BATTLING MICROSCOPIC COLITIS: PROGNOSIS, TYPES, PREVENTION, AND TREATMENT

Medically Reviewed by Dr. Sony Sherpa (MBBS) - September 23, 2024

Microscopic colitis is classified as an inflammatory bowel disease (IBD) known to affect the colon or large intestine. Chronic watery diarrhea and colonic inflammation are the hallmark features of the condition.

This condition is often misdiagnosed and mistaken for the digestive diseases Celiac disease and irritable bowel syndrome (IBS). It is essential to understand the different types of microscopic colitis and their symptoms to receive proper treatment.

This article will cover the main microscopic colitis types (collagenous colitis and lymphocytic colitis) and how they can impact your digestive system and overall quality of life.

What is Microscopic Colitis?

Microscopic colitis is an inflammatory bowel disease affecting the colon or large intestine. The name relates to the way its diagnosis occurs under a microscope.^[1]

The incidence of collagenous colitis ranges from 2.0-10.8 per 100,000 and 2.3-16 per 100,000 for lymphocytic colitis. Northern Europe and North America observe higher rates than other regions. It is also more prevalent in individuals with an autoimmune disease such as rheumatoid arthritis.

Most diagnoses occur over the age of 50, at an average age of 65 years. Roughly 25% occur before 45 years of age.

The condition very rarely affects children and is more common in females. Collagenous colitis has a female-to-male ratio of 3:1. Lymphocytic colitis has a female-to-male ratio of nearly 2:1.

Microscopic Colitis Types

There are two officially recognized types of microscopic colitis: collagenous colitis and lymphocytic colitis. While they have similar symptoms, they differ in the type of inflammation seen in the colon.

Collagenous Colitis

Characterizing collagenous colitis is an increase in collagen, a protein seen to thicken the colon lining. This thickening can cause colonic narrowing, leading to abdominal pain and changes in bowel movements. The exact cause of this type remains unknown. Collagenous colitis likely arises from an abnormal immune response in the colon.

Lymphocytic Colitis

Lymphocytic colitis exhibits an increase in white blood cells (lymphocytes) lining the colon.

Lymphocytes are immune cells responsible for fighting off infections and foreign substances. In lymphocytic colitis, the immune system mistakenly attacks the colon's lining, causing inflammation and damage.

There is a link between lymphocytic colitis, celiac disease, and infections in the digestive tract.

Celiac disease is an autoimmune-mediated allergy to gluten. Studies show that those with lymphocytic colitis have a significantly higher likelihood^[2] of presenting with Celiac disease.

Incomplete Microscopic Colitis

Incomplete microscopic colitis lacks official recognition as a distinct subtype, sometimes called "microscopic colitis not otherwise specified."

It is a term used to describe a condition that shares some similarities with collagenous colitis and lymphocytic colitis but does not meet the diagnostic criteria for either subtype.^[3] The term refers to cases with evidence of inflammation in the colon without specific characteristics of either subtype.

Symptoms of Microscopic Colitis

Lymphocytic colitis symptoms are similar to the symptoms of collagenous colitis. The main symptom is chronic watery diarrhea, occurring 4-10 times a day on average for more than four weeks. Onset is usually gradual, yet it may be sudden in 40% of cases.

Other symptoms include:

• Abdominal pain
• Cramping
• Bloating
• Urgency to have a bowel movement

Some individuals may also experience more diarrhea episodes daily, weight loss, fatigue, and dehydration due to the frequent bowel movements.

While both types cause diarrhea, collagenous colitis exhibits more intense bowel inflammation and greater symptom severity. CC often leads to more explosive, watery stools several more times a day. LC is often less urgent and frequent and has an earlier onset.

How Serious is Microscopic Colitis?

Microscopic colitis can be a serious condition, especially if left untreated. In rare cases, severe microscopic colitis can lead to complications such as dehydration, electrolyte imbalance, or even malnutrition if not appropriately managed.

It is crucial to consult a doctor to receive suitable treatment and advice for managing the symptoms effectively.

Prognosis: Can Microscopic Colitis Be Cured?

While there is no cure for microscopic colitis, treatment and lifestyle changes can effectively control symptoms. With proper treatment, some people with microscopic colitis may experience periods of remission. However, improper trigger management can lead to flares. Flares refer to the recurrence of symptoms after a period of remission.

Therefore, individuals with microscopic colitis must work closely with their doctors to find the right treatment plan and make necessary lifestyle changes to minimize the risk of flares. These individuals can improve their prognosis and maintain a better quality of life by effectively managing triggers and following the recommended treatment.

What Causes Microscopic Colitis?

The underlying cause of microscopic colitis remains unknown. Inflammation and changes in the gut's lymphatic system (called the lamina propria) likely drive the severity of diarrhea.

Current theories suggest a malfunction in the lining of the gut barrier that results in irritation and diarrhea.^[4] The malfunction can be related to either:

• Excessive collagen growth in the gut lining
• Heightened gut permeability, allowing for more uptake of fluids and bacteria

Those with the condition often suffer from bile acid malabsorption, which means they struggle to absorb bile and dietary fats. While the cause is undetermined, bile acid malabsorption may be related to reduced sodium chloride (salt) absorption and increased chloride secretion.

More research is needed to confirm these observations.

Microscopic Colitis Risk Factors

Genetics may increase the risk of contracting microscopic colitis later in life. While a causative gene remains elusive, it can run in families. In some families, different members developed either lymphocytic or collagenous colitis, suggesting a shared cause.

Genes for autoimmunity (HLA-DQ2/DQ1,3 and HLA-DR3DQ2 haplotypes), inflammation, and excessive growth (tumor necrosis factor 2 gene variant) are also often expressed in those with the condition.

Chronic disturbances in the gut microbiome may also increase the risk.^[5]

The below section explores other risk factors known to trigger flares.

What Triggers Microscopic Colitis?

Certain factors are known to trigger symptoms^[6], such as:

• Certain medications
• Infections in the digestive tract, including Helicobacter Pylori
• Autoimmune conditions, such as rheumatoid arthritis
• Smoking
• Stress
• Foods that trigger gut irritation, sensitivity, or allergy

Medications frequently associated with microscopic colitis include^[7]:

• Non-steroidal anti-inflammatory drugs (NSAIDs). Common offenders are aspirin, ibuprofen, and diclofenac
• Proton pump inhibitors (PPIs), including omeprazole and lansoprazole
• Selective serotonin reuptake inhibitors (SSRIs)
• Acarbose
• Ranitidine
• Ticlopidine
• Statins

It is essential to note that while these factors may trigger symptoms, they do not necessarily cause microscopic colitis. The underlying cause of microscopic colitis is still not fully understood.

Diagnosis

A colonoscopy permits a doctor to diagnose the condition from a colonic biopsy. The findings are then examined under a microscope to diagnose microscopic colitis. Biopsy is the only way to confirm the presence of inflammation and damage in the colon. A biopsy can also help to rule out Crohn's disease, a disorder similar to irritable bowel syndrome (IBS).

Diarrhea-predominant irritable bowel syndrome (IBS) often mimics microscopic colitis and is diagnosed by a process of elimination. A doctor will look for symptoms of abdominal pain or cramps relieved by defecation and frequent changes in bowel movements.

Blood tests, stool tests, and endoscopic examinations, such as a flexible sigmoidoscopy, may be done to rule out other conditions, such as Celiac disease and colon cancer.

Microscopic Colitis Treatment

Despite the lack of a cure for microscopic colitis, treatments are available to manage the symptoms and improve quality of life. Treatment options include prophylactic prescription medication and dietary changes. Doctors may consider surgery in extreme cases.

Medications for Microscopic Colitis

Standard prescriptions for this condition comprise of^[8]:

• Anti-diarrheal drugs: Doctors prescribe them to help stabilize patients with acute or chronic diarrhea.
• Anti-inflammatory drugs: These actively reduce colonic inflammation and improve symptoms.
• Bile acid sequestrants: They bind to bile acids in the digestive tract, reducing diarrhea in people with microscopic colitis.
• Immunosuppressants: These may be prescribed in the worst cases of microscopic colitis to suppress the immune system and reduce inflammation in the colon. Patients should use these medications only under the supervision of a doctor.

Relapse is prevalent after stopping medication.

Dietary Modification

Making changes to your diet can also help to manage symptoms of microscopic colitis.^[9] While there is no specific microscopic colitis diet, a few common suggestions include:

• Avoiding foods that initiate inflammation in the colon, such as spicy foods, caffeine, and alcohol.
• Removing gluten from the diet.
• Moderating high-fat food and salt intake, as it can be difficult for those with microscopic colitis to absorb fats or salt.
• Increasing the consumption of stool-bulking foods and supplements, such as psyllium husk.
• Eating smaller, more frequent meals.
• Staying hydrated helps control diarrhea.
• Occasional fasting may help to improve symptoms in some patients.
• Similarly to those with IBS, a third of people with microscopic colitis might benefit from a low FODMAP diet to ease symptoms of IBS. FODMAPs are highly fermentable, prebiotic carbohydrates that may worsen symptoms in those with IBS.
• Official guidelines strongly recommend avoiding the use of probiotics. There is limited evidence to support their long-term use in improving stool frequency and consistency in those with microscopic colitis.
• It is highly advisable to consult with a qualified specialist who can devise a suitable dietary plan tailored to your individual needs.

Surgery

Up to 20% of those with microscopic colitis do not respond to prescription treatment options.

Surgery might be a viable treatment option if symptoms are severe enough and demand prompt treatment. Microscopic colitis patients only undergo surgery as a last resort.

The specific type of surgery used to treat microscopic colitis would depend on the individual case and the severity of the condition.

Prevention and Managing Flares

Managing triggers is a critical aspect of preventing flares of microscopic colitis.

Avoiding inflammatory triggers, certain foods, stress, and medication changes can help prevent symptoms from worsening. It also helps to keep the immune system strong and correct any microbial disturbances in the gut.

Individuals with microscopic colitis can reduce the frequency and severity of flare-ups by identifying and avoiding these triggers.

Working closely with a healthcare professional is highly recommended to manage your triggers and prevent symptoms.

How Long Do Flares Last?

Flares of microscopic colitis can vary in duration and may last a few days to several weeks.

The duration of flares can depend on various factors. These include the individual's overall health, flare severity, and the patient’s response to treatment.

Is There Any Link Between Microscopic Colitis and Colon Cancer?

Studies have failed to find a link between microscopic colitis and an increased risk of colon cancer.

One study reviewed around 51,000 people with the condition to assess their colon cancer risk. The results showed that these individuals have a lower chance of getting colon cancer compared to the general population.

Despite these findings, it is essential to rule out colon cancer in undiagnosed individuals with microscopic colitis. Endoscopic examinations, such as flexible sigmoidoscopy, may be done to rule out colon cancer in individuals with symptoms of microscopic colitis.

Conclusion

Microscopic colitis is an IBD or disorder of the bowel that affects the colon and can cause chronic watery diarrhea and abdominal pain. There are two types with slightly different causes and symptoms. While there is no cure for microscopic colitis, available treatments can manage symptoms and improve the quality of life for most with the condition. By working closely with your doctor and making necessary lifestyle changes, you can effectively manage this condition and live a fulfilling life.

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