Difference between revisions of "Inflammatory bowel disease"

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'''Inflammatory bowel disease''', abbreviated IBD, is the bread 'n butter of gastroenterology.   
'''Inflammatory bowel disease''', abbreviated IBD, is the bread 'n butter of gastroenterology, and a significant number of [[gastrointestinal pathology]] specimens.   


It exists in two main flavours:
It exists in two main flavours:
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Both are associated with an increased risk of [[colorectal carcinoma]].<ref name=pmid20485256>{{cite journal |author=Schmidt C, Bielecki C, Felber J, Stallmach A |title=Surveillance strategies in inflammatory bowel disease |journal=Minerva Gastroenterol Dietol |volume=56 |issue=2 |pages=189–201 |year=2010 |month=June |pmid=20485256 |doi= |url=}}</ref>
Both are associated with an increased risk of [[colorectal carcinoma]].<ref name=pmid20485256>{{cite journal |author=Schmidt C, Bielecki C, Felber J, Stallmach A |title=Surveillance strategies in inflammatory bowel disease |journal=Minerva Gastroenterol Dietol |volume=56 |issue=2 |pages=189–201 |year=2010 |month=June |pmid=20485256 |doi= |url=}}</ref>


==Clinical==
=Clinical=
*It is important to differentiate UC and CD as the management is different.  
*It is important to differentiate UC and CD as the management is different.  
*UC patients get pouches... CD patients do not.
*UC patients get pouches... CD patients do not.
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*[[Irritable bowel syndrome]].
*[[Irritable bowel syndrome]].


==Microscopic==
=Specimens=
*Biopsies for diagnosis.
*Surveillance biopsies - to rule-out dysplasia.
*Resections for disease that has failed medical management.
*Resections for dysplasia associated with inflammatory bowel disease.
 
Notes:
*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:
***[[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.
*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 in one bottle===
<pre>
COLON (SITE NOT FURTHER SPECIFIED), BIOPSIES:
- MODERATE CHRONIC ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA.
- PLEASE SEE COMMENT.
 
COMMENT:
The sections show colorectal-type mucosa with focal cryptitis and rare neutrophilic crypt
abscesses. 
 
Mild architectural changes, suggestive of a chronic colitis, are present. No granulomas are
identified. Lymphoid aggregates with germinal centre formation are present in multiple
fragments.  The lamina propria has abundant plasma cells throughout the fragments; no
fragments have apparent relative sparing.
 
Paneth cells are present focally; however, the significance of the paneth cells cannot
determined as the biopsy sites are not known.
 
The findings are compatible with inflammatory bowel disease and chronic active infectious
colitides. Clinical correlation is suggested.
</pre>
 
=Microscopic=
Features helpful for the diagnosis of IBD - as based on a study:<ref name=pmid10048734>{{cite journal |author=Tanaka M, Riddell RH, Saito H, Soma Y, Hidaka H, Kudo H |title=Morphologic criteria applicable to biopsy specimens for effective distinction of inflammatory bowel disease from other forms of colitis and of Crohn's disease from ulcerative colitis |journal=Scand. J. Gastroenterol. |volume=34 |issue=1 |pages=55–67 |year=1999 |month=January |pmid=10048734 |doi= |url=}}</ref>
Features helpful for the diagnosis of IBD - as based on a study:<ref name=pmid10048734>{{cite journal |author=Tanaka M, Riddell RH, Saito H, Soma Y, Hidaka H, Kudo H |title=Morphologic criteria applicable to biopsy specimens for effective distinction of inflammatory bowel disease from other forms of colitis and of Crohn's disease from ulcerative colitis |journal=Scand. J. Gastroenterol. |volume=34 |issue=1 |pages=55–67 |year=1999 |month=January |pmid=10048734 |doi= |url=}}</ref>
#Basal inflammation, i.e. crypt base, plasmacytosis with severe chronic inflammation.
#Basal inflammation, i.e. crypt base, plasmacytosis with severe chronic inflammation.
#*Basal cell plasmacytosis makes an infectious etiology less likely.<ref>RK. 13 December 2010.</ref>
#*Basal cell plasmacytosis makes an infectious etiology less likely.<ref name=Kirsch>Kirsch, R. 13 December 2010.</ref>
#*"Basal plasmacytosis" = plasma cells in the lamina propria between the crypts and muscularis mucosae.<ref>{{cite web |url=http://www.histopathology-india.net/UlCol.htm |title=Pathology of ulcerative colitis |author= |date= |work= |publisher= |accessdate=17 January 2011}}</ref>
#*"Basal plasmacytosis" = plasma cells in the lamina propria between the crypts and muscularis mucosae.<ref>{{cite web |url=http://www.histopathology-india.net/UlCol.htm |title=Pathology of ulcerative colitis |author= |date= |work= |publisher= |accessdate=17 January 2011}}</ref>
#Crypt architectural abnormalities.
#Crypt architectural abnormalities.
#*Atrophy = less glands ~ 3-4 glands/mm (normal = 7-8 glands/mm).
#*Atrophy = less glands ~ 3-4 glands/mm (normal = 7-8 glands/mm).
#*Branching = common (normal = very rare branching).
#*Branching = common (normal = very rare branching).
#*Distortion = bent glands, marked size variation (normal = "rack of test tubes").
#*Distortion = bent glands, marked size variation<ref>URL: [http://www.histopath.com.au/assets/documents/Inflammatory%20bowel%20disease.pdf http://www.histopath.com.au/assets/documents/Inflammatory%20bowel%20disease.pdf]. Accessed on: 25 October 2013.</ref> (normal = "rack of test tubes").
#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.
#*Some claim that (friendly right colonic) paneth cells and paneth cell metaplasia look quite different and can be distinguished.<ref name=pmid12655793>{{cite journal |author=Rubio CA, Nesi G |title=A simple method to demonstrate normal and metaplastic Paneth cells in tissue sections |journal=In Vivo |volume=17 |issue=1 |pages=67–71 |year=2003 |pmid=12655793 |doi= |url=}}</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 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.
# If you see architectural distortion (e.g. crypt branching) in the left colon, look for Paneth cells.
# If you see architectural distortion (e.g. crypt branching) in the left colon, look for Paneth cells.
# The hepatic flexure is considered the divider for normal paneth cells and abnormal paneth cells, i.e. paneth cells proximal to the hepatic flexure are normal; paneth cells distal to the hepatic flexure are abnormal.<ref>STC. 14 December 2009.</ref>
# The hepatic flexure is considered the divider for normal paneth cells and abnormal paneth cells, i.e. paneth cells proximal to the hepatic flexure are normal; paneth cells distal to the hepatic flexure are abnormal.<ref>STC. 14 December 2009.</ref>
# Stretching of tissue may mimic atrophy; tip-off it is artefact: thinning of mucosa.<ref>RK. 13 December 2010.</ref>
# Stretching of tissue may mimic atrophy; tip-off it is artifact: thinning of mucosa.<ref name=Kirsch>Kirsch, R. 13 December 2010.</ref>


Images:
====Images====
*[http://commons.wikimedia.org/w/index.php?title=File:Crohn%27s_disease_-_colon_-_high_mag.jpg Crohn's disease - beautiful granulomas in the colon - high mag. (WC)].
<gallery>
*[http://commons.wikimedia.org/wiki/File:Crohn%27s_disease_-_duodenum_-_intermed_mag.jpg Crohn's disease - duodenum - intermed. mag. (WC)].
Image:Crohn%27s_disease_-_colon_-_high_mag.jpg | Crohn's disease - very well-formed granulomas in the [[colon]] - high mag. (WC)
*[http://commons.wikimedia.org/wiki/File:Cryptitis_high_mag.jpg Cryptitis - high mag. (WC)].
Image:Crohn%27s_disease_-_duodenum_-_intermed_mag.jpg | Crohn's disease - duodenum - intermed. mag. (WC)
*[http://commons.wikimedia.org/wiki/File:Crypt_branching_high_mag.jpg Crypt branching (WC)].
Image: Cryptitis_-_alt_--_very_high_mag.jpg | Cryptitis. (WC)
Image:Crypt_branching_high_mag.jpg | Crypt branching. (WC)
</gallery>


===Grading===
===Grading===
*Several systems exists.<ref>RK. 13 December 2010.</ref>
*Several systems exists.<ref name=Kirsch>Kirsch, R. 13 December 2010.</ref>
*One that is often cited is by Gupta et al..<ref name=pmid17919486>{{cite journal |author=Gupta RB, Harpaz N, Itzkowitz S, ''et al.'' |title=Histologic inflammation is a risk factor for progression to colorectal neoplasia in ulcerative colitis: a cohort study |journal=Gastroenterology |volume=133 |issue=4 |pages=1099–105; quiz 1340–1 |year=2007 |month=October |pmid=17919486 |pmc=2175077 |doi=10.1053/j.gastro.2007.08.001 |url=}}</ref>
*One that is often cited is by Gupta et al.<ref name=pmid17919486>{{cite journal |author=Gupta RB, Harpaz N, Itzkowitz S, ''et al.'' |title=Histologic inflammation is a risk factor for progression to colorectal neoplasia in ulcerative colitis: a cohort study |journal=Gastroenterology |volume=133 |issue=4 |pages=1099–105; quiz 1340–1 |year=2007 |month=October |pmid=17919486 |pmc=2175077 |doi=10.1053/j.gastro.2007.08.001 |url=}}</ref>


====Grading schemes for IBD in a table====
====Grading schemes for IBD in a table====
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| '''Severe'''
| '''Severe'''
|-
|-
| "A grading scheme"<ref>RK. 13 December 2010.</ref>
| "A grading scheme"<ref name=Kirsch>Kirsch, R. 13 December 2010.</ref>
| -
| -
| cryptitis
| [[cryptitis]]
| PMN abscesses
| [[crypt abscesses]]
| erosions
| erosions
|-
|-
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|-
|-
|}
|}
=====Images=====
<gallery>
Image: Cryptitis_--_very_high_mag.jpg | [[Cryptitis]]. (WC)
Image: Crypt_abscess_--_very_high_mag.jpg | [[Crypt abscess]]. (WC)
</gallery>


==Crohn's disease vs. ulcerative colitis==
==Crohn's disease versus ulcerative colitis==
*Some cases cannot be classified by the experts (see [[Inflammatory_bowel_disease#.22Indeterminate_colitis.22|"indeterminate colitis"]]).
*Some cases cannot be classified by the experts (see [[Inflammatory_bowel_disease#.22Indeterminate_colitis.22|"indeterminate colitis"]]).


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** UC may have 'ileal backwash' -- mild ileal inflammation due to backwash of inflammatory soup from colon.
** UC may have 'ileal backwash' -- mild ileal inflammation due to backwash of inflammatory soup from colon.
*"No granulomas".
*"No granulomas".
**Superficial [[granulomas]] in the mucosa are non-specific, especially if they are beside an inflammed crypt, i.e. they may be present in UC.<ref name=pmid12147095>{{Cite journal  | last1 = Shepherd | first1 = NA. | title = Granulomas in the diagnosis of intestinal Crohn's disease: a myth exploded? | journal = Histopathology | volume = 41 | issue = 2 | pages = 166-8 | month = Aug | year = 2002 | doi =  | PMID = 12147095 }}</ref><ref name=pmid12121237>{{Cite journal  | last1 = Mahadeva | first1 = U. | last2 = Martin | first2 = JP. | last3 = Patel | first3 = NK. | last4 = Price | first4 = AB. | title = Granulomatous ulcerative colitis: a re-appraisal of the mucosal granuloma in the distinction of Crohn's disease from ulcerative colitis. | journal = Histopathology | volume = 41 | issue = 1 | pages = 50-5 | month = Jul | year = 2002 | doi =  | PMID = 12121237 }}</ref>
**Superficial [[granulomas]] in the mucosa are non-specific, especially if they are beside an inflamed crypt, i.e. they may be present in UC.<ref name=pmid12147095>{{Cite journal  | last1 = Shepherd | first1 = NA. | title = Granulomas in the diagnosis of intestinal Crohn's disease: a myth exploded? | journal = Histopathology | volume = 41 | issue = 2 | pages = 166-8 | month = Aug | year = 2002 | doi =  | PMID = 12147095 }}</ref><ref name=pmid12121237>{{Cite journal  | last1 = Mahadeva | first1 = U. | last2 = Martin | first2 = JP. | last3 = Patel | first3 = NK. | last4 = Price | first4 = AB. | title = Granulomatous ulcerative colitis: a re-appraisal of the mucosal granuloma in the distinction of Crohn's disease from ulcerative colitis. | journal = Histopathology | volume = 41 | issue = 1 | pages = 50-5 | month = Jul | year = 2002 | doi =  | PMID = 12121237 }}</ref>
***Deep granulomas are specific for Crohn's disease.
***Deep granulomas are specific for Crohn's disease.


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===Kirsch===
===Kirsch===
Features of UC<ref>RK. 13 December 2010.</ref> - memory device ''DDDR'':
Features of UC<ref name=Kirsch>Kirsch, R. 13 December 2010.</ref> - memory device ''DDDR'':
*Diffuse inflammation.
*Diffuse inflammation.
*Diffuse arch. changes.
*Diffuse arch. changes.
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====Words of caution====
====Words of caution====
The following may be present in UC:<ref>RK. 13 December 2010.</ref>
The following may be present in UC:<ref name=Kirsch>Kirsch, R. 13 December 2010.</ref>
*Cecal patch (cecal involvement without pancolitis).
*Cecal patch (cecal involvement without pancolitis).
*Patchy involvement  
*Patchy involvement  
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**Diffuse chronic duodenitis.
**Diffuse chronic duodenitis.
**~ 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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|-
|-
| Associated with PSC
| Associated with PSC
| ?
| not classically
| yes
| yes
|-
|-
|}
|}


==Ulcerative colitis==
=Sign out=
*Often abbreviated as ''UC''.
===Quiescent inflammatory bowel disease===
===General===
*No accepted formal definition.
*May be associated with ''toxic megacolon''.
 
May be used when:
#Non-specific "minimal abnormalities" are present.
#There is a history of inflammatory bowel disease.
 
"Minimal abnormalities" - features:
*Apoptosis.
*Macrophages in the lamina propria.
*Lymphoid nodules.
*"Abundant" plasma cells in the lamina propria.
**''Abundant'' is subjective.
 
<pre>
COLON, BIOPSIES:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.
</pre>
 
===Mild inflammation===
<pre>
SIGMOID COLON, BIOPSY:
- MILD ACTIVE COLITIS WITH CHRONIC CHANGES, SEE COMMENT.
- NEGATIVE FOR DYSPLASIA.
 
COMMENT:
No granulomata are identified.  Mild architectural changes are present.
 
The findings are compatible with inflammatory bowel disease or an infectious
etiology. Clinical correlation is required.
</pre>
 
===Mild-to-moderate inflammation===
<pre>
COLON, LEFT, BIOPSY:
- MILD-TO-MODERATE ACTIVE COLITIS WITH CHRONIC CHANGES.
- NEGATIVE FOR DYSPLASIA.


Epidemiology:
COMMENT:
*Associated with ''[[primary sclerosing cholangitis]]''.
No definite granulomata are identified.  Mild architectural changes are present.
*[[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>
Cryptitis is seen in several crypts. Rare crypt abscesses are present. Lamina propria
*[[Smoking]] is protective; the opposite is true for [[Crohn's disease]].<ref name=pmid19273505/>
plasma cells are abundant throughout the biopsy.


===Gross===
The findings are compatible with inflammatory bowel disease or an infectious
*Conventionally considered to be contiguous, i.e. no "skip lesions", with rectal involvement being most severe.  
etiology. Clinical correlation is required.
*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>
</pre>


===Microscopic===
===Moderate inflammation===
Features:
<pre>
*Lack of [[granulomas]].
RECTUM, BIOPSY:
*No full wall-thickness inflammation.
- RECTAL MUCOSA WITH MODERATE ACTIVE INFLAMMATION AND CHRONIC CHANGES.
- NEGATIVE FOR DYSPLASIA.
- SEE COMMENT.


==Crohn's disease==
COMMENT:
===General===
No definite granulomata are identified. Architectural changes, including crypt drop out,
*Often abbreviated as ''CD''.
are present. Lamina propria plasma cells are abundant throughout the biopsy and eosinophil
*Increased risk for cancer - usu. rectal cancer; classically mucinous adenocarcinoma.
numbers are mildly increased. Lymphoid aggregates with germinal centre formation are
present. All fragments of tissue are affected.


===Gross===
The findings are compatible with inflammatory bowel disease or an infectious
*Aphthous ulcer - first gross finding of IBD.
etiology. Clinical correlation is required.
*Transmural inflammation, i.e. full thickness of bowel wall.
</pre>
*Creeping fat (also "fat wrapping" and "fat hypertrophy"<ref name=pmid15888774>{{Cite journal  | last1 = Schäffler | first1 = A. | last2 = Herfarth | first2 = H. | title = Creeping fat in Crohn's disease: travelling in a creeper lane of research? | journal = Gut | volume = 54 | issue = 6 | pages = 742-4 | month = Jun | year = 2005 | doi = 10.1136/gut.2004.061531 | PMID = 15888774 }}</ref>) - abundant fat, fat on anti-mesenteric side of the bowel.<ref>{{Cite journal  | last1 = Schäffler | first1 = A. | last2 = Herfarth | first2 = H. | title = Creeping fat in Crohn's disease: travelling in a creeper lane of research? | journal = Gut | volume = 54 | issue = 6 | pages = 742-4 | month = Jun | year = 2005 | doi = 10.1136/gut.2004.061531 | PMID = 15888774 }}
</ref>
**Can be seen radiologically; may be seen in [[vasculitis]].<ref name=pmid18815796>{{Cite journal  | last1 = Golder | first1 = WA. | title = The "creeping fat sign"-really diagnostic for Crohn's disease? | journal = Int J Colorectal Dis | volume = 24 | issue = 1 | pages = 1-4 | month = Jan | year = 2009 | doi = 10.1007/s00384-008-0585-y | PMID = 18815796 }}</ref>
*Cobblestone appearance -- may be described as such on endoscopy; due to edema.
*Serpiginous ulcers.
** Image: [http://en.wikipedia.org/wiki/File:CD_serpiginous_ulcer.jpg Serpiginous ulcer (endoscopy) - wikipedia.org].


===Microscopic===
=Specific diagnoses=
Features:<ref name=pmid10048734/>
==Ulcerative colitis==
*Segmental crypt architectural abnormalities.
*Often abbreviated as ''UC''.
*Mucin depletion -- less goblet cells. (???)<ref name=pmid2318990>{{cite journal |author=McCormick DA, Horton LW, Mee AS |title=Mucin depletion in inflammatory bowel disease |journal=J. Clin. Pathol. |volume=43 |issue=2 |pages=143–6 |year=1990 |month=February |pmid=2318990 |pmc=502296 |doi= |url=}}</ref>
{{Main|Ulcerative colitis}}
*Mucin preservation at the active sites.
*Focal chronic inflammation without crypt atrophy.


DDx:
==Crohn's disease==
*Infectious colitis:
*Abbreviated ''CD''.
**[[Amebiasis]].
{{Main|Crohn's disease}}
*[[Ulcerative colitis]].


=="Indeterminate colitis"==
=="Indeterminate colitis"==
*"Indeterminate colitis" is a confusing term and should be avoided.<ref>{{cite journal |author=Geboes K, Colombel JF, Greenstein A, ''et al.'' |title=Indeterminate colitis: a review of the concept--what's in a name? |journal=Inflamm. Bowel Dis. |volume=14 |issue=6 |pages=850–7 |year=2008 |month=June |pmid=18213696 |doi=10.1002/ibd.20361 |url=}}</ref>
*"Indeterminate colitis" is a confusing term and should be avoided.<ref name=pmid18213696>{{cite journal |author=Geboes K, Colombel JF, Greenstein A, ''et al.'' |title=Indeterminate colitis: a review of the concept--what's in a name? |journal=Inflamm. Bowel Dis. |volume=14 |issue=6 |pages=850–7 |year=2008 |month=June |pmid=18213696 |doi=10.1002/ibd.20361 |url=}}</ref>


===Terminology===
===Suggested terminology===
#IBDU = IBD unclassified.
#IBDU = IBD unclassified.
#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==
===General===
Classified as per Riddell ''et al.'':<ref name=pmid6629368>{{Cite journal  | last1 = Riddell | first1 = RH. | last2 = Goldman | first2 = H. | last3 = Ransohoff | first3 = DF. | last4 = Appelman | first4 = HD. | last5 = Fenoglio | first5 = CM. | last6 = Haggitt | first6 = RC. | last7 = Ahren | first7 = C. | last8 = Correa | first8 = P. | last9 = Hamilton | first9 = SR. | title = Dysplasia in inflammatory bowel disease: standardized classification with provisional clinical applications. | journal = Hum Pathol | volume = 14 | issue = 11 | pages = 931-68 | month = Nov | year = 1983 | doi =  | PMID = 6629368 }}</ref><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><ref name=pmid11936264>{{Cite journal  | last1 = Greenson | first1 = JK. | title = Dysplasia in inflammatory bowel disease. | journal = Semin Diagn Pathol | volume = 19 | issue = 1 | pages = 31-7 | month = Feb | year = 2002 | doi =  | PMID = 11936264 }}</ref>
*Negative for dysplasia.
*[[Indefinite for dysplasia]].
*Low grade dysplasia.
*High grade dysplasia.
Notes:
*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===
Features:<ref>URL: [http://surgpathcriteria.stanford.edu/gi/ulcerative-colitis/printable.html http://surgpathcriteria.stanford.edu/gi/ulcerative-colitis/printable.html]. Accessed on: 12 March 2013.</ref>
*Nuclear changes at the surface - '''key feature'''.
**Nuclear hyperchromasia.
**Nuclear enlargement - ellipsoid ''or'' spherical.


==Dysplasia-associated lesion or mass==
==Dysplasia-associated lesion or mass==
*Abbreviated ''DALM''.
*Abbreviated ''DALM''.
{{Main|Dysplasia-associated lesion or mass}}
==Pouchitis==
===General===
===General===
*Proving invasive malignancy in the setting of chronic inflammation is difficult.<ref name=pmid7450425>{{Cite journal  | last1 = Blackstone | first1 = MO. | last2 = Riddell | first2 = RH. | last3 = Rogers | first3 = BH. | last4 = Levin | first4 = B. | title = Dysplasia-associated lesion or mass (DALM) detected by colonoscopy in long-standing ulcerative colitis: an indication for colectomy. | journal = Gastroenterology | volume = 80 | issue = 2 | pages = 366-74 | month = Feb | year = 1981 | doi =  | PMID = 7450425 }}</ref>
*Inflammation of an ileal pouch; pouches are a treatment for [[ulcerative colitis]].
**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>
*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>
===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>
*[[Neutrophil]]s - intraepithelial ([[cryptitis]]).
*+/-[[Crypt abscess]] (cluster of neutrophils in a gland) - indicator of moderate or severe.
*Ulceration.


===Microscopic===
Note:
Features:
*Absence of Paneth cells and villi = colonic metaplasia,<ref name=pmid22892912/> associated with inflammation.<ref>{{Cite journal  | last1 = Fruin | first1 = AB. | last2 = El-Zammer | first2 = O. | last3 = Stucchi | first3 = AF. | last4 = O'Brien | first4 = M. | last5 = Becker | first5 = JM. | title = Colonic metaplasia in the ileal pouch is associated with inflammation and is not the result of long-term adaptation. | journal = J Gastrointest Surg | volume = 7 | issue = 2 | pages = 246-53; discussion 253-4 | month = Feb | year = 2003 | doi =  | PMID = 12600449 }}</ref>
*Flat or polypoid.<ref name=pmid7450425/>
*Cytologic dysplasia - as in [[adenomatous polyps]].


DDx:
DDx:
*Sporadic [[adenomatous polyp]].
*[[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>
**Several papers have been written on differentiating 'em.<ref name="Suzuki-1998">{{Cite journal  | last1 = Suzuki | first1 = K. | last2 = Muto | first2 = T. | last3 = Shinozaki | first3 = M. | last4 = Yokoyama | first4 = T. | last5 = Matsuda | first5 = K. | last6 = Masaki | first6 = T. | title = Differential diagnosis of dysplasia-associated lesion or mass and coincidental adenoma in ulcerative colitis. | journal = Dis Colon Rectum | volume = 41 | issue = 3 | pages = 322-7 | month = Mar | year = 1998 | doi = | PMID = 9514427 }}</ref><ref name="Fogt-2000">{{Cite journal  | last1 = Fogt | first1 = F. | last2 = Urbanski | first2 = SJ. | last3 = Sanders | first3 = ME. | last4 = Furth | first4 = EE. | last5 = Zimmerman | first5 = RL. | last6 = Deren | first6 = JJ. | last7 = Noffsinger | first7 = AE. | last8 = Vortmeyer | first8 = AO. | last9 = Hartmann | first9 = CJ. | title = Distinction between dysplasia-associated lesion or mass (DALM) and adenoma in patients with ulcerative colitis. | journal = Hum Pathol | volume = 31 | issue = 3 | pages = 288-91 | month = Mar | year = 2000 | doi =  | PMID = 10746669 }}</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]].
 
Images:
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3400158/figure/f4-cln_67p705/ Pouchitis (nih.gov)].<ref name=pmid22892912>{{Cite journal  | last1 = Arashiro | first1 = RT. | last2 = Teixeira | first2 = MG. | last3 = Rawet | first3 = V. | last4 = Quintanilha | first4 = AG. | last5 = Paula | first5 = HM. | last6 = Silva | first6 = AZ. | last7 = Nahas | first7 = SC. | last8 = Cecconello | first8 = I. | title = Histopathological evaluation and risk factors related to the development of pouchitis in patients with ileal pouches for ulcerative colitis. | journal = Clinics (Sao Paulo) | volume = 67 | issue = 7 | pages = 705-10 | month = Jul | year = 2012 | doi =  | PMID = 22892912 | PMC = 3400158 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3400158/}}</ref>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3400158/figure/f3-cln_67p705/ Colonic metaplasia (nih.gov)].<ref name=pmid22892912/>
 
====Scoring system====
Pouchitis disease activity index (PDAI) - based on clinical and pathologic factors:
*Active pouchitis >= 7.
*Remission < 7.
 
The histologic component of the PDAI:<ref name=pmid12794576/>
*Neutrophils.
**Mild.
**Moderate - crypt abscesses.
**Severe - crypt abscesses.
*Ulceration per [[LPF]] (mean).
**<25%.
**25-50%.
**>50.
 
===Sign out===
Note:
*Dr. Robert Riddell is of the opinion: "Do '''not''' call any pouch inflammation as consistent with Crohn's disease."
 
<pre>
SMALL BOWEL POUCH, BIOPSY:
- SMALL BOWEL MUCOSA WITH CHRONIC ACTIVE INFLAMMATION WITH ULCERATION, EARLY
  CRYPT ABSCESS FORMATION, CRYPTITIS, AND LOSS OF THE VILLOUS ARCHITECTURE.
- NEGATIVE FOR GRANULOMAS AND NEGATIVE FOR PYLORIC GLAND METAPLASIA.
- NEGATIVE FOR DYSPLASIA.
 
COMMENT:
The findings are consistent with pouchitis.
</pre>
 
====Pyloric gland metaplasia present====
<pre>
SMALL BOWEL POUCH, BIOPSY:
- SMALL BOWEL MUCOSA WITH CHRONIC ACTIVE INFLAMMATION WITH ULCERATION, EARLY
  CRYPT ABSCESS FORMATION, CRYPTITIS, AND LOSS OF THE VILLOUS ARCHITECTURE.
- PYLORIC GLAND METAPLASIA, FOCAL, SEE COMMENT.
- NEGATIVE FOR GRANULOMAS.
- NEGATIVE FOR DYSPLASIA.
 
COMMENT:
The presence of pyloric gland metaplasia raises the possibility of Crohn's disease;
however, in the context of previous biopsies with inflammation, the concurrent
negative ileal biopsy and lack of granulomas, this individual is favoured to have
pouchitis.</pre>


==See also==
=See also=
*[[Colon]].
*[[Colon]].
*[[Colorectal tumours]].
*[[Colorectal tumours]].
Line 246: Line 409:
*[[Gastrointestinal pathology]].
*[[Gastrointestinal pathology]].
*[[Intestinal polyps]].
*[[Intestinal polyps]].
*[[Diverticular disease-associated colitis]].
*[[Pseudopyloric mucous glands]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


==External links==
=External links=
*[http://kathrin.unibas.ch/game/diffdiag01/index.html Crohn's disease vs. ulcerative colitis vs. pseudomembranous colitis puzzle (unibas.ch)] in a collection of [http://kathrin.unibas.ch/game/index.html games] by [http://kathrin.unibas.ch/kathrin/ Katharina Glatz-Krieger].
*[http://kathrin.unibas.ch/game/diffdiag01/index.html Crohn's disease vs. ulcerative colitis vs. pseudomembranous colitis puzzle (unibas.ch)] in a collection of [http://kathrin.unibas.ch/game/index.html games] by [http://kathrin.unibas.ch/kathrin/ Katharina Glatz-Krieger].


[[Category:Gastrointestinal pathology]]
[[Category:Gastrointestinal pathology]]
Michael
48,460

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