Complications of collagenous colitis

A delayed benign anastomotic stricture after anterior resection for sigmoid adenocarcinoma with concomitant collagenous colitis

Benign anastomotic strictures most commonly occur within 3-12 months after anterior resection (AR) with chronic symptoms amenable to endoscopic treatment. This case describes an acute large bowel obstruction secondary to a severe delayed benign anastomotic stricture in a 74-year-old female who had previously underwent a laparoscopic AR for sigmoid adenocarcinoma 3 years prior. The pathophysiology of benign anastomotic strictures remains poorly understood. This case was likely multifactorial. Potential contributing factors include anastomotic ischaemia and concomitant collagenous colitis, with inflammation leading to fibrosis and stricture development. Surgical techniques to optimize anastomotic vascularity are important to consider, particularly in older patients with multiple co-morbidities.

Spontaneous colonic perforation with collagenous colitis in an elderly patient

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

Celiac Disease Is Associated with Microscopic Colitis in Refractory Cases in Adults: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Microscopic colitis and Celiac disease have been shown to occur concomitantly, but their relationship has yet to be systematically evaluated. Some patients with refractory microscopic colitis may have simultaneous celiac disease, and the converse is also true.

AIMS

We performed a systematic review and meta-analysis of observational studies to assess the prevalence and possible association between these two conditions.

METHODS

PubMed, Embase, Cochrane, Web of Science, SciELO, and CINAHL Plus were systematically searched through January 26, 2021, to include relevant observational studies assessing the prevalence of microscopic colitis in celiac disease population or vice versa. DerSimonian-Laird approach using random effects was used to pool data and compare outcomes. Pooled prevalence, 95% confidence interval (CI), and p values (where applicable) were calculated.

RESULTS

Five studies (with 2589 patients, age range 39.5-52 years and females 66.6%) and 21 studies (with 7186 patients, age range 46.4-65.8 years and females 76.3%) were included assessing the prevalence of microscopic colitis in refractory celiac disease and celiac disease in refractory microscopic colitis cohort. The overall prevalence was 4.5% (2.6-6.3%) and 6.7% (5.2-8.1%), respectively. Five studies showed higher odds of celiac disease diagnosis in the refractory microscopic colitis population compared to the control group (OR 8.12, CI 4.92-13.41, p < 0.001).

CONCLUSION

Celiac disease and microscopic colitis are concomitantly prevalent in a subset of population with either refractory diagnosis. Clinicians should explore alternate diagnosis when one condition has been appropriately treated and patients continue to have refractory symptoms.

A Tale of Two Colitides

Inflammatory bowel disease (IBD) and microscopic colitis (MC) are two distinct subgroups within the larger group of colitides. MC could manifest as collagenous colitis (CC) or lymphocytic colitis (LC). The co-occurrence of MC in patients with IBD is rare, with few cases reported. No concurrent case of MC and ulcerative colitis (UC) each presenting with distinct clinical manifestations was found in the literature review. We report a case of a 76-year-old male presenting with concurrent CC and UC. The patient's initial flare of UC was characterized by episodes of bloody diarrhea while his flare of CC was evidenced by watery diarrhea.

Collagenous Gastritis in Primary Selective IgM Deficiency: Transition to EBV+ Gastric Adenocarcinoma

Selective IgM deficiency (SIgMD) and isolated collagenous gastritis are two independent rare disorders. Our purpose is to report the 1^st case of SIgMD and isolated collagenous gastritis and collagenous gastritis that has transitioned to EBV + gastric adenocarcinoma. Gastric biopsy tissue was analyzed by EBV-related encoded RNA in situ hybridization assay. Subsets of CD4, CD8, T follicular helper cells (T_FH), and members of the “regulatory lymphocytes club” were measured with multiple panels of monoclonal antibodies and isotype controls by multicolor flow cytometry. The patient was diagnosed with SIgMD (extremely low serum IgM 9 mg/dl and normal IgG and IgA and exclusion of secondary causes of low IgM). Soon after SIgMD diagnosis, the patient developed collagenous gastritis and, 8 years later, developed gastric adenocarcinoma that was positive for EBV. An extensive immunological analysis revealed reduced naïve CD4 and CD8 effector memory T cells and increased naïve and central memory CD8 T cells. Among the circulating follicular helper T cells (cT_FH), T_FH1 and T_FH2 were increased whereas T_FH17 was decreased. CD4 Treg cells and T_FR cells were increased, whereas Breg and CD8 Treg were comparable to control. In conclusion, SIgMD may be associated with isolated collagenous gastritis, and collagenous gastritis may transition to EBV + gastric adenocarcinoma. A role of regulatory lymphocytes in gastric cancer is discussed.

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

BACKGROUND AND STUDY AIMS

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Collagenous Gastritis, a Rare Cause of Dyspepsia Resistant to Treatment; A Case Report

Collagenous gastritis is hardly ever found in children and adults. Based on the extent of collagenous changes in the bowel, various symptoms may develop including iron deficiency, anemia, and abdominal pain in most of the patients.

We present a 30-year-old man with persistent abdominal pain and anemia due to collagenous gastritis.

Lymphocytic colitis complicated by a mass in the terminal ileum

Lymphocytic colitis is a chronic inflammatory disease affecting the bowel. The clinical course of lymphocytic colitis is believed to be benign with watery diarrhoea. We report herein what is, to the best of our knowledge, the first case of lymphocytic colitis complicated by a terminal ileal mass. A 23-year-old man presented with diarrhoea. Blind biopsies of samples taken from the terminal ileum, caecum and ascending colon showed features of lymphocytic colitis. He declined treatment with budesonide or 5-aminosalicylates. He presented 14 months later with pain over the right lumbar region and nausea. Computed tomographic enteroclysis showed a focal soft tissue enhancing mass at the terminal ileum. Excision of the soft tissue mass revealed that it was reactive nodular lymphoid hyperplasia with fibrous granulation tissue. In conclusion, an untreated lymphocytic colitis may result in the formation of an inflammatory mass lesion.

Collagenous gastritis: Review

Collagenous gastritis is a rare disease characterized by the subepithelial deposition of collagen bands thicker than 10 μm and the infiltration of inflammatory mononuclear cells in the lamina propria. Collagenous colitis and collagenous sprue have similar histological characteristics to collagenous gastritis and are thought to be part of the same disease entity. However, while collagenous colitis has become more common in the field of gastroenterology, presenting with clinical symptoms of chronic diarrhea in older patients, collagenous gastritis is rare. Since the disease was first reported in 1989, only 60 cases have been documented in the English literature. No safe and effective treatments have been identified from randomized, controlled trials. Therefore, better understanding of the disease and the reporting of more cases will help to establish diagnostic criteria and to develop therapeutic strategies. Therefore, here we review the clinical characteristics, endoscopic and histological findings, treatment, and clinical outcomes from case reports and case series published to date, and provide a summary of the latest information on the disease. This information will contribute to improved knowledge of collagenous gastritis so physicians can recognize and correctly diagnose the disease, and will help to develop a standard therapeutic strategy for future clinical trials.

Computer aided measurement of sub-epithelial collagen band in colon biopsies for collagenous colitis diagnosis

This paper presents a novel computer aided technique for screening of Collagenous Colitis (CC). CC is a type of microscopic colitis mostly characterized by chronic watery diarrhea which is a common feature with a range of other etiologies. Routine paraclinical tests from CC patients such as endoscopic and radiographic studies are usually normal, and diagnosis must be made by biopsy. The gold standard for a confirmative diagnosis of CC is to measure the thickness of the sub-epithelial collagen (SEC) in colon tissue samples. Visual inspection of microscopic samples is often time-consuming, cumbersome and subject to human errors. This fact demonstrates the necessity of developing an automated method which assists pathologists in evaluating histopathological samples more accurately in the busy clinical environment. To the best of our knowledge, this is the first time that a computer-assisted diagnosis algorithm has been applied to CC detection. The proposed method uses a pre-trained Multi-Layer Perceptron neural network to segment SEC band in colon tissue images. We compared a variety of different color and texture descriptors and explore the best set of features for this task. The investigation of the proposed method shows 94.5% specificity and 95.6% sensitivity rate.

Collagenous colitis-like condition in immunosuppressed infant baboons

BACKGROUND

Collagenous colitis is a chronic inflammatory bowel disease of unknown etiology. It is fairly common in adult humans, but rare in infants, and has been associated with autoimmune disorders.

METHODS

We report four infant baboons (age 7-12 months) that had received a transplant at 3 months of age and subsequent immunosuppressive therapy for periods of 4-10 months. All presented identical symptoms within a period of 4 weeks, including weight loss associated with chronic watery diarrhea that was unresponsive to standard antimicrobial treatment.

RESULTS

Clinical chemistry evaluations were within normal ranges, viral causes were ruled out, and fecal and blood cultures were repeatedly negative. At necropsy, two infant baboons were found to have a form of collagenous colitis. In the remaining two baboons that had identical clinical features, immunosuppressive therapy was discontinued and treatment with budesonide was initiated. Both baboons recovered and remained well on no medication until the end of follow-up (24 months).

CONCLUSIONS

Collagenous colitis has occasionally been reported in patients with organ transplants. It has been reported only once previously in baboons. The four cases reported here strongly suggest that 1) clinical features as well as histopathological findings of collagenous colitis in baboons are very similar to those in human patients; 2) it was associated with the immunocompromised state of the baboons, as two nonimmunosuppressed age-matched baboons in close proximity did not develop the condition; and 3) it may have had an infectious origin, as all four cases developed within a 4-week period of time.

Mucosal atrophy in collagenous colitis: a case report

BACKGROUND

Mucosal atrophy as a potential cause of impaired colonic compliance has not yet been described as a complication in Collagenous Colitis (CC).

CASE PRESENTATION

We present a 51-year-old female patient with a 20-year history of diarrhea and diagnosed with CC ten years prior to her presentation. We reviewed reports from three colonoscopies performed after the diagnosis. Overall 12 biopsies obtained in the last two colonoscopies were re-analyzed by two pathologists blinded to the aim of the study. Besides the typical histological findings of CC, the endoscopic appearance was normal, and no histological signs of atrophy were found during the first colonoscopy. Surprisingly, the second and third colonoscopy revealed a region of advanced segmental mucosal atrophy in the cecum with the mucosal height normalizing toward the transverse colon. This pattern of atrophy was inversely related to the pattern of sub-epithelial collagen deposition, which increased toward the rectum.

CONCLUSION

If no chance occurrence, our observation supports the idea that additional factors, probably luminal in nature, may be co-responsible for the mucosal atrophy in this case. Thus, mucosal atrophy in the proximal colon appears to be a new candidate among the growing list of rare complications associated with long standing CC.

Colonic perforation in collagenous colitis: a systematic review of a rare complication and guidance on management

OBJECTIVE

Collagenous colitis is an increasingly diagnosed clinical and pathological variant of microscopic colitis, mainly affecting middle-aged and elderly women; herein we review the literature for a rare complication (colonic perforation) and the most appropriate management.

METHODS

EMBASE, MEDLINE and abstracts from major gastroenterological congresses were searched in addition to hand-searching of electronic journals. Ten case reports and short series were identified as relevant to this study, and full papers of all these articles were obtained.

RESULTS

A total of 30 cases were recorded (28 female; age range 37-86 years, median 66 years). Colonic perforation was reported in 21 cases, mainly following colonoscopy (15 cases) or barium enema (4 cases). The site of colonic perforation/tears was predominantly right sided (17 cases). These cases were managed differently in different series, and none of the collagenous colitis-related colonic perforations that were treated conservatively (n = 5), or with diagnostic laparotomy but no colonic resection (n = 2), required further surgical intervention.

CONCLUSIONS

Conservative management of collagenous colitis-related perforation seems to be an appropriate initial approach. However, diagnosis of collagenous colitis is usually retrospective in colonic perforations related to endoscopy or barium enema, i.e. when the histology results are available, and it seems difficult to provide a management plan specific to these patients in the clinical setting. Therefore general guidelines for management of all colonoscopy- and barium enema-related perforation are required. When perforation occurs in an otherwise intact colon, diagnostic laparoscopy can be considered as appropriate initial management.

Long term diarrhoea caused by simultaneous Crohn's disease and coeliac disease in the same patient

Coeliac disease and Crohn's disease are among the most well known gastrointestinal disorders, with distinct pathogenic mechanisms. However, because of some overlapping features between these two conditions, there may be some inevitable misdiagnoses. In addition, diarrhoea and changes in bowel habit may lead the physician to misdiagnose more common disorders such as irritable bowel syndrome. There are a few cases reporting both coeliac and Crohn's disease in the same patient. Here we report a case of a 32-year-old woman suffering from long term diarrhoea who was eventually discovered to have coeliac disease and Crohn's disease simultaneously.

Response to infliximab in SAPHO syndrome

Infliximab has become increasingly important in the treatment of SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome. There is, however, little experience with this biological agent, and treatment protocols usually follow the regimens for spondylarthropathies. We report a patient with a highly unusual and severe clinical presentation of SAPHO syndrome including widespread bone and skin disease, and collagenous colitis. Infliximab treatment (5 mg/kg) given at weeks 0, 2 and 6 and every 8 weeks thereafter, induced rapid remission of the osteoarticular symptoms, although the skin lesions improved only partially, and after 10 months continuous therapy with infliximab a bone scan even uncovered new active bone lesions. Collagenous colitis is unresponsive to tumour necrosis factor α (TNFα) blocking agents. This moderate response to infliximab may indicate that a more aggressive treatment protocol is mandatory. We further believe that remission of osteoarticular complaints should be routinely confirmed by scintigraphic findings to verify treatment response.