Chronic diarrhea

The histological painting of the colon biopsy specimen ( Figure 3 ) was feature of collagenous colitis.The key findings were a plasmacytic infiltrate in the lamina propria, small testify of crypt destruction, an addition in intraepithelial lymphocytes, loss of regularity of the columniform epithelium, and, of course, thickening of the subepithelial collagen table, which gives this discipline its name. It is significant to note that although mucosal inflammation was present, the diarrhea produced in this discipline is categorized as secretory and not incendiary. This is because the mucous membrane stays intact ; there normally is no bleed or pus in the stools. These patients have reduced body of water and electrolyte assimilation in the colon because of the inflammatory changesand thus own excess stool urine. The adjacent screen should be one that can distinguish between these 2 possibilities. Biopsy of the colon can do that. The main issue is whether to perform sigmoidoscopy or colonoscopy to obtain the biopsy samples.Colonoscopy affords the opportunity to examine the entire colon, and, in some situations, such as diarrhea in a patient with acquire immunodeficiency syndrome, this may be valuable. For finding microscopic colitis, biopsy samples from any part of the colon are likely to be positivist ( < 10 % of patients with microscopic colitis will have negative rectosigmoid biopsy results ), so the decision about what test to perform depends on early factors.In this patient a full colonoscopy could be justified on the footing of a necessitate for colon cancer screening. Were that not a factor, biopsy specimens from the rectosigmoid colon would most probable be adequate for diagnosis. In our shell, the stool sodium concentration was 80 mmol/L, and the stool potassium concentration was 55 mmol/L, making the faecal osmotic opening equal to 290 − 2 × ( 80 + 55 ) or 20 mOsm/kg, clearly in the image of a secretory diarrhea. The most likely diagnoses in a middle-aged woman with a history of new-onset secretory diarrhea without evidence of systemic disease, infection, or excitement would be microscopic colitis syndrome ( lymphocytic colitis or collagenous colitis ) or chronic idiopathic secretory diarrhea. On the basis of the referral population of patients with chronic diarrhea seen in a tertiary referral center, the preponderance of both microscopic colitis syndrome and chronic idiopathic secretory diarrhea is approximately 10 % –20 % each. The absence of excess faecal adipose tissue eliminated chronic fatty diarrhea as a likely diagnostic class. This left chronic watery diarrhea as the remaining category. Determining whether this was a case of chronic osmotic diarrhea or chronic secretory diarrhea could well be performed by calculation of the faecal osmotic gap.The principle behind this calculation is that in secretory diarrhea, urine is held intraluminally by incompletely absorbed electrolytes, whereas in osmotic diarrhea, electrolyte assimilation is normal, and water is held intraluminally by the ailing absorbed, osmotically active voice substance. therefore, secretory diarrheas have high electrolyte concentrations, and osmotic diarrheas have broken electrolyte concentrations. The contribution of electrolytes to stool osmolality is calculated by doubling the total of the sodium and potassium concentrations to account for the anions accompanying these cations. This product is then subtracted from 290 mOsm/kg, the osmolality of intraluminal contents in the catgut ( the small intestine and colon are excessively permeable to urine to allow a substantial difference in osmolality between the lumen and plasma ; measured stool osmolality increases quickly in vitro because of bacterial metabolism and consequently should not be used in this calculation ). This is the faecal osmotic gap. Values < 50 mOsm/kg are consistent with secretory diarrhea, and values > 50 mOsm/kg are consistent with osmotic diarrhea.

management of collagenous colitis

11

• Schiller L.R.

Microscopic colitis syndrome lymphocytic colitis and collagenous colitis .13

• Pardi D.S.
• Smyrk T.C.
• Tremaine W.J.
• Sandborn W.J.

Microscopic colitis a recapitulation .14

• Fine K.D.
• Do K.
• Schulte K.
• Ogungi F.
• Guerra R.
• Osowski L.
• McCormack J.

high preponderance of celiac sprue-like HLA-DQ genes and enteropathy in patients with the microscopic colitis syndrome . The fundamental causes of collagenous colitis are not known. Most patients with this diagnosis are women with autoimmune problems, such as arthritis, thyroid gland disease, or diabetes, so it may have an autoimmune basis.Many patients with collagenous colitis have HLA-DQ types similar to those of patients with celiac disease, raising the possibility that the condition relates to antigen presentation by the immune system ( although the antigen is not likely to be gluten ) .We do not at present have any raise dietary advice or management for this condition .15

• Schiller L.R.

Antidiarrheal pharmacology and therapeutics . nonspecific treatments besides have a limited character. Stool weight rarely exceeds 800 g/24 hours, so dehydration is not a major issue unless access to salt and water is restricted. consequently, oral or intravenous hydration normally is not needed. Antidiarrheal drugs have a assorted record in these patients. In some, regular use of opiate antidiarrheal drugs can reduce diarrhea sufficiently ; in others, they are ineffective. They may be of most manipulation in patients with coexisting faecal incontinence, but this has not been established .11

• Schiller L.R.

Microscopic colitis syndrome lymphocytic colitis and collagenous colitis .16

• Loftus Jr, E.V.

Microscopic colitis epidemiology and discussion . When microscopic colitis syndrome was first being defined in the 1980s, therapy was based on treatments for more established forms of inflammatory intestine disease, such as ulcerative colitis and Crohn ’ s disease.The initial treatments used included 5-aminosalicylate drugs and corticosteroids in doses similar to those used for ulcerative colitis. many reports of response to these and other agents were published, but it has been difficult to judge potency in the absence of control trials. This is particularly true in this condition, because it tends to have ad-lib remissions .11

• Schiller L.R.

Microscopic colitis syndrome lymphocytic colitis and collagenous colitis .17

• Fernandez-Banares F.
• Salas A.
• Esteve M.
• Espinos J.
• Forne M.
• Viver J.M.

collagenous and lymphocytic colitis. evaluation of clinical and histological features, response to treatment, and long-run follow-up .18

• Marshall J.K.
• Irvine E.J.

lymphocytic and collagenous colitis medical management . In most publish series of cases, use of 5-aminosalicylate drugs resulted in extenuation of diarrhea in up to 40 % of patients.There was little impression on histology when this was evaluated, and get worse was patronize. There was no clear advantage to any of the assorted 5-aminosalicylate drug preparations when used in standard doses. however, because these drugs have an enviable condom and tolerance record, they are often tried beginning by many experience clinicians.Results should be apparent within 1 month.

11

• Schiller L.R.

Microscopic colitis syndrome lymphocytic colitis and collagenous colitis .19

• Munck L.K.
• Kjeldsen J.
• Philipsen E.
• Fischer Hansen B.

incomplete remission with short-run prednisolone treatment in collagenous colitis a randomized learn . anomalously high doses of systemic corticosteroids are needed to control symptoms in microscopic colitis syndrome as compared with ulcerative colitis.Typically, 60–80 milligram of prednisone day by day may be required. One late modest study from Denmark suggested that prednisolone 50 mg/day for 2 weeks induced an incomplete remittance in patients with microscopic colitis, although statistically not more frequently than placebo.Because many patients with microscopic colitis are older, the gamble of complications with high-dose steroids may be prohibitive. Results should be seen within 1 month, but diarrhea may recur as the steroid is tapered .11

• Schiller L.R.

Microscopic colitis syndrome lymphocytic colitis and collagenous colitis . other immunosuppressant drugs have been tried and reported in isolated shell reports.These include 6-mercaptopurine and azathioprine. Patients respond to low doses, but it may take respective months for any impression to be seen. These drugs could be considered when patients can not be weaned from corticosteroids .20

• Fine K.D.
• Lee E.L.

efficacy of open-label bismuth subsalicylate for the treatment of microscopic colitis .21

• Fine K.D.
• Ogunji F.
• Lee E.

Randomized, double-blind, placebo-controlled test of bismuth subsalicylate for microscopic colitis . Because of its anti-inflammatory and antibacterial effects, bismuth subsalicylate was tried in microscopic colitis syndrome. In one series, 90 % of patients had a clinical absolution, and 80 % had histological improvement.This effect was duplicated subsequently in a little control trial, suggesting that this agent has a real place in treatment.Most patients who will respond have had a clinical answer within 1 calendar month. It is recommended that responders continue treatment for an extra month to increase the find of a durable remittance. Because bismuth subsalicylate is cheap, well tolerated, and associated with a high reception rate, it is the initial therapy of choice for microscopic colitis .22

• Ung K.-.A
• Gillberg R.
• Kilander A.
• Abrahamsson H.

Role of bile acids and bile acerb binding agents in patients with collagenous colitis . Two agents have been subjected to larger controlled clinical trials : cholestyramine and budesonide. Cholestyramine was better than placebo at controlling diarrhea and inducing histological remittance in one european study.It was utilitarian not only in the subset of patients with bile acid malabsorption ( as defined by a radioisotope memory method acting ), but besides in patients without coexisting bile acid malabsorption, suggesting that the resin may have been binding some early intraluminal kernel that was causing the problem. Bile acid—binding resins are unmanageable to take regularly, so conformity may be an issue when these drugs are prescribed .23

• Baert F.
• Schmitt A.
• D’Haens G.
• Dedeurwaerdere F.
• Louis E.
• Cabooter M.
• De Vos M.
• Fontaine F.
• Naegels S.
• Schurmans P.
• Stals H.
• Geboes K.
• Rutgeerts P.

Budesonide in collagenous colitis a double-blind placebo-controlled trial with histological follow-up .24

• Miehlke S.
• Heymer P.
• Bethke B.
• Bastlein E.
• Meier E.
• Bartram H.P.
• Wilhelms G.
• Lehn N.
• Dorta G.
• DeLarive J.
• Tromm A.
• Bayerdorffer E.
• Stolte M.

Budesonide treatment for collagenous colitis a randomized, double-blind, placebo-controlled, multicenter trial .25

• Bonderup O.K.
• Hansen J.B.
• Birket-Smith L.
• Vestergaard V.
• Teglbjaerg P.S.
• Fallingborg J.

Budesonide treatment of collagenous colitis a randomized, double blind, placebo controlled trial with morphometric analysis.

26

• Chande N.
• McDonald J.W.
• MacDonald J.K.

Interventions for treating collagenous colitis . Budesonide is a corticosteroid that has a high hepatic first-pass metabolism, which efficaciously limits it to a topical effect in the intestine. It has been used locally for allergic rhinitis and for asthma, with a dependable condom record. Ingested budesonide can produce systemic corticosteroid side effects when used chronically, so the drug should be tapered equally soon as feasible. Individual studiesand a meta-analysisshow that budesonide is superior to placebo in inducing both clinical and histological remission in microscopic colitis. Of all the available treatments, it has the best attest basis for efficacy. In choosing therapy for an individual patient, the doctor must balance the peculiarities of a particular patient, the electric potential benefit and risks of a given drug, and the costs involved. In most patients with microscopic colitis, it makes sense to use opiate antidiarrheal drugs for their diagnostic benefit, to try bismuth subsalicylate for 1 month with an extra month of therapy for responders, and to reserve budesonide for those who do not respond to 1 calendar month of bismuth therapy. Cholestyramine and 5-aminosalicylates should be reserved for those who do not respond to budesonide or who relapse cursorily when it is tapered and withdrawn .

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