Patient's Query
Hello doctor,
My son is 7 years old and has been diagnosed with collagenous colitis. He is taking Budesonide every day in the afternoon. However, his health is not improving. Is it because he had been taking Budesonide in the afternoon instead of the morning? Why is it important to take it in the morning?
Please help.
Hello,
Welcome to icliniq.com.
I went through your query and understood your concern.
I am reviewing your case history and will get back to you in a while.
Thank you.
Patient's Query
Hello,
Thanks for your reply.
The doctor suggested a colonoscopy and biopsy for the diagnosis. True collagenous colitis is uncommon for 7-year-old boys. What to do?
Please help.
Hello,
Welcome back to icliniq.com.
I understand your concern.
Budesonide should work well in the afternoon also. There is no difference in its effect based on the timings. The natural cycle of human steroids would be affected if the medication is given at night. I suggest you visit a local physician for a physical evaluation.
Hope this helps.
Thank you.
Patient's Query
Hello doctor,
Thanks for replying.
My son has developed itchiness, strange rashes, and also bruises. The doctor suggested he might be allergic to Budesonide. I am scared. What could it be?
Please help.
Hello,
Welcome back to icliniq.com.
I can understand your concern.
It is less likely to develop an allergy due to Budesonide. Usually, the patient is allergic to the initial dose of medicine. An allergy test is always carried out before taking this medication. After a couple of weeks, the onset of the rash is not a drug allergy. It should be evaluated properly. There is a good possibility that he might had a superimposed infection due to steroids. Because steroids act as immunity-suppressant agents.
I think you should continue treatment with Budesonide and your child should be physically examined by a specialist doctor for physical evaluation.
Hope it helps.
Thank you.
Patient's Query
Hello doctor,
Thanks for replying.
He has hives, an itching body, and a bruise. The bruise is not resolving. The hives come and go. Why so?
Please help.
Hello,
Welcome back to icliniq.com.
I understand your concern.
As I mentioned, a steroid allergy is relatively less likely, as he had been taking steroids for a couple of weeks.
It can be an allergy to anything else, like food or any other medicine.
Another possibility is a superimposed skin infection in patients on steroids.
These points can be sorted out after a detailed history and physical examination of the baby.
I hope this information will help you.
Thank you.
Patient's Query
Hi doctor,
Thank you for the reply.
We consulted with my son's gastroenterologist, who agrees that this might be a side effect rather than an allergy. Therefore, we continued giving him Budesonide 6 mg daily, but it has yet to be effective.
To clarify, my son, who is six years old, began taking Budesonide 6 mg daily to treat collagenous colitis. Initially, we administered it for two weeks at 6 mg daily between 1 and 4 pm, unaware that it should be taken in the morning. Subsequently, he became very ill and required antibiotics for 10 days.
His Budesonide dosage was reduced to 3 mg daily, administered at 5 pm during this period. After ten days, we resumed the 6 mg dosage of Budesonide. This was three weeks ago.
I administered it for the first two weeks between 1 and 3 pm, and since one week ago, I have switched to morning administration. So, he was on 6 mg for two weeks, then 3 mg for 10 days, and now back on 6 mg for four weeks. However, he is still not showing improvement.
What would you recommend in this situation?
Please suggest.
Thanks.
Hello,
Welcome back to icliniq.com.
I understand your concern.
Budesonide should be continued for the time being, but close monitoring is crucial. In some patients, there may be a relatively delayed response. Suppose there is still no improvement after another two weeks.
In that case, his colonoscopic biopsy report should be reviewed again in a hospital multidisciplinary team (MDT) meeting to confirm the diagnosis or to investigate additional issues. If the diagnosis remains the same, we may need to escalate treatment by transitioning to a more potent immunosuppressive medication. Specifically, what symptoms is he experiencing?
I hope this information will help you.
Thanks.
Patient's Query
Hi doctor,
Thank you for the reply.
So, he has only improved by around 20 percent. He still experiences watery diarrhea both during the day and at night, along with stomach pain. Essentially, all his symptoms persist, albeit slightly improved compared to before. I am curious about one thing: how did reducing the dosage to half for ten days impact his treatment?
Initially, he received 6 mg for two weeks, then 3 mg for ten days, and finally back to 6 mg for the past three weeks. Does this mean we essentially restarted the treatment three weeks ago? How did the reduced dosage affect his condition? Do you think adding Budesonide foam to his treatment regimen would be beneficial?
There has already been a meeting at the hospital regarding my son's case. All the gastroenterologists, including the manager, convened to review the biopsies because he is the first child here to be diagnosed with this condition. It is a challenging situation; the doctors are pediatric gastroenterology specialists and have not encountered collagenous colitis in children before.
Therefore, it is valuable to seek your expertise to supplement the information and obtain a second opinion. It took us two years to receive the diagnosis, and during this time, he has been suffering. I have consulted with many doctors, but you are the first one who has instilled confidence in us with your extensive knowledge.
Thanks.
Hello,
Welcome back to icliniq.com.
I understand your concern.
If there is something significant, I believe one should wait a little longer, perhaps around two weeks, to observe his response. While we typically adhere to a specific pattern and dosage of Budesonide, it is not uncommon to adjust the dose based on the patient's response or the development of superimposed infections.
If you are referring to the rectal form, it is more tailored for distal colon involvement. However, since collagenous colitis is a diffuse pathology, I would recommend sticking with the systemic (oral) form of Budesonide, which he is already receiving.
Since they have already convened a meeting and are now well-informed about the case, I anticipate a relatively slow response, but treatment should be continued without immediately opting for strong immunosuppressive medications. Mesalazine is an anti-inflammatory drug that could offer some relief, especially when combined with Budesonide.
I suggest discussing this option with your treating physician, as Mesalazine has minimal side effects and is typically a first-line treatment for ulcerative colitis, but it also works for microscopic colitis.
I hope this information will help you.
Thanks.
Patient's Query
Hi doctor,
Thank you for the reply.
Please answer a few questions:
Thanks.
Hello,
Welcome back to icliniq.com.
I understand your concern.
If there is more inflammation within the distal colon, such as in the rectum or rectosigmoid area, then enemas would be beneficial (this refers to the rectal form of treatment). Otherwise, oral treatment would suffice. I do not see significant benefits with enemas if the disease is diffuse and not primarily localized in the distal colon. Regarding cholestyramine, I would not recommend combining it with Budesonide, especially if it has already been tried without success. Instead, I would suggest trying Mesalazine in combination with Budesonide.
I hope this information will help you.
Thanks.
Patient's Query
Hi doctor,
Thank you for the reply.
We spoke with his doctor, and as you suggested, we will continue the high dose of Budesonide for another two weeks. Doctor, he will have been on a high dose of Budesonide for seven weeks. Is not that concerning for his health? He has begun experiencing hair loss. Will his hair grow back in the future when we stop the medication?
Thanks.
Hello,
Welcome back to icliniq.com.
I understand your concern.
Nothing is 100 percent safe; when treating difficult cases, there will always be a risk versus benefits assessment. Patients often use steroids for extended periods. This dosage and duration are not unusual. Hair loss is not a very common side effect; other causes and autoimmune diseases should be ruled out. If it is determined to be secondary to steroids, it should grow back once the treatment is discontinued.
I hope this information will help you.
Thanks.
Patient's Query
I now have the results from the biopsy, which were taken during a meeting involving all the gastroenterologists regarding my son's case: Gastroscopy and colonoscopy revealed no macroscopic findings in the lower half of the colon.
Biopsy results indicate intermittently thickened subepithelial collagen in the colon, specifically from the left flexure to the rectum. The appearance is consistent with collagenous colitis.
Do you still believe that Budesonide is a better option than rectal foam?
Can Budesonide effectively treat my son if collagenous colitis is observed in the left flexure of the rectum?
Why do you think the doctors did not initially prescribe a combination of both Budesonide and rectal foam?
My son has been on a high dosage of Budesonide for seven weeks. If there is no improvement after one more week, they plan to change the approach. They will continue with Budesonide but at a reduced dosage of 3 mg, and they will introduce rectal foam at 2 mg, totaling a steroid dosage of 5 mg.
He is only seven years old and weighs 37 pounds. Do you think it is wise to wait one more week with the high dose of Budesonide before starting the combination therapy? Why is waiting beneficial, considering the cumulative steroid intake during this time?
Please help.
Hello,
Welcome back to icliniq.com.
Rectal forms of steroids are typically effective in cases of distal disease, such as involvement limited to the rectum. Technically, when administering rectal enemas, they may not reach upwards to the left flexure of the colon, which is more than 25 to 30 inches away from the anal verge.
While I am not against rectal enemas, in your son's case, they may effectively treat the rectum, but reaching 30 inches against the natural flow seems unlikely. This is not a major change in management.
I mean, high doses of systemic steroids (oral or intravenous) are more effective than local forms (rectal). However, this additional treatment could be considered to help reduce the dosage of oral steroids.
I understand your concern about using steroids in a young child. Steroids always present a double-edged sword in all patients; they are essential for treating diseases, but can also have side effects. Budesonide is the safest option, and considering your son's lengthy history and challenging diagnosis, it is important to bear in mind what you are battling in terms of the disease. Steroids are the best option for him; other immunosuppressive drugs have significant side effects.
I understand this is a difficult time for you and your family, but it is important to stay calm to make better decisions.
Wishing him good health.
Patient's Query
Hello doctor,
Please check our earlier conversation regarding my seven-year-old son's diagnosis of collagenous colitis. Two weeks ago, his doctor decided to reduce his oral Budesonide dosage from 6 mg to 3 mg once every morning. She also suggested trying rectal foam, which, as you advised, did not provide any relief.
We began administering it every evening two weeks ago, and after one week, we reduced it to every other day. Tomorrow will be his last dose of rectal foam, and we will not continue with it anymore. He has been on oral Budesonide for ten weeks now. Two weeks ago, we started giving him 3 mg every morning instead of 6 mg.
My question is, when can we completely stop the medication once we have started reducing the dosage? How long should he continue taking 3 mg? His doctor has been away for a month, and perhaps you can provide some guidance.
Please help.
Hello,
Welcome back to icliniq.com.
I understand your concern.
Low-dose Budesonide should be continued for the time being. Stool tests, such as fecal calprotectin levels, monitoring the number of stools per day, and clinical examinations of the child, will indicate when to discontinue the medication entirely. If he is responding well, the low dose may need to be continued for a couple of weeks more.
I hope this information will help you.
Thanks.
Patient's Query
Hello doctor,
Typically, how do you discontinue oral Budesonide when a patient has recovered? For my son, for example, we reduced the dosage from 6 mg to 3 mg two weeks ago. When can he stop taking it completely? Should he continue for two more weeks and then stop altogether? Or should we start giving him one tablet every other day now and then stop after two weeks?
I am asking because I understand that with steroids, it is important to taper off gradually. We will, of course, discuss this with the doctor, but I also value your input. So far, you have been right about everything you have advised us.
Please help.
Hello,
Welcome back to icliniq.com.
I understand your concern.
You are correct, we gradually discontinue steroids by tapering the dosage. In your son's case, we are not addressing any infection; it is an autoimmune process (suppressing immunity with Budesonide will improve his condition). Budesonide is among the best options with minimal systemic side effects.
Now, regarding your question: You should maintain this low dosage for now. For further tapering, I suggest alternating days of Budesonide. However, it should be continued until your son is seen by his primary doctor.
This is important for a clinical examination of the child, monitoring the number of stools in 24 hours, and assessing inflammatory markers in stools, such as fecal calprotectin levels. These factors will help us decide whether to completely stop this medication.
Typically, patients remain asymptomatic after discontinuing medication for a considerable period. Yes, there is a chance of symptom recurrence as it is an autoimmune issue, not an infection. It is advisable to continue some good probiotics. Sometimes, with the passage of time and increasing age in young children, these issues resolve to some extent on their own.
I hope this information will help you.
Thanks.
Patient's Query
Hi doctor,
It would help if you continue this low dose now for further tapering. I suggest alternating days of Budesonide. How many more weeks should we take 3 mg before further tapering? And what do you mean by alternating days of Budesonide? His fecal calprotectin is normal; it has always been normal. His doctor mentioned that since collagenous colitis is not an infection, the calprotectin levels tend to remain normal. However, we will still consult the doctor and not make any decisions without their guidance. The issue is that his doctor is on vacation, and I wanted some advice on tapering next. Your information is beneficial and will facilitate our discussion with his doctor.
Hello,
Welcome back to icliniq.com.
I understand your concern.
He has been on a 3 mg daily dose for the past two weeks, and if he is responding well, I believeit should be continued for another two weeks. We can then transition to alternate days (one day on, one day off) for approximately two weeks. Then, we can reduce it to twice weekly for about a week before discontinuing it altogether. If his fecal calprotectin was normal before, it should also remain normal now. Therefore, the decision regarding stopping the medication will be based on his clinical response.
I hope this information will help you.
Patient's Query
Hi doctor,
Thanks for the reply.
I am contacting you now regarding my daughter, who is four years old. She has been experiencing constipation and stomach pain for the past one and a half years. One year ago, we conducted the calprotectin test and TGA (tissue transglutaminase) test for celiac disease, and everything was fine. However, her grandmother and many relatives on my husband's side have celiac disease. Nonetheless, over the past four months, her constipation and pain have worsened. We conducted a new calprotectin test, which showed a level of 69 μg/g, and her HLA (human leukocyte antigen) type test showed positivity for DQ2. With the elevated calprotectin level, family history of celiac disease, and my son's diagnosis of microscopic colitis, we are concerned about her health.
What could be the cause of these symptoms? What should be our next step? I am asking because I currently live abroad, and accessing a gastroenterologist promptly is difficult in this country due to government ownership of medical facilities. It took my son two years to receive proper care due to these constraints. Could delaying diagnosis pose risks to her health? Unfortunately, we have to wait at least one year to see a specialist gastroenterologist here.
Thanks.
Hello,
Welcome back to icliniq.com.
I understand your concern.
Constipation is not a typical feature of celiac disease; rather, it typically presents with altered bowel habits, predominantly loose stools, and bloating, triggered by wheat or wheat-related products. Abdominal pain is again a nonspecific symptom with multiple potential causes, including simple constipation; it cannot be directly linked to celiac disease. Raised fecal calprotectin is merely an inflammatory marker and is non-specific; it does not contribute to the diagnosis of celiac disease.
Being HLA-DQ positive does not necessarily indicate that a patient has celiac disease; it suggests that a few people may develop celiac disease. In her case, I would recommend testing for TTG IgA levels (tissue transglutaminase immunoglobulin A levels) and anti-DGP (deamidated gliadin peptide) antibodies. If both tests are negative, it is less likely that she is suffering from celiac disease.
Children commonly experience abdominal pain due to constipation. It is advisable to increase her water and fiber intake to help with constipation. Additionally, monitor her weight and check her blood for hemoglobin levels. If she is not anemic and the above two suggested tests are normal, celiac disease is very unlikely.
I hope your queries are resolved, and any further queries are welcome.
Thank you.
Patient's Query
Hi doctor,
Thanks for the reply.
My daughter's stool for four weeks is slimy mucus and bloody stool. She has had a lot of IBD symptoms. My son has IBD, and my daughter also has a lot of stomach pain. Calprotectin was positive at 69. Does this stool look like IBD? Is that red blood in stool? We Will, of course, go to the doctor for further investigation regarding her condition.
Thanks.
Hello,
Welcome back to icliniq.com.
I understand your concern.
1) It is difficult to tell IBD by seeing at stool sample.
2) This seems to be brown stool to me.
3) Faecal calprotectin is not very high or in range of IBD.
I hope this information will help you.
Thanks.
Patient's Query
Hello doctor,
I have a question about my 5-year-old daughter, who is scheduled for an endoscopy in 6 days to check for celiac disease. She has been eating a varied diet without excluding gluten, but there are days when she only craves rice and stews, which don't contain gluten. I recently learned that she should have been eating gluten daily for 14 days before the endoscopy, but she hasn't. Over the past week, I have noticed that on Saturday, Sunday, and Monday, she didn't consume any gluten. However, on other days, she has. With six days left until the procedure, I'm planning to ensure she eats gluten daily. My concern is, will the results still be accurate, given that she missed 3 out of the 14 days of gluten consumption before the endoscopy?
Please help.
Hello,
Welcome back to icliniq.com.
Yes, you can reintroduce gluten into her diet. It may cause some symptoms like bloating or diarrhea, which is part of the gluten challenge.
If the diagnosis is uncertain and the patient has already been on a gluten-free diet, tests may come back negative, leading to more confusion. To avoid this, gluten is typically included for 2-4 weeks to trigger a hypersensitivity reaction. This ensures that both blood tests and the duodenum biopsy provide more conclusive results. Missing gluten for three days is not a problem.
For now, continue her gluten intake until the endoscopy and biopsy. Wishing her good health.
Kind regards.
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