Economic burden of microscopic colitis in relation to disease activity: a nationwide cost-of-illness study.

Association Between Collagenous and Lymphocytic Colitis and Risk of Severe Coronavirus Disease 2019

INTRODUCTION: Microscopic colitis (MC) is a diarrheal illness difficult to differentiate from other gastrointestinal disorders. Historical cues and understanding of disease prevalence are critical to the evaluation of MC patients experiencing continued symptoms despite adequate treatment or histologic improvement. This study examines the prevalence of concomitant small intestine bacterial overgrowth (SIBO) and carbohydrate malabsorption in a MC population. METHODS: Records were reviewed from 6/2015 to 6/2020 at a single-center private gastroenterology practice. Patients with MC were identified by ICD10 codes and grouped into either collagenous (CC) (K52.831), lymphocytic (LC) (K52.832), or other microscopic colitis (K52.839). Patient demographics, surgical history, disease activity, medications, fecal calprotectin, date of initial diagnosis, and breath testing results were recorded in a HIPAA compliant dataset. Data were analyzed using chi-squared, Fisher’s exact, Pearson correlation, and T testing where indicated. RESULTS: 223 MC patients were reviewed with 67 included based on the presence of SIBO hydrogen (H2) breath testing: 50 with LC, 10 with CC, 4 with CC and MC, and 3 indeterminate. The average age at MC diagnosis was 64.9 ± 14.6, with a higher prevalence of females (73.1%) and whites (78.9%). SIBO positive rates were 19/54 (35.2%) in the LC group and 5/14 (35.7%) in the CC group (P = 0.97) (Figure 1). There was no difference in SIBO positivity between age groups (< 70 vs > 70, P = 0.82), genders (P = 0.33), or ethnicities (P = 0.35). SIBO rates in patients with active MC (defined as > 3 watery bowel movements daily) did not differ from patients in remission (30.6% vs 28.6%, P = 0.89). The average fecal calprotectin (FC) in the SIBO positive group was 84.4 mg/mg, compared to 262.6 mg/mg in the SIBO negative group (P = 0.31) (Figure 2). Concurrent carbohydrate malabsorption was observed in 47.4% of SIBO positive patients, compared to 61.1% in the SIBO negative group (P = 0.33) (Figure 3). CONCLUSION: This retrospective cross sectional study illustrates rates of SIBO positivity in the MC population are similar to symptomatic patients in the general population (Figure 1). There was no difference in positive rates between the LC and CC groups, limited by a small CC sample size. Furthermore, carbohydrate malabsorption was frequently superimposed on the MC diagnosis, highlighting the need to consider H2 breath testing for both SIBO and carbohydrate malabsorption in symptomatic MC patients who are unresponsive to therapy.Figure 1.: Similar rates of SIBO positivity were observed between collagenous and lymphocytic colitis (35.2% vs 35.7%, P = 0.97). Rates of bacterial overgrowth in the general population are estimated 2-22%, though our study’s rates of positive SIBO breath testing correlate with rates from a Vizuete et al, which found SIBO positivity in 32.9% of patients with “flatulence, eructation, and gas pain”. No statistical difference in SIBO positivity was seen between age groups (39.1% (< 70) vs 36.4% (> 70), P = 0.82), genders (27.8% (M) vs 40.8% (F), P = 0.33), or ethnicities (43.3% (white) vs 25.0% (non-white), P = 0.35).Figure 2.: There was no difference in SIBO positive rates between patients with active microscopic colitis (described as at least 3 bowel movements per day) versus patients in remission (30.6% vs 28.6%, P = 0.89). When comparing SIBO positive to negative patients, there was no difference in the percentage of patients on steroid therapy at the time of breath testing (12.0 vs 14.3%, P = 0.79).Figure 3.: Carbohydrate malabsorption was frequently observed in all tested patients (56.4%). Positive rates of fructose/lactose/sucrose intolerance were observed more frequently in the SIBO negative group (47.4% vs 61.1%, P = 0.33). There was no observed difference between collagenous colitis patients (CC) and lymphocytic colitis patients (LC) with regard to rates of individual carbohydrate malabsorption.

The role of endoscopy in the management of patients with diarrhea

P1221 Microscopic colitis and risk of venous thromboembolism: A nationwide matched cohort study

Microscopic colitis (MC) has been associated with several immune-mediated diseases including psoriasis, but earlier research has been limited to psoriasis occurring before MC. Data from large-scale cohort studies investigating MC and risk of future psoriasis are lacking. To examine the association between MC and psoriasis. In a nationwide, population-based, matched cohort study in Sweden from 2007 to 2021, we identified 8404 patients with biopsy-verified MC (diagnosed in 2007-2017), 37,033 matched reference individuals, and 8381 siblings without MC. Information on MC was obtained through the ESPRESSO cohort (a Swedish histopathology database with nationwide coverage). Using Cox regression, we calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for psoriasis up until 2021. During a median follow-up of 9.2 years (interquartile range = 6.7-11.7), 179 MC patients and 440 reference individuals were diagnosed with psoriasis (241.1 vs 131.8 events per 100,000 person-years), corresponding to one extra case of psoriasis in 91 patients with MC over 10 years. After adjustment for the matching variables (birth year, sex, county of residence, and calendar period) and level of education, we computed an adjusted hazard ratio (aHR) of 1.82 (95% CI = 1.53-2.17). Stratified by sex, estimates were similar and when examining the aHR across different lengths of follow-up, we found significantly elevated estimates up to 10 years after MC diagnosis. Compared to MC-free siblings, the aHR was 1.85 (95% CI = 1.36-2.51). Patients with MC are at an almost doubled risk of psoriasis compared to the general population. Clinicians need to consider psoriasis in MC patients with skin lesions.

Microscopic Colitis and Risk of Inflammatory Bowel Disease in a Nationwide Cohort Study

Microscopic colitis (MC) is an inflammatory condition of the large intestine. Primarily diagnosed in middle-aged and older adults, the incidence of the disease has increased markedly during the past few decades. While MC is associated with a reduced quality of life, large-scale studies on the association with future psychiatric disorders are lacking. We conducted a nationwide matched cohort study in Sweden from 2006 to 2021. Through a nationwide histopathology database (the Epidemiology Strengthened by histoPathology Reports in Sweden study), we identified 5,816 patients with a colorectal biopsy consistent with MC. These patients were matched with 21,509 reference individuals from the general population all of whom with no previous record of psychiatric disorders. From 2006 to 2021, 519 patients with MC (median age 64.4 years [interquartile range = 49.5-73.3]) and 1,313 reference individuals were diagnosed with psychiatric disorders (9.9 vs 6.5 events per 1,000 person-years), corresponding to 1 extra case of psychiatric disorder in 29 patients with MC over 10 years. After adjustments, the hazard ratio for psychiatric disorders was 1.57 (95% confidence interval = 1.42-1.74). We found significantly elevated estimates up to 10 years after MC diagnosis and a trend toward higher risk with increasing age. Specifically, we observed increased risks for unipolar depression, anxiety disorders, stress-related disorders, substance abuse, and suicide attempts. In sibling-controlled analysis, the adjusted hazard ratio was 1.76 (95% confidence interval = 1.44-2.15). Patients with MC are at increased risk of incident psychiatric disorders compared with the general population.

Microscopic colitis (MC) is characterized by chronic watery diarrhea. MC comprises two entities: collagenous colitis (CC) and lymphocytic colitis (LC), which are separated by typical histopathological characteristics. The colonic mucosa appears endoscopically normal in general so it can be diagnosed only by colonic mucosal biopsies. But, macroscopic subtle nonspecific abnormalities in the colon such as erythema, edema, or abnormal vessel pattern were seen in 60 patients of the 199 patients with LC (30%) and in 42 patients of the 105 patients with CC (29%).1,2 But these findings have been accepted not so meaningful features in the diagnosis of MC. Exceptionally colonic mucosal tears (“cat-scratch colon”) are occasionally seen during colonoscopy in CC, and might indicate an increased risk of colonic perforation during the procedure.3 In this issue of Gut and Liver, Park et al.4 report their retrospective analysis comparing the endoscopic, clinical, and histopathologic features of LC with and without mucosal lesions (MLs). The authors showed MLs were observed in seven of the 14 LC cases. Six of the MLs exhibited hypervascularity, three exhibited exudative bleeding and one exhibited edema. The patients with MLs had more severe diarrhea and were taking aspirin or proton pump inhibitors (PPIs). More intraepithelial lymphocytes were observed during histologic examination in the patients with MLs compared to the patients without MLs, although this difference was not significant. The numbers of mononuclear cells and neutrophils in the lamina propria were independent of the presence or absence of MLs. Authors focused on hypervasculaity and exudative bleeding in this report. Depending on colonoscopic examples provided, these findings are not only nonspecific, but also can be observed in patients without MC. On this report, patients with MLs showed 10 years older than patients without MLs, and they had been taking aspirin and PPI at the time of diagnosis. These medications also affect bleeding tendency. Because gross ulcerations can be seen rarely in patients with MC who are taking nonsteroidal anti-inflammatory drugs (NSAIDs).5 So, we could not make any conclusion from these mucosal findings yet. By histological review, this study show more intraepithelial lymphocytes were observed in the patients with MLs compared to the patients without MLs, although this difference was not significant. As we know, MC is not evenly involved in the whole colon. It can help diagnostic sensitivity of MC in patients with chronic diarrhea, if we could choose adequate biopsy site. In the future, laser endomicroscopy, which enables “real-time” microscopic imaging of the mucosa during endoscopy, may possibly allow in vivo diagnosis of MC.6–8 In previous prospective multicenter study in Korea, the prevalence of LC was 18% similar with this study.9 That study showed many of LC (18/100) was younger than 50 years old, all of CC (4/100) was older than 50 years old. The cause of MC is not known, but is probably multifactorial. Currently, CC and LC are considered to represent specific mucosal responses to different thus-far-unidentified luminal agents in predisposed individuals, resulting in an uncontrolled mucosal immune response.10 As CC and LC have similar clinical presentations and share histopathological features, except for the subepithelial collagen band in CC, it has been discussed whether CC and LC are actually the same disease seen in different phases of development. Conversion of CC to LC or the reverse has been reported, but is rare.11 In this point of view, it is so interesting whether LC with MLs show different prognosis comparing with LC without MLs in the follow-up. In Korean situation, old age patients having medications such as aspirin, PPI and NSAIDs will be continuously increasing. Early diagnosis and adequate management of MC are important. We need to have more concern about MC and colonic mucosal biopsy must be performed for patients with chronic diarrhea with no or subtle mucosal alteration. Also it is suggested that we need large scaled prospective study of LC concerning about minor mucosal alteration and change of mucosal abnormality after treatment.

BackgroundLittle is known about disease activity at start of biologic therapy and influence on productivity losses.ObjectivesTo compare work loss in patients with RA starting their first ever biologic therapy with...

Microscopic colitis is a common cause of chronic watery diarrhea of unknown origin. Some patients develop diarrhea after cholecystectomy, and some patients with microscopic colitis have evidence of bile acid malabsorption. However, the association between cholecystectomy and microscopic colitis has not been studied. A protective effect of appendectomy on the development of ulcerative colitis also has been reported, but its relationship with microscopic colitis has not been studied. The aim of this study was to assess cholecystectomy and appendectomy as potential risk factors for the development of microscopic colitis in a nested case-control study. Using the Rochester Epidemiology Project, we identified all Olmsted County (Minnesota) residents with an initial diagnosis of microscopic colitis between January 1, 1985, and December 31, 2001. Rates of antecedent cholecystectomy or appendectomy in patients with microscopic colitis were compared with age-, gender-, and calendar year-matched community controls through conditional logistic regression. Microscopic colitis was identified in 130 cases. Cholecystectomy preceded the diagnosis of microscopic colitis in 12 cases (9%) compared with 17 (13%) in the control group (odds ratio [OR] 0.7; 95% CI 0.3-1.5). Appendectomy preceded the diagnosis of microscopic colitis in 39 subjects (30%) compared with 28 (22%) in the control group (OR 1.6; 95% CI 0.9-2.7). Similar results were obtained when the analysis was restricted to microscopic colitis subtype (lymphocytic colitis or collagenous colitis). In this population-based nested case-control study, no significant association was seen between cholecystectomy or appendectomy and the development of microscopic colitis or its subtypes.

Purpose: Crohn's disease is associated with cigarette smoking whereas ulcerative colitis is associated with non-smoking. It is unknown if any association exists between microscopic colitis (MC) and smoking. We studied the association between smoking status and the diagnosis of MC in a population-based cohort. Methods: The Rochester Epidemiology Project, a unique medical records linkage system providing data on all health care for a defined population in Olmsted County, MN was used to identify all county residents with a diagnosis of MC between 1/1/85-12/31/01. These biopsies were reviewed by an expert GI pathologist for confirmation. In addition, all colon biopsies for evaluation of diarrhea in county residents over the same time period were reviewed be sure that cases were not missed. Smoking status was determined by review of the medical record at the time that MC was diagnosed. The smoking status of an age-, gender-, and calendar year-matched control group of county residents without MC was assessed for comparison using hazard ratios. Results: 135 cases were identified (89 lymphocytic colitis [LC] and 46 collagenous colitis [CC]). Median age was 68 (23–96); 69% were women. The hazard ratios for current or former smoking in cases compared to controls are listed in Table 1. For LC, there was no significant association with smoking status. For CC, the association with current smoking was significant (p = 0.04).Table: Hazard Ratios and 95% confidence intervals CurrentConclusions: In this population-based cohort, the diagnosis of CC was associated with current but not former cigarette smoking. In LC, there was no association with smoking status. In these very similar clinicopathologic entities, cigarette smoking may be one factor that favors the deposition of subepithelial collagen.

Vedolizumab for the Induction of Remission in Treatment-refractory Microscopic Colitis in a Pediatric Patient.

Microscopic colitis (MC) is an inflammatory disorder of the colon. To date, the relationship between inflammatory eye diseases and MC is unclear. To assess whether inflammatory eye disease (iridocyclitis and episcleritis) is a risk factor for MC. We conducted a nationwide matched case control study in Sweden leveraging the ESPRESSO-study (a Swedish database containing data on all biopsies from the gastrointestinal tract from 1965 to 2017). In total, we identified 14,338 patients with biopsy-verified MC (diagnosed from 1981 to 2017). Patients with MC were matched (by age, sex, county and year of birth) with 68,753 controls from the general population and the occurrence of preceding inflammatory eye diseases (defined as diagnosis of episcleritis or iridocyclitis) in the two groups was compared. Multivariable adjusted odds ratios (aORs) were calculated using conditional logistic regression conditioned on the matching variables. A majority of patients with MC were women (71.9%) and the median age at MC diagnosis was 63.3years (interquartile range (IQR)=50.7-72.6). Some 225 (1.6%) MC patients had an earlier record of inflammatory eye disease compared with 614 (0.9%) in controls. These figures corresponded to an aOR of 1.77 (95% CI=1.52-2.07) for inflammatory eye diseases in patients with MC. Compared to siblings, the aOR for previous inflammatory eye diseases in MC was 1.52 (95% CI=1.17-1.98) and patients treated with budesonide, as a proxy for clinically significant disease, had a somewhat higher aOR for previous inflammatory eye diseases. Inflammatory eye diseases are more common in patients subsequently being diagnosed with MC. Our findings highlight that these conditions may have shared causes and inflammatory pathways and are of clinical interest to gastroenterologists, ophthalmologists and general practitioners.

Microscopic colitis (MC) has been linked to several autoimmune conditions. Results from previous studies on the association with rheumatoid arthritis (RA) have been inconsistent. To assess the risk of future RA in MC. We conducted a nationwide matched cohort study in Sweden of 8179 patients with biopsy-verified MC (diagnosed in 2007-2017), 36,400 matched reference individuals and 8202 siblings without MC, with follow-up until 2021. Information on MC was obtained from all of Sweden's regional pathology registers (n = 28) through the ESPRESSO cohort. Data on incident RA were collected from the National Patient Register. Using Cox regression, we calculated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs). During a median follow-up of 9.1 years (interquartile range = 6.7-11.7), 73 MC patients and 183 reference individuals from the general population were diagnosed with RA (99 vs. 55 events per 100,000 person-years), equivalent to one extra case of RA in 226 patients with MC followed for 10 years. These rates corresponded to an aHR of 1.83 (95% CI = 1.39-2.41). The aHR was highest during the first year of follow-up (2.31 [95% CI = 1.08-4.97]) and remained significantly elevated up to 5 years after MC diagnosis (aHR 2.16; 95% CI = 1.42-3.30). Compared to siblings, without MC, the aHR was 2.04 (95% CI = 1.18-3.56). Patients with MC are at a nearly two-fold risk of developing RA compared to the general population. Knowledge of this increased risk may expedite evaluation for RA in patients with MC presenting with joint symptoms and/or arthralgia, thus preventing delay until RA diagnosis.

The aims were to determine whether a wide variation exists between hospitals in the diagnosis of microscopic colitis and to assimilate clinical data. Retrospective study of 90 patients with microscopic colitis aged between 16 and 92 years from 11 hospitals in south-east England. A questionnaire was designed to collect relevant data from all patients in whom a new diagnosis of microscopic colitis had been made at the source hospital between January 1990 and December 1996. The inclusion criteria were presentation with watery diarrhoea, a normal endoscopy and a histological report of microscopic colitis. Histology slides were then requested and reviewed. Clinical data were analysed with reference to the confirmed diagnosis. The number of patients diagnosed at each hospital ranged between zero and 30, with a median of six. Sixty-eight patients had histological slides reviewed. The numbers of patients with a final reviewed diagnosis of collagenous colitis, lymphocytic colitis and microscopic colitis, type undesignated, were 37, 18 and seven respectively. In thirty-one patients (34%) there was a recent history of the use of non-steroidal anti-inflammatory drugs. These data confirm that there is wide hospital variation in the diagnosis of microscopic colitis. Furthermore, the small group with the undesignated type may be associated with the use of non-steroidal anti-inflammatory drugs.