Mucosal Tear in Collagenous Colitis

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The patient is a 60-year-old woman with a long history of constipation. One year before presentation she started to experience rectal pain and watery, nonbloody diarrhea. She had a 6-pound weight loss, and empiric treatment elsewhere with antimotility agents was unsuccessful. Physical examination and stool and blood test results were unremarkable. She did not use nonsteroidal anti-inflammatory drugs, enemas, or other rectal manipulations. Colonoscopy showed a 3-cm-long linear, raised mucosal tear in the sigmoid on insertion of the endoscope (Figure A). The remaining colon and terminal ileum were normal. Random colon biopsy specimens showed diffuse, irregular thickening of the subepithelial collagen table accompanied by focal denudation of the surface epithelium and increased intraepithelial lymphocytes, diagnostic of collagenous colitis (Figure B). Biopsy specimens of the mucosal tear showed granulation tissue with acute inflammation consistent with a nonspecific ulcer (Figure B). The patient was treated with Pepto-Bismol, budesonide, mesalamine enemas, metronidazole, and ciprofloxacin. After 3 days the diarrhea and rectal pain resolved, and after 3 weeks all medications, except budesonide, were stopped. After 2 years of follow-up evaluation the patient remains asymptomatic and colonoscopy with biopsy examination was normal.

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Discussion 

In microscopic colitis, the mucosa generally is normal endoscopically, but histology shows characteristic abnormalities. However, endoscopically visible mucosal tears occur in these patients. Mucosal tears have been reported previously in 12 patients with collagenous colitis.¹ The cause is unclear, but it may be related to underlying inflammation with mucosal friability, akin to the equally uncertain pathogenesis of furrows in eosinophilic esophagitis. Standard treatment for collagenous colitis appears adequate for management of mucosal tears. However, 3 of the referenced patients had colonic perforation immediately after the colonoscopy. Even though the lesion itself appears limited to the mucosa, this phenomenon necessitates that great care be taken when performing colonoscopy in patients suspected of collagenous colitis.

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Reference 

1. Wickbom A, Lindqvist M, Bohr J, et al. Colonic mucosal tears in collagenous colitis. Scand J Gastroenterol. 2006;41:726–729
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