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June 2018, Volume 68, Issue 6

Letter to the Editor

Microscopic colitis: Diarrhoea or constipation

Umair Iqbal  ( Dow Medical College )
Hafsa Anwar  ( Jinnah Sindh Medical University, Karachi )

Madam, Microscopic colitis is a chronic inflammatory disease of the colon characterized by chronicwatery diarrhoea usually affecting middle-aged women. 1 The diagnosis is mostly made on biopsy, as colonoscopic appearance is usually normal. It has two well-defined types; lymphocytic colitis, characterized by intraepithelial lymphocytes, and collagenous colitis, characterized by the presence of sub-epithelial collagenous band > 10 mm in thickness. 2 Though diarrhoea is a presenting symptom in the majority of patients, multiple biopsy-proven cases of microscopic colitis have been reported in the literature in which constipation is the only symptom. 3-5 A study done on 32 patients with histologically proven collagenous colitis revealed the presence of chronic constipation in 18 individuals, all of whom responded (improvement in stool frequency) to budesonide, which is a first-line treatment of microscopic colitis. 4 This study also revealed increased prevalence of food allergies in patients with collagenous colitis, which explains the paradox of diarrhoea-constipation and response to steroids. Similar results were seen in a study done on 21 patients in whom chronic constipation was present in 3 patients. 5 Although it is unclear from both studies that whether they have diarrhoea in the past or has recently been treated with anti-diarrhoeal medications. A review of the literature also revealed patients with microscopic colitis can also be asymptomatic or present with Irritable bowel syndrome (IBS) -like symptoms with diarrhoea alternating with constipation. Studies show that symptomatic overlap of microscopic colitis and IBS can be present in as many as 56% of patients. 6,7 Biopsy is the only way to differentiate between the two entities, as biopsy is usually unremarkable in patients with IBS. We recently encountered a patient who during the workup for chronic constipation was found to have biopsy-proven lymphocytic colitis and was started on budesonide with improvement in symptoms. Although diarrhoea has been well-defined as the presenting symptom of microscopic colitis, in light of the above-mentioned evidence we can conclude that it can be presented with chronic constipation or IBS-like symptoms of diarrhoea alternating with constipation.

Disclaimer: None to declared.
Conflict of Interest: None to declared.
Funding Disclosure: None to declared.


1.  Veress B, Löfberg R, Bergman L. Microscopic colitis syndrome. Gut 1995; 36: 880-6.
2.  Giardiello FM, Lazenby AJ, Bayless TM, Levine EJ, Bias WB, Ladenson PW, et al. Lymphocytic (microscopic) colitis. Clinicopathologic study of 18 patients and comparison to collagenous colitis. Dig Dis Sci 1989; 34: 1730-8.
3.  Leigh C, Elahmady A, Mitros FA, Metcalf A, al-Jurf A. Collagenous colitis associated with chronic constipation. Am J Surg Pathol 1993; 17: 81-4.
4.  Barta Z, Toth L, Szabo GG, Szegedi G. Collagenous colitis: constipation or diarrhoea? Gut 2003; 52: 1230.
5.  Widgren S, Jlidi R, Cox JN. Collagenous colitis: histologic, morphometric, immunohistochemical and ultrastructural studies. Report of 21 cases. Virchows Arch A Pathol Anat Histopathol 1988; 413: 287-96.
6.  Fernández-Bañares F. How much symptom overlap is there between microscopic colitis and IBS? Nat Clin Pract Gastroenterol Hepatol 2007; 4: 304-5.
7.  Abboud R, Pardi DS, Tremaine WJ, Kammer PP, Sandborn WJ, Loftus EV. Symptomatic overlap between microscopic colitis and irritable bowel syndrome: a prospective study. Inflamm Bowel Dis 2013; 19: 550-3.

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