Difference between revisions of "Inflammatory bowel disease"

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Inflammatory bowel disease (view source)

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*Surveillance biopsies should specify the (anatomical) site - so, it possible to find any site of interest on a follow-up colonoscopy.<ref name=pmid16609751>{{Cite journal  | last1 = Panaccione | first1 = R. | title = The approach to dysplasia surveillance in inflammatory bowel disease. | journal = Can J Gastroenterol | volume = 20 | issue = 4 | pages = 251-3 | month = Apr | year = 2006 | doi =  | PMID = 16609751 | PMC = 2659899}}</ref>
*Surveillance biopsies should specify the (anatomical) site - so, it possible to find any site of interest on a follow-up colonoscopy.<ref name=pmid16609751>{{Cite journal  | last1 = Panaccione | first1 = R. | title = The approach to dysplasia surveillance in inflammatory bowel disease. | journal = Can J Gastroenterol | volume = 20 | issue = 4 | pages = 251-3 | month = Apr | year = 2006 | doi =  | PMID = 16609751 | PMC = 2659899}}</ref>


===Biopsies all submitted it all in one bottle===
===Biopsies all submitted in one bottle===
<pre>
<pre>
COLON (SITE NOT FURTHER SPECIFIED), BIOPSIES:
COLON (SITE NOT FURTHER SPECIFIED), BIOPSIES:
Line 298: Line 298:
==Ulcerative colitis==
==Ulcerative colitis==
*Often abbreviated as ''UC''.
*Often abbreviated as ''UC''.
===General===
{{Main|Ulcerative colitis}}
*May be associated with ''[[toxic megacolon]]''.
 
Epidemiology:
*Associated with ''[[primary sclerosing cholangitis]]''.
*[[Appendicitis]] is considered protective against UC.<ref name=pmid19685454>{{Cite journal  | last1 = Beaugerie | first1 = L. | last2 = Sokol | first2 = H. | title = Appendicitis, not appendectomy, is protective against ulcerative colitis, both in the general population and first-degree relatives of patients with IBD. | journal = Inflamm Bowel Dis | volume =  | issue =  | pages =  | month = Aug | year = 2009 | doi = 10.1002/ibd.21064 | PMID = 19685454 }}</ref><ref name=pmid19273505>{{Cite journal  | last1 = Timmer | first1 = A. | last2 = Obermeier | first2 = F. | title = Reduced risk of ulcerative colitis after appendicectomy. | journal = BMJ | volume = 338 | issue =  | pages = b225 | month =  | year = 2009 | doi =  | PMID = 19273505 }}</ref>
*[[Smoking]] is protective; the opposite is true for [[Crohn's disease]].<ref name=pmid19273505/>
 
===Gross===
*Conventionally considered to be contiguous, i.e. no "skip lesions", with rectal involvement being most severe.
*Dependent on the study one reads... rectal sparing may be seen in 15% of UC patients.<ref>{{cite journal |author=Bernstein CN, Shanahan F, Anton PA, Weinstein WM |title=Patchiness of mucosal inflammation in treated ulcerative colitis: a prospective study |journal=Gastrointest. Endosc. |volume=42 |issue=3 |pages=232-7 |year=1995 |month=September |pmid=7498688 |doi= |url=}}</ref>
 
===Microscopic===
Features:
*Inflammation:
**Active:
***Neutrophils:
****Intraepithelial ([[cryptitis]]).†
****Clusters in crypts ([[crypt abscesses]]).
****Erosions.
**Chronic:
***Architectural distortion.
***Basal plasmacytosis.
***Foveolar metaplasia.
***Paneth cell metaplasia (distal).
**Lack of [[granulomas]].
*Mucin depletion - common in UC.<ref name=pmid2318990>{{Cite journal  | last1 = McCormick | first1 = DA. | last2 = Horton | first2 = LW. | last3 = Mee | first3 = AS. | title = Mucin depletion in inflammatory bowel disease. | journal = J Clin Pathol | volume = 43 | issue = 2 | pages = 143-6 | month = Feb | year = 1990 | doi =  | PMID = 2318990 }}</ref>
 
Notes:
*†Neutrophils are usually numerous in the lamina propria in minimal/mild active inflammation.
*No full wall-thickness inflammation.
*Epithelial apoptosis correlated with inflammation.<ref name=pmid19958058>{{Cite journal  | last1 = Seidelin | first1 = JB. | last2 = Nielsen | first2 = OH. | title = Epithelial apoptosis: cause or consequence of ulcerative colitis? | journal = Scand J Gastroenterol | volume = 44 | issue = 12 | pages = 1429-34 | month =  | year = 2009 | doi = 10.3109/00365520903301212 | PMID = 19958058 }}</ref>
 
DDx:
*[[Crohn's disease]].
*[[Infectious colitis]].
*[[Ischemic colitis]].
*[[Diversion colitis]].
 
===Sign out===
<pre>
SIGMOID COLON, BIOPSY:
- MODERATE ACTIVE COLITIS WITH CHRONIC CHANGES, SEE COMMENT.
- NEGATIVE FOR DYSPLASIA.
 
COMMENT:
No granulomata are identified. The sampled mucosa is diffusely inflamed. Crypt drop-out and
architectural distortion are present.
 
The findings are consistent with inflammatory bowel disease; however, an infectious etiology
should be considered as a possibility.
</pre>
 
<pre>
SIGMOID COLON, BIOPSY:
- MILD ACTIVE COLITIS, SEE COMMENT.
- NEGATIVE FOR DYSPLASIA.
 
COMMENT:
No granulomata are identified.
</pre>
 
<pre>
A. RIGHT COLON, BIOPSY:
- MODERATE ACTIVE COLITIS, SEE COMMENT.
- NEGATIVE FOR DYSPLASIA.
 
B. LEFT COLON, BIOPSY:
- MODERATE-TO-SEVERE CHRONIC ACTIVE COLITIS, SEE COMMENT.
- NEGATIVE FOR DYSPLASIA.
 
COMMENT:
No granulomata are identified. The mucosa is diffusely inflamed. Architectural distortion
is present in the left colon.  The findings are consistent with ulcerative colitis;
however, an infectious etiology should be considered as a possibility.
</pre>
 
<pre>
RECTUM, BIOPSY:
- MODERATE DIFFUSE CHRONIC ACTIVE PROCTITIS.
- NEGATIVE FOR DYSPLASIA.
 
COMMENT:
No definite granulomata are identified. Crypt drop-out is present.
Within the proper clinical context, these are findings of
inflammatory bowel disease.
</pre>
 
====Inactive disease====
<pre>
SIGMOID COLON, BIOPSY:
- CHRONIC COLITIS, SEE COMMENT.
- NEGATIVE FOR ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA.
 
COMMENT:
The sections show chronic changes (basal plasmacytosis, marked crypt architectural
distortion, crypt branching); however, no active colitis is present. Also, lamina propria
neutrophils, which are often easy to identify in an active colitis, are not apparent.
Appreciable numbers of lamina propria eosinophils are present and focally intraepithelial.
No granulomas are identified. Clinical correlation is required.
</pre>
 
====Surveillance====
<pre>
A. ASCENDING COLON, BIOPSY:
- COLONIC MUCOSA WITHOUT APPARENT PATHOLOGY.
- NEGATIVE FOR ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA.
 
B. TRANSVERSE COLON, BIOPSY:
- COLONIC MUCOSA WITHOUT APPARENT PATHOLOGY.
- NEGATIVE FOR ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA.
 
C. DESCENDING COLON, BIOPSY:
- COLONIC MUCOSA WITHOUT APPARENT PATHOLOGY.
- NEGATIVE FOR ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA.
 
D. SIGMOID COLON, BIOPSY:
- COLONIC MUCOSA WITHOUT APPARENT PATHOLOGY.
- NEGATIVE FOR ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA.
 
E. RECTUM, BIOPSY:
- RECTAL MUCOSA WITHOUT APPARENT PATHOLOGY.
- NEGATIVE FOR ACTIVE PROCTITIS.
- NEGATIVE FOR DYSPLASIA.
 
COMMENT:
Morphologically benign lymphoid aggregates are found focally. No granulomas are
identified. Minimal architectural changes are seen focally.
</pre>
 
<pre>
A. CECUM, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.
 
B. ASCENDING COLON, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.
 
C. COLON, HEPATIC FLEXURE, BIOPSY,
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.
 
D. TRANSVERSE COLON, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.
 
E. COLON, SPLENIC FLEXURE, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.
 
F. DESCENDING COLON, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.
 
G. SIGMOID COLON, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.
 
H. RECTUM, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.
 
COMMENT:
No granulomas are identified. Mild architectural distortion is present. No active
inflammation is identified. Scattered mucosal lymphoid nodules with germinal center
formation are present.
</pre>
 
====Granulomas and inflamed crypts - clinically UC====
<pre>
A. CECUM, BIOPSY:
- ACTIVE CECITIS, MILD.
- SMALL MUCOSAL GRANULOMAS, SUPERFICIAL, SEE COMMENT.
- NEGATIVE FOR DYSPLASIA.
 
...
 
COMMENT - PART A:
The small granulomas are mucosal and near, but not all adjacent to, inflamed crypts; this
finding raises the possibility of Crohn's disease. It should be noted that mucosal
granulomas may be seen in ulcerative colitis beside inflamed crypts.
 
COMMENT - GENERAL:
The inflammation is diffuse and chronic changes are seen throughout. Distal paneth cell
metaplasia is present. The diffuse nature of the inflammation would be more in keeping with
ulcerative colitis. Clinical correlation is required.
</pre>
 
====Micro====
The sections show focal intraepithelial neutrophils (cryptitis).  No crypt abscesses are identified. Granulation tissue is present. There is focal Paneth cell metaplasia and foveolar metaplasia. No granulomata are identified.


==Crohn's disease==
==Crohn's disease==
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#CUTE = Colitis of uncertain type or etiology.
#CUTE = Colitis of uncertain type or etiology.
#*Should be reserved for resection specimens only.
#*Should be reserved for resection specimens only.


==Dysplasia in inflammatory bowel disease==
==Dysplasia in inflammatory bowel disease==
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**Generally, pouches are ''not'' used in Crohn's disease.
**Generally, pouches are ''not'' used in Crohn's disease.
*Chronic pouchitis seen in approximately 15% of patients.<ref name=pmid12617884 >{{Cite journal  | last1 = Gionchetti | first1 = P. | last2 = Amadini | first2 = C. | last3 = Rizzello | first3 = F. | last4 = Venturi | first4 = A. | last5 = Poggioli | first5 = G. | last6 = Campieri | first6 = M. | title = Diagnosis and treatment of pouchitis. | journal = Best Pract Res Clin Gastroenterol | volume = 17 | issue = 1 | pages = 75-87 | month = Feb | year = 2003 | doi =  | PMID = 12617884 }}</ref>
*Chronic pouchitis seen in approximately 15% of patients.<ref name=pmid12617884 >{{Cite journal  | last1 = Gionchetti | first1 = P. | last2 = Amadini | first2 = C. | last3 = Rizzello | first3 = F. | last4 = Venturi | first4 = A. | last5 = Poggioli | first5 = G. | last6 = Campieri | first6 = M. | title = Diagnosis and treatment of pouchitis. | journal = Best Pract Res Clin Gastroenterol | volume = 17 | issue = 1 | pages = 75-87 | month = Feb | year = 2003 | doi =  | PMID = 12617884 }}</ref>
*May be assessed by fecal calprotectin.<ref name=pmid18301296>{{Cite journal  | last1 = Johnson | first1 = MW. | last2 = Maestranzi | first2 = S. | last3 = Duffy | first3 = AM. | last4 = Dewar | first4 = DH. | last5 = Forbes | first5 = A. | last6 = Bjarnason | first6 = I. | last7 = Sherwood | first7 = RA. | last8 = Ciclitira | first8 = P. | last9 = Nicholls | first9 = JR. | title = Faecal calprotectin: a noninvasive diagnostic tool and marker of severity in pouchitis. | journal = Eur J Gastroenterol Hepatol | volume = 20 | issue = 3 | pages = 174-9 | month = Mar | year = 2008 | doi = 10.1097/MEG.0b013e3282f1c9a7 | PMID = 18301296 }}</ref>
*May be assessed by [[fecal calprotectin]].<ref name=pmid18301296>{{Cite journal  | last1 = Johnson | first1 = MW. | last2 = Maestranzi | first2 = S. | last3 = Duffy | first3 = AM. | last4 = Dewar | first4 = DH. | last5 = Forbes | first5 = A. | last6 = Bjarnason | first6 = I. | last7 = Sherwood | first7 = RA. | last8 = Ciclitira | first8 = P. | last9 = Nicholls | first9 = JR. | title = Faecal calprotectin: a noninvasive diagnostic tool and marker of severity in pouchitis. | journal = Eur J Gastroenterol Hepatol | volume = 20 | issue = 3 | pages = 174-9 | month = Mar | year = 2008 | doi = 10.1097/MEG.0b013e3282f1c9a7 | PMID = 18301296 }}</ref>
*Considered a clinico-pathologic diagnosis.<ref name=pmid20958905>{{Cite journal  | last1 = Royston | first1 = DJ. | last2 = Warren | first2 = BF. | title = Are we reporting ileal pouch biopsies correctly? | journal = Colorectal Dis | volume = 13 | issue = 11 | pages = 1285-9 | month = Nov | year = 2011 | doi = 10.1111/j.1463-1318.2010.02452.x | PMID = 20958905 }}</ref><ref name=pmid12617884 >{{Cite journal  | last1 = Gionchetti | first1 = P. | last2 = Amadini | first2 = C. | last3 = Rizzello | first3 = F. | last4 = Venturi | first4 = A. | last5 = Poggioli | first5 = G. | last6 = Campieri | first6 = M. | title = Diagnosis and treatment of pouchitis. | journal = Best Pract Res Clin Gastroenterol | volume = 17 | issue = 1 | pages = 75-87 | month = Feb | year = 2003 | doi =  | PMID = 12617884 }}</ref>
*Considered a clinico-pathologic diagnosis.<ref name=pmid20958905>{{Cite journal  | last1 = Royston | first1 = DJ. | last2 = Warren | first2 = BF. | title = Are we reporting ileal pouch biopsies correctly? | journal = Colorectal Dis | volume = 13 | issue = 11 | pages = 1285-9 | month = Nov | year = 2011 | doi = 10.1111/j.1463-1318.2010.02452.x | PMID = 20958905 }}</ref><ref name=pmid12617884 >{{Cite journal  | last1 = Gionchetti | first1 = P. | last2 = Amadini | first2 = C. | last3 = Rizzello | first3 = F. | last4 = Venturi | first4 = A. | last5 = Poggioli | first5 = G. | last6 = Campieri | first6 = M. | title = Diagnosis and treatment of pouchitis. | journal = Best Pract Res Clin Gastroenterol | volume = 17 | issue = 1 | pages = 75-87 | month = Feb | year = 2003 | doi =  | PMID = 12617884 }}</ref>
===Microscopic===
===Microscopic===
Michael
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