New York-Presbyterian/Weill Cornell Medical Center New York, NY
Rochelle Wong, MD1, Parul Shukla, MD, MS, FRCS2, Lihui Qin, MD, PhD3, David Wan, MD2; 1New York-Presbyterian/Weill Cornell Medical Center, New York, NY; 2Weill Cornell Medical College, Cornell University, New York, NY; 3Weill Cornell Medicine, New York, NY
Introduction: Microscopic colitis (MC) is a common, though underdiagnosed, cause of non-bloody watery diarrhea. MC’s two subtypes, collagenous and lymphocytic, are differentiated based on histology. Despite MC’s increasing incidence, understanding of the disease remains limited1.
Methods: A 67-year-old woman with hyperlipidemia on simvastatin and rectal prolapse status post rectopexy and sigmoidectomy 4 weeks prior presented with new diarrhea. She had up to 15 large, watery bowel movements per day, regardless of fasting or time of day. Stool studies were negative for infection. Physical exam had no prolapse. Past colonoscopies showed internal hemorrhoids, and recently resected colon specimen only had microscopic prolapse findings. Colonoscopy performed 3-months post-surgery showed healthy appearing mucosa, but biopsy revealed collagenous colitis (CC) (Fig. 1, 2). Budesonide was started for 8 weeks with dramatic clinical improvement. Simvastatin was stopped as possible trigger of CC. Her diarrhea recurred while tapering off budesonide, necessitating an extended course and slower taper. Discussion: MC is a chronic inflammatory disease of unclear pathogenesis. Known risk factors include increasing age, female sex, and certain medications (NSAIDs, statins, proton-pump inhibitors)1. Though there is no known association between rectal prolapse or sigmoidectomy with development of MC, post-surgical changes in gut microbiota may have contributed (similar to dysbiosis implicated in inflammatory bowel disease)2. The treatment aim is to induce clinical remission. While steroid-sparing agents are available, budesonide is most effective3. Patients with baseline higher stool frequency ( >5/day) have higher risk of symptom relapse with tapering budesonide, and may need long-term maintenance therapy4.
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Miehlke S, et al. Budesonide is more effective than mesalamine or placebo in short-term treatment of collagenous colitis. Gastroenterology 2014;146:1222-1230.e1–2.
Miehlke S, et al. Risk factors for symptom relapse in collagenous colitis after withdrawal of short-term budesonide therapy. Inflamm Bowel Dis 2013;19:2763–2767.
Trichrome stain of colon biopsy highlighting the subepithelial collagen deposition (blue).
Hematoxylin and eosin (H&E) stain of colon biopsy highlighting subepithelial collagen deposition (light pink).
Disclosures: Rochelle Wong indicated no relevant financial relationships. Parul Shukla indicated no relevant financial relationships. Lihui Qin indicated no relevant financial relationships. David Wan indicated no relevant financial relationships.