Hindawi Publishing Corporation Case Reports in Medicine Volume 2013, Article ID 461485, 2 pages http://dx.doi.org/10.1155/2013/461485 Case Report Microscopic Colitis with Macroscopic Endoscopic Findings Atif Saleem, 1 Parag A. Brahmbhatt, 2 Sarah Khan, 2 Mark Young, 1 and Gene D. LeSage 1 1 Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Tennessee State University, P.O. Box 70622, Johnson City, TN 37614, USA 2 Department of Internal Medicine, East Tennessee State University, Johnson City, TN 37614, USA Correspondence should be addressed to Atif Saleem; [email protected] Received 6 February 2013; Accepted 25 March 2013 Academic Editor: Gianfranco D. Alpini Copyright © 2013 Atif Saleem et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Microscopic Colitis (MC) is characterized by chronic watery diarrhea, grossly normal appearing colonic mucosa during conventional white light endoscopy, and biopsy showing microscopic inflammation. We report a case of collagenous colitis with gross endoscopic findings. 1. Case Report A 71-year-old female with past medical history of coronary artery disease, carotid artery disease, hypertension, and dia- betes mellitus type 2 was being evaluated for recurrent inter- mittent diarrhea. Patient denied any abdominal pain, weight loss, or any blood in stool. Patient was not on any medications and lab work was within normal limits. Colonoscopy was required to further evaluate patient’s diarrhea. Colonoscopy revealed multiple scattered segments throughout the colon with increased nodularity and loss of vascular markings in the hepatic flexure, descending colon and cecum (Figures 1(a) and 1(b)). ese findings were more pronounced in cecum. Colonoscopy findings were reported as nonspecific colitis involving scattered segments in the colon, consistent with a Crohn’s disease. Multiple biopsies were taken from both affected and nonaffected areas of the colon for pathologic determination. Microscopic examination showed lymphocytic colitis with marked thickening of the superficial collagen table con- sistent with collagenous colitis. e submucosal collagen was dense and paucicellular with several entrapped lymphocytes and capillaries (red arrow). e lamina propria displays an increase in eosinophils, plasma cells, and lymphocytes (black arrow) (Figure 2). 2. Discussion Microscopic Colitis (MC) is characterized by chronic watery diarrhea, grossly normal appearing colonic mucosa dur- ing conventional white light endoscopy, and biopsy show- ing microscopic inflammation. It accounts for 4%–13% of patients evaluated for chronic diarrhea and divided into lymphocytic and collagenous colitis [1]. MC is usually con- sidered disease of the elderly and patients with age of more than 65 years have five times higher risk for MC. Female predominance has been noted particularly for collagenous colitis [2]. Certain medications such as NSAIDs, PPIs, and SSRIs, as well as autoimmune disease such as thyroid disease, and celiac disease are associated with increased risk of MC [1, 2]. Although identical clinically, both types of colitis have distinct microscopic findings. Lymphocytic colitis is char- acterized by intraepithelial lymphocytosis (more than 20 lymphocytes for every 100 epithelial cells) while collagenous colitis is diagnosed by thickening of subepithelial collagen layer of more than 10 micrometer [2]. By definition colonic mucosa has a normal appearance in MC. Yet distinct endoscopic findings, particularly for collagenous colitis, have been described in the literature. ese findings include alteration of mucosal vascular pattern,
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Hindawi Publishing CorporationCase Reports in MedicineVolume 2013, Article ID 461485, 2 pageshttp://dx.doi.org/10.1155/2013/461485
Case ReportMicroscopic Colitis with Macroscopic Endoscopic Findings
Atif Saleem,1 Parag A. Brahmbhatt,2 Sarah Khan,2 Mark Young,1 and Gene D. LeSage1
1 Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Tennessee State University, P.O. Box 70622,Johnson City, TN 37614, USA
2Department of Internal Medicine, East Tennessee State University, Johnson City, TN 37614, USA
Correspondence should be addressed to Atif Saleem; [email protected]
Received 6 February 2013; Accepted 25 March 2013
Academic Editor: Gianfranco D. Alpini
Copyright © 2013 Atif Saleem et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Microscopic Colitis (MC) is characterized by chronic watery diarrhea, grossly normal appearing colonic mucosa duringconventional white light endoscopy, and biopsy showing microscopic inflammation. We report a case of collagenous colitis withgross endoscopic findings.
1. Case Report
A 71-year-old female with past medical history of coronaryartery disease, carotid artery disease, hypertension, and dia-betes mellitus type 2 was being evaluated for recurrent inter-mittent diarrhea. Patient denied any abdominal pain, weightloss, or any blood in stool. Patient was not on anymedicationsand lab work was within normal limits. Colonoscopy wasrequired to further evaluate patient’s diarrhea. Colonoscopyrevealed multiple scattered segments throughout the colonwith increased nodularity and loss of vascular markings inthe hepatic flexure, descending colon and cecum (Figures 1(a)and 1(b)). These findings were more pronounced in cecum.Colonoscopy findings were reported as nonspecific colitisinvolving scattered segments in the colon, consistent witha Crohn’s disease. Multiple biopsies were taken from bothaffected and nonaffected areas of the colon for pathologicdetermination.
Microscopic examination showed lymphocytic colitiswith marked thickening of the superficial collagen table con-sistent with collagenous colitis. The submucosal collagen wasdense and paucicellular with several entrapped lymphocytesand capillaries (red arrow). The lamina propria displays anincrease in eosinophils, plasma cells, and lymphocytes (blackarrow) (Figure 2).
2. Discussion
Microscopic Colitis (MC) is characterized by chronic waterydiarrhea, grossly normal appearing colonic mucosa dur-ing conventional white light endoscopy, and biopsy show-ing microscopic inflammation. It accounts for 4%–13% ofpatients evaluated for chronic diarrhea and divided intolymphocytic and collagenous colitis [1]. MC is usually con-sidered disease of the elderly and patients with age of morethan 65 years have five times higher risk for MC. Femalepredominance has been noted particularly for collagenouscolitis [2]. Certain medications such as NSAIDs, PPIs, andSSRIs, as well as autoimmune disease such as thyroid disease,and celiac disease are associated with increased risk of MC[1, 2].
Although identical clinically, both types of colitis havedistinct microscopic findings. Lymphocytic colitis is char-acterized by intraepithelial lymphocytosis (more than 20lymphocytes for every 100 epithelial cells) while collagenouscolitis is diagnosed by thickening of subepithelial collagenlayer of more than 10 micrometer [2].
By definition colonic mucosa has a normal appearancein MC. Yet distinct endoscopic findings, particularly forcollagenous colitis, have been described in the literature.These findings include alteration ofmucosal vascular pattern,
2 Case Reports in Medicine
(a) (b)
Figure 1: Colonoscopy images showing increased nodularity and loss of vascular markings.
Figure 2: Show prominent thickening of the submucosal collagentable. The submucosal collagen is dense and paucicellular withseveral entrapped lymphocytes and capillaries (red arrow). Thelamina propria display an increase in eosinophils, plasma cells, andlymphocytes (black arrow).
mucosal abnormalities such as red spots, increased mucosalnodularity, or textural alteration, and pseudomembranes [3].
Recent advance in endoscopy may enhance the abilityto detect MC. A newly developed post processing lightfilters such as i-Scan (Pentax, Japan) helps to enhance thevisualization of mucosal pattern and vascular architecture.Chromoendoscopy using indigocarmine dye sprays mayshow amosaic pattern of mucosa in lymphocytic colitis and anodular, grooved pattern in collagenous colitis [4].These newtechniques can increase the yield of endoscopic diagnosisof MC by targeted biopsy compared to random biopsies atconventional white light endoscopy [4].
3. Conclusion
Microscopic Colitis is traditionally known to have normalcolonic mucosa on endoscopy. Recent advance in endoscopictechniques has shown that various mucosal abnormalities
such as alteration of mucosal vascular pattern and increasedmucosal nodularity are associated with MC. These newertechniques will allow us to get targeted biopsy, which willincrease the yield of endoscopic diagnosis of MC.
Conflict of Interests
The authors declare that they have no conflict of interests.
Authors’ Contribution
All authors participated fully in the conception, development,and creation of this paper. All authors read and approved thefinal version of the paper.
Acknowledgment
The authors are grateful to Brian Klazynski, MD of pathologydepartment for providing images of histopathology stains.
References
[1] D. S. Pardi, T. C. Smyrk, W. J. Tremaine, and W. J. Sandborn,“Microscopic colitis: a review,” American Journal of Gastroen-terology, vol. 97, no. 4, pp. 794–802, 2002.
[2] J. J. Williams, P. L. Beck, C. N. Andrews, D. B. Hogan, and M.A. Storr, “Microscopic colitis—a common cause of diarrhoea inolder adults,” Age and Ageing, vol. 39, no. 2, Article ID afp243,pp. 162–168, 2010.
[3] A. Koulaouzidis and A. A. Saeed, “Distinct colonoscopy find-ings of microscopic colitis: not so microscopic after all?”WorldJournal of Gastroenterology, vol. 17, no. 37, pp. 4157–4165, 2011.
[4] M. Iacucci and S. Urbanski, “Recognition of microscopic colitisat colonoscopy,” Canadian Journal of Gastroenterology, vol. 26,no. 4, pp. 183–184, 2012.
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