Microscopic colitis is an autoimmune chronic inflammatory disease of the colon that is characterized by a lot of watery, non-bloody chronic diarrhea. Most commonly in women 40s-60s, it can be easy to miss on colonoscopy unless your GI takes the right biopsies. There are 2 types- lymphocytic colitis and collagenous colitis. VERY IMPORTANT to note that MC does not increase the risk of colorectal cancer or precancerous polyps..How to diagnose it
Colonoscopy, colonoscopy, colonoscopy. With biopsies of course. A “half” colonoscopy (“sigmoidoscopy”) is not enough as the inflammation can be patchy and biopsies of the right and left colon are necessary- as well as looking at the ILEUM (end of the small intestine) to rule out Crohn’s. Everything else is nonspecific but could be a “clue” such as mild anemia, high ESR (erythrocyte sedimentation rate), protein losing enteropathy/low protein level and + autoimmune antibodies such as ANA. Stool tests can be helpful for increased levels of the inflammatory markers such as fecal calprotectin and eosinophil protein X – both measured on the GI MAP test done at the Center for Integrative Gut Health!ALWAYS make sure to rule out infections: stool Clostridioides difficile toxin, routine stool cultures (Salmonella, Shigella, Campylobacter, Yersinia), Escherichia coli O157:H7, microscopy for ova and parasites (three samples) and a Giardia stool antigen test. And always check for celiac and thyroid disease!
As usual, autoimmune conditions develop in genetically predisposed individuals with a trigger such as exposure to a certain substance in the gut lumen and then a disordered gut immune response. The most common triggers are:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) — this includes ASPIRIN!!!! Yes even baby aspirin! Also Celecoxib
- Smoking
- Proton pump inhibitors (PPIs), specifically lansoprazole
- Statins such as Fluvastatin, Simvastatin
- Selective serotonin reuptake inhibitors MOST commonly Sertraline (ZOLOFT), also Duloxetine, Paroxetine
- Acarbose
- Clozapine
- Entocapone
- Flavonoid- Venotonic drugs containing flavonoids (diosmin, rutin, or hesperidin)
- Ticlopidine
- Also: Carbamazepine, Flutamide, Oxetorone, Anti-parkinsonian drugs, containing levodopa and benserazide (Madopar) and carbidopa, levodopa and entocapone (Stalevo), Cimetidine, Gold salts, Piascledine and others..
An alternative hypothesis is that a defect in epithelial barrier function (leaky gut!) and luminal factors may lead to an increased transmucosal permeability of antigens and bacteria, leading to immune dysregulation and gut inflammation. Also possibly associated with gut infections such as C. difficile and Yersinia. Interestingly, resolution of collagenous colitis has been described following treatment for Helicobacter pylori. Bile acid malabsorption is also frequently involved. Also autoimmune conditions cluster together therefore always think about your symptoms possibly originating from multiple autoimmune origins- from autoimmune thyroiditis to type 1 diabetes mellitus to autoimmune arthritis to celiac.
How to heal
1. Take out the bad! Identify and stop any culprit such as NSAIDS.
2. Make sure to do a deep dive root cause investigations into infections!
3. Standard GI docs will tell you imodium and steroids. But it doesn’t have to come to that – here are some steroid-sparing treatments to discuss with your doctor:
- Cholestyramine to bind bile acids
- Bismuth to combat inflammation — at the Center for Integrative Gut Health we only use compounded bismuth- not the pink stuff!
- Probiotic E. coli strain Nissle, Boswellia serrata extract, and Lactobacillus acidophilus and Bifidobacterium subspecies. For example, in a VSL#3 study, a significant reduction in stool weight at 8 weeks was demonstrated (p = 0.03) but no change in stool frequency.
5. Talk to Dr. Ivanina at the Center for Integrative Gut Health about treating leaky gut.Will MC go away?
MC has a chronic, intermittent course in most people- diarrhea may resolve within weeks with or without treatment, but relapses are common (~ 30-60%) Treating MC (as opposed to just watching/waiting) is associated with long-term success of stopping diarrhea in ~ 70% of people… but 25-30% relapse and get it again.To heal your body you need to be mindful of the negative harmful impacts that industrialization and toxic habits our culture has instilled in us and break free, reconnect with the world around you and let go of stereotypes of what society tells you is normal (nsaids for pain! SSRIs for the slightest hint of anxiety/depression, statins for heart disease prevention- before even discussing diet & lifestyle…. and many, many more.)
MC european guidelines: https://onlinelibrary.wiley.com/doi/full/10.1177/2050640620951905
MC USA guidelines: https://www.gastrojournal.org/article/S0016-5085(15)01625-X/pdf