Collagenous colitis: a rare cause of chronic diarrhea: A case report : Medicine: Case Reports and Study Protocols
Get new issue alertsGet alerts
Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy.
Subscribe to eTOC
Secondary Logo
All Articles Images Videos Podcasts Blogs
Criteria for Acceptance
Pre-Submission Checklist
MCRSP FAQs
CME for Reviewers
Peer Review Training
September 2021 - Volume 2 - Issue 9
Article as EPUB
Export All Images to PowerPoint File
Colleague's E-mail is Invalid
Separate multiple e-mails with a (;).
Thought you might appreciate this item(s) I saw in Medicine: Case Reports and Study Protocols.
Your message has been successfully sent to your colleague.
Some error has occurred while processing your request. Please try after some time.
Clinical Case Report
Collagenous colitis: a rare cause of chronic diarrhea
A case report
Wu, Ping-Ju MDa,b; Lin, Chien-Chieh MDa; Wang, Jiunn-Wei MDb,c,d,∗
aDepartment of Internal medicine
bDivision of Gastroenterology, Department of Internal medicine, Kaohsiung Medical University Hospital
cDepartment of Medicine
dGraduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
∗Correspondence: Jiunn-Wei Wang, Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, 100 Tz-You 1st Road, Kaohsiung 807, Taiwan (e-mail: [email protected]).
Abbreviation: Fig. = Figure.
How to cite this article: Wu PJ, Lin CC, Wang JW. Collagenous colitis: a rare cause of chronic diarrhea: a case report. Med Case Rep Study Protoc. 2021;2:9(e0154).
P-JW and C-CL contributed equally.
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
The authors have no conflicts of interest to disclose.
All data generated or analyzed during this study are included in this published article.
This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0
Medicine Case Reports and Study Protocols 2(9):p e0154, September 2021. | DOI: 10.1097/MD9.0000000000000154
Collagenous colitis is a chronic inflammatory disease of the colon with a peak incidence in middle-aged adults. It is characterized by chronic diarrhea and pain from abdominal cramping, with near normal mucosa morphology under gross colonic examination by colonoscopy. Currently, the pathogenesis remains unclear but there is speculation of an association with abnormal collagen metabolism, contributing to prominent sub-epithelial matrix deposition.
Patient concerns:
A 51-year-old male patient without any underlying disease presented after experiencing watery light brown diarrhea 4–5 times per day for the past 2 months.
The diagnosis of collagenous colitis was confirmed by the pathological examination of the second colonic biopsy, which reported positive Masson's trichrome staining.
The patient was initially diagnosed with unspecified functional bowel disorder, but showed no clinical improvement after treatment with oral medication. Mesalamine therapy was administered after collagenous colitis was diagnosed by follow-up colonoscopy.
Normal bowel movement was restored in the patient after 2 weeks of mesalamine therapy.
Collagenous colitis is a rare etiology of chronic diarrhea, which can only be diagnosed by pathology of colonic mucosa. Consequently, repeat colonoscopy with multiple stepwise random colonic biopsies at suspicious lesion sites or even normal-appearing mucosa should be considered in refractory chronic diarrhea patients without established diagnoses.
Collagenous colitis, a subtype of microscopic colitis, is a chronic inflammatory disease of the colon and is associated with abnormal collagen metabolism and inflammation of the colon.[1] Colonoscopic and radiographic examinations of collagenous colitis are usually normal, hence a colonic biopsy is required to make a definite diagnosis.[2] Microscopic colitis has been linked to smoking as a risk factor, and it is thought to be related to some pharmaceutical exposure, such as nonsteroidal anti-inflammatory drugs, proton pump inhibitors, and selective serotonin reuptake inhibitors.[3] The epidemiology of collagenous colitis is only 2.0 to 10.8 per 100,000 persons and is estimated to be higher in northern Europe and America.[4] However, cases are relatively rare in eastern countries, including Taiwan.
We report the case of a 51-year-old man with no known underlying disease, who had watery diarrhea for 2 months before presenting to our clinic. He was initially diagnosed with unspecified functional bowel disorder, but further analysis at follow-up revealed collagenous colitis.
2 Case report
A 51-year-old man with no known underlying disease visited our clinic for treatment of diarrhea that had been ongoing for 2 months. The stool was light brown and watery, and bowel movement occurred 4 to 5 times per day. Diarrhea was exacerbated especially after meals. The patient did not report abdominal pain, or bloody or tarry stools. He also did not report any history of relevant travel, occupational risks, contact with other individuals, or any allergy to medication or food that may have explained his symptoms. Prior to these symptoms, he had regular stool movements once to twice per day with normal stool shape and characteristics. The patient did not report alcohol or betel nut consumption but had smoked one pack of cigarettes per day for 30 years up until 3 months prior. He also took Chinese herbal medicines to maintain liver function. Family history revealed no malignancies or significant gastrointestinal tract disorders.
Initially, esophagogastroduodenoscopy and colonoscopy were performed. We observed reflux esophagitis, chronic gastritis with Helicobacter pylori infection, terminal ileum ulcers, and patchy dark blue pigmentation of the colonic mucosa (Fig. 1) with non-specific chronic inflammatory infiltration and bacterial clump identified by histologic examination. We first treated the Helicobacter pylori infection and subsequently the unspecified functional bowel disorder by medication, diet education, and lifestyle modification. Regular follow-up appointments were scheduled after this initial treatment. After the 6-month follow-up visit, the patient responded poorly to our treatment. He reported the persistence of diarrhea, leading to disturbed sleep quality. Blood tests, including infection parameters and autoimmune profiles, revealed nearly normal results, except for slightly elevated serum immunoglobulin A levels. Stool examination showed no specific findings and was negative for parasitic infections. Abdominal computed tomography revealed no significant abnormalities. Therefore, we suggested that the patient stop the consumption of the Chinese herbal medicine. A second colonoscopy was performed after 10 months of treatment.
Findings of colonoscopy (A) Round ulcerations with regular margins and peripheral erythema over the terminal ileum. (B) Uneven distribution of dark blue pigmentation over all the colon segments.
In this follow-up colonoscopy, terminal ileum ulcers and patchy pigmentation of the colonic mucosa were still present. Eleven random mucosal specimens were collected from the terminal ileum and all colon segments in this colonoscopy examination. Pathological examination of the colonic biopsy revealed that the colonic mucosa had preserved crypt architecture, lymphocyte and eosinophil infiltration in the lamina propria and a thickened layer of subepithelial collagen, which was positive for Masson's trichrome staining, leading to the diagnosis of collagenous colitis (Fig. 2). Based on this diagnosis, we not only discontinued all anti-diarrheal medicines and administered mesalamine 1600 mg twice daily, but also encouraged him to quit smoking. The patient recovered to normal bowel movements after two weeks of treatment adjustment, and no more recurrent diarrhea was noted under mesalamine use in one-year outpatient follow-up.
Histopathological and immunohistochemical findings of colonic biopsy (A) Histopathology: Preserved pattern of crypt architecture and thickened subepithelial collagen band. The surface epithelium was denuded, and lymphocyte and eosinophils had infiltrated the lamina propria. (B) Immunohistochemistry: Positive staining with Masson's Trichrome stain highlights the thickened and irregular collagen band in blue in the lamina propria.
The clinical manifestation of collagenous colitis is characterized by chronic, watery, and non-bloody diarrhea.[5] Pathogenesis could be associated with abnormal collagen metabolism, which causes increased production of nitric oxide in the colonic epithelium, inducing secretory diarrhea.[6] This typically occurs in middle-aged patients, and although it is three times more prevalent in females than in males,[7] our case study is of a male patient. Generally, the colonic mucosa appears normal or almost normal in the colonoscopy examination of patients with collagenous colitis.[8] The first colonic biopsy did not identify the subepithelial collagen deposition lesions. This could be attributed to the patchy distribution of histological changes associated with the lesions,[8] and the differences in clinical judgement between pathologists. Moreover, the clinical manifestations of unspecified functional bowel disorders and collagenous colitis can be easily confused. Both conditions can present with chronic diarrhea, abdominal pain, and bloating. Therefore, tissue examination is exceptionally important for identification. However, the challenge facing endoscopists in the diagnosis of collagenous colitis is the absence of macroscopic features on colonoscopy. To improve diagnostic sensitivity, we took multiple random biopsies throughout the colon to obtain more specimen in the follow-up colonoscopy. This method is proven to be able to enhance diagnostic accuracy according to the American Society for Gastrointestinal Endoscopy recommendations.[9] Some autoimmune diseases, such as celiac disease, autoimmune thyroid disease, and Sjögren's syndrome, could also be concomitant with collagenous colitis.[10] In our patient, no parenteral symptoms, such as fatigue, itchy rashes, ataxia, arthralgia, tachycardia and perspiration which might be seen in collagenous colitis patients,[3] were observed, other than abnormal levels of serum immunoglobulin A, which has no diagnostic relevance to autoimmune diseases and collagenous colitis.[11] It is worth noting that cigarette smoking is a well-known contributing factor for the pathogenesis of the disease, which can exacerbate watery diarrhea, and decrease the likelihood of achieving clinical remission.[12,13] Therefore, the cessation of cigarette smoking accompanied with lifestyle modifications can be extremely beneficial for the clinical course of disease.
Finally, in patients with symptomatic microscopic colitis, the American Gastroenterological Association recommends treatment with budesonide over mesalamine to induce clinical remission.[14] We chose mesalamine instead of budesonide as the first-line treatment because the payment policy of the Taiwan National Health Insurance Administration regulates budesonide use only after mesalamine failure.
In conclusion, collagenous colitis is a rare etiology of chronic diarrhea, which can only be diagnosed by pathology of colonic mucosa. Consequently, repeat colonoscopy with multiple stepwise random colonic biopsies at suspicious lesion sites or even normal-appearing mucosa should be considered in refractory chronic diarrhea patients without established diagnoses.
The authors thank the patient described for allowing us to share his details, and also thank Department of Pathology of Kaohsiung Medical University Hospital to provide the pathology images of the patient.
Jiunn-Wei Wang was involved with patient assessment, examination, medication prescription, and follow-up. Ping-Ju Wu, Chien-Chieh Lin and Jiunn-Wei Wang reviewed the available literatures. Ping-Ju Wu and Chien-Chieh Lin drafted the manuscript. Jiunn-Wei Wang made corrections to the drafted manuscript. All authors have read and approved the manuscript.
[1]. Boland K, Nguyen GC. Microscopic colitis: a review of collagenous and lymphocytic colitis. Gastroenterol Hepatol (N Y) 2017;13:671–7.
Cited Here
[2]. Lazenby AJ, Yardley JH, Giardiello FM, et al. Pitfalls in the diagnosis of collagenous colitis: experience with 75 cases from a registry of collagenous colitis at the Johns Hopkins Hospital. Hum Pathol 1990;21:905–10.
Cited Here |
PubMed | CrossRef
[3]. Park T, Cave D, Marshall C. Microscopic colitis: a review of etiology, treatment and refractory disease. World J Gastroenterol 2015;21:8804–10.
[4]. Fernández-Bañares F, Salas A, Forné M, et al. Incidence of collagenous and lymphocytic colitis: a 5-year population-based study. Am J Gastroenterol 1999;94:418–23.
[5]. Pardi DS. Diagnosis and management of microscopic colitis. Am J Gastroenterol 2017;112:78–85.
View Full Text | PubMed | CrossRef
[6]. Andresen L, J⊘rgensen VL, Perner A, et al. Activation of nuclear factor kappaB in colonic mucosa from patients with collagenous and ulcerative colitis. Gut 2005;54:503–9.
[7]. Tong J, Zheng Q, Zhang C, et al. Incidence, prevalence, and temporal trends of microscopic colitis: a systematic review and meta-analysis. Am J Gastroenterol 110:265–76.
[8]. Shor J, Churrango G, Hosseini N, et al. Management of microscopic colitis: challenges and solutions. Clin Exp Gastroenterol 2019;12:111–20.
[9]. Sharaf RN, Shergill AK, et al. ASGE., Standards of Practice Committee. Endoscopic mucosal tissue sampling. Gastrointest Endosc 2013;78:216–24.
[10]. Vigren L, Tysk C, Ström M, et al. Celiac disease and other autoimmune diseases in patients with collagenous colitis. Scand J Gastroenterol 2013;48:944–50.
[11]. Holstein A, Burmeister J, Plaschke A, et al. Autoantibody profiles in microscopic colitis. J Gastroenterol Hepatol 2006;21:1016–20.
[12]. Burke KE, Ananthakrishnan AN, Lochhead P, et al. Smoking is associated with an increased risk of microscopic colitis: results from two large prospective cohort studies of US women. J Crohns Colitis 2018;12:559–67.
[13]. Münch A, Tysk C, Bohr J, et al. Smoking status influences clinical outcome in collagenous colitis. J Crohns Colitis 2016;10:449–54.
[14]. Nguyen GC, Smalley WE, Vege SS, et al. Clinical Guidelines Committee. American gastroenterological association institute guideline on the medical management of microscopic colitis. Gastroenterology 2016;150:242–6.
case report; chronic diarrhea; collagenous colitis; inflammatory bowel disease; microscopic colitis
Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.
View full article text
Collagenous colitis: a rare cause of chronic diarrhea: A case report
Medicine: Case Reports and Study Protocols2(9):e0154, September 2021.
+ Favorites
Keyword Highlighting
Highlight selected keywords in the article text.
collagenous colitis
microscopic colitis
Search for Similar Articles
You may search for similar articles that contain these same keywords or you may modify the keyword list to augment your search.
case report\r, chronic diarrhea\r, collagenous colitis\r, inflammatory bowel disease\r, microscopic colitis
Articles in PubMed by Ping-Ju Wu, MD
Articles in Google Scholar by Ping-Ju Wu, MD
Other articles in this journal by Ping-Ju Wu, MD
Data is temporarily unavailable. Please try again soon.
Never Miss an Issue
Get new journal Tables of Contents sent right to your email inbox
Get New Issue Alerts
Browse Journal Content
Register on the website
Get eTOC Alerts
800-638-3030 (within the USA)
301-223-2300 (outside of the USA)
Privacy Policy (Updated December 15, 2022)
Wolters Kluwer Health, Inc. and/or its subsidiaries. All rights reserved.