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Epidemiological Aspects of Microscopic Colitis

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Epidemiological Aspects of Microscopic Colitis Epidemiological aspects of Microscopic Colitis To Amanda, Olle, Henrik Örebro Studies in Medicine 160 ANNA WICKBOM Epidemiological aspects of Microscopic Colitis © Anna Wickbom, 2017 Title: Epidemiological aspects of microscopic colitis. Publisher: Örebro University 2017 www.oru.se/publikationer-avhandlingar Print: Örebro University, Repro 04/2017 ISSN 1652-4063 ISBN 978-91-7529-188-8 Abstract Anna Wickbom (2017): Epidemiological aspects of microscopic colitis. Örebro Studies in Medicine 160. Microscopic colitis (MC) constitutes the main entities collagenous colitis (CC) and lymphocytic colitis (LC), diseases that are relatively recently described (in 1976 and 1989, respectively). The aims of this thesis were to study the epidemiology of MC, to de- scribe how these diseases affect patients in terms of symptom burden and health-related quality of life (HRQoL), to study potential risk fac- tors such as familial factors, childhood circumstances, educational level, marital status, smoking and comorbidity, and to describe a cohort of patients with ulcerative colitis (UC) or Crohn’s disease (CD) and subse- quent MC, and vice versa. During 1999–2008 in Sweden, the mean annual incidence of MC was 10.2 per 105 inhabitants, compared with 5.2 per 105 inhabitants for CC, and 5.0 per 105 inhabitants for LC. The prevalence of MC on 31 De- cember 2008 was 123 per 105 inhabitants. Women appeared to be espe- cially affected – the female:male ratio was 3.6:1 in CC and 4.6:1 in LC. Patients’ HRQoL is impaired both in active CC and in LC. Patients with CC in clinical remission have persisting symptoms: abdominal pain, fatigue, arthralgia and myalgia; LC patients in remission have persistent fatigue compared with controls. This illustrates that the long- term outcome is different in CC compared with LC. Microscopic colitis is associated with a family history of MC, indicating that familial factors may play a role in the pathogenesis of this disease. We confirm earlier reports that smoking is a risk factor in MC. In the present study population, CC was associated with rheumatic dis- ease and previous appendicectomy. Moreover, CC and LC were associated with thyroid disease and coeliac disease and, interestingly, with a history of UC. Most patients with UC or CD and subsequent MC, or vice versa, had UC or CD first and later developed MC. The majority had extensive UC and later onset of CC. Microscopic colitis should be considered in patients with UC or CD if there is onset of chronic watery diarrhoea without endo- scopic relapse of mucosal inflammation. Key words: microscopic colitis, epidemiology, risk factors, comorbidity, health-related quality of life Anna Wickbom, School of Health and Medical Sciences Örebro University, SE701 82, Sweden, [email protected] Table of Contents LIST OF PUBLICATIONS ....................................................................... 11 ABBREVIATIONS ................................................................................... 12 INTRODUCTION ................................................................................... 13 History of collagenous and lymphocytic colitis ........................................ 13 Clinical presentation and diagnosis .......................................................... 13 Epidemiology ........................................................................................... 16 Pathophysiology ....................................................................................... 16 Clinical course, symptom burden and quality of life ................................ 17 Treatment and prognosis .......................................................................... 17 Risk factors .............................................................................................. 18 Co-morbidity ........................................................................................... 19 Links with ulcerative colitis and Crohn’s disease...................................... 19 AIMS OF THE STUDIES ......................................................................... 20 Study I ...................................................................................................... 20 Study II ..................................................................................................... 20 Study III ................................................................................................... 20 Study IV ................................................................................................... 20 ETHICS .................................................................................................... 20 MATERIALS AND METHODS .............................................................. 21 Study I ...................................................................................................... 21 Catchment area .................................................................................... 21 Patients ................................................................................................ 21 Diagnostic criteria ................................................................................ 21 Statistics ............................................................................................... 22 Studies II and III ....................................................................................... 22 Patients ................................................................................................ 22 Controls ............................................................................................... 22 Questionnaire ....................................................................................... 22 Definitions ........................................................................................... 23 Statistics ............................................................................................... 23 Study II ................................................................................................ 23 Study III ............................................................................................... 23 Study IV ................................................................................................... 24 Statistics ............................................................................................... 24 RESULTS ................................................................................................. 25 Study I ...................................................................................................... 25 Collagenous colitis ............................................................................... 25 Lymphocytic colitis .............................................................................. 25 Prevalence ............................................................................................ 26 Comparison of the present study period with the previous period, 1993- 1998 ..................................................................................................... 26 Endoscopy data .................................................................................... 28 Studies II and III ....................................................................................... 29 Characteristics of the study population in Studies II and III ................. 29 Patients ................................................................................................ 29 Controls ............................................................................................... 29 Missing data ......................................................................................... 30 Results, Study II ................................................................................... 30 Symptom burden .................................................................................. 30 Collagenous colitis ........................................................................... 30 Lymphocytic colitis .......................................................................... 31 Assessment of health-related quality of life using the Short Health Scale32 Collagenous colitis ........................................................................... 32 Lymphocytic colitis .......................................................................... 32 Results, Study III .................................................................................. 33 Family history, childhood circumstances, educational level and marital status .................................................................................................... 33 Tobacco use ......................................................................................... 33 Association with autoimmune and other diseases ................................. 34 Collagenous colitis ........................................................................... 34 Lymphocytic colitis .......................................................................... 35 Study IV ................................................................................................... 36 Swedish cohort ..................................................................................... 36 Patients ................................................................................................ 36 Patients with ulcerative colitis who developed microscopic colitis ....... 36 Patients with Crohn’s disease who developed microscopic colitis ........ 37 Patient with microscopic colitis who developed
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