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*Biopsies for diagnosis should specify the (anatomical) site: | *Biopsies for diagnosis should specify the (anatomical) site: | ||
**Slight gradients exist in the large bowel that can be exploited for diagnostic purposes if the site information is known, for example: | **Slight gradients exist in the large bowel that can be exploited for diagnostic purposes if the site information is known, for example: | ||
***Paneth cell distal to the splenic flexure are abnormal. | ***[[Paneth cell]]s distal to the splenic flexure are abnormal. | ||
***Ulcerative colitis is often more severe distally - even in a pancolitis, as the disease starts in the rectum and progresses toward the cecum. | ***Ulcerative colitis is often more severe distally - even in a pancolitis, as the disease starts in the rectum and progresses toward the cecum. | ||
*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 | ===Biopsies all submitted in one bottle=== | ||
<pre> | <pre> | ||
COLON (SITE NOT FURTHER SPECIFIED), BIOPSIES: | COLON (SITE NOT FURTHER SPECIFIED), BIOPSIES: | ||
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#Distal Paneth cell metaplasia. | #Distal Paneth cell metaplasia. | ||
#*Paneth cells should ''not'' be in the left colon<ref name=pmid11851832>{{cite journal |author=Tanaka M, Saito H, Kusumi T, ''et al'' |title=Spatial distribution and histogenesis of colorectal Paneth cell metaplasia in idiopathic inflammatory bowel disease |journal=J. Gastroenterol. Hepatol. |volume=16 |issue=12 |pages=1353–9 |year=2001 |month=December |pmid=11851832 |doi= |url=http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0815-9319&date=2001&volume=16&issue=12&spage=1353}}</ref> - if you see 'em think of IBD and other long-standing injurious processes. | #*Paneth cells should ''not'' be in the left colon<ref name=pmid11851832>{{cite journal |author=Tanaka M, Saito H, Kusumi T, ''et al'' |title=Spatial distribution and histogenesis of colorectal Paneth cell metaplasia in idiopathic inflammatory bowel disease |journal=J. Gastroenterol. Hepatol. |volume=16 |issue=12 |pages=1353–9 |year=2001 |month=December |pmid=11851832 |doi= |url=http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0815-9319&date=2001&volume=16&issue=12&spage=1353}}</ref> - if you see 'em think of IBD and other long-standing injurious processes. | ||
#*Paneth cells have basal nuclei and coarse luminal granules.<ref name=Ref_H4P3_631>{{Ref H4P3|631}}</ref> | #*Paneth cells have basal nuclei and coarse luminal granules.<ref name=Ref_H4P3_631>{{Ref H4P3|631}}</ref> | ||
#**They should '''not''' be confused with endocrine cells -- these have apical nuclei and fine granules. | #**They should '''not''' be confused with endocrine cells -- these have apical nuclei and fine granules. | ||
#**They should '''not''' be confused with intraepithelial | #**They should '''not''' be confused with intraepithelial [[eosinophil]]s -- have smaller (~1/2) more intensely red granules. | ||
Notes: | Notes: | ||
# Microscopic features can be remembered by [[mnemonic]] ''CPP'': Crypts (abnormal), Plasmacytosis, Paneth cells where they don't belong. | # Microscopic features can be remembered by [[mnemonic]] ''CPP'': Crypts (abnormal), Plasmacytosis, Paneth cells where they don't belong. | ||
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====Images==== | ====Images==== | ||
<gallery> | <gallery> | ||
Image:Crohn%27s_disease_-_colon_-_high_mag.jpg | Crohn's disease - | Image:Crohn%27s_disease_-_colon_-_high_mag.jpg | Crohn's disease - very well-formed granulomas in the [[colon]] - high mag. (WC) | ||
Image:Crohn%27s_disease_-_duodenum_-_intermed_mag.jpg | Crohn's disease - duodenum - intermed. mag. (WC) | Image:Crohn%27s_disease_-_duodenum_-_intermed_mag.jpg | Crohn's disease - duodenum - intermed. mag. (WC) | ||
Image: Cryptitis_-_alt_--_very_high_mag.jpg | Cryptitis. (WC) | Image: Cryptitis_-_alt_--_very_high_mag.jpg | Cryptitis. (WC) | ||
Image:Crypt_branching_high_mag.jpg | Crypt branching. (WC) | Image:Crypt_branching_high_mag.jpg | Crypt branching. (WC) | ||
</gallery> | </gallery> | ||
===Grading=== | ===Grading=== | ||
*Several systems exists.<ref name=Kirsch>Kirsch, R. 13 December 2010.</ref> | *Several systems exists.<ref name=Kirsch>Kirsch, R. 13 December 2010.</ref> | ||
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**~ 10% of UC patients. | **~ 10% of UC patients. | ||
**~ 40% of UC + colectomy + [[pouchitis]]. | **~ 40% of UC + colectomy + [[pouchitis]]. | ||
Another study compares UC, CD and control individuals:<ref name=pmid20848539>{{Cite journal | last1 = Sonnenberg | first1 = A. | last2 = Melton | first2 = SD. | last3 = Genta | first3 = RM. | title = Frequent occurrence of gastritis and duodenitis in patients with inflammatory bowel disease. | journal = Inflamm Bowel Dis | volume = 17 | issue = 1 | pages = 39-44 | month = Jan | year = 2011 | doi = 10.1002/ibd.21356 | PMID = 20848539 }}</ref> | |||
*Gastritis: | |||
**UC: 19%. | |||
**CD: 33% | |||
**Controls: 13%. | |||
*Duodenitis: | |||
**UC: 3%. | |||
**CD: 26%. | |||
**Controls: 1%. | |||
Note: | |||
*Younger individuals (<18 years old) have significantly more gastritis and duodenitis.<ref name=pmid20848539/> | |||
====A tabular comparison==== | ====A tabular comparison==== | ||
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=Sign out= | =Sign out= | ||
===Quiescent inflammatory bowel disease=== | ===Quiescent inflammatory bowel disease=== | ||
*No accepted formal definition. | |||
May be used when: | |||
#Non-specific "minimal abnormalities" are present. | #Non-specific "minimal abnormalities" are present. | ||
#There is a history of inflammatory bowel disease. | #There is a history of inflammatory bowel disease. | ||
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*Macrophages in the lamina propria. | *Macrophages in the lamina propria. | ||
*Lymphoid nodules. | *Lymphoid nodules. | ||
*Abundant plasma cells in the lamina propria. | *"Abundant" plasma cells in the lamina propria. | ||
**''Abundant'' is subjective. | |||
<pre> | <pre> | ||
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No definite granulomata are identified. Architectural changes, including crypt drop out, | No definite granulomata are identified. Architectural changes, including crypt drop out, | ||
are present. Lamina propria plasma cells are abundant throughout the biopsy and eosinophil | are present. Lamina propria plasma cells are abundant throughout the biopsy and eosinophil | ||
numbers are mildly increased. Lymphoid aggregates with germinal centre formation are present. All fragments of tissue are affected. | numbers are mildly increased. Lymphoid aggregates with germinal centre formation are | ||
present. All fragments of tissue are affected. | |||
The findings are compatible with inflammatory bowel disease or an infectious | The findings are compatible with inflammatory bowel disease or an infectious | ||
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==Ulcerative colitis== | ==Ulcerative colitis== | ||
*Often abbreviated as ''UC''. | *Often abbreviated as ''UC''. | ||
{{Main|Ulcerative colitis}} | |||
==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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Notes: | Notes: | ||
*GI experts and generalists have similar rates agreement.<ref name=pmid11400142>{{Cite journal | last1 = Eaden | first1 = J. | last2 = Abrams | first2 = K. | last3 = McKay | first3 = H. | last4 = Denley | first4 = H. | last5 = Mayberry | first5 = J. | title = Inter-observer variation between general and specialist gastrointestinal pathologists when grading dysplasia in ulcerative colitis. | journal = J Pathol | volume = 194 | issue = 2 | pages = 152-7 | month = Jun | year = 2001 | doi = 10.1002/path.876 | PMID = 11400142 }}</ref> | *GI experts and generalists have similar rates of agreement.<ref name=pmid11400142>{{Cite journal | last1 = Eaden | first1 = J. | last2 = Abrams | first2 = K. | last3 = McKay | first3 = H. | last4 = Denley | first4 = H. | last5 = Mayberry | first5 = J. | title = Inter-observer variation between general and specialist gastrointestinal pathologists when grading dysplasia in ulcerative colitis. | journal = J Pathol | volume = 194 | issue = 2 | pages = 152-7 | month = Jun | year = 2001 | doi = 10.1002/path.876 | PMID = 11400142 }}</ref> | ||
===Microscopic=== | ===Microscopic=== | ||
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==Dysplasia-associated lesion or mass== | ==Dysplasia-associated lesion or mass== | ||
*Abbreviated ''DALM''. | *Abbreviated ''DALM''. | ||
{{Main|Dysplasia-associated lesion or mass}} | |||
==Pouchitis== | ==Pouchitis== | ||
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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=== | ||
Features:<ref name=pmid12794576>{{Cite journal | last1 = Shen | first1 = B. | last2 = Achkar | first2 = JP. | last3 = Connor | first3 = JT. | last4 = Ormsby | first4 = AH. | last5 = Remzi | first5 = FH. | last6 = Bevins | first6 = CL. | last7 = Brzezinski | first7 = A. | last8 = Bambrick | first8 = ML. | last9 = Fazio | first9 = VW. | title = Modified pouchitis disease activity index: a simplified approach to the diagnosis of pouchitis. | journal = Dis Colon Rectum | volume = 46 | issue = 6 | pages = 748-53 | month = Jun | year = 2003 | doi = 10.1097/01.DCR.0000070528.00563.D9 | PMID = 12794576 | URL = http://www.lri.ccf.org/pathobio/achkar/documents/Shen2003DisColonRectum.pdf }}</ref> | Features:<ref name=pmid12794576>{{Cite journal | last1 = Shen | first1 = B. | last2 = Achkar | first2 = JP. | last3 = Connor | first3 = JT. | last4 = Ormsby | first4 = AH. | last5 = Remzi | first5 = FH. | last6 = Bevins | first6 = CL. | last7 = Brzezinski | first7 = A. | last8 = Bambrick | first8 = ML. | last9 = Fazio | first9 = VW. | title = Modified pouchitis disease activity index: a simplified approach to the diagnosis of pouchitis. | journal = Dis Colon Rectum | volume = 46 | issue = 6 | pages = 748-53 | month = Jun | year = 2003 | doi = 10.1097/01.DCR.0000070528.00563.D9 | PMID = 12794576 | URL = http://www.lri.ccf.org/pathobio/achkar/documents/Shen2003DisColonRectum.pdf }}</ref> | ||
*[[Neutrophil]]s - intraepithelial ([[cryptitis]]). | *[[Neutrophil]]s - intraepithelial ([[cryptitis]]). | ||
*+/-Crypt abscess (cluster of neutrophils in a gland) - indicator of moderate or severe. | *+/-[[Crypt abscess]] (cluster of neutrophils in a gland) - indicator of moderate or severe. | ||
*Ulceration. | *Ulceration. | ||
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DDx: | DDx: | ||
*[[Crohn's disease]] - pyloric gland metaplasia (PGM) suggestive but not diagnostic.<ref name=pmid23543088>{{Cite journal | last1 = Agarwal | first1 = S. | last2 = Stucchi | first2 = AF. | last3 = Dendrinos | first3 = K. | last4 = Cerda | first4 = S. | last5 = O'Brien | first5 = MJ. | last6 = Becker | first6 = JM. | last7 = Heeren | first7 = T. | last8 = Farraye | first8 = FA. | title = Is pyloric gland metaplasia in ileal pouch biopsies a marker for Crohn's disease? | journal = Dig Dis Sci | volume = 58 | issue = 10 | pages = 2918-25 | month = Oct | year = 2013 | doi = 10.1007/s10620-013-2655-4 | PMID = 23543088 }}</ref> | *[[Crohn's disease]] - [[pyloric gland metaplasia]] (PGM) suggestive but not diagnostic.<ref name=pmid23543088>{{Cite journal | last1 = Agarwal | first1 = S. | last2 = Stucchi | first2 = AF. | last3 = Dendrinos | first3 = K. | last4 = Cerda | first4 = S. | last5 = O'Brien | first5 = MJ. | last6 = Becker | first6 = JM. | last7 = Heeren | first7 = T. | last8 = Farraye | first8 = FA. | title = Is pyloric gland metaplasia in ileal pouch biopsies a marker for Crohn's disease? | journal = Dig Dis Sci | volume = 58 | issue = 10 | pages = 2918-25 | month = Oct | year = 2013 | doi = 10.1007/s10620-013-2655-4 | PMID = 23543088 }}</ref> | ||
**PGM = glands with tall columnar cells with pale pink cytoplasm and a small basal nuclei - typically in the deep mucosa.<ref name=pmid23925821>{{Cite journal | last1 = Weber | first1 = CR. | last2 = Rubin | first2 = DT. | title = Chronic pouchitis versus recurrent Crohn's disease: a diagnostic challenge. | journal = Dig Dis Sci | volume = 58 | issue = 10 | pages = 2748-50 | month = Oct | year = 2013 | doi = 10.1007/s10620-013-2816-5 | PMID = 23925821 }}</ref> | **PGM = glands with tall columnar cells with pale pink cytoplasm and a small basal nuclei - typically in the deep mucosa.<ref name=pmid23925821>{{Cite journal | last1 = Weber | first1 = CR. | last2 = Rubin | first2 = DT. | title = Chronic pouchitis versus recurrent Crohn's disease: a diagnostic challenge. | journal = Dig Dis Sci | volume = 58 | issue = 10 | pages = 2748-50 | month = Oct | year = 2013 | doi = 10.1007/s10620-013-2816-5 | PMID = 23925821 }}</ref> | ||
*Irritable pouch disease<ref name=pmid15073663>{{Cite journal | last1 = Beart | first1 = RW. | title = Is pouchitis a clinical, endoscopic, or histologic problem? | journal = Dis Colon Rectum | volume = 47 | issue = 6 | pages = 949; author reply 949-50 | month = Jun | year = 2004 | doi = 10.1007/s10350-004-0516-0 | PMID = 15073663 }}</ref><ref name=pmid18702649>{{Cite journal | last1 = Shen | first1 = B. | last2 = Liu | first2 = W. | last3 = Remzi | first3 = FH. | last4 = Shao | first4 = Z. | last5 = Lu | first5 = H. | last6 = DeLaMotte | first6 = C. | last7 = Hammel | first7 = J. | last8 = Queener | first8 = E. | last9 = Bambrick | first9 = ML. | title = Enterochromaffin cell hyperplasia in irritable pouch syndrome. | journal = Am J Gastroenterol | volume = 103 | issue = 9 | pages = 2293-300 | month = Sep | year = 2008 | doi = 10.1111/j.1572-0241.2008.01990.x | PMID = 18702649 }}</ref> - functional disease similar to [[irritable bowel syndrome]]. | *Irritable pouch disease<ref name=pmid15073663>{{Cite journal | last1 = Beart | first1 = RW. | title = Is pouchitis a clinical, endoscopic, or histologic problem? | journal = Dis Colon Rectum | volume = 47 | issue = 6 | pages = 949; author reply 949-50 | month = Jun | year = 2004 | doi = 10.1007/s10350-004-0516-0 | PMID = 15073663 }}</ref><ref name=pmid18702649>{{Cite journal | last1 = Shen | first1 = B. | last2 = Liu | first2 = W. | last3 = Remzi | first3 = FH. | last4 = Shao | first4 = Z. | last5 = Lu | first5 = H. | last6 = DeLaMotte | first6 = C. | last7 = Hammel | first7 = J. | last8 = Queener | first8 = E. | last9 = Bambrick | first9 = ML. | title = Enterochromaffin cell hyperplasia in irritable pouch syndrome. | journal = Am J Gastroenterol | volume = 103 | issue = 9 | pages = 2293-300 | month = Sep | year = 2008 | doi = 10.1111/j.1572-0241.2008.01990.x | PMID = 18702649 }}</ref> - functional disease similar to [[irritable bowel syndrome]]. | ||
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===Sign out=== | ===Sign out=== | ||
Note: | |||
*Dr. Robert Riddell is of the opinion: "Do '''not''' call any pouch inflammation as consistent with Crohn's disease." | |||
<pre> | <pre> | ||
SMALL BOWEL POUCH, BIOPSY: | SMALL BOWEL POUCH, BIOPSY: | ||
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*[[Intestinal polyps]]. | *[[Intestinal polyps]]. | ||
*[[Diverticular disease-associated colitis]]. | *[[Diverticular disease-associated colitis]]. | ||
*[[Pseudopyloric mucous glands]]. | |||
=References= | =References= |
edits