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High prevalence of microscopic colitis in patients with diarrhea and normal colonoscopy, a prospective study
A378 AGA ABSTRACTS
GASTROENTEROLOGY Vol. 118, No.4
1999
2001
ENHANCED mSTAMINE PRODUCTION IN COLLAGENOUS COLITIS (CC) DURING UNRESTRICTED AND ELIMINATION (POTATO-RICE) DIET.
HIGH PREVALENCE OF MICROSCOPIC COLITIS IN PATIENTS WITH DIARRHEA AND NORMAL COLONOSCOPY, A PRO· SPECTIVE STUDY.
Dieter Schwab, Sandra Winterkamp, Michael Weidenhiller, Eckhart G. Hahn, Martin Raithel, Dept of Medicine I, Erlangen, Germany. Background: The cause of CC is unknown, but the activation of inflammatory cells like eosinophils or mast cells has been described, suggesting an allergic pathomechanism. Additionally, the therapeutic efficacy of fecal stream diversion shows that luminal factors play an important role in the pathogenesis of CC. Taken together, this is suggestive for a role of food allergy in CC. Methods: In 13 patients with CC, 12-h-urine (for histamine (UH) and methyl-histamine (UMH)) was collected during a non-restricted diet (NO) and a elimination diet (ED) consisting of potato and rice. The values obtained were compared with those of patients with food allergy (FA)(n=42) and healthy controls (n=27). Measurement was performed using a RIA (Methyl-Histamine: Pharmacia, Freiburg, Germany; Histamine: Coulter-Immunotech, Hamburg, Germany). Results: When tested during NO, 27 urine samples or patients with CC were available (for ED: 20). UMH was significantly elevated when compared with controls (p=0.02), but not UH. UMH was unchanged, when the patients were switched on a elimination diet - in contrast to values obtained in patients with food allergy, who showed similar elevation of UH and UMH, but a significant reduction under ED (p=0.02 for both). Conclusion: In patients with CC, the extensive activation of mast cells appears not to be influenced by an elimination diet. This finding suggests an induction of histamine secretion by rice and potato. Since allergic reactions to potato or rice are rare, this could be realized by salicylates, which are present abundantly in potatoes. This could further add to the evidence of an association of NSAID-consumption and presence of Cc.
Willem 1. Thijs, Gerard H. Olffen, Nico van Bentem, Joop Baarlen, Jeroen J. Kolkman, Medicine Spectrum Twente, Enschede, Netherlands; Streeklaboratorium Pathology Oost-Nederland, Enschede, Netherlands. Introduction Microscopic colitis, encompassing lymphocytic and collagenous colitis, is characterized by intraepithelial Iymfocytosis (IEL) in an endoscopically normal colon. The clinical picture consists of chronic, usually intermittent diarrhea and abdominal cramps. The prevalence is unclear, with some studies reporting microscopic colitis in up to 10% of patients with chronic diarrhea and normal colonoscopy. There are conflicting data concerning the distribution of microscopic colitis: some studies suggested that biopsies from the sigmoid region suffice, others described patchy as well as predominantly right-sided microscopic colitis, and therefore advised to take biopsies throughout the colon. This study aimed to assess I) the incidence of microscopic colitis in patients with chronic diarrhea and normal colonoscopy and 2) whether or not sigmoid biopsies alone would be sufficient to diagnose microscopic colitis. Patients & Methods In all patients with chronic diarrhea in whom colonoscopy was normal mucosal biopsies were obtained from the ileum, ascending, transverse, descending and sigmoid colon and the rectum (two per segment). These biopsies were oriented on a strip paper for routine histology and histomorphometry, using a CD3 marker. Lymphocytic colitis was defined as IEL > 20 I 100 epithelial cells, and collagenous colitis as thickening of basal membrane> 10 /Lm. Results In a 10 month period, 103 patients were eligible (66 F), aged 17-82 (mean 46). In 13 patients (12.6%) microscopic colitis was found (I I F, aged 17-82, mean 52 yr); 1 collagenous colitis and 12 lymphocytic colitis. The abnormalities were diffuse in 10 and patchy in 3. In 3/13 the IEL was more pronounced proximal than distal in the colon. Standard sigmoidal biopsies would have led to false-negative diagnosis in 3/13 (23%) patients. Duodenal biopsies (to exclude celiac disease) were performed in 7. Of these, 6 (86%) showed increased IEL (3 Marsh I, 3 Marsh II). Conclusion The incidence of miscroscopic colitis among patients with chronic diarrhea and normal colonoscopy was almost 13% in this prospective study. Lymphocytic colitis is far more common than collagenous colitis and associated with gluten enteropathy (present in 46%). As the distribution of IEL can be patchy as well as most pronounced in the proximal colon, biopsies of all colon segments should be obtained. Biopsies from the sigmoid region only, as sometimes advocated, would have led to a 23% false negative rate.
Parameters ofMastcell·Activation inCC, FA and Controls
UH [Ilg/mmol Creat'BSAI UMH [Ilg/mmol Creat'BSAj
CC·NO
CC·EO
FA.NO
FA·EO
Controls
198±2.38
134±101
2.23±1,99
1,65±1.22
18±0.6
9,63±7.09
8.56±618
7.61:t5.82
5.81±446
3.7±1.8
2002 2000
IDENTIFICATION OF NUTRITIONAL ALLERGENS AND BENEFICIAL EFFECT OF ANTIALLERGIC TREATMENT IN PATIENTS WITH COLLAGENOUS AND LYMPHOCYTIC COLITIS.
WHAT IS THE YIELD OF COLONIC BIOPSIES IN CHRONIC DIARRHEA PATIENTS WITH NORMAL COLONOSCOPY?
Michael Weidenhiller, Dieter Schwab, Sandra Winterkamp, Eckhart Georg Hahn, Martin Raithel, Dept of Medicine 1, Univ of Erlangen, Erlangen,
Jose Guilhenne N. Silva, Maria Roseneli S. D'Este, Aytan M. Sipahi, Aderson Orne Damiao, Andre Za Leite, Antonio A. Laudanna, Univ of Sao Paulo (USP), Sao Paulo, Brazil; Sao Paulo Univ, Sao Paulo, Brazil. Background: Multiple colonic biopsies during a normal colonoscopy in patients with chronic and unexplained diarrhea is not a consensus. Although it does not significantly rise the morbidity and mortality of the procedure, it can increase the length and the cost of colonoscopy. Histologic analysis of macroscopicaly normal colonic mucosa can show abnormalities of inflammatory bowel disease, collagenous and lynphocytic colitis. Aim: The aim of this study was to determine the frequency of histologic abnormalities in normal colonic mucosa in patients with chronic unexplained diarrhea. Patients and Methods: Of a total of 584 consecutive patients undergoing colonoscopy over a 3-yr period, colonic biopsies were taken from 118 (20.2%) cases with unexplained diarrhea in which the colon was macroscopicaly normal. The routine was to take four biopsies from terminal ileum, ascending, transverse, dencending and sigmoid colons and from the rectum. Results: Histologic examination contributed for the diagnosis in 13 (11%) patients: collagenous colitis in 06 (5.1%), Crohn's disease in 03 (2.5%), schistosomiasis in 01 (0.9%), lymphocytic colitis in 02 (1.7%) and ischemic disease in 01 (0.9%). One of the patients with collagenous colitis had a carcinoid tumor of the rectum. Conclusion: We conclude that colonic biopsies in patients with diarrhea and macroscopicaly normal colonoscopy is worthwhile and that some diseases may be missed without it.
Germany. Introduction Gastrointestinal allergy (GA) is thought to be a rare disease entity mediated by pathological TH2-cell response and hyperactivity of immune effector cells like mast cells and eosinophils. Apart from extraintestinal symptoms, mediator degranulation of these cells may cause diarrhea, bloating and abdominal pain. Collagenous and lymphocytic colitis are also rare diseases with predominance of diarrhea of unknown etiology, but supposed immunopathology as evidenced by lymphocytic infiltrates; mast cells and eosinophils, known effector of immunologic reaction, are also present. Patients and methods We report on five patients who suffered from diarrhea and were first diagnosed as having collagenous colitis by histological assessment. A thorough diagnostic work-up with measurement of methylhistamine in urine, intestinal IgE detection or therapeutic benefit from disodium cromoglycatelH I-receptor antagonists lead to the diagnosis of gastrointestinal allergy with diverse allergies. After elimination of the allergens and anti-allergic therapy, patients were free of symptoms. In one case studied up to date, the degree of eosinophil degranulation and collagen deposition were clearly reduced after antiallergic therapy. Discussion As reported from other investigators, this study shows that mast cell mediators may playa pathogenic role in collagenousllymphocytic colitis. However, to date this is the first report documenting the coincidence of manifest GA with this type of non-IBD colitis. Strict allergen avoidance and antiallergic treatment were found to be an effective means to completely abolish chronic diarrhea or partly reduce collagen deposition.
GASTROENTEROLOGY Vol. 118, No.4
1999
2001
ENHANCED mSTAMINE PRODUCTION IN COLLAGENOUS COLITIS (CC) DURING UNRESTRICTED AND ELIMINATION (POTATO-RICE) DIET.
HIGH PREVALENCE OF MICROSCOPIC COLITIS IN PATIENTS WITH DIARRHEA AND NORMAL COLONOSCOPY, A PRO· SPECTIVE STUDY.
Dieter Schwab, Sandra Winterkamp, Michael Weidenhiller, Eckhart G. Hahn, Martin Raithel, Dept of Medicine I, Erlangen, Germany. Background: The cause of CC is unknown, but the activation of inflammatory cells like eosinophils or mast cells has been described, suggesting an allergic pathomechanism. Additionally, the therapeutic efficacy of fecal stream diversion shows that luminal factors play an important role in the pathogenesis of CC. Taken together, this is suggestive for a role of food allergy in CC. Methods: In 13 patients with CC, 12-h-urine (for histamine (UH) and methyl-histamine (UMH)) was collected during a non-restricted diet (NO) and a elimination diet (ED) consisting of potato and rice. The values obtained were compared with those of patients with food allergy (FA)(n=42) and healthy controls (n=27). Measurement was performed using a RIA (Methyl-Histamine: Pharmacia, Freiburg, Germany; Histamine: Coulter-Immunotech, Hamburg, Germany). Results: When tested during NO, 27 urine samples or patients with CC were available (for ED: 20). UMH was significantly elevated when compared with controls (p=0.02), but not UH. UMH was unchanged, when the patients were switched on a elimination diet - in contrast to values obtained in patients with food allergy, who showed similar elevation of UH and UMH, but a significant reduction under ED (p=0.02 for both). Conclusion: In patients with CC, the extensive activation of mast cells appears not to be influenced by an elimination diet. This finding suggests an induction of histamine secretion by rice and potato. Since allergic reactions to potato or rice are rare, this could be realized by salicylates, which are present abundantly in potatoes. This could further add to the evidence of an association of NSAID-consumption and presence of Cc.
Willem 1. Thijs, Gerard H. Olffen, Nico van Bentem, Joop Baarlen, Jeroen J. Kolkman, Medicine Spectrum Twente, Enschede, Netherlands; Streeklaboratorium Pathology Oost-Nederland, Enschede, Netherlands. Introduction Microscopic colitis, encompassing lymphocytic and collagenous colitis, is characterized by intraepithelial Iymfocytosis (IEL) in an endoscopically normal colon. The clinical picture consists of chronic, usually intermittent diarrhea and abdominal cramps. The prevalence is unclear, with some studies reporting microscopic colitis in up to 10% of patients with chronic diarrhea and normal colonoscopy. There are conflicting data concerning the distribution of microscopic colitis: some studies suggested that biopsies from the sigmoid region suffice, others described patchy as well as predominantly right-sided microscopic colitis, and therefore advised to take biopsies throughout the colon. This study aimed to assess I) the incidence of microscopic colitis in patients with chronic diarrhea and normal colonoscopy and 2) whether or not sigmoid biopsies alone would be sufficient to diagnose microscopic colitis. Patients & Methods In all patients with chronic diarrhea in whom colonoscopy was normal mucosal biopsies were obtained from the ileum, ascending, transverse, descending and sigmoid colon and the rectum (two per segment). These biopsies were oriented on a strip paper for routine histology and histomorphometry, using a CD3 marker. Lymphocytic colitis was defined as IEL > 20 I 100 epithelial cells, and collagenous colitis as thickening of basal membrane> 10 /Lm. Results In a 10 month period, 103 patients were eligible (66 F), aged 17-82 (mean 46). In 13 patients (12.6%) microscopic colitis was found (I I F, aged 17-82, mean 52 yr); 1 collagenous colitis and 12 lymphocytic colitis. The abnormalities were diffuse in 10 and patchy in 3. In 3/13 the IEL was more pronounced proximal than distal in the colon. Standard sigmoidal biopsies would have led to false-negative diagnosis in 3/13 (23%) patients. Duodenal biopsies (to exclude celiac disease) were performed in 7. Of these, 6 (86%) showed increased IEL (3 Marsh I, 3 Marsh II). Conclusion The incidence of miscroscopic colitis among patients with chronic diarrhea and normal colonoscopy was almost 13% in this prospective study. Lymphocytic colitis is far more common than collagenous colitis and associated with gluten enteropathy (present in 46%). As the distribution of IEL can be patchy as well as most pronounced in the proximal colon, biopsies of all colon segments should be obtained. Biopsies from the sigmoid region only, as sometimes advocated, would have led to a 23% false negative rate.
Parameters ofMastcell·Activation inCC, FA and Controls
UH [Ilg/mmol Creat'BSAI UMH [Ilg/mmol Creat'BSAj
CC·NO
CC·EO
FA.NO
FA·EO
Controls
198±2.38
134±101
2.23±1,99
1,65±1.22
18±0.6
9,63±7.09
8.56±618
7.61:t5.82
5.81±446
3.7±1.8
2002 2000
IDENTIFICATION OF NUTRITIONAL ALLERGENS AND BENEFICIAL EFFECT OF ANTIALLERGIC TREATMENT IN PATIENTS WITH COLLAGENOUS AND LYMPHOCYTIC COLITIS.
WHAT IS THE YIELD OF COLONIC BIOPSIES IN CHRONIC DIARRHEA PATIENTS WITH NORMAL COLONOSCOPY?
Michael Weidenhiller, Dieter Schwab, Sandra Winterkamp, Eckhart Georg Hahn, Martin Raithel, Dept of Medicine 1, Univ of Erlangen, Erlangen,
Jose Guilhenne N. Silva, Maria Roseneli S. D'Este, Aytan M. Sipahi, Aderson Orne Damiao, Andre Za Leite, Antonio A. Laudanna, Univ of Sao Paulo (USP), Sao Paulo, Brazil; Sao Paulo Univ, Sao Paulo, Brazil. Background: Multiple colonic biopsies during a normal colonoscopy in patients with chronic and unexplained diarrhea is not a consensus. Although it does not significantly rise the morbidity and mortality of the procedure, it can increase the length and the cost of colonoscopy. Histologic analysis of macroscopicaly normal colonic mucosa can show abnormalities of inflammatory bowel disease, collagenous and lynphocytic colitis. Aim: The aim of this study was to determine the frequency of histologic abnormalities in normal colonic mucosa in patients with chronic unexplained diarrhea. Patients and Methods: Of a total of 584 consecutive patients undergoing colonoscopy over a 3-yr period, colonic biopsies were taken from 118 (20.2%) cases with unexplained diarrhea in which the colon was macroscopicaly normal. The routine was to take four biopsies from terminal ileum, ascending, transverse, dencending and sigmoid colons and from the rectum. Results: Histologic examination contributed for the diagnosis in 13 (11%) patients: collagenous colitis in 06 (5.1%), Crohn's disease in 03 (2.5%), schistosomiasis in 01 (0.9%), lymphocytic colitis in 02 (1.7%) and ischemic disease in 01 (0.9%). One of the patients with collagenous colitis had a carcinoid tumor of the rectum. Conclusion: We conclude that colonic biopsies in patients with diarrhea and macroscopicaly normal colonoscopy is worthwhile and that some diseases may be missed without it.
Germany. Introduction Gastrointestinal allergy (GA) is thought to be a rare disease entity mediated by pathological TH2-cell response and hyperactivity of immune effector cells like mast cells and eosinophils. Apart from extraintestinal symptoms, mediator degranulation of these cells may cause diarrhea, bloating and abdominal pain. Collagenous and lymphocytic colitis are also rare diseases with predominance of diarrhea of unknown etiology, but supposed immunopathology as evidenced by lymphocytic infiltrates; mast cells and eosinophils, known effector of immunologic reaction, are also present. Patients and methods We report on five patients who suffered from diarrhea and were first diagnosed as having collagenous colitis by histological assessment. A thorough diagnostic work-up with measurement of methylhistamine in urine, intestinal IgE detection or therapeutic benefit from disodium cromoglycatelH I-receptor antagonists lead to the diagnosis of gastrointestinal allergy with diverse allergies. After elimination of the allergens and anti-allergic therapy, patients were free of symptoms. In one case studied up to date, the degree of eosinophil degranulation and collagen deposition were clearly reduced after antiallergic therapy. Discussion As reported from other investigators, this study shows that mast cell mediators may playa pathogenic role in collagenousllymphocytic colitis. However, to date this is the first report documenting the coincidence of manifest GA with this type of non-IBD colitis. Strict allergen avoidance and antiallergic treatment were found to be an effective means to completely abolish chronic diarrhea or partly reduce collagen deposition.