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59 year old female with history of severe daily migraines and HTN presents with fecal incontinence and watery diarrhea for last 2 months. Her medications include HCTZ and daily ibuprofen.
Colonoscopy finding:
What is the most likely diagnosis? How can we confirm it? and give 2 management options.
Microscopic colitis secondary to long term NSAID exposure.
On biopsy: Collagenous or lymphocytic variants.
Management: Discontinue the use of NSAIDS and budesonide. Anti-diarrheals like bismuth can help with symptoms.
The diagnosis of MC is made by histologic evaluation of colonic biopsies; the classic finding is intraepithelial lymphocytosis (>20 intraepithelial lymphocytes per 100 epithelial cells). In collagenous colitis, the main histologic feature is thickening of the subepithelial collagen band (usually >10 µm).
A diagnosis of microscopic colitis should prompt a careful review of prescription and over-the-counter medications such as NSAIDs, aspirin, proton pump inhibitors, and others. Celiac disease should also be considered, as it can be associated with microscopic colitis.
For patients who do not respond to or do not tolerate budesonide, treatment with a bile salt binder such as cholestyramine may be effective. In severe cases, treatment with an anti-TNF agent may be needed.