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PubMed2003

Pseudomembranous collagenous colitis.

The classic clinical and histologic features of collagenous colitis are well characterized; however, the acute or neutrophilic inflammatory changes that may accompany this entity are less well established. In this report of 10 patients, we describe the first series of pseudomembranous collagenous colitis. Because superimposed Clostridium difficile infection was only demonstrated in one patient and no other causes of pseudomembranous colitis were evident in the remaining nine patients, we conclude that pseudomembranes are part of the spectrum of collagenous colitis itself. This case series illustrates the importance of searching for collagenous colitis in the evaluation of pseudomembranous colitis. At the same time, superimposed infectious or ischemic etiologies need to be excluded clinically in any patient with superimposed pseudomembranes. The existence of pseudomembranes in collagenous colitis also lends support to the hypothesis that toxin- and/or ischemia-mediated injury may be involved in the pathogenesis of collagenous colitis.

Adult↗

PubMed2003

Budesonide treatment of collagenous colitis: a randomised, double blind, placebo controlled trial with morphometric analysis.

BACKGROUND: Collagenous colitis is characterised by diarrhoea, lymphocytic inflammation, and a thickened subepithelial collagen layer in the colorectal mucosa. No standard treatment of the disease is established. AIMS: To investigate the clinical and histological effect of oral budesonide (Entocort, AstraZeneca) in the treatment of collagenous colitis. PATIENTS: Twenty patients with collagenous colitis (collagen layer >10 micro m) and diarrhoea (>4 stools/day and/or stool weight >200 g/day). METHODS: A randomised, double blind, placebo controlled trial of budesonide treatment. Patients were randomised to placebo or budesonide for eight weeks. Stool frequency and stool weight were registered before and after treatment. Sigmoidoscopy was performed before and after treatment, and biopsies at fixed locations were obtained for morphometric analysis. RESULTS: Ten patients were randomised to budesonide and 10 to placebo. All 10 patients receiving budesonide had a clinical response compared with two in the placebo group (p<0.001). In the budesonide group, stool weight was reduced from 574 g/day to 200 g/day and stool frequency was reduced from 6.2/day to 1.9/day (p<0.01). The histological inflammation grade in the sigmoid mucosa and the thickness of the collagen layer were significantly reduced. A correlation between the grade of inflammation as well as collagen layer thickness and stool weight was found. No side effects were reported. Eight of 10 patients had relapse of symptoms within eight weeks after stopping treatment. CONCLUSIONS: Budesonide is a highly effective and well tolerated treatment of collagenous colitis. There is a high risk of relapse after stopping eight weeks of treatment.

Adult↗

PubMed2002

The terminal ileum is affected in patients with lymphocytic or collagenous colitis.

Lymphocytic colitis (LC) and collagenous colitis (CC) are diseases characterized by the presence of marked intraepithelial lymphocytosis. Both of these disorders affect primarily the colon. However, involvement of the distal small intestine has not been systematically studied. The purpose of this study was to evaluate the type and degree of intraepithelial lymphocytosis in the terminal ileum of patients with LC or CC. Terminal ileal mucosal biopsies from 22 patients with LC (male/female ratio 0.22, mean age 47 years) and 23 with CC (male/female ratio 0.43, mean age 54 years) were evaluated for the number of intraepithelial lymphocytes (IEL) per 100 epithelial cells (EC) both in the villi and crypts. The results were compared with 30 patients with inflammatory bowel disease (16 with Crohn's disease [CD], 14 with ulcerative colitis [UC]) and 24 patients (male/female ratio 0.33, mean age 44 years) without colonic pathology as normal controls. None of the patients had celiac sprue. Paired terminal ileum and colonic mucosal biopsies from 6 patients with LC, 4 with CC, 5 with CD, 5 with UC, and 10 normal controls were also immunohistochemically stained with monoclonal antibodies to CD3, CD8, CD20, and a class II MHC antigen (LN3-HLA-DR). In the villi the IEL count/100 EC was 11.8 +/- 1.8 in LC and 10.3 +/- 1.9 in CC (p = 0.3). These values were both significantly higher than in CD (2.8 +/- 0.4, p <0.001), UC (3.1 +/- 0.4, p <0.001), or normal controls (2.2 +/- 0.2, p <0.001). In the crypts the IEL count was 3.8 +/- 0.5 in LC and 3.2 +/- 0.5 in CC (p = 0.3). These values were also significantly higher than in CD (2.3 +/- 0.4, p = 0.02), UC (2.1 +/- 0.3, p = 0.02), or normal controls (1.5 +/- 0.2, p <0.001). The presence of >5 IELs/100 EC in terminal ileum biopsies was highly specific for LC and CC (specificity 98%, sensitivity 73% and 56% for LC and CC, respectively). The IEL phenotype was similar in all groups of patients and in the ileum and colon of individual patients. Intraepithelial lymphocytes were CD3+, CD8+, CD20-, and LN3-HLA-DR-, indicative of a suppressor T-cell phenotype. Intraepithelial lymphocytosis occurs in the terminal ileum in patients with LC or CC and may be helpful in diagnosing these conditions and distinguishing LC or CC from CD or UC in diagnostically difficult cases. The results suggest that the terminal ileum may be involved by a similar pathogenic process as the colon in LC and CC.

Adult↗

PubMed1993

Collagenous colitis: a cause of chronic diarrhea.

Collagenous colitis should be added to the differential diagnosis of chronic, watery, nonbloody diarrhea with normal endoscopic findings. Patients with collagenous colitis are often middle-aged women previously diagnosed as having irritable bowel syndrome. The diagnosis of collagenous colitis is based on histologic evaluation of a rectal biopsy specimen. Biopsy shows a thickened, subepithelial, acellular, eosinophilic collagen band. Symptoms often resolve after treatment with oral sulfasalazine.

Age Factors↗

PubMed1988

Collagenous colitis: an association with fecal leukocytes.

Collagenous colitis is an idiopathic inflammatory disorder of the colon associated with watery diarrhea, minimal to normal endoscopic findings, and a pathognomonic subepithelial band of collagen. This band is associated with a mucosal, acute and chronic inflammatory infiltrate. During the evaluation of four cases of collagenous colitis, we noted a remarkable number of acute inflammatory cells in the stool. This association has not been well recognized and carries important diagnostic significance because the mucosal appearance of the colon is frequently normal and nondiagnostic biopsies can occur early in the course of the disease or if obtained from the rectum. These cases suggest that collagenous colitis should be added to the differential diagnosis of diarrhea where fecal leukocytes are present.

Adult↗

PubMed1992

[Collagenous colitis: a new case of exudative enteropathy].

Collagenous colitis with intestinal protein loss was discovered in a sixty-six year-old female who presented with recurrent and prolonged diarrhea associated with hypoprotidemia, hypoalbuminemia, and increased clearance of alpha-1-antitrypsin. Histologic lesions of collagenous colitis were found during each episode of diarrhea. Biological and histological examinations were normal during the remission phases. Intestinal protein loss appeared to be due to collagenous colitis because of the parallel course of the clinical, biological and histological signs, and because no other cause had been discovered. The possibility of protein exudation, probably secondary to the extent of the epithelial detachment, could be an additional argument for the inflammatory etiology of collagenous colitis.

Aged↗

PubMed1989

Diarrhoea caused by collagenous colitis.

The first case of collagenous colitis in a child with protracted watery diarrhoea and abdominal pain is reported. Small bowel investigations and the macroscopic appearances were normal, but histological examination of the colon showed collagenous colitis. Steroids temporarily relieved the diarrhoea and induced transient dissolution of the subepithelial collagen band.

Child, Preschool↗

PubMed2000

Collagenous colitis and lymphocytic colitis: clinical and endoscopic findings.

OBJECTIVE: collagenous colitis (CC) and lymphocytic colitis (LC) are two entities of unknown cause, characterized by chronic watery diarrhea, grossly normal-appearing colonic mucosa and abnormal histopathological findings in colonic biopsies. The clinical features of the disease are based mainly on case reports or small uncontrolled series. Although normal colonoscopic findings are, as a rule, part of the diagnosis of CC, several cases of macroscopic colitis associated with CC have been reported, and the spectrum of endoscopic mucosal changes has not been described in large series. METHODS: we present a retrospective study of all patients who underwent total colonoscopy and mucosal biopsy in our Endoscopy Unit between 1991 and 1997. Clinical and endoscopic findings in patients diagnosed as having CC or LC were recorded. RESULTS: of 676 patients studied, 398 suffered from chronic diarrhea. Collagenous colitis was diagnosed in 22 patients and LC in 10. Eleven per cent of the patients with CC and 20% of those with LC did not have diarrhea. Macroscopic colitis was observed in 6 out of 22 patients with CC (27%) and in 4 out of 10 with LC (40%). Macroscopic lesions included edema, erythema, abnormal vascular pattern, superficial erosions or ulcerations and hemorrhagic lacerations. In this series 7.03% of the patients with chronic diarrhea were diagnosed as having CC or LC. CONCLUSIONS: collagenous colitis and LC are two entities that should be considered in the differential diagnosis of chronic diarrhea. Total colonoscopy with multiple biopsies that include the right colon are mandatory. The presence of macroscopic lesions on endoscopy does not rule out a diagnosis of either entity. We identified patients who fulfilled the histopathological criteria for CC or LC but who did not have diarrhea.

Adult↗

PubMed1992

Collagenous colitis: jejunal and colorectal pathology.

AIMS: To determine: (1) whether there is an association between collagenous colitis and coeliac disease or lymphocytic colitis; (2) the distribution of lymphocyte subsets and macrophages in the lamina propria and surface epithelial layer in collagenous colitis; and (3) the colorectal distribution of the disease and whether a mucosal biopsy specimen, using a flexible sigmoidoscope, is sufficient to diagnose it. METHODS: The clinical data and colorectal biopsy specimens from 38 patients with collagenous colitis were studied. In 10, small bowel biopsy specimens were also available for review. Immunostaining of the mucosal lymphoid infiltrate with a panel of relevant antibodies was carried out on formalin fixed tissue in seven cases; in three the phenotyping was performed on fresh biopsy specimens separately frozen or fixed in B5 solution. RESULTS: Coeliac disease was found in four out of the 10 patients with collagenous colitis who had had a small bowel biopsy, in contrast to the prevalence of the disease in Australia of 1 in 3000. Collagenous colitis did not respond to gluten withdrawal. Five of 29 (17%) of the patients had a mixed pattern of lymphocytic and collagenous colitis. Immunostaining of the lymphoid infiltrate showed that the striking increase in intraepithelial lymphocytes in collagenous colitis was due to an influx of CD8 positive cells. The occurrence and severity of collagenous colitis along the large bowel were independent of the anatomical site, and in more than 90% of cases biopsy specimens from the sigmoid colon or rectum were diagnostic. CONCLUSIONS: There is a very high incidence of coeliac disease among patients with collagenous colitis so that jejunal biopsy should be an essential part of their investigations, especially if symptoms persist. However, only a minority showed a mixed pattern of lymphocytic and collagenous colitis. The intraepithelial lymphocytes in collagenous colitis are CD8 positive cells. Collagenous colitis can be diagnosed from rectal or sigmoid colon biopsy specimens in more than 90% of cases.

Adult↗

PubMed2003

[Treatment of collagenous colitis. An analysis of a systematic Cochrane review].

BACKGROUND: Collagenous colitis is a disorder that is recognized as a cause of chronic diarrhea. Treatment has been based mainly on anecdotal evidence. This review was performed to identify therapies for collagenous colitis that have been proven in randomized trials. OBJECTIVES: To determine effective treatments for patients with clinically active collagenous colitis. SEARCH STRATEGY: Relevant papers published between 1970 and October 2002 were identified via the MEDLINE, PUBMED, and EMBASE databases. Manual searches from the references of identified papers, as well as review papers on collagenous or microscopic colitis were performed to identify additional studies. Abstracts from major gastroenterological meetings were searched to identify research submitted in abstract form only. Finally, the Cochrane Controlled Trials Register and the Cochrane Inflammatory Bowel Disease Group Specialized Trials Register were searched for other studies. SELECTION CRITERIA: Four randomized trials were identified. One trial studied bismuth subsalicylate (published in abstract form only), and 3 trials (1 published in abstract form only) studied budesonide in the therapy of collagenous colitis. DATA COLLECTION AND ANALYSIS: Data were extracted independently by each author onto 2 x 2 tables (treatment versus placebo and response versus no response). For therapies assessed in one trial only, p-values were derived using the chi-square test. For therapies assessed in more than one trial, summary test statistics were derived using the Peto odds ratio and 95% confidence intervals. Data were combined for analysis only if the outcomes were sufficiently similar in definition. MAIN RESULTS: There were 9 patients with collagenous colitis in the trial studying bismuth subsalicylate (nine 262 mg tablets daily for 8 weeks). Those randomized to active drug were more likely to have clinical (p = 0.003) and histological (p = 0.003) improvement than those assigned to placebo. A total of 94 patients were enrolled in 3 trials studying budesonide (9 mg daily for 6 to 8 weeks). The pooled odds ratio for clinical response to treatment with budesonide was 12.32 (95% CI 5.53-27.46), with a number needed to treat of 2 patients. There was significant histological improvement with treatment in all 3 trials studying budesonide therapy. REVIEWERS' CONCLUSIONS: Budesonide is effective in the treatment of collagenous colitis. The evidence for bismuth subsalicylate is weaker, but still important. The roles of these and other therapies in inducing or maintaining remission (as opposed to clinical or histological improvement) of collagenous colitis are unknown.

Anti-Inflammatory Agents↗

PubMed1999

Budesonide for the treatment of collagenous colitis: first results of a pilot trial.

OBJECTIVE: Collagenous colitis is a chronic watery diarrhea disorder characterized by a subepithelial collagen layer and a lymphoplasmacytic infiltration within the lamina propria. However, no standard treatment has been introduced by controlled clinical trials. Aim of the present pilot trial was to investigate the clinical effects of orally administered budesonide (3 mg t.i.d.) in 7 patients with collagenous colitis. In addition, the histomorphological changes after budesonide treatment were described in a group of 3 patients. METHODS: The study was performed as an open label pilot trial. Study end point was the clinical remission of collagenous colitis defined by stool frequency and stool consistency. RESULTS: The results indicate a rapid and sustained clinical response in all patients. Stool frequency significantly decreased (p < 0.001) from 10.43 +/- 5.56 per day (4-20 per day) to 3.3 +/- 1.2 (1-5 per day) after 10 days and to 1.86 +/- 0.69 per day (1-3 per day) after 10 wk. Moreover stool consistency changed from watery (6 patients) or soft (1 patient) to soft (1 patient) or solid (6 patients). Clinical improvement was achieved within the first 10 days in all patients and maintained after dose reduction. In 3 patients no diarrhea recurred within 7, 12, or 15 months after treatment with budesonide was terminated. In these patients control biopsies were taken and showed a marked regression of both characteristics, the collagen band and the lymphoplasmacytic infiltration. CONCLUSIONS: With respect to the preliminary data from this pilot trial, budesonide with its high topical and low systemic effects seems to be of therapeutic clinical benefit in collagenous colitis. A therapeutic effect could be demonstrated for both therapeutic goals, the clinical response and morphological changes. Further studies on the effects of budesonide on mucosal collagen metabolism and long-term follow-up are warranted.

Anti-Inflammatory Agents↗

PubMed1990

Collagenous colitis as a cause of chronic diarrhea.

Collagenous colitis should be considered in the differential diagnosis of chronic diarrheal syndromes. Colonoscopy or sigmoidoscopy in such patients should include biopsy of the mucosa proximal to the rectum, even though the mucosa appears grossly normal. Some patients have associated autoimmune disease, but the etiology of collagenous colitis is unclear. Microscopic colitis has been observed to precede collagenous colitis in some patients. Treatment with antimotility agents, sulfasalazine, oral 5-ASA compounds or corticosteroids may be effective in reducing symptoms.

Aged↗

PubMed1996

Autoantibodies and immunoglobulins in collagenous colitis.

BACKGROUND: The aetiology and pathogenesis of collagenous colitis are unknown. Autoimmunity has been suggested, but no serological findings have supported such a theory. AIMS AND METHODS: Serum from 38 collagenous colitis patients and 38 matched healthy controls was analysed for autoantibodies--that is, antinuclear antibodies, antineutrophil cytoplasmic antibodies, smooth muscle and mitochondrial antibodies, rheumatoid factor and antibodies to thyroglobulin and microsomal antigen, together with antibodies to endomysium, gliadin, and cardiolipin. The serum values of IgA, IgG, IgM, and IgG-subclasses, and complement factors C3 and C4 were also determined. RESULTS: In patients with collagenous colitis the mean value of IgM was significantly increased 2.5 g/l (95% CI; 1.9, 3.2) compared with 1.4 g/l (95% CI; 1.2, 1.7) in controls (p = 0.002). Antinuclear antibodies occurred in nine of 38 patients compared with three of 38 controls, this difference was not statistically significant (p = 0.11). The results of all other immunoglobulins, complement factors, and specific antibodies showed no statistical difference between patients and controls. CONCLUSIONS: No firm evidence for an autoimmune genesis in collagenous colitis is found in this study, although the findings of a positive ANA-titre in some patients and an increased IgM level might give some support for this hypothesis.

Adult↗

PubMed1990

Coeliac disease and collagenous colitis.

We describe a case of collagenous colitis in a young man with coeliac disease who had responded clinically and histologically to a gluten-free diet three years previously. The collagenous colitis responded initially to oral corticosteroid therapy and he is now asymptomatic (and with normal rectal mucosa) on oral mesalazine. Collagenous colitis should be considered in the coeliac patient with diarrhoea despite adherence to a gluten-free diet.

Adult↗

PubMed1999

Diagnosing collagenous colitis: does it make a difference?

Collagenous colitis is part of the spectrum of disorders known as microscopic colitis, which also include lymphocytic colitis and a mixed disorder with both a collagen band present and also intra-epithelial lymphocytes. Collagenous colitis appears to be caused by mucosal injury from toxins in the faecal stream. The collagen band is a result of the underlying inflammatory process and not the cause of symptoms. The diagnosis is based on colonic mucosal pathology and a compatible clinical presentation. Treatment is empiric and ranges from no therapy, to anti-inflammatory or anti-secretory agents, to diverting ileostomy.

Colitis↗

PubMed2005

Dynamics of mucosal permeability and inflammation in collagenous colitis before, during, and after loop ileostomy.

Collagenous colitis has become a more frequent diagnosis but the aetiology of this disease is still unknown. We describe a female patient with intractable collagenous colitis who was treated with a temporary loop ileostomy. She was followed clinically, histopathologically, and functionally by measuring mucosal permeability before surgery, after ileostomy, and after bowel reconstruction. In our case report, active collagenous colitis was combined with increased transcellular and paracellular mucosal permeability. Diversion of the faecal stream decreased inflammation of the mucosa and normalised epithelial degeneration and mucosal permeability. After restoration of bowel continuity, mucosal permeability was altered prior to the appearance of a collagenous layer.

Colitis↗

PubMed1986

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.

Aged↗

PubMed1990

Collagenous colitis in setting of nonsteroidal antiinflammatory drugs and antibiotics.

Collagenous colitis is a clinicopathologic syndrome characterized by chronic watery diarrhea and a mucosal inflammatory process with increased subepithelial collagen band on colonic biopsy. This disorder occurs primarily in females, and the etiology is unknown. We report the atypical presentation of collagenous colitis in two older-aged men following prolonged use of nonsteroidal antiinflammatory agents and short-term use of antibiotics. Although one patient had colonic pseudomembranes, neither patient had microbiological evidence of C. difficile toxin or infection. A variety of medications were initially given to these patients without resolution of diarrhea. Only after the diagnosis of collagenous colitis was made and antiinflammatory drugs directed at the colitis given did the diarrhea abate. These cases illustrate an unusual presentation of collagenous colitis with possible implications for pathogenesis.

Aged↗