Case Presentation:
A 61year old female with hypertension treated with olmesartan and recently diagnosed stroke was admitted for a one month history of recurrent non‐bloody emesis and watery diarrhea. Her symptoms started 1 month prior after a camping trip. Since then she has had watery diarrhea 5 times/day and clear emesis resulting in a 15 lb. unintentional weight loss which has prompted several ED visits. She was submitted to a colonoscopy prior to admission which showed microscopic colitis and she was recently started on budesonide with no improvement in symptoms. She denied hematochezia, abdominal pain, melena, hematemesis, fever or chills. Review of systems was negative for any other complaints except for dysarthria related to her recent stroke. She denied recent travel or exposure to sick.
Physical examination showed an ill appearing women. Mucous membranes were dry, revealing dehydration. Neurologic examination revealed dysarthria and right facial droop. There were no other significant findings. Initial blood count and chemistries were significant for hypokalemia at 3.0 mmol/L, contraction alkalosis with a bicarbonate of 13mmol/L and AKI with Cr 2.61 mg/dL. Stool cultures, ova and parasites were negative. Electrolytes were replaced and she was aggressively hydrated, with improvement in renal function. She persisted with severe emesis despite antiemetics and with severe watery diarrhea despite antidiarrheal medications. EGD was performed and was normal. Budesonide was discontinued as she was not improving. Losartan was thought to be the cause of her microscopic colitis and it was discontinued, with improvement in diarrhea and vomiting. She was discharged home on no antiemetics or antidiarrheals.
Discussion:
Microscopic colitis is characterized by histologic inflammation in an endoscopically normal colonic mucosa. Patients typically have chronic watery diarrhea of up to 2 L/day without bleeding, often associated with fecal urgency, nausea and vague abdominal pain. The symptoms are usually intermittent but can be continuous. It is diagnosed by colonoscopy. Colonic mucosa will appear normal but colonic biopsies reveals colitis without any mucosal ulcerations. Microscopic colitis can be idiopathic or can be caused by drugs, the most common being NSAIDS, PPIs, ticlopidine and sertraline. Other medications that are associated with microscopic colitis are simvastatin, lisinopril and olmesartan. The treatment of microscopic colitis can be as simple as discontinuation of the offending agent. If medical therapy is needed, the first line agent is budesonide, followed by aminosalicylate and cholestyramine.
Conclusions:
This case highlights medications as cause of severe chronic diarrhea associated with microscopic colitis. The diagnosis of microscopic colitis should prompt a careful review of prescription and over‐the counter medications by hospitalists, as the simple discontinuation of the offending agents will prompt resolution of symptoms in such patients.