Study Exposes Treatment Gaps in Microscopic Colitis Care

Microscopic colitis hides in plain sight. It causes chronic diarrhea, but the disease itself remains poorly understood, and the people who have it often don't know they do. A new study from the University of North Carolina reveals just how broken the system is: patients leave their colonoscopy without understanding their diagnosis, doctors don't prescribe the standard treatment, and a year later, many are still sick.

Walker Redd, a clinical fellow in gastroenterology at UNC, led research that followed 74 patients with biopsy-confirmed microscopic colitis and 162 others with chronic diarrhea from other causes. All had undergone colonoscopy between April 2015 and December 2020. A year later, the researchers surveyed them. What they found was startling: one in ten microscopic colitis patients didn't even know they had the disease. Some had received only a letter or a phone call with their pathology results—no conversation, no explanation of what came next.

The communication failures extended further. Among the control group—people with diarrhea from other sources—seven percent reported having microscopic colitis despite no clinical documentation of it. Another fifteen percent of controls thought they might have it or were simply unsure. The researchers noted that patients with a new microscopic colitis diagnosis might benefit from a follow-up appointment in the gastroenterology clinic, where a doctor could explain what the diagnosis meant and discuss treatment options. Instead, many patients were left to figure it out alone.

Treatment gaps were equally stark. The first-line therapy for microscopic colitis is budesonide, a corticosteroid that reduces inflammation in the colon. Yet only forty-six percent of microscopic colitis patients received it. Among the control group with diarrhea severe enough to warrant colonoscopy, just twenty-six percent were offered any prescription treatment at all. Redd expressed surprise at this finding: patients who remained symptomatic weren't being treated with medication, which suggested a fundamental disconnect between diagnosis and care.

The symptoms themselves are relentless. Microscopic colitis causes watery diarrhea, abdominal pain, an urgent need to have a bowel movement, fecal incontinence, and weight loss. A year after colonoscopy, the study found that forty percent of microscopic colitis patients still experienced fecal urgency, twenty-eight percent had abdominal pain, thirty-two percent reported weight loss, and twenty-one percent dealt with fecal incontinence. Fifteen percent had nocturnal stools—waking at night to use the bathroom. These are not minor inconveniences. They disrupt sleep, work, and daily life.

What made the findings more complex was that symptom overlap between microscopic colitis and other causes of chronic diarrhea—particularly irritable bowel syndrome—makes reliable diagnosis difficult for providers. The disease is easy to miss or confuse with something else. Yet the study showed that patients with confirmed microscopic colitis did improve over the year, whether or not they received budesonide. Among the control group, however, only thirty-seven percent showed improvement on the Microscopic Colitis Disease Activity Index, a tool that measures disease severity and quality of life. For many of them, symptoms stayed the same or worsened.

Redd and his team concluded that colonoscopy should be considered for patients with diarrhea who don't respond to initial treatment or who carry higher risk for microscopic colitis. More importantly, they emphasized that follow-up appointments, patient education, and clear communication about diagnosis and management are essential. Right now, the system is failing patients at the moment they need help most—when they've just learned they have a chronic disease and need to understand what to do about it.