A 58-year-old woman comes to the office due to diarrhea over the past 6 months. Every day, the patient has 3 or 4 watery bowel movements that sometimes awaken her at night. She has had no nausea, vomiting, fever, or recent travel. She also has associated fecal urgency and mild abdominal discomfort that is partially relieved after bowel movements. Other medical problems include seasonal allergies and tension headaches. She smokes a pack of cigarettes a day but does not use alcohol. Medications include regular use of naproxen and loratadine.
Vital signs are normal. Examination shows no abnormalities. There are no skin rashes.
Laboratory results show normal complete blood count and comprehensive metabolic panel. Serum TSH is normal. Stool studies for occult blood, leukocytes, ova and parasites, and Clostridium difficile toxin are negative. Colonoscopy is grossly normal, but random mucosal biopsies reveal an abnormally thickened subepithelial collagen band.
Which of the following is the most appropriate next step in management of this patient?

Question

A 58-year-old woman comes to the office due to diarrhea over the past 6 months.  Every day, the patient has 3 or 4 watery bowel movements that sometimes awaken her at night.  She has had no nausea, vomiting, fever, or recent travel.  She also has associated fecal urgency and mild abdominal discomfort that is partially relieved after bowel movements.  Other medical problems include seasonal allergies and tension headaches.  She smokes a pack of cigarettes a day but does not use alcohol.  Medications include regular use of naproxen and loratadine.
Vital signs are normal.  Examination shows no abnormalities.  There are no skin rashes.
Laboratory results show normal complete blood count and comprehensive metabolic panel.  Serum TSH is normal.  Stool studies for occult blood, leukocytes, ova and parasites, and Clostridium difficile toxin are negative.  Colonoscopy is grossly normal, but random mucosal biopsies reveal an abnormally thickened subepithelial collagen band.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_97fe_f9ba_853d_0d2f3c8f3290_MD0002_00 This woman with chronic watery diarrhea and use of nonsteroidal anti-inflammatory drugs (NSAIDs) likely has microscopic colitis, a type of inflammatory bowel disease that most commonly affects middle-aged women. Microscopic colitis is likely due to an abnormal immune response to various gastrointestinal and external agents, including certain medications (eg, NSAIDs, proton pump inhibitors, sertraline) and smoking. Microscopic colitis presents with chronic watery, nonbloody diarrhea; patients may have fecal urgency, incontinence, nocturnal diarrhea, abdominal pain, fatigue, and weight loss. Diagnosis is made with colonoscopy and biopsy; the colon appears grossly normal, but biopsy of the mucosa reveals mononuclear lymphocytic infiltrates in the lamina propria. The disease is subdivided histologically into 2 types: Collagenous colitis - characterized by a thickened subepithelial collagen bandLymphocytic colitis - characterized by high levels of intraepithelial lymphocytes (≥20 for every 100 epithelial cells); focal cryptitis may be noted Collagenous colitis - characterized by a thickened subepithelial collagen band Lymphocytic colitis - characterized by high levels of intraepithelial lymphocytes (≥20 for every 100 epithelial cells); focal cryptitis may be noted Initial treatment is smoking cessation and stoppage of possible triggering medications (ie, naproxen in this patient). Antidiarrheal agents and oral budesonide may be used for active disease or persistent symptoms. (Choice A) Mesalamine is used to treat inflammatory bowel disease; however, colonoscopy would be expected to show friable colonic mucosa with crypt abscesses (in ulcerative colitis) or aphthous ulcers with cobblestoning and discontinuous lesions (in Crohn disease). Mesalamine has not been shown to be beneficial in collagenous microscopic colitis. (Choice B) Patients suspected of surreptitious laxative abuse require psychological assessment. However, excess collagen deposition on colonic biopsy is not explained by laxative abuse. (Choice D) Patients with celiac disease have a markedly increased risk of developing microscopic colitis; however, overall, celiac disease is uncommon in patients with microscopic colitis. This patient's biopsy results are diagnostic of microscopic colitis and she should be treated appropriately. Serologic studies for celiac disease could be considered if the patient fails to improve with initial therapy. (Choice E) Lactose intolerance (due to lactase deficiency) can cause abdominal discomfort and flatulence, but diarrhea is rare. In addition, lactose intolerance would not be expected to cause abnormalities on colonic biopsy. Educational objective: Microscopic colitis causes a chronic nonbloody diarrhea and is often triggered by medications (eg, nonsteroidal anti-inflammatory drugs) and smoking. Colonoscopy reveals normal-appearing mucosa with mononuclear lymphocytic infiltrates on biopsy. Management includes removal of offending agents, antidiarrheal agents, and budesonide. __________ References: Evaluation of chronic diarrhea. (http://www.ncbi.nlm.nih.gov/pubmed/22085666)

A 58-Year-Old Woman Comes to the Office Due to Diarrhea