Clinical Gastroenterology and Hepatology 2014;-:1

LETTER TO THE EDITOR Readers are encouraged to write letters to the editor concerning articles that have been published in Clinical Gastroenterology and Hepatology. Short, general comments are also considered, but use of the Letters to the Editor section for publication of original data in preliminary form is not encouraged. Letters should be typewritten and submitted electronically to http://www. editorialmanager.com/cgh.

Diagnosing Microscopic Colitis: Is Flexible Sigmoidoscopy a Reliable Alternative to Colonoscopy? Dear Editor: We read with interest the excellent review of microscopic colitis by Münch et al.1 In line with the recommendations of the European Microscopic Colitis Group, the authors stated the diagnostic importance of taking multiple biopsy specimens throughout the whole colon, citing the potential risk of missed cases with sigmoid and/or rectal biopsy specimens alone. Although it is clear that microscopic colitis frequently will be missed with rectal biopsy specimens alone, a number of large studies have shown that biopsy specimens taken from the left colon were diagnostic for both collagenous and lymphocytic colitis in more than 95% of cases.2–5 Although a recent study by Aust et al6 suggested that there was improved detection of collagenous band thickening, present in collagenous colitis, in biopsy specimens from the ascending colon/cecum compared with the descending colon, the absolute percentage difference in detection was only 5.3%. Interestingly, lymphoplasmacytic infiltrates, although not specific for microscopic colitis, were distributed evenly throughout the colon and still could be detected in more than 98% of sigmoid and descending colonic biopsy specimens. The high diagnostic yield of left-sided biopsy specimens is important because it follows that a good-quality flexible sigmoidoscopy, with a biopsy series including the descending colon, will reliably confirm a suspected diagnosis of microscopic colitis. We agree that colonoscopy should remain the gold standard, but suggest there may be a subset of patients in whom flexible sigmoidoscopy is preferable. Most notably, a significant proportion of patients with microscopic colitis are elderly and this group may be less likely to tolerate a full colonoscopy. Indeed, accumulating evidence suggests that patients

older than age 65 (particularly those 80 y) are at higher risk of complications from colonoscopy including both direct gastrointestinal injury and cardiovascular/ pulmonary morbidity.7 We therefore suggest that in patients in whom colonoscopy is considered a higher risk, or who decline full colonoscopy, flexible sigmoidoscopy may represent a reliable alternative for the diagnosis of microscopic colitis. THOMAS P. CHAPMAN, MBBS, MRCP Translational Gastroenterology Unit John Radcliffe Hospital University of Oxford Oxford, United Kingdom GEORGE MACFAUL, BMBS, FRCP Department of Gastroenterology Milton Keynes Hospital NHS Foundation Trust Milton Keynes, United Kingdom ANN ABRAHAM, MBBS, FRCPath Department of Histopathology Milton Keynes Hospital NHS Foundation Trust Milton Keynes, United Kingdom

References 1.

Münch A, et al. Clin Gastroenterol Hepatol 2014 (Epub ahead of print).

2.

Bjornbak C, et al. Aliment Pharmacol Ther 2011;34:1225–1234.

3.

Matteoni CA, et al. Am J Med 2000;108:416–418.

4.

Fine KD, et al. Gastrointest Endosc 2000;51:318–326.

5. 6.

Palmer RM, et al. Gut 2009;58:A131–A132. Aust DE, et al. Gastroenterology 2013;144:S-421(Su1183).

7.

Day LW, et al. Gastrointest Endosc 2011;74:885–896.

Conflicts of interest The authors disclose no conflicts. http://dx.doi.org/10.1016/j.cgh.2014.08.033

Diagnosing microscopic colitis: is flexible sigmoidoscopy a reliable alternative to colonoscopy?

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