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Microscopic colitis

Key sources
The following summarized guidelines for the evaluation and management of microscopic colitis are prepared by our editorial team based on guidelines from the United European Gastroenterology (UEG/EMCG 2021), the American College of Gastroenterology (ACG 2017), and the American Gastroenterological Association (AGA 2016).


1.Screening and diagnosis

Differential diagnosis: rule out microscopic colitis in patients fulfilling the criteria for functional bowel disease, especially in presence of risk factors for microscopic colitis and/or in absence of IBS-therapy response.
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  • Histological criteria

2.Classification and risk stratification

Severity assessment: consider assessing disease activity and clinical remission in patients with microscopic colitis by the Hjortswang criteria, in the absence of a formally validated metric of disease activity. Consider a mean of < 3 stools/day and a mean of < 1 water stool/day during a 1-week registration as a criteria for clinical remission.

3.Diagnostic investigations

Stool studies: do not obtain fecal calprotectin for exclusion of microscopic colitis or monitoring of patients with microscopic colitis.

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  • Testing for celiac disease

  • Testing for bile acid diarrhea

4.Diagnostic procedures

Colonoscopy: perform ileocolonoscopy with biopsies from at least the right and left side of the colon in patients with suspected microscopic colitis.

5.Medical management

Budesonide: as per UEG 2021 guidelines, administer oral budesonide to induce remission in patients with collagenous
and lymphocytic colitis.
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  • Prednisolone

  • Aminosalicylates

  • Other immunosuppressants

  • Bismuth salicylate

  • Antidiarrheal agents

  • Probiotics

  • Antibiotics

6.Nonpharmacologic interventions

Withdrawal of offending medications: consider withdrawal of any drugs with a suspected chronological relationship between drug introduction and onset of diarrhea.

7.Surgical interventions

Indications for surgery: consider surgery in selected patients with microscopic colitis as last option if all medical therapy fails.

8.Preventative measures

Immunizations: provide annual vaccination against influenza in all adult patients with IBD. Administer the non-live trivalent inactivated influenza vaccine, and not the live inhaled influenza vaccine, in patients on immunosuppressive therapies and their household contacts.
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9.Follow-up and surveillance

Surveillance colonoscopy: do not obtain more frequent surveillance colonoscopy for CRC in patients with microscopic colitis, as the disease does not increase the risk of CRC or adenoma.

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  • Surveillance biopsy

  • Cervical cancer surveillance