Welcome everyone to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health. 

At Performance Medicine, we see a lot of GUT issues that don’t have obvious answers. When I see someone in the office that has an autoimmune disease, the first question I ask them is, “How’s your gut?” and their response is usually “It’s dysfunctional”. If that is you, then this Note will be of great interest. 

My topic is MICROSCOPIC COLITIS. Something you may not have heard of, but you should definitely know about (especially if you have chronic diarrhea). 

Let’s get started.


What is IBS? 


Irritable bowel syndrome, or IBS, is a group of symptoms that affect your digestive system. It’s a common, but uncomfortable gastrointestinal (GI) disorder that causes bloating, excessive gas, abdominal pain and cramps, diarrhea, and/or constipation. 

Most people with these symptoms get a GI workup done (a series of x-rays that examine your GI tract, including your esophagus, stomach, small intestine, large intestine and rectum) and are  disappointed when they find out nothing comes back positive. YET, they still have stomach cramps, diarrhea, constipation, etc.

It is frustrating to clearly have a gut problem and the workup doesn’t show anything. What else could it be? Some doctors will tell you it is a “functional illness”. Note: when we say “functional illness” that means it’s in your head. It’s psychological. But what if it’s not? Granted, stress can cause GI problems (there’s no doubt in my mind that it’s a contributing factor), BUT usually there are other problems that go along with it. 

We need to get to the root cause of our gut problems so that we can address this chronic condition. The problem is we use the term (IBS) when we don’t really know what it is (much less the cure).


IBSD or Microscopic Colitis? 

IBSD means irritable bowel syndrome with diarrhea. I recently had a patient come in for a regular office visit and our conversation ended up with her telling me about her “gut story”. Note: I love talking to my patients about unresolved medical issues! This lady suffered from chronic diarrhea, and all of the gut tests came back negative. This includes colonoscopies, upper GI’s, ultrasounds, all of the blood tests and stool studies. Everything looked negative! 

In this situation, most GI doctors (and most doctors in general) would call it IBSD. There’s not a problem with that, but there is a reason. And that’s what we want to find out! Through this patient’s own persistence and research, she learned that she had classic symptoms of microscopic colitis

Note: the reason they call it microscopic is because you can’t see it! You can have a normal colonoscopy, but unless they do some biopsies and look under the microscope they aren’t going to be able to see it. You almost have to tell them to do this, or they need to pay attention to your symptoms, because they’re classic. 

When you do a colonoscopy on a patient with Ulcerative Colitis, Crohn’s, or a biopsy for Celiac Disease, you can usually see changes. Microscopic colitis can only be diagnosed with a biopsy and looking at it under a microscope. 


Symptoms and Causes of Microscopic Colitis 


This vastly under diagnosed condition is characterized by non-bloody diarrhea. It’s usually worse at night. That can be a hallmark! It’s thought to be autoimmune, and more common in middle-aged women. 

There are two types of microscopic colitis: Collagenous and Lymphocytic. You can also have a mix of the two. Honestly, which one isn’t really a concern. If you have it, you have it. For the most part they’re treated the same way. 

There can be many triggers, including medications. Whenever I see someone that’s sick or doesn’t feel good, I always ask them for a list of their medicines. Note: I try to avoid any medicines that can trigger this. 

The most common ones that can cause microscopic colitis are:

  • the PPIs (like omeprazole) 
  • Non-Steroidal Anti-Inflammatories (Motrin)
  • Beta Blockers 
  • Statins
  • SSRIs (especially Zoloft)

Other factors: 

  • Smoking 
  • Previous autoimmune diseases (Celiac, Type 1 Diabetes, Thyroiditis)
  • Rheumatoid Arthritis (any kind of inflammatory arthritis)
  • Bile Acid Malabsorption 
  • Gut microbiome dysfunction 
  • Food (people with Celiac Disease are 70 times more likely to have Microscopic Colitis)
  • Synthetic hormones (estrogen especially)

The diagnosis can be difficult. The hallmark is chronic, non-bloody, watery, diarrhea (up to 15 times a day). You can also have stomach cramps with microscopic colitis. More at night. You can have urgency and even fecal incontinence. Note: This is when you just can’t make it to the bathroom (very common with this). There’s usually weight loss and fatigue because your stomach is not absorbing what you eat. Depression often comes alongside. 

Blood tests, even stool biomarkers like calprotectin, zonulin, and lactoferrin are usually not helpful for this diagnosis. It usually requires two biopsies of the right, transverse, descending, and sigmoid colon. This disease can have spontaneous remissions and exacerbations, but it’s usually chronic. Note: Microscopic colitis does not increase your risk of colon cancer. 


Managing Microscopic Colitis 


What do you do if you suspect you have this? And how do you manage it? 

Get a colonoscopy. Again, if you’ve had a normal colonoscopy, you don’t really want to go back and get another one (with the biopsies that are necessary), BUT it’s really the only way to get a definitive diagnosis. If you are going in for a GUT workup, point this out to your GI doctor and if you have any of these symptoms, make sure they do some biopsies (even if it looks normal to them). 

You might want to empirically treat this. A lot of times in medicine we treat empirically (which means we’re taking an educated guess). There’s nothing wrong with this. Here are a few things you can do.

  1. Stop smoking. 
  2. Stop any of the above medications under your doctor’s supervision. 
  3. Get on an autoimmune diet. This usually means no glutens, dairy, soy, sugars, nightshades, or corn. 
  4. Stop drinking alcohol. 
  5. Balance your gut microbiome with prebiotics and probiotics. 
  6. Take Imodium. Note: To help with the symptoms, you can use Imodium with this freely, and for however long you need it. This isn’t a viral type of diarrhea. This is chronic. So, don’t worry about using Imodium. It works! In fact, it was the main course of treatment for this until recently. 


Budesonide For Microscopic Colitis 


They’ve discovered that a drug called Budesonide (which we used a lot with Covid through nebulizers) is a game changer with this disease. The brand name is EntoCort EC. It’s a steroid, but it’s not a systemic steroid. This means that the medicine is not released from the capsule until it hits your colon. Therefore, it doesn’t have the systemic effects like you would have if you took prednisone. It’s a lot safer, and it shouldn’t pop your sugars up, or cause swelling. It’s been a really good treatment in capsule form. 

Cholestyramine is another good treatment for this disease. I’ve used it a lot for chronic diarrhea, especially in bile acid malabsorption cases (which may be a part of microscopic colitis). Cholestyramine is a gut binder. People know it as a cholesterol medication (it does lower cholesterol), but really it’s a bile acid gut binder. 

ASACOL (Mesalamine) is another one. We use this for more extreme and obvious cases of colitis. It’s a salicylate. Before budesonide, it was a mainstay of treatment. Sometimes immunomodulators like Azathioprine can be used for severe refractory cases. 

Methotrexate, the chemotherapeutic drug, could be helpful. There are a lot of side effects with this one. I don’t like to use it unless I have to. 

Even biologics like HUMIRA have been tested with some success. Humira is a high dollar medication that could also have a lot of side effects. For those reasons, you probably would not want to choose this treatment route, even though it has been tried and used successfully in some case studies.  

Fecal transplants have been helpful. Surgeries are a last resort, if nothing else is working, and you’re wasting away. 


Final Thoughts 


If you suffer from chronic diarrhea and don’t have any answers, you need to think about MICROSCOPIC COLITIS. Maybe try some of the empirically supported treatments with a doctor who understands this. Get a colonoscopy with a biopsy, if you can. Remember Budesonide capsules are an option, and may help. 

Note: It is possible that Covid can be a trigger for this. We’ve seen a lot of gut dysfunction (diarrhea, constipation, stomach cramps, etc.) from Covid. If you suffer from chronic, non-bloody, diarrhea look deeper into microscopic colitis. 

As always, do your own research. There’s always hope.

Till next week.