Lymphocytic Colitis in Nigeria: A Case Series 

Aderemi Oluyemi1, Martins Momoh2, Emuobor Odeghe3, Samuel Keshinro4

1. ReMay Consultancy & Medical Services, Ikeja, Lagos, Nigeria
2. Department of Morbid Anatomy, Lagos University Teaching Hospital, Lagos, Nigeria
3. Department of Medicine, College of Medicine, University of Lagos, Lagos, Nigeria
4. Arrive Alive Diagnostics and Imaging Services, Lagos, Nigeria                 

Correspondence to: Dr. Oluyemi Aderemi. Email: remioluyemi@yahoo.com 

Received: 28 October 2020 ; Revised: 6 February 2021 ; Accepted: 22 March 2021 ; Available online: 22nd April 2021 

Summary 

The term “microscopic colitis” (MC) is used to describe a chronic inflammatory bowel disease that includes two main subtypes based on histopathologic features: collagenous and lymphocytic. Scientific literature is replete with documentation of the disease from various regions of the world. However, the condition is rarely described in black African patients. We herein present the details of the clinical aspects and endoscopic findings of 3 Nigerian patients with the lymphocytic variant of MC. A short literature review of the clinical, endoscopic, and pathologic features of this rare condition as well as other relevant aspects of MC is also presented.

Keywords: Microscopic colitis, Lymphocytic colitis, Nigeria.


Ann Afr Surg. 2021 ; 18(3): 180-184 
DOI : http://dx.doi.org/10.4314/aas.v18i3.10
Conflicts of Interest: None
Funding: None
© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License 

Introduction

Microscopic colitis (MC) is a known cause of chronic, non-bloody diarrhea. The term itself was first introduced in 1980 by Read et al. (1). The classical description of MC as not having any visible anomaly on colonoscopic examination means that the diagnosis rests on specific histologic findings in colonic biopsies demonstrating either lymphocytic colitis (LC) or collagenous colitis (CC), which are the subtypes of MC (2). It is a disease that affects different nationalities and has varying prevalence rates across the continents (2). However, reports of this condition among black Africans are sparse (3). The reason for this in Nigeria might be related to our limited use of colonoscopy for evaluation of gastrointestinal (GI) disease and the lack of adequate histopathologic infrastructure and personnel for identification of uncommon GI conditions.
However, there has been an increase in the use of colonoscopy across the country. Therefore, as might be expected, there will be an increase in the number of such diagnoses. This article reviewed the database of a private out-patient endoscopy services center in Lagos and aimed to document the important aspects of the cases of histologically diagnosed MC, all of them of the LC sub-type.


Case series

Over the course of 38 months (from February 2016 to April 2019), 400 colonoscopies were carried out at a private endoscopy facility based in Lagos. The biopsy results from these procedures were reviewed, and only 3 cases were diagnosed as MC on histology (Fig. 1). In another instance, the suspicion of LC was raised. Despite an increase in the number of intraepithelial lymphocytes (IELs), this particular case was excluded from this case series because the histologic criterion of having >20 IELs per 100 epithelial cells was not met. The records were then reviewed for relevant clinical data and endoscopic findings in the identified cases.

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Case 1 
A 70-year-old man presented with a 6-month history of passage of watery stools. The rectal wall was markedly edematous and friable, and a longitudinal ulcer was also noted (Fig. 2). The rest of the mucosa lining was observed to be erythematous. Samples from the rectum and random biopsies of the other inflamed parts of the left side were reported as LC.

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Case 2 
A 66-year-old man was referred for his yearly colonoscopy approximately 4 months earlier than his scheduled checkup because of diarrhea. He undergoes annual colonoscopy because part of his colon was surgically removed 2 years prior as treatment for transverse colon cancer. He had no history of radiotherapy. The mucosal lining in the cecum was edematous with associated exuberance of the colonic folds. A striking attenuation to complete absence of the usual vascular markings was observed as well (Fig. 3). Biopsy reports for the cecal samples indicated LC.

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Case 3 
A 50-year-old woman presented with a 4-month history of diarrhea. Long before these bouts of watery stools, she had noticed intermittent drops of blood whenever she strained to pass stools. During colonoscopy, second-degree hemorrhoids with evidence of recent bleeding were observed. The patient’s rectum and rectosigmoid regions were edematous and intensely erythematous as well (Fig. 4); the pattern of exudative hemorrhagic changes in this friable mucosa was reminiscent of barotrauma. The more proximal aspects of the left side of her colon were less intensely inflamed. Histopathology results of the random rectosigmoid biopsies indicated LC.
 

Click to view Figure 4