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Songtanin B, Chen JN, Nugent K. Microscopic Colitis: Pathogenesis and Diagnosis. J Clin Med 2023; 12:4442. [PMID: 37445477 DOI: 10.3390/jcm12134442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
Microscopic colitis is a type of inflammatory bowel disease and is classified as either collagenous colitis or lymphocytic colitis. The typical presentation is chronic watery diarrhea. The disease occurs more frequently in women aged 60-65 years and is increasing in incidence. The pathophysiology of microscopic colitis remains poorly understood and has not been well-described with possible several pathogeneses. To date, the diagnosis of microscopic colitis depends on histological tissue obtained during colonoscopy. Other non-invasive biomarkers, such as inflammatory markers and fecal biomarkers, have been studied in microscopic colitis, but the results remains inconclusive. The approach to chronic diarrhea is important and being able to differentiate chronic diarrhea in patients with microscopic colitis from other diseases, such as inflammatory bowel disease, functional diarrhea, and malignancy, by using non-invasive biomarkers would facilitate patient management. The management of microscopic colitis should be based on each individual's underlying pathogenesis and involves budesonide, bile acid sequestrants, or immunosuppressive drugs in refractory cases. Cigarette smoking and certain medications, especially proton pump inhibitors, should be eliminated, when possible, after the diagnosis is made.
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Affiliation(s)
- Busara Songtanin
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Jason N Chen
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
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2
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Songtanin B, Evans A, Nugent K, Costilla V. The Utility of Fecal Calprotectin in the Diagnosis and Management of Microscopic Colitis. J Community Hosp Intern Med Perspect 2023; 13:71-73. [PMID: 37868242 PMCID: PMC10589029 DOI: 10.55729/2000-9666.1215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 04/21/2023] [Accepted: 05/01/2023] [Indexed: 10/24/2023] Open
Abstract
Background The incidence of microscopic colitis has increased over time. To date, there is no specific biomarker for microscopic colitis, and the diagnosis relies on histopathological tissue obtained during colonoscopy which is an invasive and costly procedure. Unlike Crohn's disease and ulcerative colitis, the utility of fecal calprotectin in diagnosing or monitoring microscopic colitis has not been established, and studies on the role of fecal calprotectin in microscopic colitis are limited. In this retrospective study, we analyzed the utility of this biomarker in the diagnosis of microscopic colitis. Methods The medical records of patients who have been diagnosed with collagenous colitis and lymphocytic colitis aged 18-89 years old were retrospectively reviewed. Patient characteristics were recorded in those who had fecal calprotectin measured. Results There were 198 patients who were diagnosed with collagenous colitis and lymphocytic between October 1, 2015, and July 31, 2022. Twenty-three patients had fecal calprotectin levels measured and were included in this study. The mean age was 51.7 ± 7.8 years in all groups. Thirteen patients were female. Six patients (26.1%) were diagnosed with collagenous colitis, and 17 patients (73.9%) were diagnosed with lymphocytic colitis. The fecal calprotectin cut-off in this lab is 50 μg/g stool. Median fecal calprotectin levels were 30.1 μg/g (15.6, 122.5), 19.5 μg/g (16.5, 64.6), and 33.2 μg/g (15.6, 134.9) in all groups, collagenous colitis, and lymphocytic colitis, respectively. Conclusion The utility of fecal calprotectin in diagnosing microscopic colitis is limited. Our study suggests the diagnosis should be based on histopathology tissue obtained during colonoscopy.
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Affiliation(s)
- Busara Songtanin
- Department of Internal Medicine, Texas Tech University Health Sciences Center Lubbock, TX,
USA
| | - Abbie Evans
- Department of Internal Medicine, Texas Tech University Health Sciences Center Lubbock, TX,
USA
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center Lubbock, TX,
USA
| | - Vanessa Costilla
- Department of Gastroenterology, University Medical Center, Lubbock, TX,
USA
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Songtanin B, Kahathuduwa C, Nugent K. Fecal calprotectin level in microscopic colitis: a systematic review and meta-analysis. Proc AMIA Symp 2023; 36:641-646. [PMID: 37614849 PMCID: PMC10444001 DOI: 10.1080/08998280.2023.2223950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/04/2023] [Accepted: 06/07/2023] [Indexed: 08/25/2023] Open
Abstract
Background There are no specific biomarkers for microscopic colitis (MC), and the diagnosis depends on histopathological tissue obtained during colonoscopy. Studies on the role of fecal calprotectin (FCP) in MC are limited. A literature search of PubMed, Embase, and Scopus was conducted from each database's inception through September 2022. Methods A DerSimonian-Liard random-effects meta-analysis was performed to examine the standardized mean difference (SMD) in FCP levels between patients with MC and control patients with chronic diarrhea. Results Six studies with 96 active MC patients and 200 controls were included in the meta-analysis. Random effects meta-analysis revealed that FCP was significantly and moderately elevated in patients with MC compared to the control group (SMD = 0.6 [95% CI 0.3, 1.0], P = 0.001). Imputing one effect size confirmed the observation that FCP is significantly higher in patients with MC than control subjects with chronic diarrhea (SMD = 0.5 [95% CI 0.2, 0.9], P = 0.004). Study heterogeneity between the SMDs was not significant (I2 = 41%, P = 0.1). Conclusion These results indicate that FCP levels in patients with chronic diarrhea can help identify patients with MC. More studies with serial measurements of FCP would provide a better understanding of its utility in MC.
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Affiliation(s)
- Busara Songtanin
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Chanaka Kahathuduwa
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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Hamilton P, Buhler K, MacDonald JK, Kaplan GG, Seow CH, Lu C, Novak KL, Andrews CN, Singh S, Jairath V, Panaccione R, Ma C. Meta-analysis: Placebo rates in microscopic colitis randomised trials and applications for future drug development using a historical control arm. Aliment Pharmacol Ther 2023; 57:837-850. [PMID: 36825479 DOI: 10.1111/apt.17433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/05/2023] [Accepted: 02/11/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Effective medical therapies for patients with microscopic colitis (MC) who fail budesonide are lacking. However, conducting randomised controlled trials (RCTs) in MC has been challenging due to small sample sizes. Understanding placebo responses can help inform more efficient future trials. AIMS The aim of this study is to estimate clinical and histologic placebo response rates and to determine factors associated with placebo response in MC. METHODS EMBASE, MEDLINE, and CENTRAL were searched until 7 January 2022, to identify placebo-controlled RCTs in adult patients with MC. Clinical and histologic response in the placebo arms were pooled using random-effects models. Stratified analyses based on disease- and trial-level characteristics, leave-one-out meta-analysis, and cumulative meta-analysis were performed. RESULTS Twelve RCTs enrolling a total of 391 patients (placebo n = 163) with MC were included. Pooled clinical and histologic placebo response rates were 24.4% (95% CI: 12.4%-38.4%), I2 = 60.8%, p < 0.01, and 19.9% (95% CI: 5.3%-39.0%), I2 = 66.4%, p = 0.01 (tests for heterogeneity), respectively. Clinical response to placebo was numerically higher in patients with lymphocytic compared to collagenous colitis (39.9% vs. 19.8%, p = 0.08). Heterogeneity in clinical response to placebo was significantly reduced when the Miehlke 2014 RCT was excluded in the leave-one-out meta-analysis or when a more stringent secondary definition of response based on the Hjortswang criteria was applied. CONCLUSIONS Approximately one-quarter of patients in MC trials respond to placebo, although with substantial heterogeneity, reflecting the need for standardised outcome definitions and study designs for MC. This analysis also serves to inform future MC trials that may consider incorporating an external, historical placebo control arm, rather than directly randomising patients to placebo.
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Affiliation(s)
- Patrick Hamilton
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Katherine Buhler
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Gilaad G Kaplan
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Lu
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher N Andrews
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Vipul Jairath
- Alimentiv Inc., London, Ontario, Canada
- Division of Gastroenterology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Remo Panaccione
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alimentiv Inc., London, Ontario, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Chojnacki C, Gąsiorowska A, Popławski T, Błońska A, Konrad P, Zajdler R, Chojnacki J, Blasiak J. Reduced Intake of Dietary Tryptophan Improves Beneficial Action of Budesonide in Patients with Lymphocytic Colitis and Mood Disorders. Nutrients 2023; 15:nu15071674. [PMID: 37049514 PMCID: PMC10097278 DOI: 10.3390/nu15071674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/25/2023] [Accepted: 03/29/2023] [Indexed: 04/01/2023] Open
Abstract
Lymphocytic colitis (LC) is a gastrointestinal (GI) tract disease with poorly known pathogenesis, but some environmental and lifestyle factors, including certain dietary components, may play a role. Tryptophan is an essential amino acid, which plays important structural and functional roles as a component of many proteins. It is important in the development and maintenance of the body, in which it is metabolized in two main pathways: kynurenine (KYN) and serotonin. In this work, we explored the effect of reducing of TRP in the diet of patients with LC with mood disorders. We enrolled 40 LC patients who had a normal diet, 40 LC patients with the 8-week diet with TRP content reduced by 25% and 40 controls. All LC patients received budesonide at 9 mg per day, and the severity of their GI symptoms was evaluated by the Gastrointestinal Symptoms Rating Scale. Mood disorders were evaluated by the Hamilton Anxiety Rating Scale (HAM-A) and the Hamilton Depression Rating Scale (HAM-D). The concentration of TRP and its metabolites, 5-hydroxyindoleacetic acid (5-HIAA), kynurenine (KYN), kynurenic acid (KYNA) and quinolinic acid (QA), in urine were determined. Budesonide improved the GI and mental states of LC patients, and the diet with reduced TRP content further amended these symptoms. Dietary intervention decreased the concentration of 5-HIAA by about 50% (3.4 vs. 6.3) and QA by about 45% (3.97 vs. 7.20). These changes were correlated with a significant improvement in the profitable action of budesonide on gastrointestinal and mental health of LC patients as they displayed significantly lower GSRS, HAM-A and HAM-B scores after than before the intervention—10.5 vs. 32, 11.0 vs. 21 and 12 vs. 18, respectively. In conclusion, a reduction in TRP intake in diet may improve GI and mental symptoms in LC patients treated with budesonide and these changes may be mediated by the products of TRP metabolism.
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Anindita B, Sugihartono T, Miftahussurur M, Maimunah U, Nusi IA, Setiawan PB, Purbayu H, Kholili U, Widodo B, Thamrin H, Vidyani A, Rezkitha YAA, Yamaoka Y. High levels of fecal calprotectin and C-reactive protein in patients with colitis. J Med Life 2023; 16:48-51. [PMID: 36873123 PMCID: PMC9979164 DOI: 10.25122/jml-2021-0311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/22/2022] [Indexed: 03/07/2023] Open
Abstract
Inflammatory bowel disease (IBD) with a poor prognosis may be due to persistent colitis. According to the latest guidelines, monitoring has become a part of the treatment process for colitis. Adequate monitoring of the patient's condition is necessary to determine the course of the disease to prevent the worsening of the condition and suppress the subclinical inflammatory process. This analytical study with a cross-sectional design was conducted to evaluate the activity of colitis using the results of C-reactive protein (CRP) and fecal calprotectin (FC) assays. FC levels were analyzed by ELISA, while CRP levels were analyzed using Siemens Flex particle-enhanced turbidimetric immunoassay. In 30 subjects with endoscopy and biopsy of colitis, 16 men and 14 women had a median age of 52.5 (18-70) years. The median FC value increased by 67 (7.3-722 g/g) and was positive (≥50 g/g) in 20 subjects (66.7%), and the mean CRP value was 13.64 mg/L, positive (10-15 mg/L) in 13 subjects (43.33%), and negative (<10 mg/L) in 17 subjects (56.67%). This study demonstrated that FC had a significant relationship with CRP (r=0.57; p<0.001) in patients with colitis. Assessing the levels of FC and CRP among patients with colitis can be useful to assess the worsening of symptoms early and reduce mortality and morbidity.
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Affiliation(s)
- Brinna Anindita
- Department of Internal Medicine, Dr. Soetomo Teaching Hospital, Faculty of Medicine Universitas Airlangga, Surabaya, Indonesia
| | - Titong Sugihartono
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Muhammad Miftahussurur
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.,Helicobacter pylori and Microbiota Study Group, Institute Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
| | - Ummi Maimunah
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Iswan Abbas Nusi
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Poernomo Boedi Setiawan
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Herry Purbayu
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Ulfa Kholili
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Budi Widodo
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Husin Thamrin
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Amie Vidyani
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Yudith Annisa Ayu Rezkitha
- Helicobacter pylori and Microbiota Study Group, Institute Tropical Disease, Universitas Airlangga, Surabaya, Indonesia.,Department of Internal Medicine, Faculty of Medicine, University of Muhammadiyah Surabaya, Surabaya, Indonesia
| | - Yoshio Yamaoka
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.,Department of Environmental and Preventive Medicine, Faculty of Medicine, Oita University, Yufu, Japan
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Lesnovska KP, Münch A, Bonderup O, Magro F, Kupcinskas J, Zabana Y, Tontini GE, Munck LK, Guagnozzi D, Latella G, Fernandez-Banares F, Miehlke S, Madisch A, Wildt S, Hjortswang H. The Process of Developing a Disease Activity Index in Microscopic Colitis. J Crohns Colitis 2022; 16:452-459. [PMID: 34562005 DOI: 10.1093/ecco-jcc/jjab170] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Patient-reported outcome measures [PROMs] aim to measure patients' perception of how their disorder influences everyday functioning. The objective of this study was to develop a PROM to assess disease activity in microscopic colitis [MC] fulfilling the requirements of the Food and Drug Administration [FDA]. METHODS The European Microscopic Colitis Activity Index [E-MCAI] was developed in four steps. [1] A list of symptoms associated with active MC was created by a group of experts in the field. [2] Content validity of the symptoms was performed by experts [n = 14] and patients [n = 79] using the Content Validity Index. [3] Questions and response alternatives were created for each symptom, and validity of the E-MCAI was evaluated with cognitive interviews with patients [n = 7] and by the experts. [4] A pilot postal survey was performed to ensure usability. RESULTS Seven of the symptoms related to active MC fulfilled the criteria for content validity and were included in the E-MCAI: stool consistency, stool frequency, stools at night, feel a need to pass more stools shortly after a bowel movement, urgent need to empty the bowel, leakage of stool and abdominal pain. The development and validation process resulted in the current version of the E-MCAI consisting of six questions related to MC. CONCLUSIONS The E-MCAI was developed using the methods advocated by the FDA. The evaluation indicates good content validity. Further evaluation will be performed to achieve construct validity, reliability and responsiveness in future cross-sectional and longitudinal studies.
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Affiliation(s)
- Katarina Pihl Lesnovska
- Department of Gastroenterology and Hepatology in Linköping, and Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
| | - Andreas Münch
- Department of Gastroenterology and Hepatology in Linköping, and Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
| | - Ole Bonderup
- Diagnostik Center, Hospitalenhed Midt, Regionhospitalet Silkeborg, Silkeborg, Denmark
| | - Fernando Magro
- Department of Pharmacology, Hospital de Sao Joao, Porto, Portugal
| | - Juozas Kupcinskas
- Department of Gastroenterology and Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Yamile Zabana
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Barcelona, Spain.,Department of Gastroenterology, Hospital Universitari Mutua de Terrassa, University of Barcelona, Barcelona, Spain
| | - Gian Eugenio Tontini
- Department of Pathophysiology and Organ Transplantation, University of Milan and Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lars Kristian Munck
- Department of Gastroenterology, Zealand University Hospital, Koege, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Danila Guagnozzi
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Barcelona, Spain.,Neuro-Immuno-Gastroenterology Group, Digestive Physiology and Pathophysiology Unit, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Giovanni Latella
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Fernando Fernandez-Banares
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Barcelona, Spain.,Department of Gastroenterology, Hospital Universitari Mutua de Terrassa, University of Barcelona, Barcelona, Spain
| | - Stephan Miehlke
- Center for Digestive Diseases, Internal Medicine Center Eppendorf, Hamburg, Germany.,Center for Esophagal Disorder, University Hospital Eppendorf, Hamburg, Germany
| | - Ahmed Madisch
- Department of Gastroenterology, CRH Clinic Siloah, Hannover, Germany
| | - Signe Wildt
- Department of Gastroenterology, Zealand University Hospital, Koege, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Hjortswang
- Department of Gastroenterology and Hepatology in Linköping, and Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
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Pisani LF, Tontini G, Vecchi M, Croci GA, Pastorelli L. NF-kB pathway is involved in microscopic colitis pathogenesis. J Int Med Res 2022; 50:3000605221080104. [PMID: 35301900 PMCID: PMC8935566 DOI: 10.1177/03000605221080104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To investigate the potential inflammatory pathways involved in the development of microscopic colitis (MC). METHODS This prospective study analysed human intestinal tissue that was collected and classified as healthy controls (HC), microscopic colitis (MC) and ulcerative colitis (UC). An RT2 Profiler PCR Array for human inflammatory response and autoimmunity was used to evaluate the expression of 84 specific genes related to the inflammatory and autoimmunity pathways. Data were validated by means of real-time polymerase chain reaction on an independent group of MC intestinal tissue samples. RESULTS This study measured the expression of inflammatory genes in HC (n = 10), in patients with MC (n = 8) and in patients with active UC (n = 10). Of the 84 genes included in the array, the expression of the C-C motif chemokine ligand 19, C-C motif chemokine ligand 21, lymphotoxin beta and complement C3 genes that are involved in the non-canonical nuclear transcription factor kappa B (NF-kB) pathway was increased by 2.96, 6.05, 5.96 and 5.93 times in MC compared with HC, respectively. These results were confirmed by real-time polymerase chain reaction. CONCLUSIONS The findings suggest that an impairment of the non-canonical NF-kB pathway is involved in the development of MC.
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Affiliation(s)
- Laura Francesca Pisani
- Gastroenterology and Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- Laura Francesca Pisani, Gastroenterology and Endoscopy Unit, IRCCS Policlinico San Donato, Piazza Malan, San Donato Milanese, Lombardy 20097, Milano, Italy.
| | - Gianeugenio Tontini
- Department of Medical-Surgical Physiopathology and Transplantation, Università degli Studi di Milano, Milano, Italy
- Gastroenterology and Endoscopy Unit, IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Maurizio Vecchi
- Department of Medical-Surgical Physiopathology and Transplantation, Università degli Studi di Milano, Milano, Italy
- Gastroenterology and Endoscopy Unit, IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Giorgio Alberto Croci
- Department of Medical-Surgical Physiopathology and Transplantation, Università degli Studi di Milano, Milano, Italy
- Pathology Unit, IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Luca Pastorelli
- Gastroenterology and Liver Unit, ASST Santi Paolo e Carlo, ASST Santi Paolo e Carlo, Milano, Italy
- Department of Health Sciences, School of Medicine Ospedale San Paolo, Università degli Studi di Milano, Milano, Italy
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Zabana Y, Tontini G, Hultgren-Hörnquist E, Skonieczna-Żydecka K, Latella G, Østvik AE, Marlicz W, D'Amato M, Arias A, Mielhke S, Münch A, Fernández-Bañares F, Lucendo AJ. Pathogenesis of Microscopic Colitis: A Systematic Review. J Crohns Colitis 2022; 16:143-161. [PMID: 34272945 DOI: 10.1093/ecco-jcc/jjab123] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Whereas the exact aetiology of microscopic colitis [MC] remains unknown, a dysregulated immune response to luminal factors or medications is the most accepted pathogenesis hypothesis. METHODS We conducted a systematic review of the pathogenesis of MC. We applied the Joanna Briggs Institute methodologies and the PRISMA statement for the reporting of systematic reviews [PROSPERO Trial Identifier: CRD42020145008]. Populations, Exposure of interest, and Outcome [PEO] questions were used to explore the following topics in MC: 1] intestinal luminal factors; 2] autoimmunity; 3] innate immunity; 4] adaptive immunity; 5] extracellular matrix; 6] genetic risk factors; and 7] mechanism of diarrhoea. A search was done in PubMed, Embase, and Web of Science up to February 2020. A narrative description was performed explaining the findings for each aspect of MC aetiopathogenesis. RESULTS Thirty-eight documents provided evidence for PEO1, 100 for PEO2, 72 for PEO3 and 4, 38 for PEO5, 20 for PEO6, and 23 for PEO7. The majority of documents were cohorts, case reports, and case series, with a few case-control and some experimental studies. Consistency among data provided by different studies was considered to support pathogenetic hypotheses. MC is a multifactorial disease believed to involve innate and adaptive immune responses to luminal factors, genetic risk, autoimmunity, and extracellular matrix alterations, all contributing by varied mechanisms to watery diarrhoea. CONCLUSIONS This is the first systematic review on the aetiology of MC supporting the notion that MC is a multifactorial disease. However, high-profile studies are lacking, and most evidence derives from small heterogeneous studies.
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Affiliation(s)
- Yamile Zabana
- Gastroenterology Department, Hospital Universitari Mútua de Terrassa, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Gian Tontini
- Department of Pathophysiology and Transplantation, University of Milan and Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - Giovanni Latella
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Ann Elisabeth Østvik
- Department of Clinical and Molecular Medicine [IKOM], Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Gastroenterology and Hepatology, Clinic of Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Wojciech Marlicz
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland
- Centre for Digestive Diseases Endoklinika, Szczecin, Poland
| | - Mauro D'Amato
- Gastrointestinal Genetics Lab, CIC bioGUNE - BRTA, Derio, Spain
- Ikerbasque, Basque Foundation for Science, Bilbao, Spain
| | - Angel Arias
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
- Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Stephan Mielhke
- Centre for Digestive Diseases, Internal Medicine Centre Eppendorf & Endoscopy Centre, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Andreas Münch
- Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
| | - Fernando Fernández-Bañares
- Gastroenterology Department, Hospital Universitari Mútua de Terrassa, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Alfredo J Lucendo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
- Gastroenterology Department, Hospital General de Tomelloso-Spain and Instituto de Investigación Sanitaria Princesa [IIS-IP], Madrid, Spain
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10
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Pisani LF, Tontini GE, Pastorelli L. Editorial: The Dark Side of Microscopic Colitis. Front Med (Lausanne) 2021; 8:809136. [PMID: 34926537 PMCID: PMC8674686 DOI: 10.3389/fmed.2021.809136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/16/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Laura Francesca Pisani
- Gastroenterology and Endoscopy Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Gian Eugenio Tontini
- Department of Medical-Surgical Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy.,Gastroenterology and Endoscopy Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Luca Pastorelli
- Gastroenterology and Liver Unit, ASST Santi Paolo e Carlo, Milan, Italy.,Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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11
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Bakke I, Walaas GA, Bruland T, Røyset ES, van Beelen Granlund A, Escudero-Hernández C, Thorsvik S, Münch A, Sandvik AK, Østvik AE. Mucosal and faecal neutrophil gelatinase-associated lipocalin as potential biomarkers for collagenous colitis. J Gastroenterol 2021; 56:914-927. [PMID: 34414506 PMCID: PMC8478740 DOI: 10.1007/s00535-021-01814-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 07/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Collagenous colitis (CC) is an inflammatory bowel disease where chronic diarrhoea is the main symptom. Diagnostic markers distinguishing between CC and other causes of chronic diarrhoea remain elusive. This study explores neutrophil gelatinase-associated lipocalin (NGAL) and its mRNA lipocalin2 (LCN2) as histological and faecal disease markers in CC. METHODS NGAL/LCN2 were studied in colonic biopsies from CC patients before and during budesonide treatment using RNA sequencing (n = 9/group), in situ hybridization (ISH) (n = 13-22/group) and immunohistochemistry (IHC) (n = 14-25/group). Faecal samples from CC (n = 3-28/group), irritable bowel syndrome diarrhoea (IBS-D) (n = 14) and healthy controls (HC) (n = 15) were assayed for NGAL and calprotectin. RESULTS NGAL/LCN2 protein and mRNA expression were upregulated in active CC vs HC, and vs paired samples of treated CC in clinical remission. IHC and ISH localized increased NGAL/LCN2 mainly to epithelium of active CC, compared to almost absence in HC and treated CC. In contrast, calprotectin was solely expressed in immune cells. Despite great individual differences, faecal NGAL was significantly increased in active CC compared to HC, IBS-D and treated CC and had high test sensitivity. Faecal calprotectin levels were variably increased in active CC, but the values remained below usual clinical cut-offs. CONCLUSION NGAL/LCN2 is upregulated in the epithelium of active CC and reduced during budesonide-induced clinical remission to the level of HC and IBD-S. This was reflected in NGAL faecal concentrations. We propose NGAL as an IHC marker for disease activity in CC and a potential faecal biomarker discriminating CC from HC and IBS-D.
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Affiliation(s)
- Ingunn Bakke
- Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Prinsesse Kristinas Gate 1, 7489, Trondheim, Norway
- Clinic of Laboratory Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Gunnar Andreas Walaas
- Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Prinsesse Kristinas Gate 1, 7489, Trondheim, Norway
| | - Torunn Bruland
- Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Prinsesse Kristinas Gate 1, 7489, Trondheim, Norway
- Clinic of Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Elin Synnøve Røyset
- Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Prinsesse Kristinas Gate 1, 7489, Trondheim, Norway
- Clinic of Laboratory Medicine, St. Olav's University Hospital, Trondheim, Norway
- Department of Pathology, Clinic of Laboratory Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Atle van Beelen Granlund
- Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Prinsesse Kristinas Gate 1, 7489, Trondheim, Norway
- Centre of Molecular Inflammation Research (CEMIR), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Prinsesse Kristinas Gate 1, 7489, Trondheim, Norway
| | - Celia Escudero-Hernández
- Department of Biomedical and Clinical Sciences (BVK), Linköping University, Linköping, Sweden
- Institute of Clinical Molecular Biology (IKMB), Christian-Albrechts-University Kiel, and University Hospital Schleswig Holstein, Kiel, Germany
| | - Silje Thorsvik
- Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Prinsesse Kristinas Gate 1, 7489, Trondheim, Norway
- Clinic of Medicine, St. Olav's University Hospital, Trondheim, Norway
- Department of Gastroenterology and Hepatology, Clinic of Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Andreas Münch
- Department of Biomedical and Clinical Sciences (BVK), Linköping University, Linköping, Sweden
- Division of Gastroenterology and Hepatology, Linköping University Hospital, Linköping, Sweden
| | - Arne Kristian Sandvik
- Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Prinsesse Kristinas Gate 1, 7489, Trondheim, Norway
- Clinic of Medicine, St. Olav's University Hospital, Trondheim, Norway
- Centre of Molecular Inflammation Research (CEMIR), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Prinsesse Kristinas Gate 1, 7489, Trondheim, Norway
- Department of Gastroenterology and Hepatology, Clinic of Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Ann Elisabet Østvik
- Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Prinsesse Kristinas Gate 1, 7489, Trondheim, Norway.
- Clinic of Medicine, St. Olav's University Hospital, Trondheim, Norway.
- Department of Gastroenterology and Hepatology, Clinic of Medicine, St. Olav's University Hospital, Trondheim, Norway.
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12
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Lucendo AJ. Editorial: tissue findings fail to predict disease activity or prognosis in microscopic colitis: an opportunity to look at the molecular level. Aliment Pharmacol Ther 2021; 54:192-193. [PMID: 34170543 DOI: 10.1111/apt.16403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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13
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Olsen LM, Engel PJH, Goudkade D, Villanacci V, Thagaard J, Walbech JS, Bohr J, Kupcinskas J, Verhaegh B, Münch A, Guagnozzi D, Fernández-Bañares F, Munck LK, Fiehn AMK. Histological disease activity in patients with microscopic colitis is not related to clinical disease activity or long-term prognosis. Aliment Pharmacol Ther 2021; 54:43-52. [PMID: 34018208 DOI: 10.1111/apt.16381] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/02/2021] [Accepted: 04/07/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Microscopic colitis (MC) is a common cause of chronic watery diarrhea. Biopsies with characteristic histological features are crucial for establishing the diagnosis. The two main subtypes are collagenous colitis (CC) and lymphocytic colitis (LC) but incomplete forms exist. The disease course remains unpredictable varying from spontaneous remission to a relapsing course. AIM To identify possible histological predictors of course of disease. METHODS Sixty patients from the European prospective MC registry (PRO-MC Collaboration) were included. Digitised histological slides stained with CD3 and Van Gieson were available for all patients. Total cell density and proportion of CD3 positive lymphocytes in lamina propria and surface epithelium were estimated by automated image analysis, and measurement of the subepithelial collagenous band was performed. Histopathological features were correlated to the number of daily stools and daily watery stools at time of endoscopy and at baseline as well as the clinical disease course (quiescent, achieved remission after treatment, relapsing or chronic active) at 1-year follow-up. RESULTS Neither total cell density in lamina propria, proportion of CD3 positive lymphocytes in lamina propria or surface epithelium, or thickness of collagenous band showed significant correlation to the number of daily stools or daily watery stools at any point of time. None of the assessed histological parameters at initial diagnosis were able to predict clinical disease course at 1-year follow-up. CONCLUSIONS Our data indicate that the evaluated histological parameters were neither markers of disease activity at the time of diagnosis nor predictors of disease course.
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14
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Chojnacki C, Popławski T, Gasiorowska A, Chojnacki J, Blasiak J. Serotonin in the Pathogenesis of Lymphocytic Colitis. J Clin Med 2021; 10:jcm10020285. [PMID: 33466782 PMCID: PMC7830326 DOI: 10.3390/jcm10020285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/07/2021] [Accepted: 01/12/2021] [Indexed: 12/21/2022] Open
Abstract
Lymphocytic colitis (LC) is a chronic inflammatory disease associated with watery diarrhea, abdominal pain, and colonic intraepithelial lymphocytosis. Serotonin (5-hydroxytryptamine, 5-HT) is reported to increase in certain colon diseases; however, little is known regarding its metabolism in LC. In the present work, the level of 5-HT in serum and the number of enteroendocrine cells (EECs) as well as the expression of the 5-HT rate-limiting enzyme tryptophan hydroxylase 1 (TPH1) in colonic biopsies and urine 5-hydroxyindoeoacetic acid (5-HIAA) were determined in 36 LC patients that were treated with budesonide and 32 healthy controls. The 5-HT serum and 5-HIAA urine levels were measured using ELISA, the EEC number was determined immunohistochemically, and the colonic TPH1 mRNA expression was determined using RT-PCR. The levels of 5-HT and 5-HIAA and the number of EECs were higher in LC patients than in the controls, and positive correlations were observed between the 5-HT and 5-HIAA levels, 5-HT and EEC number, TPH1 mRNA and EEC number, as well as the severity of disease symptoms and 5-HIAA. Budesonide decreased the levels of 5-HT, 5-HIAA, and TPH1 expression and the number of EECs to values that did not differ from those for controls. In conclusion, the serotonin metabolism may be important for LC pathogenesis, and the urinary level of 5-HIAA may be considered as a non-invasive marker of this disease activity.
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Affiliation(s)
- Cezary Chojnacki
- Department of Clinical Nutrition and Gastroenterological Diagnostics, Medical University of Lodz, 90-647 Lodz, Poland;
- Correspondence: ; Tel.: +48-42-639-3040
| | - Tomasz Popławski
- Department of Molecular Genetics, Faculty of Biology and Environmental Protection, University of Lodz, 90-236 Lodz, Poland; (T.P.); (J.B.)
| | - Anita Gasiorowska
- Department of Gastroenterology, Medical University of Lodz, 90-647 Lodz, Poland;
| | - Jan Chojnacki
- Department of Clinical Nutrition and Gastroenterological Diagnostics, Medical University of Lodz, 90-647 Lodz, Poland;
| | - Janusz Blasiak
- Department of Molecular Genetics, Faculty of Biology and Environmental Protection, University of Lodz, 90-236 Lodz, Poland; (T.P.); (J.B.)
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15
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Abstract
Microscopic colitis encompasses both collagenous and lymphocytic colitis and is a relatively common condition with rising incidence. Diagnosis is by colonoscopy (which is usually normal but may show some mild changes) and biopsies which reveal characteristic histological findings. Symptoms include non-bloody diarrhoea with urgency which may be associated with faecal incontinence and abdominal pain. Microscopic colitis is associated with a reduced health-related quality of life, and treatment is aimed at symptom control. Medications linked with the development of microscopic colitis, including proton pump inhibitors, non-steroidal anti-inflammatory drugs and selective serotonin-reuptake inhibitors, should be discontinued. If symptoms persist, budesonide is a licensed treatment for microscopic colitis which has been shown to be effective in clinical trials and real-world practice.
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Affiliation(s)
- Omer F Ahmad
- Department of Gastroenterology, University College Hospital, London, UK
| | - Ayesha Akbar
- Department of Gastroenterology, St Mark's Hospital, LNWH Trust, Harrow, UK
- Department of Surgery, Imperial College London, London, UK
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16
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Nyboe Andersen N, Munck LK, Hansen S, Jess T, Wildt S. All-cause and cause-specific mortality in microscopic colitis: a Danish nationwide matched cohort study. Aliment Pharmacol Ther 2020; 52:319-328. [PMID: 32583929 DOI: 10.1111/apt.15868] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/09/2020] [Accepted: 05/18/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The long-term natural history of microscopic colitis remains uncertain. AIM To describe the mortality in a large unselected cohort of patients with microscopic colitis. METHODS All Danish patients above 18 years with an incident diagnosis of microscopic colitis from 2001 to 2018 were identified from nationwide registries and compared to age- and sex-matched controls (variable 1:10 ratio). Patients were categorised according to subtypes: lymphocytic colitis and collagenous colitis. The relative risk of death by any cause was analysed with Cox regression models estimating both crude and comorbidity-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs). Cause-specific death was evaluated with cumulative incidence functions. An E-value was calculated to address the impact of unmeasured confounding. RESULTS The final cohort consisted of 14 024 patients with microscopic colitis. The mean follow-up was 5.8 (standard deviation SD, 2.9) years and the mean age at diagnosis was 61.1 (SD 13.9) years, 70% were women and 41% were diagnosed with lymphocytic colitis. The main results showed a 25% increased risk of all-cause death in patients with microscopic colitis; however, the relative risk was attenuated to 9% when adjusting for comorbidities (95% CI, 1.05-1.14). The E-value indicates that unmeasured confounding could explain the residual observed increased all-cause mortality. Mortality was significantly increased in patients with both lymphocytic colitis (HR 1.15; 95% CI, 1.08-1.23) and collagenous colitis (HR 1.06; 95% CI, 1.01-1.12) in fully adjusted analyses. The absolute difference in death between patients with microscopic colitis and matches was 0.9% at 1 year, 2.8% at 5 years, 5.0% at 10 years and 3.0% at 15 years. Cumulative incidence functions showed that patients with microscopic colitis were more likely to die due to smoking-related diseases including ischemic heart and lung diseases, but had a significant decreased risk of death due to colorectal cancers (P < 0.0001). CONCLUSION In an unselected large nationwide cohort of patients with microscopic colitis, the risk of death was significantly increased compared to the background population. However, the increased mortality seemed to be associated to a high burden of comorbidities and unmeasured life-style factors including smoking and not microscopic colitis per se.
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Affiliation(s)
- Nynne Nyboe Andersen
- Department of Medical Gastroenterology and Hepatology, Rigshospitalet, Copenhagen, Denmark
| | - Lars Kristian Munck
- Department of Gastroenterology, Zealand University Hospital, Køge, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Hansen
- Centre for Clinical Research and Prevention, Frederiksberg and Bispebjerg Hospital, Copenhagen, Denmark
| | - Tine Jess
- Department of Epidemiology Research, Statens Serum Institute, Copenhagen, Denmark
| | - Signe Wildt
- Department of Gastroenterology, Zealand University Hospital, Køge, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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17
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Miehlke S, Verhaegh B, Tontini GE, Madisch A, Langner C, Münch A. Microscopic colitis: pathophysiology and clinical management. Lancet Gastroenterol Hepatol 2020; 4:305-314. [PMID: 30860066 DOI: 10.1016/s2468-1253(19)30048-2] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/18/2019] [Accepted: 01/18/2019] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Stephan Miehlke
- Centre for Digestive Diseases, Internal Medicine Centre Eppendorf, Hamburg, Germany; Centre for Oesophageal Disorders, University Hospital Eppendorf, Hamburg, Germany.
| | - Bas Verhaegh
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Gian Eugenio Tontini
- Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ahmed Madisch
- Department of Gastroenterology, CRH Clinic Siloah, Hannover, Germany
| | - Cord Langner
- Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Andreas Münch
- Department of Gastroenterology, Linköping University, Linköping, Sweden
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18
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Davie M, Trimble R, Robertson AR, Koulaouzidis A. Faecal Calprotectin and 7-α Cholestenone Levels in Microscopic Colitis: Experience from Edinburgh. Clin Exp Gastroenterol 2020; 13:115-121. [PMID: 32440188 PMCID: PMC7210022 DOI: 10.2147/ceg.s246004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/13/2020] [Indexed: 12/05/2022] Open
Abstract
Introduction Microscopic colitis (MC) is an important cause of chronic, watery diarrhoea. Currently, there is no specific biomarker available to guide diagnosis. The use of faecal calprotectin (FCP) as a potential marker has been addressed in only a few studies. Further, bile acid malabsorption (BAM) often accompanies MC. Current practice recommends the selenium-labelled homocholic acid-taurine (SeHCAT) test, but at our centre, 7 alpha-hydroxy-4-cholesten-3-one (7αC) is used as a simpler and less expensive alternative to SeHCAT, with values over 22ng/mL indicating BAM. This study aims to evaluate the use of FCP as a biomarker in the diagnosis of MC and the role of 7αC in detecting concomitant BAM with MC. Methods Pathology records were retrospectively reviewed for patients diagnosed with collagenous colitis (CC) between 2000 and 2018 and lymphocytic colitis (LC) between 1995 and 2011. FCP and 7αc results, if measured within 6 months of pathological diagnosis, were extracted for analysis. Results Between 2000 and 2018, 646 CC cases were confirmed on histology. Of 646 patients, 147 had FCP measured; in 111 (75.5%) FCP was elevated with mean levels 238.1μg/g (SD±273.0); 140/646 had 7αC measured; 16 (11.4%) indicated BAM. Mean levels were 10.2ng/mL (SD±9.4). During a 21-year period (1995–2011), 204 LC diagnoses were made: 14/204 had FCP measured; 8 (57.1%) were elevated. Mean levels were 128.4μg/g (SD±107.7). Of 204 LC patients, 20 had 7αC measured, 5 (25%) indicating BAM. Mean levels were 13.95ng/mL (SD±9.4). Discussion Both CC and LC were associated with raised FCP during the diagnostic phase, supporting the potential role of its use in clinical practice. Furthermore, we present results of using 7αC in identifying BAM amongst patients with MC. In our cohort, low levels of 7αC suggest relatively low concordance of BAM with MC.
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Affiliation(s)
- Matt Davie
- The University of Edinburgh, NHS Lothian, Edinburgh EH16 4SA, UK
| | - Rebecca Trimble
- The University of Edinburgh, NHS Lothian, Edinburgh EH16 4SA, UK
| | - Alexander R Robertson
- Department of Gastroenterology, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
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19
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Münch A, Sanders DS, Molloy-Bland M, Hungin APS. Undiagnosed microscopic colitis: a hidden cause of chronic diarrhoea and a frequently missed treatment opportunity. Frontline Gastroenterol 2020; 11:228-234. [PMID: 32419914 PMCID: PMC7223274 DOI: 10.1136/flgastro-2019-101227] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/30/2019] [Accepted: 06/20/2019] [Indexed: 02/04/2023] Open
Abstract
Microscopic colitis (MC) is a treatable cause of chronic, non-bloody, watery diarrhoea, but physicians (particularly in primary care) are less familiar with MC than with other causes of chronic diarrhoea. The colon in patients with MC is usually macroscopically normal. MC can only be diagnosed by histological examination of colonic biopsies (subepithelial collagen band >10 µm (collagenous colitis) or >20 intraepithelial lymphocytes per 100 epithelial cells (lymphocytic colitis), both with lamina propria inflammation). The UK National Health Service exerts downward pressure to minimise colonoscopy referrals. Furthermore, biopsies are often not taken according to guidelines. These factors work against MC diagnosis. In this review, we note the high incidence of MC (comparable to ulcerative colitis and Crohn's disease) and its symptomatic overlap with irritable bowel syndrome. We also highlight problems with the recommendation by National Health Service/National Institute for Health and Care Excellence guidelines for inflammatory bowel diseases that colonoscopy referrals should be based on a faecal calprotectin level of ≥100 µg/g. Faecal calprotectin is <100 µg/g in over half of individuals with active MC, building into the system a propensity to misdiagnose MC as irritable bowel syndrome. This raises important questions-how many patients with MC have already been misdiagnosed, and how do we address this silent burden? Clarity is needed around pathways for MC management; MC is poorly acknowledged by the UK healthcare system and it is unlikely that best practices are being followed adequately. There is an opportunity to identify and treat patients with MC more effectively.
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Affiliation(s)
- Andreas Münch
- Division of Gastroenterology and Hepatology, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden
| | - David S Sanders
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | | | - A Pali S Hungin
- The Institute of Health and Society, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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20
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21
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Abstract
Microscopic colitis (MC), encompassing lymphocytic and collagenous colitis, is a common cause for chronic nonbloody diarrhoea, which impacts significantly on the quality of life for patients. Despite increasing awareness of the condition and its treatment, there is considerable variation in therapeutic approaches. To conduct a systematic review and meta-analysis on the efficacy and safety of budesonide in the treatment of MC. We searched Medline, Embase and Central databases using predefined search methodology for randomised trials using budesonide in the treatment of MC. We extracted data, on the efficacy and safety of budesonide, from studies identified that met the feasibility for analysis criteria. These data were pooled with a fixed effects model. Nine studies met the inclusion criteria for analysis. The pooled odds ratios (ORs) for a response to budesonide therapy at induction and maintenance were 7.34 [95% confidence interval (CI): 4.08-13.19] and 8.35 (95% CI: 4.14-16.85) respectively. Histological response rates were superior in budesonide-treated patients compared to placebo following induction (OR: 11.52; 95% CI: 5.67-23.40) and maintenance treatment (OR: 5.88; 95% CI: 1.90-18.17). There was no difference in adverse events. Significant relapse rates (>50%) were observed following treatment cessation with no difference noted between the budesonide or the placebo-treated patients. Budesonide is an effective treatment option for MC for achieving induction and maintenance of both clinical and histological response. High relapse rates on treatment cessation were observed.
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22
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Why does this patient have chronic diarrhea? JAAPA 2018; 32:52-53. [PMID: 30589739 DOI: 10.1097/01.jaa.0000550298.75971.2b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Chojnacki C, Błasiak J, Fichna J, Chojnacki J, Popławski T. Evaluation of Melatonin Secretion and Metabolism Exponents in Patients with Ulcerative and Lymphocytic Colitis. Molecules 2018; 23:molecules23020272. [PMID: 29382152 PMCID: PMC6017024 DOI: 10.3390/molecules23020272] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 01/21/2018] [Accepted: 01/26/2018] [Indexed: 12/15/2022] Open
Abstract
Inflammatory bowel diseases, particularly ulcerative colitis (UC) and lymphocytic colitis (LC), affect many people. The role of melatonin in the pathogenesis of UC is precisely determined, whereas in LC it remains unknown. The aim of this study was to compare the expression of the melatonin-synthesizing enzymes tryptophan hydroxylase (TPH1), arylalkylamine-N-acetyltransferase (AANAT), and N-acetylserotonin methyltransferase (ASMT) in the colonic mucosa and urinary excretion of 6-sulfatoxymelatonin in patients with ulcerative and lymphocytic colitis. The study included 30 healthy subjects (group C), 30 patients with severe ulcerative colitis (group UC), and 30 patients with lymphocytic colitis (group LC). The diagnosis was based on endoscopic, histological, and laboratory examinations. Biopsy specimens were collected from right, transverse, and left parts of the colon. The levels of mRNA expression, TPH1, AANAT, and ASMT were estimated in the colonic mucosa with RT-PCR. The urine concentration of aMT6s was determined by the photometric method. The expression of TPH1, AANAT, and ASMT in colonic mucosa in UC and LC patients was significantly higher than in healthy subjects. Significant differences were found in the urinary aMT6s excretion: group C—13.4 ± 4.8 µg/24 h, group UC—7.8 ± 2.6 µg/24 h (p < 0.01), group LC—19.2 ± 6.1 µg/24 h (p < 0.01). Moreover, a negative correlation was found between fecal calprotectin and MT6s—in patients with UC − r = −0.888 and with LC − r = −0.658. These results indicate that patients with UC and those with LC may display high levels of melatonin-synthesizing enzymes in their colonic mucosa, which could possibly be related to increased melatonin synthesis as an adaptive antioxidant activity.
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Affiliation(s)
- Cezary Chojnacki
- Department of Clinical Nutrition and Gastroenterological Diagnostics, Medical University, 90-647 Lodz, Poland.
| | - Janusz Błasiak
- Department of Molecular Genetics, University of Lodz, 90-647 Lodz, Poland.
| | - Jakub Fichna
- Department of Biochemistry, Medical University of Lodz, 90-647 Lodz, Poland.
| | - Jan Chojnacki
- Department of Clinical Nutrition and Gastroenterological Diagnostics, Medical University, 90-647 Lodz, Poland.
| | - Tomasz Popławski
- Department of Molecular Genetics, University of Lodz, 90-647 Lodz, Poland.
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24
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Chi ZC. Research progress and perspectives of microscopic colitis. Shijie Huaren Xiaohua Zazhi 2017; 25:2858-2865. [DOI: 10.11569/wcjd.v25.i32.2858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Zhao-Chun Chi
- Department of Gastroenterology, Qingdao Municipal Hospital, Qingdao 266011, Shandong Province, China
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25
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Marlicz W, Skonieczna-Żydecka K, Yung DE, Loniewski I, Koulaouzidis A. Endoscopic findings and colonic perforation in microscopic colitis: A systematic review. Dig Liver Dis 2017; 49:1073-1085. [PMID: 28847471 DOI: 10.1016/j.dld.2017.07.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 07/23/2017] [Accepted: 07/25/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Microscopic colitis (MC) is a clinical syndrome of severe watery diarrhea with few or no endoscopic abnormalities. The incidence of MC is reported similar to that of other inflammatory bowel diseases. The need for histological confirmation of MC frequently guides reimbursement health policies. With the advent of high-definition (HD) coloscopes, the incidence of reporting distinct endoscopic findings in MC has risen. This has the potential to improve timely diagnosis and cost-effective MC management and diminish the workload and costs of busy modern endoscopy units. METHODS Publications on distinct endoscopic findings in MC available until March 31st, 2017 were searched systematically (electronic and manual) in PubMed database. The following search terms/descriptors were used: collagenous colitis (CC) OR lymphocytic colitis (LC) AND endoscopy, colonoscopy, findings, macroscopic, erythema, mucosa, vasculature, scars, lacerations, fractures. An additional search for MC AND perforation was made. RESULTS Eighty (n=80) articles, predominantly single case reports (n=49), were found. Overall, 1582 (1159F; 61.6±14.1 years) patients (pts) with MC and endoscopic findings were reported. The majority of articles (n=62) were on CC (pts 756; 77.5% females). We identified 16 papers comprising 779 pts (69.2% females) with LC and 7 articles describing 47 pts (72.3% females) diagnosed as MC. The youngest patient was 10 and the oldest a 97-year-old. Aside diarrhea, symptoms included abdominal pain, weight loss, bloating, flatulence, edema and others. In the study group we found 615 (38.8%) persons with macroscopic lesions in gut. Isolated linear ulcerations were identified in 7 pts (1.1%) while non-ulcerous lesions i.e. pseudomembranes, a variable degree of vasculature pruning & dwindling, mucosal lacerations and abnormalities such as erythema/edema/nodularity, or surface textural alteration in 608 pts (98.1%). The location of endoscopic findings was not reported in 27 articles. The distinct endoscopic findings were described in the left (descending, sigmoid, rectum - 10/21/11 studies), right (cecum, ascending - 7/7 studies), transverse colon (n=12), as well as duodenum (n=4), and terminal ileum (n=2). In 17 (1.1%) pts colonic perforation occurred. CONCLUSION Endoscopic findings are recognized with increased frequency in pts with MC. This could improve MC diagnosis by prompting a more extensive biopsy protocol in such cases and an earlier initiation of treatment. Procedure-related perforation has been reported in this group; therefore, cautious air insufflation is advisable when endoscopic findings are recognised.
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Affiliation(s)
- Wojciech Marlicz
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland.
| | | | - Diana E Yung
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Igor Loniewski
- Department of Biochemistry and Human Nutrition, Pomeranian Medical University, Szczecin, Poland; Sanprobi Sp. z o.o. Sp. K, Szczecin, Poland
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