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Microscopic colitis

Abstract

Microscopic colitis (MC) is an inflammatory disease of the large intestine associated with urgent watery diarrhoea. MC may occur in people of all ages, although the disease primarily affects older women. Once believed to be rare, MC is now known to be a common cause of chronic watery diarrhoea in high-income countries, affecting 1 in 115 women and 1 in 286 men during their lifetime in Swedish population-based estimates. An inappropriate immune response to disturbances in the gut microenvironment is implicated in the pathogenesis of MC. Evidence also supports an underlying genetic basis for disease. The diagnosis of MC relies on clinical symptoms and microscopic assessment of colonic biopsy samples. MC is categorized histologically into collagenous colitis, lymphocytic colitis and their incomplete forms. The mainstay of treatment includes the use of budesonide, with or without adjunctive therapies, and withdrawal of offending drugs. Emerging studies suggest a role for biologicals and immunosuppressive therapies for the management of budesonide-refractory or budesonide-dependent disease. MC can have a substantial negative effect on patient quality of life. The outlook for MC includes a better understanding of the immune response, genetics and the microbiome in disease pathogenesis along with progress in disease management through robust clinical trials.

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Fig. 1: Incidence of collagenous colitis and lymphocytic colitis.
Fig. 2: Incidence of microscopic colitis by age and sex.
Fig. 3: Pathogenesis of MC.
Fig. 4: Histological criteria for MC.
Fig. 5: Management algorithm for MC.

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Acknowledgements

H.K. acknowledges the funding from an American College of Gastroenterology Clinical Research Award and J.F.L. and H.K. acknowledge the National Institutes of Health for funding their research NIA R01 (AG068390).

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Authors

Contributions

Introduction (K.E.B., D.S.P. and H.K.); Epidemiology (K.E.B., J.F.L., D.S.P. and H.K.); Mechanisms/pathophysiology (K.E.B., S.C.N. and H.K.); Genetics (K.E.B. and M.D.); Diagnosis, screening and prevention (K.E.B., D.S.P. and H.K.); Management (K.E.B. and D.S.P.); Quality of life (K.E.B. and H.K.); Outlook (K.E.B., J.F.L., M.D. and H.K.); Overview of the Primer (H.K.).

Corresponding authors

Correspondence to Kristin E. Burke or Hamed Khalili.

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Competing interests

D.S.P. reports grant funding from Pfizer, Vedanta, Seres, Finch, Applied Molecular Transport and Takeda. J.F.L. coordinates a study on behalf of the Swedish IBD quality register (SWIBREG). This study has received funding from Janssen corporation. H.K. reports grant funding from Takeda and Pfizer and serves as a consultant to Takeda. All other authors declare no competing interests.

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Nature Reviews Disease Primers thanks Nilesh Chande, Taku Kobayashi, Stephan Miehlke, Lars Kristian Munck, Ole Nielsen and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Burke, K.E., D’Amato, M., Ng, S.C. et al. Microscopic colitis. Nat Rev Dis Primers 7, 39 (2021). https://doi.org/10.1038/s41572-021-00273-2

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