Some patients remained unaware of their microscopic colitis diagnosis and reported persistent symptoms one year after biopsies confirmed their disease, according to the results of a recent case–control study.
The study investigators found that 10% of patients diagnosed with microscopic colitis (MC) “did not recall or were unsure of their diagnosis,” often despite its clear documentation in their electronic health records. In addition, 7% of controls reported an MC diagnosis, “despite no clinical documentation to support the diagnosis.”
Furthermore, the researchers reported that only 60% of cases and 26% of controls received medication for diarrhea, and only half of the cases were treated with the first-line therapy budesonide.
“It is not clear why some patients were not aware of their diagnosis and others with symptoms were not prescribed medications, but this likely represents an opportunity to improve how physicians communicate results with patients and manage persistent symptoms,” lead researcher Walker D. Redd, MD, a clinical outcomes and epidemiology fellow in the Department of Gastroenterology and Hepatology at the University of North Carolina (UNC) at Chapel Hill, told Gastroenterology & Endoscopy News.
Recall bias could explain why 10% of MC cases didn’t remember their diagnosis, according to Jami A. Kinnucan, MD, an inflammatory bowel disease specialist at Mayo Clinic, in Jacksonville, Fla., who was not involved with the study. Despite this possibility, “as the authors state, it highlights the importance of clear communication and education after diagnostic evaluation to ensure patient understanding,” she said.
More Controls Reported Symptoms
In the study, Dr. Redd and his co-investigators analyzed data from outpatient colonoscopies performed at UNC hospitals between April 1, 2015, and Dec. 22, 2020, to evaluate diarrhea (Gastro Hep Advances 2023 Dec 6. doi:10.1016/j.gastha.2023.11.019). They looked at 362 patients, including 110 cases with and 252 controls without MC, conducting follow-up interviews in 74 cases and 162 controls one year after colonoscopy.
Compared with cases, controls suffered worse symptoms at follow-up, measured on the Microscopic Colitis Disease Activity Index (MCDAI), with a median score of 3.0 versus 2.3 (out of 12). Controls also had less improvement (=2 point decrease) in their MCDAI score at follow-up (61% vs. 37%).
With respect to specific symptoms, more controls than cases reported nocturnal stools (33% vs. 15%; P=0.006), abdominal pain (55% vs. 28%; P<0.001), fecal urgency (64% vs. 40%; P<0.002) and fecal incontinence (38% vs. 21%; P=0.01).
The results showing that “controls have persistent symptoms over cases [highlight] the effectiveness of treatment,” Dr. Kinnucan said. “I suspect controls with diarrhea and biopsies were negative for MC and other etiologies, including dietary-related or irritable bowel syndrome diarrhea. It’s possible these patients were not under the care of a gastroenterologist, but rather a primary care provider [PCP], or they didn’t seek follow-up or just tolerated their symptoms.”
Limitations of the study included incomplete telephone interviews by 33% of cases and 36% of controls, the exclusion of celiac disease data and the fact that the MCDAI has not been validated in other etiologies of chronic diarrhea, which could cause overestimations in symptom severity. The study also did not capture use of over-the-counter (OTC) medications.
“Since we only asked about prescription medications, we did not have information about how patients used OTC medications. It would be helpful for future studies to collect data about how patients with and without MC used OTC medications at follow-up,” Dr. Redd said.
Review Other Possible Causes
Although Dr. Kinnucan suggested the research should be expanded to multicenter or larger population-based data sets, she said there are takeaways related to patient–provider discussions and education about chronic, unexplained diarrhea and newly diagnosed MC.
She noted that discussion of causes of diarrhea would benefit patients with MC as well as those without it. “Even when a patient receives an MC diagnosis, it might not be the only etiology to their diarrhea. It is important to evaluate for celiac disease and review medications that increase risk for MC,” she said. “For those where biopsies exclude MC diagnosis, it is important to educate patients about what might be causing their diarrhea symptoms.”
Dr. Redd agreed, adding that some additional steps could help with communication and also with symptom management. “Whether patients have MC or other causes of chronic diarrhea, it is important to see them in clinic for follow-up to reassess symptoms and offer symptomatic management based on guideline recommendations.
“Endoscopists could consider directly communicating with the referring provider or PCP about a new MC diagnosis and offer follow-up if needed,” he said. “Efforts to improve the communication of diagnostic colonoscopy results would help make sure patients understand their MC diagnosis and empower them to seek care for any persistent symptoms.”
—Sherree Geyer
Drs. Kinnucan and Redd reported no relevant financial disclosures.
This article is from the March 2024 print issue.