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Difference between revisions of "Ischemic colitis"
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{{ Infobox diagnosis | {{ Infobox diagnosis | ||
| Name = {{PAGENAME}} | | Name = {{PAGENAME}} | ||
| Image = Ischemic_colitis_-_high_mag.jpg | | Image = Ischemic_colitis_-_high_mag.jpg | ||
| Width = | | Width = | ||
| Caption = Ischemic colitis. [[H&E stain]]. | | Caption = Ischemic colitis. [[H&E stain]]. | ||
| Micro = withering crypts (colonic epithelium has decreased cytoplasm - NC ratio increased, usually with decreased goblet cells), crypt loss/drop-out, lamina propria hyalinization, submucosa hyalinization, +/-pseudomembranes, +/-vascular thrombi | | Micro = withering crypts (colonic epithelium has decreased cytoplasm - NC ratio increased, usually with decreased goblet cells), crypt loss/drop-out, lamina propria hyalinization, submucosa hyalinization, +/-pseudomembranes, +/-vascular thrombi, +/-cryptitis | ||
| Subtypes = | | Subtypes = | ||
| LMDDx = [[inflammatory bowel disease]], [[radiation colitis]], toxins/drugs, [[infectious colitis]] | | LMDDx = [[inflammatory bowel disease]], [[radiation colitis]], toxins/drugs, [[infectious colitis]] | ||
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Features: | Features: | ||
*Withering crypts - '''important'''. | *Withering crypts - '''important'''. | ||
**Colonic epithelium has decreased cytoplasm - NC ratio increased. | **Colonic epithelium has decreased cytoplasm - [[NC ratio]] increased. | ||
**Usually with decreased goblet cells. | **Usually with decreased goblet cells. | ||
*Crypt loss/drop-out. | *Crypt loss/drop-out. | ||
| Line 86: | Line 86: | ||
**Dense pink material replaces loose connective tissue. | **Dense pink material replaces loose connective tissue. | ||
*Submucosa hyalinization. | *Submucosa hyalinization. | ||
*+/-[[Cryptitis]].<ref name=pmid11175639>{{Cite journal | last1 = Zhang | first1 = S. | last2 = Ashraf | first2 = M. | last3 = Schinella | first3 = R. | title = Ischemic colitis with atypical reactive changes that mimic dysplasia (pseudodysplasia). | journal = Arch Pathol Lab Med | volume = 125 | issue = 2 | pages = 224-7 | month = Feb | year = 2001 | doi = 10.1043/0003-9985(2001)1250224:ICWARC2.0.CO;2 | PMID = 11175639 }}</ref> | |||
*+/-Pseudomembranes (microscopic):<ref name=Ref_PBoD837-8>{{Ref PBoD|837-8}}</ref> | *+/-Pseudomembranes (microscopic):<ref name=Ref_PBoD837-8>{{Ref PBoD|837-8}}</ref> | ||
**Loss of surface epithelium. | **Loss of surface epithelium. | ||
**[[PMN]]s in lamina propria. | **[[PMN]]s in lamina propria. | ||
**+/-Capillary fibrin thrombi. | **+/-Capillary fibrin thrombi. | ||
*+/-Reactive epithelial changes - may mimic dysplasia.<ref name=pmid11175639/> | |||
Notes: | |||
*Pseudomembranes arise from the crypts - considered ''acute''. | *Pseudomembranes arise from the crypts - considered ''acute''. | ||
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**[[NSAID]] overdose.<ref name=pmid11736840>{{Cite journal | last1 = Appu | first1 = S. | last2 = Thompson | first2 = G. | title = Gangrenous ischaemic colitis following non-steroidal anti-inflammatory drug overdose. | journal = ANZ J Surg | volume = 71 | issue = 11 | pages = 694-5 | month = Nov | year = 2001 | doi = | PMID = 11736840 }}</ref> | **[[NSAID]] overdose.<ref name=pmid11736840>{{Cite journal | last1 = Appu | first1 = S. | last2 = Thompson | first2 = G. | title = Gangrenous ischaemic colitis following non-steroidal anti-inflammatory drug overdose. | journal = ANZ J Surg | volume = 71 | issue = 11 | pages = 694-5 | month = Nov | year = 2001 | doi = | PMID = 11736840 }}</ref> | ||
*[[Infectious colitis]]. | *[[Infectious colitis]]. | ||
===Ischemia versus infection on biopsy=== | |||
Dignan and Greenson<ref name=pmid9199649>{{Cite journal | last1 = Dignan | first1 = CR. | last2 = Greenson | first2 = JK. | title = Can ischemic colitis be differentiated from C difficile colitis in biopsy specimens? | journal = Am J Surg Pathol | volume = 21 | issue = 6 | pages = 706-10 | month = Jun | year = 1997 | doi = | PMID = 9199649 }}</ref> created a tabular comparison between ischemia and (''C. difficile'') infection. | |||
A modified version of the Dignan-Greenson table (below) shows that the two etiologies generally cannot be separated; however, hyalinization appears to be useful if it is present: | |||
{| class="wikitable sortable" | |||
! Histologic feature | |||
!Ischemia (24 cases) | |||
!Infection (25 cases) | |||
|- | |||
| Atrophic crypts | |||
| 75% | |||
| 24% | |||
|- | |||
| Lamina propria - haemorrhage | |||
| 75% | |||
| 36% | |||
|- | |||
| Lamina propria - hyalinization | |||
| 67% | |||
| 0% | |||
|- | |||
| Diffuse (histologic) pseudomembranes | |||
| 25% | |||
| 4% | |||
|- | |||
| Mucosal necrosis (full thickness) | |||
| 58% | |||
| 28% | |||
|} | |||
===Images=== | ===Images=== | ||
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www: | www: | ||
*[http://www.flickr.com/photos/euthman/3385570758/ Ischemic colitis (flickr.com/euthman)]. | *[http://www.flickr.com/photos/euthman/3385570758/ Ischemic colitis (flickr.com/euthman)]. | ||
==Sign out== | ==Sign out== | ||
===Biopsy=== | ===Biopsy=== | ||
<pre> | |||
Left Colon, Biopsy: | |||
- Compatible with ischemic colitis (attenuated epithelium, hyalinized | |||
lamina propria, cryptitis). | |||
Comment: | |||
The differential diagnosis includes: drug reaction, infectious etiologies and, less likely, inflammatory bowel disease. Clinical correlation is required. | |||
</pre> | |||
====Block letters==== | |||
<pre> | <pre> | ||
TRANSVERSE COLON, BIOPSY: | TRANSVERSE COLON, BIOPSY: | ||
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etiologies and, less likely, inflammatory bowel disease. Clinical | etiologies and, less likely, inflammatory bowel disease. Clinical | ||
correlation is required. | correlation is required. | ||
</pre> | |||
===Biopsy with nonspecific findings/compatible=== | |||
<pre> | |||
Colon, Random Biopsies: | |||
- Mild acute colitis with mild eosinophilia, see comment. | |||
- NEGATIVE for significant architectural distortion. | |||
Comment: | |||
The colitis could be due to ischemia, drug reaction, infection or inflammatory | |||
bowel disease. Clinical correlation is required. | |||
</pre> | </pre> | ||
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*[[Infarction]]. | *[[Infarction]]. | ||
*[[Colon]]. | *[[Colon]]. | ||
*[[Ischemic enteritis]]. | |||
*[[Colonic cast]]. | |||
==References== | ==References== | ||