7 Common Signs and Symptoms of Microscopic Colitis You Should Know

Microscopic colitis is an inflammatory bowel disease that causes chronic, watery diarrhea. The condition gets its name because the inflammation can only be seen when colon tissue is examined under a microscope. There are two main types of microscopic colitis: lymphocytic colitis and collagenous colitis. Both types share similar symptoms and affect the colon, though they have slightly different microscopic characteristics.

This condition is more common in middle-aged and older adults, particularly women. While microscopic colitis is not life-threatening, it can significantly impact quality of life. Understanding the symptoms is crucial for early detection and proper management. Below are the most common signs and symptoms associated with this condition.

1. Chronic Watery Diarrhea

The hallmark symptom of microscopic colitis is chronic, watery diarrhea that persists for weeks or months. This is not the typical diarrhea that resolves within a few days.

Characteristics of the diarrhea include:

• Watery consistency without blood
• Frequent bowel movements, often 5-10 times per day or more
• Urgent need to have a bowel movement
• Diarrhea that may come and go in episodes
• Symptoms that may worsen at night, disrupting sleep

The diarrhea associated with microscopic colitis is typically non-bloody, which helps distinguish it from other inflammatory bowel diseases like ulcerative colitis or Crohn’s disease. Episodes can last for months, then spontaneously improve, only to return later. This intermittent pattern can make diagnosis challenging and may lead some people to delay seeking medical attention.

2. Abdominal Pain and Cramping

Many people with microscopic colitis experience abdominal discomfort, pain, or cramping. This symptom can vary in intensity from mild to moderate and typically affects the lower abdomen.

The abdominal pain associated with microscopic colitis often has these features:

• Cramping sensations that come in waves
• Pain that may worsen before or during bowel movements
• Discomfort that temporarily improves after passing stool
• Mild to moderate intensity, rarely severe
• Location primarily in the lower abdomen or left side

The cramping occurs because the inflamed colon is contracting more frequently and forcefully than normal. Some patients describe the sensation as a gripping or squeezing feeling in their belly. Unlike the severe, debilitating pain that can occur with other bowel conditions, the discomfort from microscopic colitis is usually manageable, though it can still be quite bothersome and affect daily activities.

3. Urgent Need to Defecate (Fecal Urgency)

Fecal urgency, or the sudden, overwhelming need to have a bowel movement immediately, is a distressing symptom that many people with microscopic colitis experience. This urgency can significantly impact quality of life and daily functioning.

This symptom manifests as:

• Sudden, intense urge to use the bathroom with little warning
• Difficulty controlling the timing of bowel movements
• Anxiety about being far from a bathroom
• Social limitations due to fear of accidents
• Need to plan activities around bathroom availability

The urgency can be so severe that it causes people to avoid social situations, traveling, or activities where bathroom access might be limited. This can lead to social isolation and reduced quality of life. Some individuals may experience fecal incontinence (inability to control bowel movements) in severe cases, though this is less common. The unpredictable nature of the urgency can cause significant anxiety and stress, further complicating the condition.

4. Weight Loss

Unintentional weight loss is a common symptom of microscopic colitis, occurring as a result of chronic diarrhea and the body’s inability to properly absorb nutrients from food.

Weight loss in microscopic colitis typically occurs due to:

• Malabsorption of nutrients from frequent diarrhea
• Decreased appetite due to abdominal discomfort
• Avoidance of eating to prevent triggering symptoms
• Loss of fluids and electrolytes
• Increased metabolic demands from chronic inflammation

The weight loss is usually gradual but can become significant if the condition remains untreated for an extended period. Some people may lose 10-20 pounds or more over several months. This happens because the inflamed colon cannot absorb water and nutrients efficiently, and frequent bowel movements further deplete the body’s resources. Additionally, some patients deliberately reduce their food intake in an attempt to control their diarrhea, which contributes to weight loss. If you notice unexplained weight loss along with other symptoms, it’s important to consult a healthcare provider.

5. Dehydration

The chronic watery diarrhea associated with microscopic colitis can lead to dehydration, which occurs when the body loses more fluids than it takes in. Dehydration can range from mild to severe and requires attention.

Signs and symptoms of dehydration include:

• Excessive thirst
• Dry mouth and lips
• Dark-colored urine or decreased urination
• Fatigue and weakness
• Dizziness or lightheadedness
• Dry skin with reduced elasticity
• Headaches

When experiencing multiple episodes of watery diarrhea daily, the body loses significant amounts of water and electrolytes (sodium, potassium, chloride). These losses can accumulate quickly, especially in older adults who may already have a reduced sense of thirst. Dehydration can affect kidney function, blood pressure, and overall energy levels. It’s essential for people with microscopic colitis to maintain adequate fluid intake throughout the day. In severe cases of dehydration, medical attention may be necessary to restore fluid and electrolyte balance through intravenous therapy.

6. Bloating and Gas

Many individuals with microscopic colitis experience bloating, a sensation of fullness or swelling in the abdomen, along with increased gas production. These symptoms can add to the discomfort already caused by other manifestations of the condition.

Bloating and gas in microscopic colitis present as:

• Feeling of abdominal fullness or tightness
• Visible distension or swelling of the belly
• Increased flatulence or gas production
• Discomfort that worsens after eating
• Gurgling sounds from the intestines (borborygmi)

The bloating occurs because the inflamed colon doesn’t function as efficiently as it should, leading to alterations in how gas is processed and expelled. The intestinal inflammation can also affect the gut microbiome (the bacteria living in the intestines), potentially leading to increased gas production. Some people find that certain foods worsen their bloating, particularly dairy products, high-fiber foods, or foods containing artificial sweeteners. The combination of bloating, gas, and visible distension can be embarrassing and uncomfortable, affecting self-confidence and social interactions.

7. Nausea and Fatigue

Though less common than diarrhea or abdominal pain, nausea and fatigue are significant symptoms that can affect people with microscopic colitis. These symptoms often occur together and can substantially impact daily life.

These symptoms manifest as:

• Persistent feeling of tiredness despite adequate rest
• Lack of energy to perform daily activities
• Queasiness or feeling of wanting to vomit
• Reduced appetite due to nausea
• Difficulty concentrating (sometimes called “brain fog”)
• Need for more frequent rest periods

Fatigue in microscopic colitis has multiple causes. Chronic inflammation itself is exhausting for the body. Additionally, frequent nighttime diarrhea disrupts sleep quality, leading to sleep deprivation and daytime tiredness. Dehydration and electrolyte imbalances also contribute to feelings of weakness and fatigue. Malabsorption of nutrients, particularly B vitamins and iron, can lead to anemia, which further increases fatigue.

Nausea may occur due to the systemic effects of inflammation or as a side effect of the abdominal discomfort and cramping. Some people experience nausea particularly in the morning or after eating. The combination of chronic fatigue and nausea can make it difficult to maintain work productivity, social relationships, and overall quality of life. These symptoms often improve as the underlying inflammation is addressed, but they can persist and require specific attention during management of the condition.

Main Causes and Risk Factors of Microscopic Colitis

The exact cause of microscopic colitis remains unknown, but research suggests it results from a combination of factors that trigger an abnormal immune response in the colon. Understanding potential causes and risk factors can help identify those at higher risk.

Potential causes and contributing factors include:

Autoimmune Response

Microscopic colitis may result from the immune system mistakenly attacking the colon tissue. This is supported by its association with other autoimmune conditions such as celiac disease, rheumatoid arthritis, thyroid disorders, and type 1 diabetes.

Medications

Certain medications have been linked to microscopic colitis, including:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen
• Proton pump inhibitors used for acid reflux
• Selective serotonin reuptake inhibitors (SSRIs) for depression
• Some medications for diabetes and heart conditions

Bacterial Toxins or Infections

Some cases of microscopic colitis develop after bacterial infections or exposure to bacterial toxins in the digestive system. The inflammation may persist even after the infection has cleared.

Bile Acid Malabsorption

Problems with how the intestine absorbs bile acids may contribute to microscopic colitis and its symptoms, particularly diarrhea.

Smoking

Tobacco use, particularly in people with lymphocytic colitis, has been associated with increased risk of developing the condition.

Risk factors for developing microscopic colitis include:

• Age: Most commonly affects people aged 50 and older, though it can occur at any age
• Gender: Women are significantly more likely to develop microscopic colitis than men
• Autoimmune diseases: Having other autoimmune conditions increases risk
• Smoking: Current or former smokers have higher risk
• Family history: Having relatives with microscopic colitis may increase susceptibility
• Celiac disease: Strong association between these two conditions

Frequently Asked Questions About Microscopic Colitis

What is the difference between lymphocytic colitis and collagenous colitis?

Both are types of microscopic colitis with similar symptoms, but they differ in their microscopic appearance. Lymphocytic colitis shows increased lymphocytes (white blood cells) in the colon lining, while collagenous colitis has a thickened layer of collagen beneath the colon’s surface. The symptoms, risk factors, and management approaches are very similar for both types.

Can microscopic colitis go away on its own?

Yes, microscopic colitis can sometimes go into remission spontaneously without treatment. However, symptoms often recur, and the condition typically follows a pattern of flare-ups and periods of improvement. The unpredictable nature of the condition makes medical evaluation and monitoring important even during symptom-free periods.

How is microscopic colitis diagnosed?

Microscopic colitis cannot be diagnosed through standard colonoscopy images alone, as the colon typically appears normal to the naked eye. Diagnosis requires taking small tissue samples (biopsies) during colonoscopy and examining them under a microscope. This is why it’s called “microscopic” colitis—the inflammation is only visible at the microscopic level.

Is microscopic colitis serious or life-threatening?

Microscopic colitis is not considered life-threatening and does not increase the risk of colon cancer. However, it can significantly affect quality of life due to chronic symptoms. The main complications relate to dehydration, electrolyte imbalances, and weight loss, which can be serious if not addressed but are generally manageable with appropriate care.

Can diet changes help with microscopic colitis symptoms?

Many people find that certain dietary modifications can help manage symptoms. Common strategies include avoiding caffeine, dairy products, artificial sweeteners, and fatty foods. Some people benefit from a low-fat diet or eliminating gluten. However, dietary triggers vary from person to person, so it’s helpful to keep a food diary to identify personal triggers and work with a healthcare provider or dietitian.

Is microscopic colitis the same as irritable bowel syndrome (IBS)?

No, these are different conditions. IBS is a functional disorder with no visible inflammation, while microscopic colitis involves actual inflammation of the colon that can be seen under a microscope. However, the symptoms can be similar, which sometimes leads to misdiagnosis. A colonoscopy with biopsy is necessary to distinguish between the two conditions.

Will I need surgery for microscopic colitis?

Surgery is rarely needed for microscopic colitis. The condition typically responds well to dietary modifications and other management strategies when needed. Surgery is only considered in extremely rare cases when symptoms are severe and don’t respond to any other approaches.

Can stress make microscopic colitis worse?

While stress doesn’t cause microscopic colitis, it can trigger flare-ups or worsen existing symptoms, similar to other digestive conditions. The relationship between the gut and brain is complex, and emotional stress can affect gut function. Managing stress through relaxation techniques, exercise, or counseling may help some people control their symptoms better.

References:

• Mayo Clinic – Microscopic Colitis
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
• Johns Hopkins Medicine – Microscopic Colitis
• National Center for Biotechnology Information (NCBI)
• Crohn’s & Colitis Foundation