous colitis is a common cause of non-bloody, watery diarrhea. Recently, there has been increasing focus on the use of proton PPIs as a risk factor for developing collagenous colitis. Mouse CT26 colonic cells were treated with PPI and/or PPI-induced alkaline media. Expression of fibrosis-associated genes was examined by RT-PCR. In human materials, collagen expression was examined by immunohistochemistry.

RESULTS

CT26 cells expressed a Na⁺-H⁺ exchanger gene (solute carrier family 9, member A2). Treatment with PPI and/or PPI-induced alkaline media caused growth inhibition and oxidative stress in CT26 cells. The treatment increased expression of fibrosis inducing factors, transforming growth factor β and fibroblast growth factor 2. The treatment also decreased expression of a negative regulator of collagen production, replication factor C1, resulting in increased expression of collagen types III and IV in association with lipid peroxide. In biopsy specimens from patients with collagenous colitis, type III and IV collagen were increased. Increase of type III collagen was more pronounced in PPI-associated collagenous colitis than in non-PPI-associated disease.

CONCLUSION

From these findings, the reaction of colonocytes to PPI might participate in pathogenesis of collagenous colitis.

Advances for improved diagnosis of microscopic colitis in patients with chronic diarrhoea

Microscopic colitis is a generic term that includes 2 main forms, collagenous colitis and lymphocytic colitis, and describes a form of inflammatory bowel disease with a chronic and relapsing course. The incidence of microscopic colitis is between 2 and 8 times higher in women than in men, although age, more than sex, increases the risk of collagenous colitis (odds ratio [OR] 8.3 for age ≥65 vs. <65 and OR 2.8 for women). The main symptom is chronic non-bloody watery diarrhoea. Other common symptoms include abdominal pain (50%-70%), with the result that many patients with microscopic colitis meet criteria for irritable bowel syndrome. Colonoscopy with multiple colonic biopsies is currently recommended, as histological changes are the main characteristic feature. The colonic mucosa is macroscopically normal, although certain minimal endoscopic abnormalities have been described.

Proximal collagenous gastroenteritides: clinical management. A systematic review

AIM

While collagenous colitis represents the most common form of the collagenous gastroenteritides, the collagenous entities affecting the proximal part of the gastrointestinal tract are much less recognized and possibly overlooked. The aim was to summarize the latest information through a systematic review of collagenous gastritis, collagenous sprue, and a combination thereof.

METHOD

The search yielded 117 studies which were suitable for inclusion in the systematic review. Excluding repeated cases, 89 case reports and 28 case series were reported, whereas no prospective studies with or without control groups were identified. Further, no randomized, controlled trials were identified. The total number of patients with proximal collagenous gastroenteritides reported was 330.

RESULTS

An overview of clinical presentations, prognosis, pathophysiology and histopathology, as well as management of these disorders is presented. The prognosis of both collagenous gastritis and sprue seems not to be as dismal as considered previously. Data point to involvement of immune or autoimmune mechanisms potentially driven by luminal antigens initiating the fibroinflammatory condition.

CONCLUSIONS

To reach the diagnosis it is recommended that biopsies are obtained during gastroduodenoscopies. Therapies with anti-secretory strategies, glucocorticoids, and in some cases iron supplementation are suggested, although rational treatment options from randomized, controlled trials do not exist for these rare or even overlooked disorders.

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.

Inflammatory bowel disease biopsies: updated British Society of Gastroenterology reporting guidelines

Accurate histopathological assessment of biopsies is important for the diagnosis, subclassification, and management of chronic idiopathic inflammatory bowel disease (IBD). British Society of Gastroenterology (BSG) guidelines for the initial histopathological diagnosis of IBD were published in 1997. Changes since then include: more widespread use of full colonoscopy; greater recognition of the effects of time and treatment; improved documentation of variations in anatomical distribution; better understanding of the mimics of IBD; significant progress in clinical management; and modifications of terminology. Accordingly, an update is required. These revised guidelines aim to optimise the quality and consistency of reporting of biopsies taken for the initial diagnosis of IBD by summarising the literature and making recommendations based on the available evidence. Advice from existing clinical guidelines is also taken into account. Among the subjects discussed are: distinguishing IBD from other colitides, particularly infective colitis; subclassification of IBD (as ulcerative colitis, Crohn's disease, or IBD unclassified); the discriminant value of granulomas; aspects of disease distribution, including discontinuity in ulcerative colitis; time-related changes; differences between paediatric and adult IBD; the role of ileal and upper gastrointestinal biopsies; differential diagnoses such as diverticular colitis and diversion proctocolitis; and dysplasia. The need to correlate the histological features with clinical and endoscopic findings is emphasised. An approach to the conclusion of an IBD biopsy report based on the acronym Pattern, Activity, Interpretation, Dysplasia (PAID) is suggested. The key recommendations are listed at the end of the document.

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.

Lymphocytic colitis is associated with increased pro-inflammatory cytokine profile and up regulation of prostaglandin receptor EP4

Microscopic colitis (MC) is comprised of two entities, lymphocytic (LC) and collagenous colitis. Up to 20% of patients with chronic diarrhea that have a normal appearing colonoscopy will be diagnosed with MC. Since MC was first described less than 40 years ago, little is known about the mechanisms involved in disease pathogenesis. Nonsteroidal anti-inflammatory drugs are associated with an increased risk of MC and some reports suggest a dysregulation in prostaglandin production. Recent genome wide screens have found an association between prostaglandin receptor EP4 expression and inflammatory bowel disease; however, EP4 expression has never been studied in MC. The aim of this study was to assess colonic mucosal inflammatory cytokine profiles in patients with LC and to assess expression of the prostaglandin receptor EP4. Colonic mucosal biopsies were obtained from patients undergoing colonoscopy for investigation of diarrhea and in those undergoing colon cancer screening. Following histological assessment, expression of cytokines and the prostaglandin receptor EP4 was analyzed using real-time reverse transcriptase-PCR and immunohistochemistry. Patients with LC had markedly increased mRNA expression for TNF-α, IFN-γ and IL-8 compared to normal controls (p<0.001). No significant differences were noted for IL-1β, IL-4, IL-10 or IL-12/23. Interestingly, those with LC had increased EP4 receptor expression, which positively correlated with increased TNF-α expression. This is the first report to demonstrate that LC is associated with increased TNF-α, INF-γ and IL-8 concurrent with a marked up-regulation of EP4. These findings add to our knowledge on the pathogenesis of LC and may give rise to possible new therapeutic and/or diagnostic tools in the management of MC.

Gastrointestinal symptoms and psychological well-being in patients with microscopic colitis

OBJECTIVE

Microscopic colitis (MC) and irritable bowel syndrome (IBS) are both gastrointestinal disorders with female predominance that affect well-being. Autoantibodies against gonadotropin-releasing hormone (GnRH) have recently been detected in IBS patients. The purpose of this study was to compare gastrointestinal symptoms and well-being in MC female outpatients, with or without coexisting IBS-like symptoms, and to examine the prevalence of GnRH antibodies in these patients.

MATERIAL AND METHODS

Women with biopsy-verified MC, at any outpatient clinic of the Departments of Gastroenterology, Skåne, between 2002 and 2010 were invited to participate in the study. The questionnaires Gastrointestinal Symptom Rating Scale (GSRS), Psychological General Well-being Index (PGWB), Visual Analogue Scale for Irritable Bowel Syndrome (VAS-IBS), and Rome III were answered and blood samples collected. Autoantibodies (IgG, IgA, and IgM) against GnRH and GnRH-R (extracellular peptide of receptor) were determined by an enzyme-linked immunosorbent assay.

RESULTS

Altogether, 158 (66%) of 240 invited patients with MC were recruited to the study. Of these, 133 (55%) patients also accepted to provide blood samples. Patients with IBS-like symptoms (55%) experienced more symptoms and worse psychological well-being in all dimensions in GSRS and PGWB, and in all symptoms but constipation in VAS-IBS compared to patients without IBS symptoms. Only a minority of patients expressed antibodies against GnRH or GnRH-R, which did not differ between groups.

CONCLUSIONS

MC patients fulfilling criteria for IBS experience more gastrointestinal symptoms and worse psychological well-being than those who do not. Autoantibodies against GnRH or GnRH-R are not frequently observed in MC patients.

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.

Microscopic colitis: Current status, present and future challenges: statements of the European Microscopic Colitis Group

Microscopic colitis (MC) is an inflammatory bowel disease presenting with chronic, non-bloody watery diarrhoea and few or no endoscopic abnormalities. The histological examination reveals mainly two subtypes of MC, lymphocytic or collagenous colitis. Despite the fact that the incidence in MC has been rising over the last decades, research has been sparse and our knowledge about MC remains limited. Specialists in the field have initiated the European Microscopic Colitis Group (EMCG) with the primary goal to create awareness on MC. The EMCG is furthermore a forum with the intention to promote clinical and basic research. In this article statements and comments are given that all members of the EMCG have considered being of importance for a better understanding of MC. The paper focuses on the newest updates in epidemiology, symptoms and diagnostic criteria, pathophysiology and highlights some unsolved problems. Moreover, a new treatment algorithm is proposed on the basis of new evidence from well-designed, randomized control trials.

Systematic review: are lymphocytic colitis and collagenous colitis two subtypes of the same disease - microscopic colitis?

BACKGROUND

Despite similar clinical symptoms, collagenous colitis (CC) and lymphocytic colitis (LC) are considered two distinct disease entities.

AIM

To compare pathoanatomical findings, clinical presentations, risk factors, course of diseases and response to treatment in CC and LC to establish whether they could be subtypes of the same disease, microscopic colitis (MC).

METHODS

The MEDLINE was searched for CC, LC and MC, and clinical studies of >20 patients were included. Pooled results with 95% confidence intervals were calculated based on the number of patients.

RESULTS

An abnormal number of intraepithelial lymphocytes are found in 45% (40-50%) with CC, and an abnormal subepithelial collagen band in 16% (13-20%) with LC suggesting a histological overlap. The incidence of CC and LC has increased in parallel. Mean age (CC 63 years; LC 60 years) and clinical presentation are indistinguishable, and females are predominant in CC (77%; 75-79%) as well as LC (68%; 66-70%). Risk factors such as nonsteroid anti-inflammatory drugs consumption CC 39% (36-42%); LC 32% (29-35%) are similar and prevalence of concomitant autoimmune diseases such as coeliac disease (CC 5%; CI: 4-6% and LC 7%; CI: 6-9%) do not differ. Bile acid diarrhoea is highly prevalent in CC (41%; 37-45%) and LC (29%; 24-34%). The effect of budesonide is identical.

CONCLUSIONS

CC and LC could be considered histological subtypes of the same disease, MC. To facilitate recruitment to clinical trials, all MC patients could be included in future trials and stratified for subtypes.

Gastrointestinal pathology in celiac disease: a case series of 150 consecutive newly diagnosed patients

The main histologic feature of celiac disease is increased intraepithelial lymphocytes (IELs) with or without villous atrophy of the duodenal mucosa. The aim of this study was to document a broad range of additional morphologic changes in intestinal mucosa biopsy specimens from patients with celiac disease. Our cohort comprised 150 patients with positive tissue transglutaminase serologic findings; 7 were at Corazza stage A1, 58 at stage B1, and 85 at stage B2. IEL counts per 100 epithelial cells ranged from 34 to 156 (mean, 88.6); a significant neutrophilic infiltrate was present in 85 cases (56.7%); eosinophil count ranged from 3 to 50 per high-power field (mean, 14.6). Additional findings included morphologic changes in enterocytes in 68.7%, subepithelial collagen thickening in 45.3%, and associated lymphocytic gastritis in 30.4% of patients. We demonstrated that these underrecognized features, which can be misleading, are not uncommon in celiac disease and were positively associated with more advanced stages of the disease (P < .0001).

Foxp3 expression patterns in microscopic colitides: a clinicopathologic study of 69 patients

Microscopic colitides, including lymphocytic (LC) and collagenous colitis (CC), are well-described pathologic conditions. An altered immune response is implicated in the pathogenesis of both entities. CD8+ T lymphocytes (CTLs) secrete interleukin 2 which stimulates proliferation of regulatory T cells (Tregs), and Tregs, in turn, inhibit CTLs, inducing cytotoxic tissue damage. In Tregs, Foxp3 regulates T-cell-related immune responses. The distribution of Tregs and CTLs in microscopic colitides has remained underexplored. To characterize differences in the distribution pattern of Foxp3 in biopsy specimens from patients with LC and CC, 71 colonic biopsy specimens from 69 consecutive patients were categorized into 1 of 3 diagnoses: no significant histopathologic abnormality (NSHPA), LC, or CC. Further immunohistochemical evaluation of all biopsy specimens was conducted using a panel of markers including CD8 and Foxp3. Our study demonstrated that CTL distribution pattern differences exist among these 2 colitides and that differences in the immunologic recruitment of Foxp3+ Tregs in the colonic mucosa correlate with differences in the spectrum of morphologic changes seen in patients with either LC or CC.

Microscopic colitis as a missed cause of chronic diarrhea

AIM: To determine the prevalence of increased intraepithelial lymphocytes, using immunohistochemistry in patients with normal colonoscopy and near normal biopsy.

METHODS: We retrospectively reviewed all non-malignant colon mucosal biopsies between 2005 and 2007, reported as normal, chronic inflammation or melanosis coli in patients who were undergoing routine colonoscopy. Immunohistochemistry using CD3 was performed on all mucosal biopsies and an intraepithelial lymphocyte count (IEL) was determined. Cases with an IEL count of ≥ 20 IELs per 100 surface epithelial cells were correlated with demographic, clinical and follow-up data. A further subgroup was evaluated for lymphocytic colitis.

RESULTS: Twenty (8.3%) of 241 cases revealed an IEL count ≥ 20. Six (2.5%) patients were identified as having lymphocytic colitis (P < 0.001), of whom, five were missed on initial evaluation (P = 0.01). Four of these five patients were labeled with diarrhea-predominant irritable bowel syndrome (IBS). On follow-up, three of the remaining 20 cases were diagnosed with malignancy (renal cell carcinoma and myelodysplastic syndrome) and one had an unknown primary tumor with multiple liver metastases. Two cases of collagenous colitis with an IEL count < 10 were included in this study. Increased IELs were not confined to patients with diarrhea as a primary presenting symptom, but were also present in patients with abdominal pain (n = 7), constipation (n = 3) and loss of weight (n = 1).

CONCLUSION: Immunohistochemistry using CD3 is of value in identifying and quantifying IELs for the presence of microscopic colitis in patients with diarrhea-predominant IBS.

Current methods to diagnose the unresponsive and complicated forms of coeliac disease

Coeliac disease is a common disorder. Due to the protean manifestations of the disease and the often mild but indolent course, the diagnosis is often missed. The method to diagnose this in principle reversible disease after the introduction of a gluten-free diet has attracted the attention of several scientific disciplines to find the simplest and most patient-friendly test. This has resulted in a noticeable impact on the clinical practice next to a general increased awareness of its existence, its pathogenesis, its course and recent evidence of increased mortality. Amendments made in the diagnostic criteria of coeliac disease over the last half century have simplified the diagnosis. However, the aspect most relevant to the specialist in internal medicine is related to its grave consequences when the disease fails to respond to a gluten-free diet. These refractory cases may culminate in severe complications with sombre endings and malignancy. Fortunately, current technology can offer the specialist in internal medicine more facilities to diagnose the cause of the complicated cases in order to attempt to intervene in the course of disease and hopefully save these patients. We review the available tools that now exist and their indications that can be practiced in a modern clinical setting for the diagnosis of the complicated forms of this disease.

Diarrhea and malabsorption in the elderly

Acute and chronic diarrheal disorders are common problems at all ages. It has been estimated that 5% to 7% of the population has an episode of acute diarrhea each year and that 3% to 5% have chronic diarrhea that lasts more than 4 weeks. It is likely that the prevalence of diarrhea is similar in older individuals. This article reviews the impact of diarrhea in the elderly, many of whom are less fit physiologically to withstand the effect of diarrhea on fluid balance and nutritional balance.

Budesonide is effective in treating lymphocytic colitis: a randomized double-blind placebo-controlled study

BACKGROUND & AIMS

Budesonide is effective in treating collagenous colitis, but no treatment is established for lymphocytic colitis. We performed a randomized, double-blind, placebo-controlled study to evaluate the effects of budesonide in patients with lymphocytic colitis.

METHODS

Forty-two patients (median age, 61 years) with lymphocytic colitis and chronic diarrhea were randomly assigned to groups that were given oral doses of budesonide (9 mg/d) or placebo for 6 weeks. Nonresponders at week 6 were given open-label budesonide (9 mg/d) for 6 additional weeks. A complete colonoscopy and histologic and quality-of-life analyses were performed at baseline and at week 6. The primary end point was clinical remission at 6 weeks, with last observation carried forward (LOCF). All patients who left the study in clinical remission were followed for relapse.

RESULTS

At week 6, 86% of patients given budesonide were in clinical remission (with LOCF) compared with 48% of patients given placebo (P = .010). Furthermore, open-label budesonide therapy induced clinical remission in 7 of 8 patients given placebo. Histologic remission was observed in 73% of patients given budesonide compared with 31% given placebo (P = .030). Only 1 patient discontinued budesonide therapy prematurely. During a mean follow-up period of 14 months, 15 patients (44.1%) experienced a clinical relapse (after a mean of 2 months); 8 of the relapsing patients were retreated with and responded again to budesonide.

CONCLUSIONS

Budesonide effectively induces clinical remission in patients with lymphocytic colitis and significantly improves histology results after 6 weeks. Clinical relapses occur but can be treated again with budesonide.

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.

[A case of giant cell microscopic colitis?]

Microscopic colitis is the most common cause of chronic watery diarrhea, with normal mucosal appearance during colonoscopy. The diagnosis is made by pathological examination of biopsy specimens showing colitis with normal architecture of the mucosa. The two most frequent forms of microscopic colitis are lymphocytic colitis and collagenous colitis, but other atypical variants have been described. We report a case of lymphocytic colitis with multinucleated large cells and we discuss a variant of giant cells microscopic colitis.

Colonic perforation as a complication of collagenous colitis in a series of 12 patients

OBJECTIVES

The rare complication of colonic perforation in collagenous colitis following colonoscopy or barium enema is reported in this series of 12 patients.

METHODS

Patients with collagenous colitis complicated by perforation were collected from the authors' consultation files between 1992 and 2007. Colectomy and biopsy specimens were reviewed and the corresponding clinical data were analyzed.

RESULTS

The patients ranged in age from 44 to 80 yr, with a female-to-male ratio of 11:1. Perforation occurred during colonoscopy in 2 patients, within 0-5 days following colonoscopy in 8 patients, and during barium enema in 2 patients. The most notable colonoscopic findings were bleeding linear ulcers of the right colon in 9 patients, several of which developed under direct visualization during endoscopy. The perforation culminated in right hemicolectomy in 11 patients. Linear fissuring ulcers were identified in the resections of 8 patients along with features of perforation, including pneumatosis in 4 patients and barium extravasation within the muscularis propria in 2 patients.

CONCLUSIONS

This is the largest published series to date, and the first to uncover several novel clinicopathologic features of perforation in collagenous colitis, including the right colonic predilection (corresponding to disease severity), the association with not only colonoscopy, but also barium enema, the occurrence of recognizable perforation actually developing during the procedure, and a more detailed information on the marked histologic severity of these patients' collagenous colitis. An awareness of this rare but potentially fatal complication of collagenous colitis may facilitate its diagnosis and management.

Colon-targeted delivery of live bacterial cell biotherapeutics including microencapsulated live bacterial cells

There has been an ample interest in delivery of therapeutic molecules using live cells. Oral delivery has been stipulated as best way to deliver live cells to humans for therapy. Colon, in particular, is a part of gastrointestinal (GI) tract that has been proposed to be an oral targeted site. The main objective of these oral therapy procedures is to deliver live cells not only to treat diseases like colorectal cancer, inflammatory bowel disease, and other GI tract diseases like intestinal obstruction and gastritis, but also to deliver therapeutic molecules for overall therapy in various diseases such as renal failure, coronary heart disease, hypertension, and others. This review provides a comprehensive summary of recent advancement in colon targeted live bacterial cell biotherapeutics. Current status of bacterial cell therapy, principles of artificial cells and its potentials in oral delivery of live bacterial cell biotherapeutics for clinical applications as well as biotherapeutic future perspectives are also discussed in our review.

Chromoscopic endomicroscopy: in vivo cellular resolution imaging of the colorectum

Advances in imaging technology and engineering have now permitted functional integration of a confocal endomicroscope into the distal tip of a conventional video colonoscope enabling imaging of the surface epithelium and the underlying lamina propria during ongoing video endoscopy. For the first time, the endoscopist is now able to resolve the surface and subsurface mucosa at cellular resolution in vivo and in real time. A new era in endoscopic imaging has therefore begun - histoendoscopy. In addition to providing a high-accuracy in vivo optical biopsy tool for the differentiation between benign hyperplasia, intra-epithelial neoplasia and carcinoma in sporadic cohorts, endomicroscopy with targeted biopsies has now been shown to increase the yield of intra-epithelial neoplasia complicating ulcerative colitis. Furthermore, recent data examining endomicroscopic molecular ex vivo imaging using anti-CD44v6 antibody has identified aberrant crypt foci based on their surface molecular expression. Receptor overexpression in vivo in humans may, in the near future, be exploited for the diagnosis of inflammation, neoplasia and in predicting targeted molecular therapy. Endomicroscopy will be key to this immuno-imaging interface. Within the present review, we discuss the current clinical evidence in support of confocal endomicroscopy and explore the new diagnostic possibilities for this technology.

Alterations in the immunohistochemical expression of Das-1 and CG-3 in colonic mucosal biopsy specimens helps distinguish ulcerative colitis from Crohn disease and from other forms of colitis

Distinction between ulcerative colitis (UC) and Crohn disease (CD) in mucosal biopsies is often difficult. Das-1 and CG-3 are monoclonal antibodies directed against an unknown colonic epithelial protein and human tropomyosin isoform-5, respectively, both show altered expression in patients with UC. In this study, we evaluated the utility of Das-1 and CG-3 in distinguishing UC from CD and from other types of colitis. One colonic biopsy specimen from each of 85 patients with confirmed UC (n=25), CD (n=15), lymphocytic (n=15), collagenous (n=15), and ischemic (n=15) colitis, and also 10 samples from normal controls, were stained for Das-1 and CG-3 using standard techniques. Reactivity for Das-1 and CG-3 was noted to be absent or present, and the location (ie, surface+/-crypt epithelium) and degree (weak or strong) of CG-3 staining was recorded. Loss of Das-1 staining occurred more frequently in UC (96%) compared with CD (20%), lymphocytic (20%), collagenous (13%), and ischemic colitis (0%) cases, as well as controls (10%, P<0.001 for all comparisons). CG-3 positivity in crypt epithelium was significantly more common in UC (52%) compared with the other groups (P< or =0.02 for all comparisons). The combination of strong crypt CG-3 staining and loss of Das-1 staining was noted in 44% of UC cases, but not in any other type of colitis (P=0.003 for all comparisons). We conclude that the patterns of Das-1 and CG-3 staining in colonic mucosal biopsies may be clinically useful in distinguishing UC from CD and from other colitidies.

In vivo confocal laser scanning chromo-endomicroscopy of colorectal neoplasia: changing the technological paradigm

Recently, miniaturization of a novel confocal laser endomicroscope (Optiscan Pty, Notting Hill, Victoria, Australia) has permitted functional integration into the distal tip of a conventional video colonoscope (Pentax EC3870K; Pentax, Tokyo, Japan) enabling imaging of the surface epithelium and the underlying lamina propria during ongoing video endoscopy. Using endomicroscopy and intravenous sodium fluorescein as a contrast agent, 'virtual histology' can be created, which allows visualization of both the surface epithelium, and some of the lamina propria (down to a quarter of a millimetre), including the microvasculature. Confocal endomicroscopy may have major implications in the future of colonoscopy as uniquely it allows in vivo diagnosis of colonic intraepithelial neoplasia and carcinoma enabling 'smart' biopsy targeting and hence potentially influencing 'on table' management decisions. Initial pilot data have now shown that confocal imaging in vivo using the newly developed EC3870K has high overall accuracy for the immediate diagnosis of intraepithelial neoplasia and carcinoma in sporadic screened cohorts, but also has a role in the detection of intraepithelial neoplasia detection in chronic ulcerative colitis cancer screening when used in conjunction with methylene blue chromoscopy. We discuss the current evidence in support of confocal endomicroscopy in the colorectum and explore the new diagnostic possibilities for this technology.

Microscopic colitis-defining incidence rates and risk factors: a population-based study

BACKGROUND & AIMS

The burden and determinants of microscopic colitis (MC) in North America are inadequately defined. We determined the incidence rate of and risk factors for MC in a well-defined North American population.

METHODS

A population-based cohort study was conducted between April 1, 2002, and March 31, 2004. All adults with a pathologic diagnosis of MC were identified and comprehensive chart review was undertaken to confirm the diagnosis and identify risk factors. Category-specific risks for developing MC were reported as rate ratios (RRs) with exact 95% confidence intervals (CIs).

RESULTS

MC was identified in 164 individuals for an annual incidence rate of 10.0 per 100,000 person-years (lymphocytic colitis, 5.4; collagenous colitis, 4.6 per 100,000). Patients older than the age of 65 were more than 5 times more likely to develop MC (RR, 5.6; 95% CI, 4.0-7.7). Women were at higher risk of acquiring MC for both collagenous colitis (RR, 3.44; 95% CI, 2.07-5.97) and lymphocytic colitis (RR 6.29; 95% CI, 3.21-13.74). Elderly women with a history of malignancy were associated with a higher risk of MC (RR, 3.59; 95% CI, 1.68-7.01), as were patients with celiac disease (RR, 7.9; 95% CI, 4.0-14.2) and hypothyroidism (RR, 6.1; 95% CI, 3.5-10.0).

CONCLUSIONS

This was a large population-based cohort study of MC and our incidence rates were consistent with previously reported population-based studies in North America and Europe. An increased incidence of MC was observed in several disease states with the novel finding of an increased risk of MC with malignancy.

Microscopic colitis

As the diagnosis of microscopic colitis (MC) is made on the basis of histologic criteria, it is crucial to render an accurate microscopic interpretation. Features include 20 or more lymphocytes per 100 epithelial cells, mixed lamina propria inflammatory infiltrate, and preservation of crypt architecture for both lymphocytic and collagenous colitis (CC). CC is further characterized by a collagen band at least 10 mum thick. Although the pathogenesis of MC is poorly understood, medication-induced toxicity to the colonic mucosa is important to recognize, as medication cessation leads to prompt improvement. If MC is mild, symptomatic treatment is all that is needed, because some cases are self-limiting. Budesonide, 9 mg daily for at least 8 weeks, is the best documented treatment of choice for more severe or protracted cases. A 75% response rate has been reported; however, when treatment is discontinued, relapse is common, and longer-term tapering dose therapy often is necessary. There are disadvantages and no advantage to other forms of steroid therapy. Cholestyramine, bismuth, and 5-aminosalicylate derivatives appear to be less efficacious but are reasonable therapeutic options for less severe cases. Use of immunosuppressant therapy such as azathioprine or 6-mercaptopurine should be highly restricted because MC is a benign condition that does not result in other complications. Probiotic therapy with Lactobacillus acidophilus and Bifidobacterium animalis has not been shown to be effective in reducing bowel frequency. Surgical diversion of the fecal stream can control diarrhea and improve histology but is very rarely indicated and should be reserved for highly selected cases of severely symptomatic steroid-refractory MC.

Pathologist Surgeon Interface in Idiopathic Inflammatory Bowel Disease

To accomplish the important tasks of establishing the diagnosis of inflammatory bowel disease and separating ulcerative colitis from Crohn's disease, there needs to be close cooperation among gastroenterologist, surgeon, and pathologist. Paying close attention to details of sampling and historical information plays a major role in this task, and an equally great role in identifying dysplasia and determining its significance. Important elements in this clinical-pathology interface are discussed in this article.