Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
Intended for Healthcare Professionals
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
  • Subscribe BJGP on YouTube
British Journal of General Practice
Intended for Healthcare Professionals

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
Clinical Practice

Microscopic colitis: a guide for general practice

Kevin Barrett
British Journal of General Practice 2021; 71 (702): 41-42. DOI: https://doi.org/10.3399/bjgp21X714593
Kevin Barrett
New Road Surgery, Rickmansworth.
Roles: GP partner and chair of the Primary Care Society for Gastroenterology
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info
  • eLetters
  • PDF
Loading

INTRODUCTION

Irritable bowel syndrome (IBS) affects 10%–20% of the population1 but other conditions have similar symptoms. Microscopic colitis is a cause of chronic, non-bloody, watery diarrhoea, particularly in older patients in whom the impact on quality of life can be significant. Microscopic colitis affects 0.12% of the population but 12.80% of those with unexplained chronic, watery diarrhoea. The median age at diagnosis is 60,2 reflecting an older population than those typically diagnosed with other types of inflammatory bowel disease. Risk factors include smoking and long-term use of proton-pump inhibitors, non-steroidal anti-inflammatory drugs, and selective serotonin reuptake inhibitors, although a causal relationship has not been established.2

DIAGNOSIS IS DEPENDENT ON HISTOLOGICAL FINDINGS

The most common symptom in microscopic colitis is chronic, non-bloody, watery, diarrhoea, frequently associated with faecal urgency, the passage of stools at night, and faecal incontinence. Cramping abdominal pain may be present. These symptoms can be severe enough to make patients effectively housebound. Patients may be diagnosed with diarrhoea-predominant IBS but the symptoms do not respond to the standard therapies recommended by the National Institute for Health and Care Excellence (NICE).1 The diagnosis depends on characteristic histological findings. Patients may be referred to an urgent cancer pathway; colonoscopic findings are typically normal, but 4.77% of patients with normal colonoscopy findings have microscopic colitis confirmed on histology from biopsies.3

INVESTIGATION AND TREATMENT

Microscopic colitis cannot be diagnosed in primary care. A number of straightforward investigations are required in line with NICE.1 It is important to consider red-flag symptoms that may indicate an underlying colorectal or ovarian cancer and refer or investigate, respectively. Patients may be referred to a suspected colorectal cancer pathway, receive a colonoscopy without biopsies or a CT colonoscopy, and be discharged back to primary care without a diagnosis (Figure 1).

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

Investigation of patients with lower gastrointestinal symptoms.a

aSection highlighted in yellow shows where patients with microscopic colitis may be overlooked.5 Copyright © National Institute for Health and Care Excellence. CRP = C-reactive protein. FBC = full blood count. IBD = inflammatory bowel disease. IBS = irritable bowel syndrome. MCS = microscopy, culture, and sensitivity. TFT = thyroid function test. U&E = urea and electrolytes.

Inflammatory causes should be excluded with a full blood count and a C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) test, and coeliac disease with a serology test (assuming the patient has been consuming gluten daily for at least 6 weeks).1 Coeliac disease is present in 3%–4% of patients with microscopic colitis,2 reflecting an overlap with other autoimmune conditions. NICE states that the following tests are not necessary to confirm a diagnosis of IBS in adults: ultrasound, rigid/flexible sigmoidoscopy, colonoscopy, barium enema, thyroid function test, faecal ova and parasite test, faecal occult blood, and hydrogen breath test (for lactose intolerance and bacterial overgrowth).1

A faecal calprotectin test can be a useful additional test in adults with normal investigations but whose symptoms persist. If a faecal calprotectin is <100 μg/g then IBS is the likely diagnosis in 98% of this group of patients. If the patient is aged ≥50 years and the symptoms still persist after a trial of the usual initial therapies for IBS, a routine referral to gastroenterology is recommended for consideration of colonoscopy with biopsies or the exclusion of other pathologies such as bile acid diarrhoea.4

The initial treatment for most patients with microscopic colitis is oral budesonide at a dose of 9 mg/day for a period of 6–8 weeks; 81%–84% of patients respond successfully to treatment compared with 36%–43% given a placebo. Patients may enter and stay in remission at this point; however, some studies have shown that patients may need long-term budesonide (for at least 6 months) at 3 mg or 6 mg/day but this should be titrated according to clinical response.

Prednisolone, loperamide, bismuth, mesalazine, antibiotics, or probiotics are not recommended treatments. Thiopurines or biologics may be used to treat patients who do not respond to budesonide. A summary of the information on microscopic colitis is shown in Box 1.

  • Microscopic colitis is a subset of inflammatory bowel disease.

  • Patients typically have profuse watery diarrhoea, often with urgency, incontinence, and nocturnal symptoms.

  • Primary care investigations are usually normal.

  • The bowel mucosa usually appears normal, and biopsies are needed for a histological diagnosis.

  • Treatment is with oral budesonide 9 mg/day for an initial period of 6–8 weeks.

Box 1.

Summary

Notes

Provenance

Freely submitted; externally peer reviewed.

Competing interests

Kevin Barrett has received honoraria for speaking at and attending events organised by Thermo Fisher Scientific, Tillotts, Dr Falk, Ferring, Bimuno, and Norgine.

Discuss this article

Contribute and read comments about this article: bjgp.org/letters

  • Received October 16, 2020.
  • Revision requested November 1, 2020.
  • Accepted November 9, 2020.
  • © British Journal of General Practice 2021

REFERENCES

  1. 1.↵
    1. National Institute for Health and Care Excellence
    (2017) Irritable bowel syndrome in adults: diagnosis and management, CG61, https://www.nice.org.uk/Guidance/CG61 (accessed 8 Dec 2020).
  2. 2.↵
    1. Miehlke S,
    2. Guagnozzi D,
    3. Zabana Y,
    4. et al.
    (2020) European guidelines on microscopic colitis: United European Gastroenterology (UEG) and European Microscopic Colitis Group (EMCG) statements and recommendations. United European Gastroenterol J doi:10.1177/2050640620951905.
    OpenUrlCrossRef
  3. 3.↵
    1. Haq MI,
    2. Shah S
    (2013) PWE-065 colonoscopy and biopsy practice in patients with diarrhoea. Gut 62, A157.
    OpenUrlAbstract/FREE Full Text
  4. 4.↵
    1. National Institute for Health and Care Excellence
    (2017) Quantitative faecal immunochemical tests to guide referral for colorectal cancer in primary care DG30, https://www.nice.org.uk/Guidance/DG30 (accessed 8 Dec 2020).
  5. 5.↵
    1. National Institute for Health and Care Excellence
    Faecal calprotectin in primary care as a decision diagnostic for inflammatory bowel disease and irritable bowel syndrome, https://www.nice.org.uk/guidance/dg11/resources/endorsed-resource-consensus-paper-pdf-4595859614 (accessed 8 Dec 2020).
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 71 (702)
British Journal of General Practice
Vol. 71, Issue 702
January 2021
  • Table of Contents
  • Index by author
Download PDF
Download PowerPoint
Article Alerts
Or,
sign in or create an account with your email address
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Microscopic colitis: a guide for general practice
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Microscopic colitis: a guide for general practice
Kevin Barrett
British Journal of General Practice 2021; 71 (702): 41-42. DOI: 10.3399/bjgp21X714593

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Microscopic colitis: a guide for general practice
Kevin Barrett
British Journal of General Practice 2021; 71 (702): 41-42. DOI: 10.3399/bjgp21X714593
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • INTRODUCTION
    • DIAGNOSIS IS DEPENDENT ON HISTOLOGICAL FINDINGS
    • INVESTIGATION AND TREATMENT
    • Notes
    • REFERENCES
  • Figures & Data
  • Info
  • eLetters
  • PDF

More in this TOC Section

  • Ketamine misuse: an update for primary care
  • Ear wax management in primary care: what the busy GP needs to know
  • REM sleep behaviour disorder: the importance of early identification in primary care
Show more Clinical Practice

Related Articles

Cited By...

Intended for Healthcare Professionals

BJGP Life

BJGP Open

 

@BJGPjournal's Likes on Twitter

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7400
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2023 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242