Collagenous and Lymphocytic Colitis Treatment & Management

  • Author: Eric Goosenberg, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Jan 5, 2012
 

Medical Care

  • Evaluating treatment options is impaired by the fairly frequent occurrence of spontaneous remission of symptoms; however positive placebo-controlled double-blind randomized trials of budesonide have been performed and reported in both LC and CC.
  • A trial of dietary restriction and avoidance of potentially aggravating drugs (particularly nonsteroidal anti-inflammatory drugs) may alleviate symptoms in some patients, but many will require medical therapy.
  • Treatment should be initiated with the least toxic regimen or medication, with stronger medication used only if milder treatment fails. Generally, 4-6 weeks should be allowed before deeming a particular medication ineffective in the treatment of CC or LC.
  • One possible treatment algorithm is as follows:
    • First line: Loperamide (Imodium AD) or diphoxylate/atropine (Lomotil) for mild diarrhea.
    • Second line: Bismuth subsalicylate, two or three 262 mg tab tid or qid for 1-2 months (effective in up to 90% of patients); mesalamine, 3 g/d for 8 wk; or cholestyramine (especially if bile acid malabsorption is documented), at a mean dose of 8 g/d in moderate disease.
    • Third line: If patient is still not responding or if a patient has clinically more severe colitis, a 6-week course of budesonide at the lowest effective dosage (usually 9 mg each morning) or a 2-week course of high-dose prednisone (60-80 mg/d) before tapering can be prescribed. Longer courses of budesonide may be beneficial, and, while systemic adverse effects may occur, little or no adrenal suppression should be anticipated. Recurrences after discontinuation of budesonide usually respond to reinstitution of this same medication. Longer courses of prednisone (up to 2 mo before tapering) may be needed in some patients, but recurrence is common after its discontinuation. In a randomized, double-blind, placebo-controlled study, Miehlke et al evaluated treatment of lymphocytic colitis with oral budesonide.[5] At week 6, remission was documented by colonoscopy and histology in 86% of the budesonide group compared with 48% of those administered placebo (P = 0.01). Histologic remission was confirmed in 73% of those receiving budesonide and 31% of patients administered placebo (P = 0.03).[5] Relapse during follow-up was evident in about 44% (15 patients), but 8 of those who had a relapse again had a response to budesonide. Clinical remission and improved histology is achieved in a majority of patients with lymphocytic colitis when treated with budesonide.[5]
    • Fourth line: Some refractory cases may benefit from azathioprine (approximately 2 g/kg/d) or 6-mercaptopurine, but responses often take months to occur. Methotrexate can alternatively be used in this setting.
    • Patients who respond to treatment, but experience a recurrence, will often respond again to the same previously effective medication.
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Surgical Care

If colitis is refractory to continued medical therapy or if effective medication cannot be tolerated, colectomy or ileostomy might be the only effective therapy; however, this seldom is necessary.

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Consultations

Consultation with a gastroenterologist often is needed to make the diagnosis and to work through the treatment algorithm.

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Diet

  • Patients should avoid or eliminate possible secretagogues, such as caffeine, and, when appropriate, lactose-containing products.
  • A low-fat diet is advisable if steatorrhea is documented.
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Contributor Information and Disclosures
Author

Eric Goosenberg, MD  Assistant Professor of Medicine, Temple University School of Medicine

Eric Goosenberg, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and Bockus International Society of Gastroenterology

Disclosure: Nothing to disclose.

Specialty Editor Board

Terence David Lewis, MBBS, FRACP, FRCPC, FACP  Program Director, Internal Medicine Residency, & Assistant Chairman, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Loma Linda University Medical Center

Terence David Lewis, MBBS, FRACP, FRCPC, FACP is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, California Medical Association, Royal College of Physicians and Surgeons of Canada, and Sigma Xi

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Douglas M Heuman, MD, FACP, FACG, AGAF  Chief of GI, Hepatology, and Nutrition at North Shore University Hospital/Long Island Jewish Medical Center; Professor, Department of Medicine, Hofstra North Shore-LIJ School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association

Disclosure: Novartis Grant/research funds Other; Bayer Grant/research funds Other; Otsuka Grant/research funds None; Bristol Myers Squibb Grant/research funds Other; Scynexis None None; Salix Grant/research funds Other; MannKind Other

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Arun Chaudhary, MD, to the development and writing of this article.

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Lymphocytic colitis (LC) showing marked chronic inflammatory cell infiltrate of the surface epithelium (on right) with preservation of crypt architecture. Subepithelial collagen layer is not thickened.
Collagenous colitis (CC) showing similar inflammatory cell infiltration as in lymphocytic colitis (LC), with the characteristically thickened subepithelial collagen layer.
 
 
 
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