Collagenous Colitis

ABSTRACT Collagenous colitis is a very rarely recognized disease characterized clinically by watery diarrhoea and histologically by a broad, band-like deposition of collagen under the surface epithelium of the colon and rectum. Two cases of collagenous colitis are reported in this paper. After treatment of one of the patients with metronidazole, the symptoms cleared up and biopsy specimens from the colon showed regression of the pathological picture. The pathogenesis of the diarrhoea is discussed. The aetiological agent seems to be infectious, but is still unknown.     

Protein-Losing Enteropathy with Collagenous Colitis

Collagenous colitis is a distinct cause of chronic watery diarrhea characterized by abnormal deposition of collagen in the subepithelial region of the colonic mucosa. Typically, laboratory tests of blood, urine, and stool are normal. A few patients have laboratory evidence of small bowel dysfunction and malabsorption, but excessive enteric protein loss is not a commonly recognized manifestation of collagenous colitis. We report a 62-yr-old woman who had collagenous colitis associated with a marked protein-losing enteropathy in the absence of obvious small intestinal disease or colonic ulceration. Biopsies of endoscopically normal-appearing colonic mucosa should be performed in patients with protein-losing enteropathy in whom no cause is apparent after initial evaluation.     

Collagenous Colitis and Yersinia enterocolitica Infection

Collagenous colitis is a rare clinical andpathological entity characterized by watery diarrhea anddeposition of collagen beneath the surface epithelium ofthe colon. Its etiology is unknown. We present a careful retrospective clinicopathologicalanalysis of six patients with collagenous colitisdiagnosed at our hospital during a three-year period.Three of the patients had had a Yersinia enterocolitica infection, detected by stool culture andelevated serum antibody titers, preceding the diagnosisof collagenous colitis. Four patients had duodenalvillous atrophy, which in two patients was refractory to a gluten-free diet. We propose that Yersiniaenterocolitica infection may be a triggering factor forthe development of collagenous colitis in some cases.Duodenal villous atrophy not responding to gluten withdrawal is common in association withcollagenous colitis.     

Collagenous Colitis and Microscopic Colitis: The Watery Diarrhea-Colitis Syndrome

Nine patients (seven females, two males) with chronic watery diarrhea and nonspecific colonic mucosal inflammation followed for 1-5 yr are presented. Eight were diagnosed as having collagenous colitis on the basis of marked thickening of the subepithelial collagen layer in at least one set of biopsies. The thickness of the collagen table varied with time in all eight cases. When thickening was minimal, morphological features were indistinguishable from microscopic colitis, signifying that, in most cases, collagenous colitis and microscopic colitis are part of the same spectrum of colonic mucosal response. One of the eight patients had documented collagenous colitis and gluten-associated enteropathy for 12 yr. The colitis and duodenal histology improved synchronously when a gluten-free diet and corticosteroids were administered. The ninth patient had microscopic colitis and enteropathy which did not respond to gluten withdrawal. This patient never exhibited thickening of subepithelial collagen in repeated biopsies over 5 yr, suggesting that an entity of microscopic colitis may exist independent of collagenous colitis. Duodenal mucosal biopsies showed normal histology in four other patients with collagenous colitis. The histological variability of collagenization and inflammation during the course of collagenous colitis and microscopic colitis and the clinical feature of watery diarrhea suggest that these two entities be grouped together as the watery diarrhea-colitis syndrome.     

Collagenous Colitis: Are Bacterial Cytotoxins Responsible?

In a case of collagenous colitis, cholestyramine treatment resulted in symptomatic and histological normalization. After discontinuation of cholestyramine, collagenous colitis relapsed. At this time fecal cytotoxic activity was demonstrated in McCoy cell lines. Symptoms, histologic changes, and cytotoxicity disappeared when cholestyramine treatment was reinstituted. We hypothesize that a bacterial toxin is responsible for the development of collagenous colitis.     

Collagenous Enterocolitis: A Case of Collagenous Colitis with Involvement of the Small Intestine

A 78-yr-old previously well caucasian female presented with a 6-wk history of profuse watery diarrhea and weight loss. Clinical investigation showed evidence of mild malabsorption. Multiple biopsies of colonic mucosa revealed a wide subepithelial band of collagen typical of collagenous colitis. Duodenal biopsies showed similar collagen deposition and partial villous atrophy. Some amelioration of symptoms occurred with sulfasalazine therapy. This is the first reported case of collagenous colitis with histological evidence of small intestinal involvement. At least in some patients, collagenous colitis and collagenous sprue appear to be manifestations of a single disease. For such cases, the term collagenous enterocolitis is suggested.     

Collagenous Colitis Possibly Associated with Dipeptidyl Peptidase-4 Inhibitor

A 60-year-old man with type 2 diabetes mellitus treated with a dipeptidyl peptidase-4 (DPP-4) inhibitor was referred to our hospital because of his refractory watery diarrhea. Ileocolonoscopy revealed increased capillary growth, fine granular mucosa, and longitudinal mucosal tears mainly in the left side of the colon. A bioptic examination revealed thickened subepithelial collagen bands, thus confirming the diagnosis of collagenous colitis. Systemic steroid therapy was initiated, but his symptoms recurred when tapering the steroid. However, withdrawal of the DPP-4 inhibitor was successful even after the cessation of steroid therapy. We therefore considered his collagenous colitis to have been caused by the DPP-4 inhibitor.     

Lymphocytic and Collagenous Colitis: Epidemiologic Differences and Similarities

Background

It is unknown whether the subtypes of microscopic colitis (MC) represent distinct nosologic entities or related presentations of the same disease. Our aim was to search for epidemiologic differences among its various histopathologic subtypes.

Methods

In a computerized database of 789,568 colon pathology reports, we compared the characteristics of 8,745 MC patients with those of the remaining population.

Results

MC was diagnosed as three distinct histopathologic subtypes: lymphocytic colitis (LC) in 51 %, collagenous colitis (CC) in 43 %, and incomplete colitis (IC) in 6 % of patients. Only 0.65 % was simultaneously diagnosed with more than one subtype of MC. The prevalence of all three subtypes showed an age-dependent rise, with the average age (SD) being 63.3 (14.3) years in LC, 66.4 (12.1) years in CC, and 67.3 (12.7) years in IC (p < 0.0001). There was a striking female predominance in all three subtypes, the female fraction being 72 % in LC, 82 % in CC, and 79 % in IC (p < 0.0001). All three subtypes showed similar geographic distributions among different US states. They were similarly associated with diarrhea and weight loss, the odds ratios for all MC being 45.92 (43.35–48.63) and 5.12 (4.68–5.60), respectively, compared to control patients without MC. All three subtypes also harbored significantly less colonic adenomas, the overall odds ratio being 0.11 (0.10–0.12).

Conclusion

MC comes in three distinct histopathologic entities, which show striking similarities of their general epidemiologic features. The slight differences in their demographic characteristics could point at varying sets of environmental influences that affect the occurrence of subtypes.     

Yersinia Species in Collagenous Colitis: A Serologic Study

Background: The etiology of collagenous colitis is unknown. An infectious cause seems a possibility, and in a recent report three out of six patients with collagenous colitis were shown to have had an infection with Yersinia enterocolitica. The aim was to investigate the occurrence of Yersinia antibodies in collagenous colitis. Methods: Sera from 32 collagenous colitis patients and 17 healthy controls were analysed for antibodies against Yersinia virulence proteins. Results: Collagenous colitis patients had Yersinia antibodies more often than the controls, 9 having a positive and 4 an intermediate antibody score of the 32 patients. In comparison, 1 out of 17 controls had a positive and 2 an intermediate antibody score, which represents a strong, although not significant, trend ( P = 0.078). Conclusion: The data showed that Yersinia antibodies are more common in collagenous colitis patients than in healthy controls. In some cases, Yersinia might have been the triggering event in the development of collagenous colitis.     

Collagenous and Lymphocytic Colitis: Subject Review and Therapeutic Alternatives

Objective: To review the published studies on collagenous and lymphucytic (microscopic) colitis with specific emphasis on clinical features, investigational studies, characteristic histology, possible pathogenesis, disease course, and empirical treatment. Design: Comprehensive synopsis of the stated objective, prepared for the physician treating patients with collagenous or lymphocytic colitis. Materials and Methods: The medical literature on collagenous and lymphocytic colitis. Results: Collagenous and lymphocytic colitis are chronic diarrheal illnesses of indeterminate etiology that typically present in the late sixth or early seventh decade of life. These disorders may he distinct entities, although some data support the idea that they are only different manifestations of the same disease. The pathogenesis is unknown hut may be on an inflammatory, possibly autoimmune, basis. Physical examination and investigational studies are normal or nonspecific, with fecal leukocylosis the only abnormality found in the majority of patients tested. Association with various gastrointestinal, autoimmune, and rheumatoiogic conditions has been observed in some patients. Clinical and occasional histologic response has been observed after treatment with anti-inflammatory agents such as 5-aminosalicylate and corticosteroids, and should be used when there is no response to symptomatic therapy. Conclusions: Collagenous and lymphocytic colitis are uncommon but important causes of chronic diarrhea which are important to diagnose and treat.     

布地奈德治疗胶原性结肠炎疗效和安全性的荟萃分析

背景:胶原性结肠炎以慢性水样腹泻和结肠黏膜上皮下胶原带增厚为特征,目前尚无标准治疗方案。目的:系统评价口服布地奈德治疗胶原性结肠炎的疗效和安全性。方法:计算机检索Cochrane Central Register of Controlled Trials(1995～2008.1)、MEDLINE/PubMed(1978～2009.12)、Ovid(1978～2009.12)、EMBASE(1978～2009.12)、中国期刊全文数据库(1980～2009.12)和万方数据资源系统(1980～2009.12),纳入所有口服布地奈德治疗胶原性结肠炎的随机对照试验(RCT),按Cochrane协作网推荐的方法进行荟萃分析。结果:共纳入5项RCT,包括179例患者,3项研究评价了诱导缓解治疗,2项评价了维持治疗。在诱导缓解方面,布地奈德的临床和组织学缓解率均优于安慰剂(OR=15.04,95% CI:5.47～41.33,P0.000 01;OR=34.02,95% CI:5.90～196.20,P0.0001)。在维持治疗方面,布地奈德的临床复发率和组织学缓解维持率亦优于安慰剂(OR=0.11.95% CI:0.04～0.31,P0.0001;0R=5.88,95% CI:1.90～18.17,P=-0.002)。布地奈德不良反应轻微,耐受性良好。结论:口服布地奈德能有效诱导并维持胶原性结肠炎的临床和组织学缓解,耐受性良好。由于本荟萃分析纳入研究的样本量较小,故应谨慎对待上述结论,并设计、开展大样本、高质量的RCT作进一步验证。     

Clinico-Pathological Features of Collagenous Colitis: Case Report and Literature Review

Collagenous colitis is a newly identified condition, with clinical features of chronic watery diarrhea and abdominal pain. Histologically the main characteristic is the presence of a thick collagen band below the surface epithelium. Collagenous colitis occurs in adults, especially women. Endoscopy reveals no particular changes in the intestinal mucosa. Symptoms may persist for years with periods of remission and recurring acute attacks. The cause of this condition is still unknown, and because of no real knowledge only symptoms can be treated, usually with little success.