Microscopic Colitis is an increasingly recognised cause of chronic watery diarrhoea, yet it remains frequently underdiagnosed. With growing research interest and improved awareness, the ECCO Microscopic Colitis Working Group (MCWG) is playing a central role in advancing the field. We spoke with Andreas Münch about the evolving landscape of Microscopic Colitis, current challenges and future priorities.
Microscopic Colitis has long been considered a “hidden” condition. Is it finally stepping out of the shadows, or is it still largely underrecognised in daily practice?
Microscopic Colitis is often described as a “hidden” or even “invisible” disease—and for good reason. There are no visible clinical signs, laboratory values and imaging are typically unremarkable and even colonoscopy often appears normal. Diagnosis depends entirely on histology.
Although awareness has improved over the past two decades, I believe the disease remains underdiagnosed. Many patients are still not referred for colonoscopy with biopsies, which is essential for detection. Increasing awareness, also among general practitioners, is therefore key.
You are leading the ECCO MCWG at a time of growing interest in the disease. What is the vision driving the MCWG today?
Our main goal is to position Microscopic Colitis within the broader spectrum of Inflammatory Bowel Diseases. While IBD is traditionally associated with Crohn’s Disease and Ulcerative Colitis, Microscopic Colitis should also be recognised as part of this continuum.
This perspective allows us to better understand shared mechanisms and differences across diseases, ultimately improving both research and patient care. It also highlights the true burden of IBDs—if Microscopic Colitis is included, prevalence becomes even more significant.
Collaboration across ECCO Committees is central to achieving this vision.
What do you consider the most important shift in how we understand or manage Microscopic Colitis compared to a decade ago?
There has been remarkable progress. Since the establishment of the European Microscopic Colitis Group (EMCG) in 2010, we have developed European guidelines, increased disease awareness and introduced patient-reported outcome measures.
At the same time, research has expanded into areas such as genetics, microbiome and proteomics. Although the field is still smaller than that of classical IBD, the knowledge base is growing rapidly. That said, important gaps remain, particularly in long-term management and treatment optimisation.
Despite its increasing recognition, many aspects of Microscopic Colitis remain unclear. Where do you see the biggest knowledge gaps?
Several areas require further work. Epidemiological data are still lacking in many regions, although some countries report incidence rates even higher than those of classical IBD.
We also need a better understanding of environmental triggers and reliable biomarkers. Even histological definitions are evolving, as some patients with chronic diarrhoea fall outside current diagnostic thresholds but could have incomplete Microscopic Colitis.
From a therapeutic perspective, we are entering a new era. While budesonide remains the cornerstone of treatment, early data suggest that biological therapies and especially JAK inhibitors are effective in severe cases. Establishing a European registry will be an important step to better characterise these approaches.
The MCWG brings together clinicians and researchers across Europe—how is this collaborative model helping to move the field forward?
Collaboration is essential, particularly for translational research. Understanding disease mechanisms at a molecular level will help identify new therapeutic targets and possibly preventive strategies.
Importantly, we are increasingly recognising similarities with classical IBD at the molecular level. This reinforces the concept of Microscopic Colitis as part of the IBD spectrum and strengthens opportunities for cross-disciplinary research.
If you could change one thing tomorrow in how Microscopic Colitis is approached—whether in research, diagnosis or care—what would it be?
I would love clinicians to take Microscopic Colitis more seriously.
Even without alarm features such as bleeding or cancer risk, the disease has a profound impact on quality of life. Symptoms like urgency can be extremely debilitating.
We need to listen more carefully to our patients, recognise the burden of the disease and manage it proactively. Patients with Microscopic Colitis deserve the same level of attention and care as those with other forms of IBD.
Thank you, Andreas. Good luck and enjoy the work with the Microscopic Colitis Work Group.
