Do I have Microscopic Colitis?

Microscopic Colitis Treatment, Symptoms and Diet Plans

Inflammatory Bowel Disease (IBD) is a term for a group of conditions that cause inflammation and other symptoms  in the digestive tract. Microscopic Colitis is described as inflammation in the large intestine. The large intestine is about 5 feet long in adults and includes both the colon and rectum. [Ref]

Microscopic Colitis has different symptoms from those of Ulcerative Colitis and Crohn’s Disease, two other well known inflammatory bowel diseases. Importantly unlike these other two IBDs, microscopic colitis has not been shown to increase the risk of colon cancer. [Ref]

There are two main forms:

  • Collagenous Colitis (CC) – Collagen, which is a type of protein, develops in thick layers in the colon tissue
  • Lymphocytic Colitis (LC) – There is an increase in the white blood cell (lymphocytes) count  also in the colon tissue

There is a third type, incomplete Microscopic Colitis, which manifests itself as mixed features of lymphocytic and collagenous colitis.

The disorder gets its name from the fact that it’s necessary to examine colon tissue under a microscope to identify it.

Symptoms

The severity, frequency, and duration of symptoms vary. People with microscopic colitis can experience flare-ups in which they get frequent symptoms, but also periods of remission.

Microscopic colitis has a major symptom, which is ongoing watery diarrhoea. This may be sudden and/or explosive and is likely to happen several times in a day and over a night.

Equally some people may have painful, disabling symptoms, others only experience mild discomfort. And, while many people experience flare-ups that last a few days or weeks, other people have symptoms that last for months to years.

Common symptoms include:

  • abdominal pain and cramping or bloating
  • chronic watery diarrhoea
  • weight loss
  • nausea

Women, people over the age of 50 and people who have an autoimmune disease (when the immune system mistakes the individuals body for pathogens and attacks the cells) experience higher numbers of microscopic colitis instances.

Although a few cases in children have been documented, it is estimated that 75% of cases develop in people aged 50 or older.

Sufferers can also have thyroid disease, rheumatoid arthritis or celiac disease. Microscopic colitis has also been seen to correlate with IBS in the family. [Ref]

microscopic coliitis image

Causes

Microscopic colitis may have several different causes, studies suggest there is not one single cause, but a combination of several.  There is a growing research into microscopic colitis resulting from an abnormal immune system reaction to bacteria from the colon. This reaction sets off an inflammatory response. Primary contributory factors include:

  • Certain autoimmune diseases, including celiac disease, thyroid diseases, rheumatoid arthritis and psoriasis
  • Medications, including non-steroid anti-inflammatory drugs like aspirin and ibuprofen
  • Antacid and heartburn drugs; antidepressants; and certain drugs for treatment of cancer or heart disease
  • Infections
  • Genetic factors

Treatment

Medications

Persistent symptoms and signs can be treated with the prescription of one or more of the medications listed below;

  • Steroids like budesonide
  • Bile acid blocking medications (these may aggravate diarrhoea) eg colestipol (Colestid), cholestyramine (Prevalite) or cholestyramine/aspartame.
  • Diarrhea relief medications like bismuth subsalicylate (Pepto-Bismol) or loperamide (Imodium)
  • Immune system suppression medication to reduce colon inflammation, like azathioprine (Azasan, Imuran) or mercaptopurine (Purinethol)
  • TNF (Tumor Necrosis Factor) inhibitors, like adalimumab (Humira) or infliximab (Remicade). These can reduce inflammation by neutralizing the immune system protein TNF
  • Nonsteroidal anti inflammatory drugs to reduce imflamation in the colon such as  mesalamine.

Surgery

In extreme cases of microscopic colitis where symptoms are severe and medications remain ineffective, surgery to remove part or all of the colon may be an option. However, surgery is rarely required when treating microscopic colitis.

IBS Clinics approach

IBS Clinics nutritionists are fully conversant in a wide range of dietary approaches and so a typical patient may be recommended to follow a gluten free, casein free diet.

Gluten

Many research reports point out that laboratory markers and clinical symptoms of celiac disease and MC are very similar. Both celiac disease and microscopic colitis are associated with an elevated lymphocyte count in the mucosa of the intestine. With celiac disease, the lymphocytic infiltration eventually leads to villus atrophy in the small intestine. This is typically true if the patient has either a DQ2 or a DQ8 gene (Biagi et al., 2004). Note that an early stage of celiac disease, known as Marsh stage 1 enteropathy, is marked by an intraepithelial lymphocyte count greater than 30 lymphocytes per 100 enterocytes. So, both celiac disease and microscopic colitis cause identical cellular changes in the mucosa of the colon.  And even though no mention of the small intestine is made in the diagnostic criteria for microscopic colitis, researchers have found that lymphocytic infiltration is frequently present in the small intestine of MC patients, and in some cases, villus damage is sufficient to justify a diagnosis of celiac disease. Even when the formal diagnostic criteria for celiac disease are not met, a significant number (over 10 %) of microscopic colitis patients show at least a Marsh 1 level of villus damage upon biopsy analysis of their small intestine. [Ref]

icon symbolising ibs gluten free

Casein (dairy) sensitivities and other commonly allergenic foods (soy, eggs, nuts)

A few people who have MC are sensitive to the primary storage proteins in other grains, such as zein (in corn), or panicin (in millet), and orzenin (in rice). Experience shows that rice is one of the least allergenic grains of the commonly available choices. That means that most (but not all) of us can use it in an elimination diet. Unfortunately, grains are not the only foods that can cause immune system reactions for some people who have MC. Most people who are sensitive to gluten are also sensitive to casein, the primary protein in all dairy products, and approximately half of them are also sensitive to soya, the primary protein in soybeans. In addition, most individuals who are sensitive to soya are also sensitive to all or most foods known as legumes, a group that includes most beans, peas and most food grade gums that are used to replace gluten in gluten-free flours. These gums include guar gum, locust bean gum and carob bean gum.  In addition to the most common food sensitivities, some people who have MC are also sensitive to foods such as eggs, yeast, corn, nuts, and occasionally other foods.


If no significant improvement in symptoms is seen after several months of eliminating all known or suspected food sensitivities from the diet, then it might be time to suspect a mast cell problem, and to try some diet modifications, in order to confirm whether or not mast cells are indeed the source of the problem.

icon symbolising lactose free

Histamine and Mast cell activation syndrome (MCAS)

Unfortunately, the gastrointestinal symptoms of histamine disorders may be overlooked because they overlap the symptoms of microscopic colitis. These symptoms include, but are not limited to, headache, abdominal pain, gas, cramps, and diarrhoea. 

The research is very persuasive on the activity of mast cell activation in the gut and the triggering of histamine release in response to chronic inflammation.  MC is a condition characterized by chronic inflammation. A study published in 2006 showed that 70 % of patients with what was described as “chronic intractable diarrhoea”, had an elevated mast cell count that qualified for a diagnosis of mastocytic enterocolitis.

Oxalates

Oxalates may cause problems for some people who have MC. Oxalates are known to be a problem for people who have short bowel syndrome. Short bowel syndrome (SBS) normally refers to individuals who have had significant sections of their intestines surgically removed and who have problems with diarrhoea because of the procedure. In a sense, many MC sufferers have an MC-induced version of SBS because of functional issues such as a severe malabsorption problem caused by massive inflammation. This implies that significant sections of the intestines do not function very well, even though the digestive system is still intact. With SBS, the problem can be caused by foods that have a high oxalate content, such as beets, collards, cocoa, chocolate, green beans, kale, Ovaltine, parsley, raw nuts, rhubarb, spinach, strawberries, sweet potatoes, tea, turnip greens, and some instant coffees. Note that colas also contain oxalate and should be limited to approximately 12 oz. per day with SBS. This may be the reason why experience shows that many who have MC cannot tolerate foods such as chocolate, sweet potatoes, and nuts, when there is no other logical reason why they should not be tolerated.

Salicylates

There appears to be some research to suggest that a small subset of people with IBD may have a salicylate intolerance.    Salicylates naturally occur in varying concentrations in many fruits and vegetables, and are chemically very similar to the man-made chemical, acetylsalicylic acid, a key ingredient in aspirin and other pain medications. They are also frequently found in acne and wart removal products, aspirin, many NSAIDs, and other medications, both natural and pharmaceutical products such as cosmetics, fragrances, perfumes, lotions, hair spray, gels, shampoo and conditioners, bubble baths. Some herbs are especially high in salicylates for example curry powder contains 218 mg salicylate per 100 g. Others almost as high were paprika, thyme, dill powder, garam masala, oregano, and turmeric.

Lectins

Lectins can be an issue for some people and so a brief trial of a low lectin diet might be helpful in determining if this is an issue.
several bottles of supplements

Tests and supplements

Because intestinal issues often appear normal in microscopic colitis, a definite diagnosis of microscopic colitis requires a colon tissue biopsy. This can be taken during a colonoscopy or flexible sigmoidoscopy. In both subtypes of microscopic colitis, cells in colon tissue have a distinct appearance under the microscope, giving a definitive diagnosis.

A flexible sigmoidoscopy uses a flexible, narrow tube with a light and tiny camera on one end to look inside the rectum and the colon.

Blood tests can be taken to rule out a diagnosis of celiac disease