Microscopic colitis: A review of etiology, treatment and refractory disease

Abstract

Microscopic colitis is a common cause of chronic, nonbloody diarrhea. Microscopic colitis is more common in women than men and usually affects patients in their sixth and seventh decade. This article reviews the etiology and medical management of microscopic colitis. The etiology of microscopic colitis is unknown, but it is associated with autoimmune disorders, such as celiac disease, polyarthritis, and thyroid disorders. Smoking has been identified as a risk factor of microscopic colitis. Exposure to medications, such as non-steroidal anti-inflammatory drugs, proton pump inhibitors, and selective serotonin reuptake inhibitors, is suspected to play a role in microscopic colitis, although their direct causal relationship has not been proven. Multiple medications, including corticosteroids, anti-diarrheals, cholestyramine, bismuth, 5-aminosalicylates, and immunomodulators, have been used to treat microscopic colitis with variable response rates. Budesonide is effective in inducing and maintaining clinical remission but relapse rate is as high as 82% when budesonide is discontinued. There is limited data on management of steroid-dependent microscopic colitis or refractory microscopic colitis. Immunomodulators seem to have low response rate 0%-56% for patients with refractory microscopic colitis. Response rate 66%-100% was observed for use of anti-tumor necrosis factor (TNF) therapy for refractory microscopic colitis. Anti-TNF and diverting ileostomy may be an option in severe or refractory microscopic colitis.

Keywords: Chronic diarrhea, Etiology of microscopic colitis, Collagenous colitis, Refractory microscopic colitis, Microscopic colitis, Lymphocytic colitis, Steroid-dependent microscopic colitis

Core tip: The etiology of microscopic colitis (MC) is unknown. There is a strong association with autoimmune disorders, smoking, and medications, such as non-steroidal anti-inflammatory drugs, proton pump inhibitors, and selective serotonin reuptake inhibitors. There are no societal guidelines on how to manage patients with MC. Data is strongest for the use of budesonide. Budesonide can rapidly induce clinical remission but relapse occurs frequently after discontinuation of budesonide. Anti-diarrheals may be used alone in mild MC or in conjunction with other therapies in moderate to severe MC. There is limited data on management of steroid-dependent or refractory MC but anti-TNF and diverting ileostomy may be options.