Collagenous and Lymphocytic Colitis Differential Diagnoses

Updated: Jan 04, 2017
  • Author: Joyann A Kroser, MD, FACP, FACG, AGAF; Chief Editor: BS Anand, MD  more...
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Diagnostic Considerations

Important considerations

Patients who fail to respond to reasonable medical therapy should be evaluated for other conditions that may mimic LC or CC clinically.

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 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, even with normal findings on endoscopy, has a low yield. Patients clinically assessed as having diarrhea-predominant irritable bowel syndrome who do not respond to conventional medical therapy 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. Those subgroups would include 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, antidiarrheal and nonimmunosuppressive medications have an acceptable risk in pregnant patients when clinical symptoms are significant and might threaten 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, risk versus benefit must be carefully discussed before prescribing these medications to a pregnant patient.

Other problems to be considered

Associations with other small bowel diseases and other conditions include the following:

  • Concurrent lymphocytic colitis and lymphocytic gastritis [8]

  • Celiac disease – Collagenous colitis may represent a diffuse manifestation of gluten sensitivity; therefore, it is reasonable to evaluate patients for celiac disease. [9, 10]

  • Infectious colitis (other than Clostridium difficile infection)

  • Extraintestinal manifestations (eg, nonerosive, oligoarticular arthritis, thyroiditis) [11]

  • Ischemic colitis

  • Laxative abuse

Differential Diagnoses