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  Gluten Sensitivity and
    Celiac Sprue

  Microscopic Colitis

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• Overview of MC

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Frequently Asked Questions about
Microscopic Colitis

What is microscopic colitis?

What is the difference between MC, CC, and LC?

What is the cause of microscopic colitis?

Why does microscopic colitis mainly affect women?

What is known about treatment of microscopic colitis?

Can microscopic colitis be associated with symptoms other than diarrhea or abdominal pain?

How are microscopic colitis and gluten sensitivity (or celiac sprue) related?

What is microscopic colitis?
Microscopic colitis is an inflammatory disease of the colon that causes chronic diarrhea and sometimes abdominal pain. Because the majority of the inflammation can only be visualized using a microscope of biopsies, it is called "microscopic". Although originally the colon seen at colonoscopy was thought to be normal, it is routine to notice patchy areas of mild redness and swelling. In fact, I (Dr. Fine) can routinely tell by looking at the surface of the colon with a scope if it is going to be inflamed or not (because of experience). I say this because sometimes, visualization of these changes leads to an errant diagnosis of ulcerative colitis, Crohn's disease, or other forms of colitis. The latest finding I have become familiar with (although I have never experienced because I perform flexible sigmoidoscopies rather than the more risky colonoscopy) is a splitting of the surface of the colon resulting from air insufflation during the time of colonoscopy. This complication appears as a linear tear without surrounding inflammation characteristic of an ulcer. It is usually seen when there is collagen associated with the microscopic colitis (usually called collagenous colitis).

What is the difference between the terms microscopic colitis, collagenous colitis, and lymphocytic colitis?
These are three terms used to describe essentially the same syndrome. Microscopic colitis is the most general term and the one I prefer. Collagenous colitis is used when collagen (a pink protein seen on a biopsy of the colon) is present, and some people use the term lymphocytic colitis when there is no excess collagen because there are lymphocytes seen in the tissue. However, lymphocytes are seen in collagenous colitis as well, making lymphocytic colitis an inaccurate term. There is no evidence that these different forms result from a different cause, I have recently found that the causative genes are the same, they are both associated with gluten sensitivity (see below), and they both respond equally to treatment.

What is the cause of Microscopic Colitis?
Extensive data from animals (mainly rodents) suggest that any form of colitis is the result of the body's immune system setting up an unusual attack on the bacteria living in the colon. What makes the body suddenly recognize these bacteria as harmful and worthy of this attack is not fully understood but there are several clues based on my research. First, it is known that aspirin and other non-steroidal antiinflammatory drugs (NSAID's) can cause this reaction. Also, if the balance of less immune stimulating bacteria (we will call "good bacteria") and more immunostimulatory bacteria ("bad bacteria") favors the latter, inflammation can result. This can occur from use of antibiotics and probably from chronic consumption of certain foods that favor growth of bad bacteria. The role of yeast (for example Candida) in this process is unstudied and therefore unknown. However, whatever tips the scale toward this reaction, it appears that there is an underlying gene responsible for the predisposition to have this form of colitis. In fact, my recent studies have revealed in most cases, the gene is the same as the one known to cause celiac sprue and gluten sensitivity (explaining why some patients get both syndromes). Furthermore, it appears that colitis can cause the immune system to begin recognizing gluten as immunostimulatory and vice versa, gluten sensitivity can lead to colitis.

Why does microscopic colitis mainly affect women?
Although not totally understood, microscopic colitis appears to be in the family of autoimmune syndromes, all of which are more common in women. It is likely that the proinfllammatory effects of estrogen are responsible for this predisposition. For this reason, I have theorized the one of the reasons microscopic colitis is becoming more common (which I believe to be true) and that it doesn't affect women until later in life is that the use of high dose estrogens (and NSAID's) has become more common.

How should Microscopic Colitis be treated?
I have studied the use of Pepto Bismol (Procter and Gamble) for the last 6 years and have achieved good results and learned a lot about the syndrome from these studies. However, although Pepto Bismol will relieve diarrhea in 90% and resolve the colitis on biopsies in about 80%, 20-30% experience relapses after they stop the medicine, and 10% do not respond initially. It has now become clear from extensive further research over the last 3-4 years that these relapses, and in the less common instances when there is no intitial response, have been shown by my new sensitive stool testing to be caused by coexisting immunologic sensitivity to gluten in the diet, that is to a protein found in wheat, barley, rye, and oats. Although not the cause of the colitis, per se, the reaction to gluten by the immune system can perpetuate or reactivate the colonic inflammation. Because of this chance of relapse, and because Pepto Bismol is still a drug with at least the potential (albeit rare chance) for side effects or reactions to the dyes, etc., I recommend testing for gluten sensitivity and a gluten-free diet as the first line of treatment for microscopic colitis. This appraoch has brought more relief to the sufferers of colitis than any other form of treatment to date. It must be stressed that because the reaction to gluten by microscopic colitis patients is usually not fully developed celiac disease, blood tests for antibodies to gliadin and tissue transglutaminase (the diagnositc tests for gluten sensitivity) are routinely negative. This is why and how I discovered that these antibodies must be looked for at the anatomic site of their production: inside the intestine, which for a diagnostic test, is in the stool. These tests are now available from EnteroLab for this purpose. This is discussed further below.

Because it seems clear that the colitis stems from the organisms living in the colon, my latest studies have implemented steps at trying to rid the colon of these immunogenic strains of bacteria, replacing them with the good bacteria mentioned above. In general, good bacteria in this context refers to Lactobacillus species. The best way to impart this favorable effect on the bacteria of the colon is by dietary manipulation and supplementing with a Lactobacillus supplement.

Whatever treatment is used, it seems clear that use of any NSAID including aspirin may prevent successful treatment or cause relapses following treatment.

Can microscopic colitis be associated with symptoms other than diarrhea or abdominal pain?
Because microscopic colitis is a chronic inflammatory syndrome associated with production by the immune system of chemical mediators that circulate in the blood, patients with microscopic colitis often experience fatigue, joint pains, muscle aches and fibromyalgia, and even fever is possible. Because the genes involved also predispose to other autoimmune syndromes, such diseases (like arthritis, thyroid disease, etc.) do occur in patients with microscopic colitis. If gluten sensitivity is present, many additional abdominal and other symptoms may be present.

How are microscopic colitis and gluten sensitivity (or celiac sprue) related?
I have shown in a previous study that the most common cause of diarrhea in patients with celiac sprue treated with a gluten-free diet for many years is microscopic colitis. Other individuals are found at the time of diagnosis to have both of these syndromes. this realtes to the fact that the same immune system regulatory genes, called HLA, are involved in producing both syndromes, as well as many other autoimmune syndromes. The celiac sprue diagnosed in patients found to have microscopic colitis is usually of a mild variety, and appears to me to be the result of the colitis itself. This occurs because the genes causing microscopic colitis are also programmed to react with gluten if they are triggered to do so. This is why people can go their whole lives withjout apparent gluten sensitivity and then suddenly become gluten intolerant. Thus, testing for the presence of gluten sensitivity in patients with microscopic colitis, sometimes combined with assessment for the presence of the gluten-sensitive gene, is necessary in many if not all such patients. Unfortunately, as mentioned above, the currently most widely used test for this is a blood test that rarely if ever detects gluten sensitivity in patients with microscopic colitis (because it was designed for patients with full blown celiac sprue). However, my new stool test, which is being offered by EnteroLab, can detect this. The gene test for gluten sensitivity and microscopic colitis is offered as well.

For more educational information on gluten sensitivity and celiac sprue, click here.

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The Health and Nutritional information contained in this Website is based on scientific facts, medical research, and the personal and professional experiences of Dr. Kenneth D. Fine. It is provided as a free public service. It does not constitute medical diagnosis or treatment, and should not be construed or used as such.

Frequently Asked Questions about Microscopic Colitis

Frequently Asked Questions about
Microscopic Colitis