Do microscopic colitis symptoms come and go?

Microscopic Colitis Symptoms: Waxing and Waning Pattern

Yes, microscopic colitis symptoms characteristically come and go, with patients experiencing variable disease courses ranging from occasional intermittent symptoms to chronic recurrent patterns, though some patients may develop more persistent progressive symptoms. 1

Disease Course Patterns

The natural history of microscopic colitis demonstrates significant variability in symptom presentation:

• Intermittent symptoms are common, with patients experiencing periods of active diarrhea alternating with symptom-free intervals 1, 2
• Chronic recurrent course is frequently observed, where symptoms resolve and then return over time 3
• Some patients develop chronic progressive symptoms requiring ongoing management 1
• Approximately one-third of patients may not require maintenance therapy after initial treatment, suggesting spontaneous remission can occur 4

Clinical Presentation

The typical symptom profile includes:

• Chronic watery, non-bloody diarrhea as the hallmark presentation 4, 1
• Nocturnal diarrhea and fecal incontinence are frequently present 4
• Additional symptoms include fecal urgency, abdominal pain, arthralgias, and weight loss 1
• Symptoms may be less severe in lymphocytic colitis compared to collagenous colitis, though the two forms cannot be reliably distinguished based on symptoms alone 4

Factors Influencing Symptom Fluctuation

Several factors may contribute to the waxing and waning nature:

• Medication triggers: NSAIDs, proton pump inhibitors, and selective serotonin reuptake inhibitors can precipitate symptoms 5, 6
• Concurrent bile acid diarrhea is present in 41% of collagenous colitis and 29% of lymphocytic colitis cases, which may contribute to symptom variability 4
• Histologic remission strongly predicts sustained clinical remission—all patients achieving histologic remission maintained clinical remission without medication, whereas only 11.8% could discontinue therapy when histologic inflammation persisted 5

Treatment Response and Relapse

Understanding the relapsing nature is critical for management:

• Maintenance therapy should only be offered to patients who relapse after stopping induction therapy, as up to one-third may not require it 4
• Budesonide maintenance therapy (starting at 6 mg daily, tapered to lowest effective dose) reduces clinical relapse risk by 66% over 6 months 4
• Cessation of maintenance therapy can be attempted after 6-12 months, though monitoring for symptom recurrence is essential 4
• Response to budesonide during induction is significantly associated with long-term clinical remission (odds ratio 25.00,95% CI 2.63-238.10) 5

Common Pitfall

Do not assume that symptom resolution means the disease has permanently resolved. The intermittent nature means patients may experience symptom-free periods lasting weeks to months before recurrence, necessitating patient education about potential relapse and when to seek re-evaluation 1, 2.