Diagnostic Considerations

Rule out microscopic colitis (MC) in those who fulfill the criteria for functional bowel disease, especially in the presence of risk factors for microscopic colitis and/or in the absence of response to therapy for irritable bowel syndrome (IBS).

Microscopic colitis should be considered as a differential diagnosis in the workup of chronic diarrhea, especially in the elderly population. In addition, microscopic colitis should be considered in patients diagnosed with celiac disease who have diarrhea that fails to respond to a gluten-free diet.

Differential diagnosis

Different small bowel diseases and conditions may mimic microscopic colitis, including the following:

Concurrent lymphocytic colitis (LC) and lymphocytic gastritis^[31]
Celiac disease: Collagenous colitis (CC) may represent a diffuse manifestation of gluten sensitivity; therefore, it is reasonable to evaluate patients for celiac disease^[32]
Infectious colitis (other than Clostridium difficile infection)
Ischemic colitis
Laxative abuse
Bile acid malabsorption

Important considerations

Patients whose condition fails to respond to reasonable medical therapy should be evaluated for other conditions that may clinically mimic lymphocytic colitis and collagenous colitis.

The adverse effects of corticosteroids and immunosuppressants/immunomodulators may be serious. Such drugs would be difficult to justify in a patient later found to have an irritable bowel syndrome (IBS) or infectious or other causes of colitis or enteritis that should have been treated differently.

Performing a colonoscopy on patients with chronic diarrhea is commonly accepted and widely practiced, but performing biopsies in all such individuals has a low yield, even with normal findings on endoscopy. Patients clinically assessed as having diarrhea-predominant IBS (IBS-D) in whom conventional medical therapy is refractory may in fact have microscopic colitis, and these patients may benefit from colonoscopy with biopsies.

Limit biopsies to those subgroups of patients in whom microscopic colitis is most likely, such as patients with watery, severe, debilitating, or nocturnal diarrhea; substantial weight loss; an elevated erythrocyte sedimentation rate; or patients who are immunosuppressed.

Special concerns

As with the management of inflammatory bowel disease (IBD), antidiarrheal and nonimmunosuppressive medications have an acceptable risk in pregnant patients when clinical symptoms are significant and might threaten the pregnancy.

Methotrexate may induce spontaneous abortion and is contraindicated during pregnancy. 6-Mercaptopurine and azathioprine may cause fetal harm but so may refractory colitis. Consequently, the risk versus benefit considerations must be carefully discussed before prescribing these medications to a pregnant patient.

Differential Diagnoses

Workup

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Media Gallery

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

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Author

Harika Balagoni, MD Fellow, Department of Gastroenterology, Ascension Providence-Providence Park Hospital, Michigan State University College of Human Medicine

Harika Balagoni, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Crohn's and Colitis Foundation of America

Disclosure: Nothing to disclose.

Coauthor(s)

Michael H Piper, MD Clinical Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Wayne State University School of Medicine; Consulting Staff, Digestive Health Associates, PLC

Michael H Piper, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, Michigan State Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

Joyann A Kroser, MD, FACP, FACG, AGAF Adjunct Clinical Associate Professor of Medicine, Gastroenterology, and Hepatology, Drexel University College of Medicine; Adjunct Professor of Medicine, Temple University School of Medicine

Joyann A Kroser, MD, FACP, FACG, AGAF is a member of the following medical societies: American College of Physicians, Alpha Omega Alpha, Crohn's and Colitis Foundation of America, American College of Gastroenterology, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Pennsylvania Medical Society, Phi Beta Kappa, Philadelphia County Medical Society

Disclosure: Nothing to disclose.

Amandeep Singh, MBBS Resident Physician, Department of Internal Medicine, Crozer Chester Medical Center

Amandeep Singh, MBBS is a member of the following medical societies: American Academy of Family Physicians, American College of Gastroenterology, American College of Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Arun Chaudhary, MD Consulting Staff, Department of Internal Medicine, Wentworth-Douglass Hospital

Disclosure: Nothing to disclose.

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.

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