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An interesting case of a 42 year old woman with diarrhea

An interesting case of a 42 year old woman with diarrhea. Christie Seibert, MD July 28, 2004. No financial support. HPI. Roberta is a 42 yo woman with a 3 mo h/o diarrhea (“explosive and watery”) Usually ~2-3 stools/day but once had 7-8 in an hour, prompting an UC visit (2 mo prior)

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An interesting case of a 42 year old woman with diarrhea

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  1. An interesting case of a 42 year old woman with diarrhea Christie Seibert, MD July 28, 2004

  2. No financial support.

  3. HPI • Roberta is a 42 yo woman with a 3 mo h/o diarrhea (“explosive and watery”) • Usually ~2-3 stools/day but once had 7-8 in an hour, prompting an UC visit (2 mo prior) • Often “explosions” follow meals • No nocturnal stools • Has mild pain in lower abd w/ bloating • 1-2 Immodium D helped a bit • No personal h/o bowel problems

  4. Other History • PMH: DJD of hips, on chronic NSAIDS (sulindac). Otherwise healthy. • SH: no recent travel, camping. Office manager. No ill contacts. • FH: nothing remarkable • ROS: feels well except for occ nausea, no weight loss

  5. Exam • Not febrile. Normotensive. • Abdomen soft, with minimal tenderness in RLQ with deep palpation. No HSM. NL bowel sounds. • Guiaic negative.

  6. Lab evaluation • UC (after 1 mo of sxs): • Giardia and Cryptosporidium neg • TSH and CBC normal • This visit (after 3 mo of sxs): • Fecal leukocytes neg What now???

  7. Differential Diagnosis • IBS • IBD • Lactose intolerance • Factitious diarrhea (laxative abuse) • Malabsorption • Hyperthyroidism • Chronic infection (parasites)

  8. Colonoscopy with biopsy

  9. Learning Objectives • Define microscopic colitis including subtypes • Describe pathophysiology and possible drug associations • Delineate clinical features • Describe treatments, including an expert opinion treatment algorithm

  10. Microscopic Colitis • Chronic, watery diarrhea • Essentially normal endoscopy • Inflammation on colonic biopsy (no mucosal ulcerations)

  11. 2 major subsets of Microscopic Colitis • Lymphocytic colitis • Collagenous colitis

  12. Epidemiology • Prevalence of 10-16 cases/100,000 people • At referral centers, this accounts for approx 10% of patients scoped for chronic diarrhea. • Typically presents in 6th-7th decade • Female: male ratio as high as 20:1 for collagenous type

  13. Pathophysiology • Unknown • ??NSAIDs, simvastatin, lansoprazole, ticlopidine (mainly case reports and case control studies) • Association with celiac disease • Up to 1/3 of pts with celiac disease will have MC on colonic biopsy • 10% of MC pts will have celiac ds

  14. Clinical Features • Non-bloody chronic watery diarrhea (secretory) • Intermittent (85%) vs continuous (13%) vs single episode (2%) • Can be insidious or sudden • Usually 4-10 stools/day • 27% nocturnal diarrhea • Assoc with abd pain, mild weight loss • May include oligoarthritis • Fecal WBCs may be present in up to 50%

  15. Treatment • RCT (14 pts) given 3 chewable bismuth tabs TID vs placebo for 8 wks (Fine 1999) • Sig decrease in fecal freq/weight • Benefits lasted 1-8 mo in 9 pts after stopping therapy • RCT (20 pts) given Budesonide (9mg/6mg/3mg) vs placebo for 8 weeks (Baert 2002) • Clinical response in 100% of steroid pts vs 20% of placebo • 8 of 10 pts with response relapsed within 8 weeks • RCT (51 pts) given Budesonide (9mg/d) vs placebo for 6 wks (Mielhke 2002) • Clinical response in 77% of steroid pts vs 12% of placebo

  16. Other Treatments(Response rates from retrospective studies) • Antidiarrheal agents 73% • Sulfasalazine 42% • Mesalamine 45% • Cholestyramine 65% • Azathioprine/6-MP 20%

  17. Expert Opinion Treatment Algorithm • First, stop NSAIDS, other drugs • 1st line: antidiarrheal agents • 2nd line: Bismuth 2-3 chew tabs TID • 3rd line: • Sulfasalazine • Mesalamine • Cholestyramine • Then: steroids

  18. References • Pardi D. Microscopic Colitis. Mayo Clin Pro. 2003;78(5):614-7. • Bonderup Ok et al. Budesonide treatment of collagenous colitis: a randomised, double blind placebo controlled trial with morphometric analysis. Gut. 2003;52(2):1248-51. • Mielhkle et al. Budesonide treatment for microscopic colitis: a randmised, double blind, placebo-controlled, multicenter trial. Gastroenterology. 2002;123(4):978-84. • Fine K et al. Randomised, double-blind, placebo-controlled trail of bismuth subsalicylate for microscopic colitis. Gastroenterology 1999;116:A880. • Dietrich CF, Kaspary W. Lymphocytic and collagenous colitis. UptoDate.com. Accessed 6/29/04.

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