Collagenous colitis / Lymphocytic colitis
These are disorders associated with chronic watery diarrhea. The two disorders are related but have different microscopic appearances. These disorders are not related to Crohn’s disease or Ulcerative colitis. Unlike in Crohn’s and Ulcerative Colitis, the colonoscopy is typically normal. Biopsies of the colon, however, show increased numbers of chronic inflammatory cells and a pink staining stripe that looks like a collagen band in the case of collagenous colitis.
There are several theories regarding the origin of these disorders and there is some evidence to support each. Medications have been associated with the onset of these disorders. Strong associations exist between collagenous colitis/lymphocytic colitis and the following:
- NSAIDS – This is a group of medications typically used to treat arthritis, headaches and body aches including Aspirin, Ibuprofen (Motrin, Advil), Naproxen (Alleve), Diclofenac (Voltaren), and many others.
- Acid inhibitors of the Proton pump inhibitor class including Protonix, Nexium, Aciphex, Dexilant Prevacid, Prilosec (generics Omeprazole, lansoprazole)
- Acarbose, Zantac, Sertraline and Ticlopidine may also be associated. Weaker associations have been described for Tegretol (carbamazepine), Flutamide, Paxil (paroxetine), and Zocor (simvastatin).
Theories regarding abnormal collagen metabolism and bacterial toxins have also been proposed.
The approach to these disorders is to address correctable factors. Many cases of collagenous colitis respond to elimination of an offending medication. This may require substitution of an alternative medication to address the problems that the offending medication is controlling. Do not stop medications without discussing the risks and benefits with your physician. We are seeing many cases associated with the treatment of reflux/GERD using Proton pump inhibitors. Similarly, NSAID and aspirin discontinuation has resulted in the cessation of diarrhea in many cases of Collagenous colitis/ Lymphocytic colitis in our practice.
Anti diarrheal agents like Imodium and loperamide (Lomotil) typically have not worked in the patient’s that have come to my attention.
Budesonide, (Entocort), and prednisone work well for controlling symptoms but the significant side effect profiles associated with steroids should be considered carefully. I typically reserve these medications for those who respond to nothing else. The lowest effective dose to control symptoms is typically my goal in this treatment.
Bile acid binding resins are used to control elevated cholesterol. The potent constipating side effect is helpful in controlling symptoms of diarrhea. Some examples are Welchol, Questran, and Colestid. They vary in cost, with Colestid being the least expensive.
Mesalamine and Bismuth Subsalicylate have also been used in some settings.