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Abstract
Introduction: Microscopic colitis is an idiopathic, inflammatory form of colitis that is characterized by a normal macroscopic appearance of bowel but abnormal histological appearance on microscopy. Microscopic colitis can be subdivided into two histological subtypes: collagenous and lymphocytic. The collagenous subtype is characterized by proliferation of collagenous connective tissue that forms a thick subepithelial collagen band while the lymphocytic subtype is characterized by lymphocytic infiltrates and little to no proliferation of connective tissue. Classically, microscopic colitis presents with chronic, nonbloody, watery diarrhea lasting more than one month. It is typically associated with weight loss, abdominal pain, tenesmus, and nocturnal stools. Here we present a case of microscopic colitis presenting as chronic inflammatory diarrhea in the setting of comorbid internal hemorrhoids.
Case Report: A 26-year-old male with no known past medical history presented to a hospital near the U.S.-Mexico border in southern Texas due to 2 weeks of bloody diarrhea associated with tenesmus, fatigue, weight loss, blurry vision, and lower abdominal pain. For the past two years the patient had experienced intermittent monthly episodes of bloody diarrhea lasting several days. During these episodes the patient reported symptoms of bloating and abdominal cramping, most notably in the LLQ. He attempted to reduce the amount of spicy food and gluten in his diet as he these were triggers, however this did not relieve his symptoms. At no point did the patient experience non-bloody diarrhea, fever, arthralgias, eye pain, new onset rash, or nocturnal stools. The patient was not on any medications, did not use tobacco products or other substances, and drank alcohol rarely. Family history was negative for any GI pathology or cancer. The patient had never been evaluated by a gastroenterologist due to medical insurance cost barriers.
On arrival to the ED the patient was found to be afebrile, HR 60, BP 128/57, RR 16, and SpO2 100% on room air. Physical exam was significant for ill-appearance, dry mucous membranes, delayed capillary refill, LLQ tenderness to palpation, and a +DRE. Initial labs included a normal metabolic panel, normal WBC count, Hgb 9.0 with MCV 64 and MCHC 27, normal inflammatory markers, and normal coags. Iron panel was suggestive of IDA with iron 16, ferritin 4.0, and TIBC 451. GI stool pathogen panel was positive for ETEC. An abdominal x-ray was unremarkable. The patient was fluid resuscitated and admitted for further workup.
On the floors additional labs included negative IgA tissue transglutaminase Ab and a stool osm gap < 50. GI was consulted and performed endoscopy and colonoscopy with findings of suspected gastritis, grade II internal hemorrhoids, and a 9 mm sessile polyp which was removed via hot snare. Tissue samples were obtained from the gastric body, duodenum, and colon. Pathology was diagnostic of severe chronic gastritis positive for H. pylori and lymphocytic colitis. Post-procedure the patient was hemodynamically stable and able to be discharged with a single dose of azithromycin and GI follow-up.
Discussion: Microscopic colitis classically presents as chronic, nonbloody, watery diarrhea. However, when coexisting conditions such as internal and external hemorrhoids that can cause a lower GI bleed the presentation may be misleading. This case where a bacterial gastroenteritis caused an acute worsening of chronic bloody diarrhea, emphasizes the importance of completing a thorough workup for chronic diarrhea lasting more than 4 weeks. Although the patient presented with a history concerning for inflammatory bowel disease, colonoscopy was normal and only tissue biopsy resulted in a formal diagnosis. Therefore, when chronic diarrhea is present both inflammatory and non-inflammatory causes should still be considered and the stool should be analyzed for the presence of WBCs and the osmotic gap. Otherwise, one may misdiagnose their patient leading to persistence of symptoms and dissatisfaction with the healthcare system.
Recommended Citation
Haines, Corey; Moon, Sophia; Tah, Giani; Pozo, Diana Acosta; Aquino, Alejandro; and Bello, Fatimah, "A Case of Microscopic Colitis Masquerading as Chronic Inflammatory Diarrhea" (2025). Research Symposium. 50.
https://scholarworks.utrgv.edu/somrs/2025/posters/50
Included in
Digestive System Diseases Commons, Gastroenterology Commons, Pathological Conditions, Signs and Symptoms Commons
A Case of Microscopic Colitis Masquerading as Chronic Inflammatory Diarrhea
Introduction: Microscopic colitis is an idiopathic, inflammatory form of colitis that is characterized by a normal macroscopic appearance of bowel but abnormal histological appearance on microscopy. Microscopic colitis can be subdivided into two histological subtypes: collagenous and lymphocytic. The collagenous subtype is characterized by proliferation of collagenous connective tissue that forms a thick subepithelial collagen band while the lymphocytic subtype is characterized by lymphocytic infiltrates and little to no proliferation of connective tissue. Classically, microscopic colitis presents with chronic, nonbloody, watery diarrhea lasting more than one month. It is typically associated with weight loss, abdominal pain, tenesmus, and nocturnal stools. Here we present a case of microscopic colitis presenting as chronic inflammatory diarrhea in the setting of comorbid internal hemorrhoids.
Case Report: A 26-year-old male with no known past medical history presented to a hospital near the U.S.-Mexico border in southern Texas due to 2 weeks of bloody diarrhea associated with tenesmus, fatigue, weight loss, blurry vision, and lower abdominal pain. For the past two years the patient had experienced intermittent monthly episodes of bloody diarrhea lasting several days. During these episodes the patient reported symptoms of bloating and abdominal cramping, most notably in the LLQ. He attempted to reduce the amount of spicy food and gluten in his diet as he these were triggers, however this did not relieve his symptoms. At no point did the patient experience non-bloody diarrhea, fever, arthralgias, eye pain, new onset rash, or nocturnal stools. The patient was not on any medications, did not use tobacco products or other substances, and drank alcohol rarely. Family history was negative for any GI pathology or cancer. The patient had never been evaluated by a gastroenterologist due to medical insurance cost barriers.
On arrival to the ED the patient was found to be afebrile, HR 60, BP 128/57, RR 16, and SpO2 100% on room air. Physical exam was significant for ill-appearance, dry mucous membranes, delayed capillary refill, LLQ tenderness to palpation, and a +DRE. Initial labs included a normal metabolic panel, normal WBC count, Hgb 9.0 with MCV 64 and MCHC 27, normal inflammatory markers, and normal coags. Iron panel was suggestive of IDA with iron 16, ferritin 4.0, and TIBC 451. GI stool pathogen panel was positive for ETEC. An abdominal x-ray was unremarkable. The patient was fluid resuscitated and admitted for further workup.
On the floors additional labs included negative IgA tissue transglutaminase Ab and a stool osm gap < 50. GI was consulted and performed endoscopy and colonoscopy with findings of suspected gastritis, grade II internal hemorrhoids, and a 9 mm sessile polyp which was removed via hot snare. Tissue samples were obtained from the gastric body, duodenum, and colon. Pathology was diagnostic of severe chronic gastritis positive for H. pylori and lymphocytic colitis. Post-procedure the patient was hemodynamically stable and able to be discharged with a single dose of azithromycin and GI follow-up.
Discussion: Microscopic colitis classically presents as chronic, nonbloody, watery diarrhea. However, when coexisting conditions such as internal and external hemorrhoids that can cause a lower GI bleed the presentation may be misleading. This case where a bacterial gastroenteritis caused an acute worsening of chronic bloody diarrhea, emphasizes the importance of completing a thorough workup for chronic diarrhea lasting more than 4 weeks. Although the patient presented with a history concerning for inflammatory bowel disease, colonoscopy was normal and only tissue biopsy resulted in a formal diagnosis. Therefore, when chronic diarrhea is present both inflammatory and non-inflammatory causes should still be considered and the stool should be analyzed for the presence of WBCs and the osmotic gap. Otherwise, one may misdiagnose their patient leading to persistence of symptoms and dissatisfaction with the healthcare system.
