Microscopic colitis is a chronic inflammatory bowel condition that can significantly affect the quality of life. Due to its nonspecific symptoms and, in most cases, the macroscopically normal appearance of the colon, the condition may be underdiagnosed compared to the more classic subcategories of inflammatory bowel disease (IBD), ulcerative colitis and Crohn's disease. However, epidemiological studies show that the incidence of microscopic colitis has exceeded other types of IBD in some countries, especially among the elderly. Physicians should be familiar with the nuances of microscopic colitis and management strategies to appropriately address this underrecognized condition.
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What Is Microscopic Colitis?
Microscopic colitis is a chronic inflammatory condition of the colon that was first described in 1980. It has two clinically distinct forms: lymphocytic colitis and collagenous colitis. Both types are characterized by chronic, watery, and non-bloody diarrhea occurring most commonly in female, middle-aged patients. Histological variations distinguish the two subtypes. Lymphocytic colitis is characterized by lymphocytic (white blood cell) infiltration in colonic tissue. In contrast, the diagnostic feature of collagenous colitis is a colonic subepithelial collagen band greater than ten micrometers in thickness. Collagenous and lymphocytic colitis have estimated incidences of 2.0-10.8 and 2.3-16 per 100,000, respectively. (3, 6)
Symptoms of Microscopic Colitis
The hallmark symptom of microscopic colitis is non-bloody, watery diarrhea lasting longer than four weeks. Most patients experience four to nine watery stools daily, although severe cases can lead to 15 or more daily bowel movements. Fecal urgency, incontinence, and abdominal pain may accompany diarrhea. Collagenous colitis is often associated with more severe bowel inflammation, and lymphocytic colitis more commonly develops earlier in life. (3, 7)
Like other forms of IBD, extraintestinal symptoms such as weight loss, joint pain, arthritis, and uveitis (inflammation inside the eye) may occur. (3, 6)
What Causes Microscopic Colitis?
The exact cause of microscopic colitis remains unknown, but researchers believe a combination of factors may contribute to its development. Immune dysregulation is central to most theories surrounding the etiology and pathophysiology of the condition. Potential factors identified as contributory triggers to an inflammatory, autoimmune cellular response include genetic predisposition, medications, smoking, and altered intestinal epithelial barrier function. (3)
Nonsteroidal inflammatory drugs (NSAIDs) currently have the strongest link to causing flares in microscopic colitis. However, other drugs, including proton pump inhibitors (PPIs), statins, and selective serotonin reuptake inhibitors (SSRIs), have also been implicated as potential contributors to the condition. Concomitant use of PPIs and NSAIDs may increase risk even further. (7)
Functional Medicine Labs That Can Help Diagnose Microscopic Colitis
Endoscopic evaluation of the colon with mucosal biopsies is required for diagnosing microscopic colitis and distinguishing between its two subtypes. However, laboratory analysis is warranted before colonoscopy to rule out other common causes of chronic diarrhea.
Blood Work
A complete blood count (CBC) should be ordered to screen for infection and rule out anemia, which occurs in half of the patients with microscopic colitis. (7)
A comprehensive metabolic panel (CMP) should be ordered to monitor electrolytes and albumin, which can become unbalanced with chronic diarrhea.
Celiac disease should be on the differential diagnosis for patients with chronic diarrhea and other gastrointestinal symptoms. Patients with celiac disease are at a higher risk of developing microscopic colitis (3). Celiac serologies can help to rule out celiac disease.
Half of patients with microscopic colitis have an elevated erythrocyte sedimentation rate (ESR), a non-specific inflammatory marker. (7)
Stool Studies
Stool studies screening for gastrointestinal infections should include Clostridioides difficile toxin, routine stool cultures (Salmonella, Shigella, Campylobacter, and Yersinia), Escherichia coli O157:H7, ova and parasites, and Giardia stool antigen.
Increased levels of inflammatory markers, including calprotectin and eosinophil protein X (EPX), have been detected in stool from patients with intestinal pathologies, including microscopic colitis, other types of IBD, celiac disease, and colorectal cancer.
Functional Medicine Labs That Can Help Individualize Treatment for Microscopic Colitis
Functional medicine labs offer a range of diagnostic tests that provide valuable insight into the underlying factors of the condition to help healthcare providers individualize management strategies for microscopic colitis.
Comprehensive Stool Analysis
A comprehensive stool analysis measures valuable biomarkers regarding the gut microbiome and digestive health. This stool assessment can identify imbalances in commensal bacteria, pathogens, inflammation markers, and digestive secretions that influence the health and function of the gastrointestinal tract, immune dysregulation, and diarrhea severity.
Food Sensitivities
A food sensitivity panel aids in tailoring dietary modifications for patients with microscopic colitis. Identifying specific foods that may trigger an immune response or exacerbate symptoms can help guide nutritional interventions and reduce symptom severity. By identifying and eliminating trigger foods, patients may experience reduced inflammation, improved gut health, and better management of their microscopic colitis symptoms.
Autoimmune Panel
Microscopic colitis is believed to have an autoimmune component, and people with concomitant autoimmune conditions, including rheumatoid arthritis and type 1 diabetes, are at higher risk for developing microscopic colitis (3). Positive autoantibodies, including antinuclear and antimitochondrial antibodies, antineutrophilic cytoplasmic antibodies, anti-Saccharomyces cerevisiae antibodies, and antithyroid peroxidase antibodies, are found in about half of patients with microscopic colitis (6). An autoimmune panel can identify immune dysregulation and help doctors choose appropriate interventions to target and manage clinical manifestations of autoimmunity.
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Conventional Management for Microscopic Colitis
All patients with microscopic colitis should be advised to avoid NSAIDs and, if possible, to discontinue all medications associated with the condition. Patients who smoke should be counseled on smoking cessation. (6)
Per the American Gastroenterological Association (AGA) guidelines, an 8-week course of oral budesonide is the best-documented approach for achieving remission of microscopic colitis for patients with active symptoms, defined as at least three stools or at least one water stool daily. Second-line pharmacologic agents include prednisone, bismuth subsalicylate, mesalamine, and cholestyramine (1). Up to 80% of patients may experience a return of symptoms after cessation of initial budesonide treatment (6).
Pharmaceutical antidiarrheals, such as loperamide, can be used as needed for the symptomatic management of diarrhea, to be used alone in patients with mild diarrhea, or in conjunction with other therapies (1).
Surgical intervention is rarely required and reserved for those who are unresponsive to all other medical therapies (1).
Functional Medicine Management Protocol for Microscopic Colitis
A functional medicine management protocol focuses on addressing the root factors of the condition, supporting gut health, reducing inflammation, and promoting overall well-being. In alignment with conventional guidelines, the goal of management is to achieve remission of symptoms and improve the quality of life for the patient.
Therapeutic Diet and Nutrition Considerations for Microscopic Colitis
Diet can play both a contributory and supportive role in inflammatory bowel conditions. Therefore, a reasonable approach to therapeutic dietary intervention to achieve and maintain symptom remission is to propose a well-balanced, anti-inflammatory, and whole-foods diet, such as the Mediterranean diet, excluding identified food triggers. (18)
Elimination Diets
The autoimmune protocol (AIP) diet aims to remove known inflammatory foods, including grains, legumes, dairy, eggs, nuts, nightshades (except sweet potatoes), alcohol, sweeteners, refined sugars, refined oils, food additives, and processed foods. The protocol promotes eating quality meat, seafood, vegetables, fruit, high-quality fats, bone broth, and probiotic foods. (11)
The Paleo diet, on which the AIP diet is based, tries to adapt available modern foods to mimic as much as possible the hunter-gatherer diet. This means eliminating grains, dairy, legumes, refined sugar, and processed foods. The emphasis is on grass-fed animals, wild-caught fish, fruits, vegetables, nuts, and non-grain oils. (11)
The Specific Carbohydrate Diet (SCD) was designed in the 1920s by Dr. Sidney Haas to manage celiac disease symptoms in children. Since then, its principles have been extended to managing many gastrointestinal conditions. The purpose of the SCD is to remove difficult-to-digest carbohydrates from the diet to support intestinal health. Dietary guidelines propose eliminating grains, refined sugars, processed foods, starchy vegetables, and food additives. Instead, the SCD encourages the consumption of easily digestible carbohydrates, including non-starchy vegetables, fruits, nuts, seeds, and certain dairy products, along with protein from meat and eggs.
Each of these dietary plans may include problematic foods for those with microscopic colitis. Therefore, it is important to help the patient recognize individualized food triggers through observation or food sensitivity testing and modify the diet appropriately.
Fasting
Fasting allows the gut to rest by reducing the workload on the digestive system, giving it time to recover. By abstaining from food for 24-72 hours, fasting may be a method to support remission of a microscopic colitis flare. (3)
Supplements Protocol for Microscopic Colitis
Depending on the severity of the condition, a supplemental protocol can be used independently or in conjunction with conventional pharmacologic therapy to support symptom remission and manage symptoms. Supplements should be used to address underlying factors contributing to immune dysregulation and gastrointestinal inflammation. The below sample protocol is purposed to support inflammation management and restore the integrity of the intestinal barrier.
Boswellia serrata
Boswellic acid, the active ingredient derived from the gum resin on Boswellia plants, has been used traditionally for its properties in supporting inflammation management. A small study suggested that Boswellia serrata extract may increase the clinical remission rate in patients with collagenous colitis.
Dose: 400 mg (80% boswellic acid) three times daily
Duration: 6 weeks
Curcumin
Curcumin is the constituent of turmeric (Curcuma longa) that has been studied for its potential to support inflammation management. Many clinical trials have explored curcumin's role in supporting IBD symptom management. Several studies have demonstrated its safety in large doses, up to 8,000 mg daily, for up to three months.
Dose: 1 gram twice daily
Duration: six months
VSL#3
A 2018 systematic review and meta-analysis suggested that probiotics may assist in supporting remission of IBD, given their potential to help balance gut bacteria. VSL#3 is a high-potency probiotic that has been studied for its potential role in supporting IBD management, including microscopic colitis.
Dose: 900 billion CFU daily
Duration: 8 weeks
Serum-Derived Bovine Immunoglobulin (SBI)
Immunoglobulins, or antibodies, may help modulate the immune response in the gut, support inflammation management, and combat pathogens in the gastrointestinal tract. Research suggests that therapy with 5-10 grams of SBI daily may provide benefits in managing gastrointestinal symptoms and could be considered as nutritional support for patients with IBD who are not fully managed on traditional therapies. (17, 22)
Dose: 2.5 grams twice daily (up to 10 grams daily)
Duration: 4-6 weeks
When to Retest Labs
Improvement in clinical outcomes can be noted in as soon as four weeks with an effective management protocol. Monitoring patient response to management is usually performed by tracking inflammatory markers and symptom improvement at this time. Additional labs may be ordered as needed to monitor for signs of dehydration and infection. Functional medicine labs, generally less likely to be covered by insurance, are often reordered between 6-12 months after management initiation for financial reasons, but may be repeated sooner based on clinical necessity.
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Summary
A functional medicine protocol for managing microscopic colitis takes a comprehensive and personalized approach to address the underlying factors, support gut health, and reduce inflammation. By implementing a customized diet that eliminates trigger foods, supporting the gut microbiome, and incorporating appropriate supplements, individuals with microscopic colitis may experience improved symptom management and a better quality of life.
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