Irritable Bowel Syndrome (IBS) and Microscopic Colitis Symptoms Overlap
Symptoms of IBS and microscopic colitis overlap. In a group of biopsy proven microscopic colitis patients, there is noted that up to half have symptoms that meet diagnostic criteria for Irritable Bowel Syndrome (IBS). Microscopic colitis is diagnosed only by biopsies of the colon even when it appears normal. Symptom-based criteria for diagnosing IBS are not specific enough to rule out microscopic colitis. Some people with IBS have Mastocytic Enterocolitis, a newly recognized form of microscopic colitis characterized by increased numbers of mast cells in the intestinal lining. These cells can only be seen when special stains are applied to intestinal biopsies, a maneuver, not usually done by most pathologists or requested by most doctors performing intestinal biopsies.
PATIENTS WITH IBS SHOULD UNDERGO COLONOSCOPY WITH BIOPSIES OF NORMAL APPEARING INTESTINAL LINING
Patients suspected to have irritable bowel syndrome should undergo biopsies of the colon. This is absolutely necessary to exclude the possibility that they could have one of several forms of microscopic colitis. The diagnosis of microscopic colitis is made when biopsies of the colon have an increase in infection fighting or immune cells or deposits of excess collagen connective tissue in the lining of the digestive tract. In the most common form of microscopic colitis seen without special stains, excess lymphocyte white blood cells, or so called “intraepithelial lymphocytosis”, seen under the microscope. This microscopic finding is present when the colon looks normal on the surface. Many doctors don’t biopsy the colon when it looks normal despite obtaining a history of diarrhea from the patient. Microscopic colitis is a known treatable cause of diarrhea, bloating, gas and abdominal pain that can only be diagnosed by colon biopsies. In many patients who do get biopsies, special stains are not ordered when the standard stains fail to reveal an abnormality. However, under special stains, excess mast cells may be seen and a diagnosis of a treatable form of IBS known as mastocytic enterocolitis is missed.
BLOOD TESTS SHOULD ALSO BE DONE BEFORE ASSUMING A DIAGNOSIS OF IBS
Blood tests should be done to screen for Celiac disease, ulcerative colitis and Crohn’s disease. Without these blood tests and intestinal biopsies, Celiac disease, Crohn’s disease and various forms of colitis especially microscopic colitis are frequently missed.
MULTIPLE BIOPSIES SHOULD BE DONE TO AVOID MISSING PATCHY AREAS OF INVOLVEMENT
Microscopic irritation or inflammation of the intestine can be patchy. Therefore, anyone undergoing colonoscopy or upper endoscopy with symptoms, especially diarrhea, bloating, gas or abdominal pain, should have multiple intestinal biopsies. Inflammation that is the cause of these symptoms is often only seen microscopically and may be patchy. However, once a diagnosis is made treatment with medications and/or diet is often effective.
EARLY FINDINGS OF INTESTINAL INFLAMMATION OFTEN CONSISTS ONLY OF INCREASED CELLS, SOMETIMES ONLY SEEN WITH SPECIAL STAINS
The earliest intestinal biopsy findings of Celiac disease and microscopic colitis is increased number of lymphocytes per 100 epithelial (intestinal lining) cells. In the colon intraepithelial lymphocytosis is considered diagnostic for microscopic colitis if 20 or more lymphocytes per 100 epithelial cells are found. Interestingly the criteria for abnormal intraepithelial lymphocytosis in Celiac disease has more recently been reduced from 40 IELs per 100 utilized for nearly thirty years to 30 per 100. Even more recent studies have indicated that this should be reduced further to 20-25 per 100 because it is noted that early gluten injury occurs with lower levels of lymphocytes in the intestinal lining and is associated with a favorable response to gluten free diet. Microscopic colitis frequently responds favorably to a gluten-free diet.
DON’T HAVE YOUR DIAGNOSIS MISSED BY FAILURE TO GET AN INTESTINAL BIOPSY AND BLOOD TESTS BEFORE ACCEPTING IBS
Numerous patients have come to me with a diagnosis of IBS for years who I have confirmed to have Celiac disease, microscopic colitis or non-celiac gluten sensitivity. These patients typically respond dramatically to a gluten free diet even in the absence of a diagnosis of Celiac disease. Several of my patients have both Celiac disease and a form of microscopic colitis such as lymphocytic or collagenous colitis.
UNNECESSARY DELAYS IN DIAGNOSIS AND SUFFERING NOT NECESSARY IF YOU BECOME YOUR OWN ADVOCATE
People often experience years of unnecessary suffering due to delays in diagnosis of Celiac disease, microscopic colitis, Mastocytic Enterocolitis, Crohn’s disease, and food intolerance. Many developed preventable secondary complications such as osteoporosis, infertility, iron deficiency or autoimmune diseases. Most live for years with pain, stomach pains, and diarrhea under the false conclusion that they have IBS. Frustation occurs when you are told there is little to nothing that can be done besides taking anti-diarrhea and anti-spasm medications combined with a high fiber diet and fiber supplements. Yet, most note they are no better or even worse with increased fiber. If you have complained to your doctor that such agents seem to cause more severe bloating, gas, diarrhea and abdominal pain you are often scoffed at or told you are not being compliant. Little did you or your doctor know that increasing fiber intake can make you worse if you are gluten intolerant.
GLUTEN FREE DIET MAY HELP SYMPTOMS OF IBS AND SHOULD BE TRIED AFTER GETTING TESTED FOR CELIAC DISEASE FIRST
Don’t accept a diagnosis of IBS without adequate diagnostic testing or consideration of a trial of gluten free diet. Before accepting IBS learn more about the various forms of colitis, Celiac disease, non-celiac gluten sensitivity, Crohn’s disease and altered gut flora and be your own advocate when you visit your doctor.