Symptoms of Irritable Bowel Syndrome (IBS) and Microscopic Colitis Overlap

The symptoms of IBS and microscopic colitis overlap. In a group of patients with biopsy-proven microscopic colitis, up to half are found to have symptoms that meet the 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 Mast Cell Enterocolitis, a recently 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 performed by most pathologists or requested by most doctors who perform intestinal biopsies.

PATIENTS WITH IBS SHOULD UNDERGO A COLONOSCOPY WITH BIOPSIES OF THE NORMAL APPEARING GUT LINING

Patients with suspected irritable bowel syndrome should undergo colon biopsies. This is absolutely necessary to exclude the possibility that they may have one of several forms of microscopic colitis. The diagnosis of microscopic colitis is made when biopsies of the colon show increased infection-fighting or immune cells or deposits of excess collagenous connective tissue in the lining of the digestive tract. In the most common form of microscopic colitis seen without special staining, excess white blood cells of lymphocytes, or the so-called “intraepithelial lymphocytosis”, seen under the microscope. This microscopic finding is present when the colon appears normal on the surface. Many doctors do not 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 undergo biopsies, special stains are not ordered when standard stains do not reveal an abnormality. However, under special stains, excess mast cells can be seen, missing the diagnosis of a treatable form of IBS known as mast cell enterocolitis.

BLOOD TESTS SHOULD ALSO BE PERFORMED BEFORE ASSUMING A DIAGNOSIS OF IBS

Blood tests should be done to check 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 often missed.

MULTIPLE BIOPSIES SHOULD BE PERFORMED TO AVOID MISSING AREAS OF COMPROMISE IN PATCH

Irritation or microscopic inflammation of the intestine can be patchy. Therefore, anyone undergoing a colonoscopy or upper endoscopy with symptoms, especially diarrhea, bloating, gas, or abdominal pain, should have multiple intestinal biopsies. The inflammation that is the cause of these symptoms is often only seen microscopically and can be patched. However, once the diagnosis is made, treatment with medication and/or diet is usually effective.

THE FIRST FINDINGS OF INTESTINAL INFLAMMATION OFTEN CONSISTS ONLY OF AN INCREASE OF CELLS, SOMETIMES ONLY SEEN WITH SPECIAL SPOTS

The earliest intestinal biopsy findings of celiac disease and microscopic colitis is an increase in the number of lymphocytes per 100 epithelial (intestinal lining) cells. In the colon, intraepithelial lymphocytosis is considered diagnostic of microscopic colitis if 20 or more lymphocytes are found per 100 epithelial cells. Interestingly, the criteria for abnormal intraepithelial lymphocytosis in celiac disease have more recently been lowered from the 40 IEL per 100 used for almost thirty years to 30 per 100. Even more recent studies have indicated that this should be lowered further to 20-25 per 100. 100 because early gluten injury is observed to occur with lower levels of lymphocytes in the intestinal lining and is associated with a favorable response to the gluten-free diet. Microscopic colitis usually responds favorably to a gluten-free diet.

DON’T MISS YOUR DIAGNOSIS BY NOT GETTING A BOWEL BIOPSY AND BLOOD TEST BEFORE ACCEPTING IBS

Numerous patients have come to me with an IBS diagnosis over the years who I have confirmed 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 celiac disease diagnosis. 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 UNNECESSARY SUFFERING IF YOU BECOME YOUR OWN LAWYER

People often experience years of unnecessary suffering due to delays in the diagnosis of celiac disease, microscopic colitis, mast cell 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 cramps, and diarrhea under the false conclusion that they have IBS. Frustration ensues when you’re told there’s little or nothing you can do besides taking antidiarrheal and antispasmodic medications combined with a high-fiber diet and fiber supplements. However, most find that they are neither better nor worse with the increase in 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 mocked or told that you are not complying. You or your doctor didn’t know that increasing your fiber intake can make it worse if you’re gluten intolerant.

THE GLUTEN-FREE DIET CAN HELP WITH IBS SYMPTOMS AND SHOULD BE TRYED AFTER YOU GET TESTED FOR CELIAC DISEASE FIRST

Do not accept an IBS diagnosis without proper diagnostic testing or consideration of a gluten-free diet trial. Before you accept 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.