Case Report
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 21, 2015; 21(19): 6065-6071
Published online May 21, 2015. doi: 10.3748/wjg.v21.i19.6065
Fecal stream diversion and mucosal cytokine levels in collagenous colitis: A case report
Niki Daferera, Ashok Kumar Kumawat, Elisabeth Hultgren-Hörnquist, Simone Ignatova, Magnus Ström, Andreas Münch
Niki Daferera, Magnus Ström, Andreas Münch, Division of Gastroenterology and Hepatology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, 58185 Linköping, Sweden
Ashok Kumar Kumawat, Elisabeth Hultgren-Hörnquist, School of Health and Medical Sciences, Örebro University, 70182 Örebro, Sweden
Simone Ignatova, Department of Pathology, Linköping University, 58185 Linköping, Sweden
Author contributions: Daferera N and Münch A contributed equally to this work; Kumawat AK, Münch A and Hultgren-Hörnquist E designed the research; Kumawat AK and Ignatova S performed the research; Daferera N, Münch A, Ström M, Ignatova S and Hultgren-Hörnquist E analyzed the data; and Daferera N wrote the paper.
Ethics approval: The study was reviewed and approved by the regional Ethical Committee of Linkoping, Sweden (Dnr 2012/216-31).
Informed consent: All study participants provided informed written consent prior to study enrollment.
Conflict-of-interest: Andreas Münch has received fees for serving as a speaker for dr Falk Pharma and a research grand from Abbott. The rest of the co-authors have no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Andreas Münch, MD, PhD, Division of Gastroenterology and Hepatology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, 58185 Linköping, Sweden. andreas.munch@lio.se
Telephone: +46-10-1030000 Fax: +46-10-1033896
Received: October 27, 2014
Peer-review started: October 28, 2014
First decision: November 14, 2014
Revised: December 3, 2014
Accepted: January 30, 2015
Article in press: January 30, 2015
Published online: May 21, 2015
Abstract

In this case report, we examined the levels of cytokines expressed before and during fecal stream diversion and after intestinal continuity was restored in a patient with collagenous colitis. We report the case of a 46-year-old woman with chronic, active collagenous colitis who either failed to achieve clinical remission or experienced adverse effects with the following drugs: loperamide, cholestyramine, budesonide, methotrexate and adalimumab. Due to the intractable nature of the disease and because the patient was having up to 15 watery bowel movements per day, she underwent a temporary ileostomy. Colonic biopsies were analyzed for mucosal cytokine protein levels before and during fecal stream diversion and after intestinal continuity was restored. Mucosal protein levels of interleukin (IL)-1β, IL-2, IL-6, IL-12, IL-17 A, IL-23, TNF, IFN-γ, IL-4, IL-5, IL-10 and IL-13 were all higher during active disease and decreased to non-detectable or considerably lower levels during fecal stream diversion. One month after the restoration of bowel continuity, when the patient experienced a relapse of symptoms, IL-2, IL-23 and IL-21 levels were again increased. Our results indicate that fecal stream diversion in this patient suppressed the levels of all cytokines analyzed in colonic biopsies. With the recurrence of clinical symptoms and histological changes after bowel reconstruction, the levels of primarily proinflammatory cytokines increased. Our findings support the hypothesis that a luminal factor triggers the inflammation observed in collagenous colitis.

Keywords: Microscopic colitis, Collagenous colitis, Luminex, Mucosal cytokines, Fecal stream diversion

Core tip: The pathophysiology of collagenous colitis remains poorly understood. We describe a patient with chronic, active collagenous colitis who either failed to achieve clinical remission or experienced adverse effects with all medications given; therefore the patient was treated with a temporary loop ileostomy. We analyzed cytokine protein production with Luminex assays in colonic biopsy tissues obtained before and during fecal stream diversion (FSD) and after intestinal continuity was restored. Because FSD leads to clinical and histological remission, this study protocol provided a unique opportunity to study cytokine dynamics during different stages of disease. We were thus able to demonstrate that FSD was followed by a decrease in the levels of nearly all cytokines and that the restoration of bowel continuity increased the levels of the proinflammatory cytokines interleukin IL-2, IL-21 and IL-23.