Difference between revisions of "Crohn's disease"

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#redirect [[Inflammatory bowel disease#Crohn's disease]]
'''Crohn's disease''', abbreviated as '''CD''', is a atype of [[inflammatory bowel disease]]. It is the bread and butter of gastroenterology, and is often seen by pathologists.
 
==General==
*Autoimmune disease.
*Increased risk for cancer - usu. rectal cancer; classically [[colorectal adenocarcinoma|mucinous adenocarcinoma]].
 
Associations:<ref name=pmid20074146>{{Cite journal  | last1 = Gearry | first1 = RB. | last2 = Richardson | first2 = AK. | last3 = Frampton | first3 = CM. | last4 = Dodgshun | first4 = AJ. | last5 = Barclay | first5 = ML. | title = Population-based cases control study of inflammatory bowel disease risk factors. | journal = J Gastroenterol Hepatol | volume = 25 | issue = 2 | pages = 325-33 | month = Feb | year = 2010 | doi = 10.1111/j.1440-1746.2009.06140.x | PMID = 20074146 }}
</ref>
*High socioeconomic status.
*Family history of [[IBD]].
*City dwellers.
*Not breastfed.
 
Treatment:
*Immune suppression.
*Surgery considered treatment of last resort.
 
==Gross==
*Aphthous ulcer - first gross finding of IBD.
*Transmural inflammation, i.e. full thickness of bowel wall.
*[[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>
**Definition: fat on more than 50% of the intestinal surface.<ref name=pmid15888774/>
***''[[onlinepathology|OP]]'' understands this as ''fat on 50% of the circumference''.
**DDx of creeping fat: [[ulcerative colitis]], sclerosing mesenteritis, mesenteric panniculitis, epiploic appendagitis, omental infarction, gastrointestinal complication a renal transplant, idiopathic segmental ureteritis.<ref name=pmid18815796/>
**Can be seen radiologically.
*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].
 
Notes:
*Grossly, the [[margins]] should be clear of disease; the [[surgical clearance]] and microscopic involvement are not considered important.<ref name=pmid6348672>{{Cite journal  | last1 = Hamilton | first1 = SR. | title = Pathologic features of Crohn's disease associated with recrudescence after resection. | journal = Pathol Annu | volume = 18 Pt 1 | issue =  | pages = 191-203 | month =  | year = 1983 | doi =  | PMID = 6348672 }}</ref>
*The term ''creeping fat'' may be used in the context of a [[vasculitis]] outside of the abdominal cavity.<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>
 
==Microscopic==
Features:<ref name=pmid10048734/>
*Segmental crypt architectural abnormalities.
*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>
*Mucin preservation at the active sites.
*Focal chronic inflammation without crypt atrophy.
*Pseudopyloric mucous glands ([[AKA]] pyloric gland metaplasia).<ref name=medunigraz>URL: [http://www.medunigraz.at/22698 http://www.medunigraz.at/22698]. Accessed on: 6 August 2013.</ref>
**Round glands with abundant pale cytoplasm - stubby champagne flute.
**Usually in the deep aspect of the mucosa.
***Look somewhat similar to Brunner's glands.
*Granulomas - esp. deep (non-mucosal).
**Superficial [[granulomas]] in the mucosa are non-specific (especially if they are beside an inflamed crypt); they may be present in ulcerative colitis.<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>
 
DDx:
*Infectious colitis:
**[[Amebiasis]].
**[[EBV]]-associated colitis.<ref>{{Cite journal  | last1 = Karlitz | first1 = JJ. | last2 = Li | first2 = ST. | last3 = Holman | first3 = RP. | last4 = Rice | first4 = MC. | title = EBV-associated colitis mimicking IBD in an immunocompetent individual. | journal = Nat Rev Gastroenterol Hepatol | volume = 8 | issue = 1 | pages = 50-4 | month = Jan | year = 2011 | doi = 10.1038/nrgastro.2010.192 | PMID = 21119609 }}</ref>
*[[Ulcerative colitis]].
*[[Diverticular disease-associated colitis]] - only in areas with [[diverticular disease]].
*NSAID-induced small bowel injury.<ref name=pmid19148795>{{Cite journal  | last1 = Hayashi | first1 = Y. | last2 = Yamamoto | first2 = H. | last3 = Taguchi | first3 = H. | last4 = Sunada | first4 = K. | last5 = Miyata | first5 = T. | last6 = Yano | first6 = T. | last7 = Arashiro | first7 = M. | last8 = Sugano | first8 = K. | title = Nonsteroidal anti-inflammatory drug-induced small-bowel lesions identified by double-balloon endoscopy: endoscopic features of the lesions and endoscopic treatments for diaphragm disease. | journal = J Gastroenterol | volume = 44 Suppl 19 | issue =  | pages = 57-63 | month =  | year = 2009 | doi = 10.1007/s00535-008-2277-3 | PMID = 19148795 }}</ref>
*Others - a long DDx is [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2914216/table/T1/ here].<ref name=pmid20532706>{{Cite journal  | last1 = Dilauro | first1 = S. | last2 = Crum-Cianflone | first2 = NF. | title = Ileitis: when it is not Crohn's disease. | journal = Curr Gastroenterol Rep | volume = 12 | issue = 4 | pages = 249-58 | month = Aug | year = 2010 | doi = 10.1007/s11894-010-0112-5 | PMID = 20532706 }}</ref>
===Images===
www:
*[http://www.medunigraz.at/images/content/image/presse/patho-netzwerk/1012_06.jpg Crohn's disease - pyloric gland metaplasia (medunigraz.at)].<ref name=medunigraz>URL: [http://www.medunigraz.at/22698 http://www.medunigraz.at/22698]. Accessed on: 6 August 2013.</ref>
*[http://www.medunigraz.at/images/content/image/presse/patho-netzwerk/1012_07.jpg Crohn's disease - pyloric gland metaplasia (medunigraz.at)].<ref name=medunigraz/>
 
==Sign-out==
===Biopsies===
<pre>
TERMINAL ILEUM, BIOPSY
- PATCHY MILD ACTIVE ILEITIS.
 
COMMENT:
No granulomas are identified. An infective etiology should be considered, as
it cannot be excluded on pathologic grounds. 
</pre>
====Classic====
<pre>
A. TERMINAL ILEUM, BIOPSY
- MODERATE GRANULOMATOUS ILEITIS.
 
B. CECUM, BIOPSY:
- MILD PATCHY ACTIVE CECITIS.
 
C. SIGMOID COLON, BIOPSY:
- CHRONIC INFLAMMATORY CHANGES. NO ACTIVE COLITIS.
 
COMMENT:
The histomorphological findings (patchy inflammation, granulomas, ileitis, paneth cell
metaplasia, crypt loss and crypt elongation) are suggestive of Crohn's disease. An infective
etiology should be considered, as it cannot be excluded on pathologic grounds.
</pre>
====Quiescent Crohn's disease====
<pre>
DESCENDING COLON, BIOPSY:
- COLONIC MUCOSA WITH PROMINENT LAMINA PROPRIA PLASMA CELLS.
- NEGATIVE FOR ACTIVE COLITIS.
 
COMMENT:
Minimal architectural changes consistent with chronic inflammation are present. There are
no granulomas. No dysplasia is identified. The findings are compatible with quiescent
Crohn's disease.
</pre>
 
===Resection===
<pre>
TERMINAL ILEUM, CECUM, AND APPENDIX, CECUM-ILEUM RESECTION:
- CHRONIC ACTIVE GRANULOMATOUS ILEITIS -- INCLUDING:
-- MURAL MICROABSCESS FORMATION.
-- SEROSITIS.
-- A STRICTURE.
-- DEEP ULCERATION (AT LEAST THROUGH THE MUSCULARIS PROPRIA).
- PERIAPPENDICITIS, NEGATIVE FOR APPENDICITIS.
- CECUM WITHIN NORMAL LIMITS.
- TEN LYMPH NODES NEGATIVE FOR MALIGNANCY ( 0 POSITIVE / 10 ).
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
 
COMMENT:
The sections show patchy transmural inflammation and skip lesions.
The findings are consistent with Crohn's disease.
</pre>
 
<pre>
TERMINAL ILEUM, CECUM, APPENDIX, AND ASCENDING COLON, RIGHT HEMICOLECTOMY:
- CHRONIC ACTIVE ILEITIS -- INCLUDING:
-- INFLAMMATORY PSEUDOPOLYP.
-- STRICTURE ASSOCIATED WITH LARGE LYMPHOID AGGREGATE.
- THIRTEEN LYMPH NODES NEGATIVE FOR MALIGNANCY ( 0 POSITIVE / 13 ).
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
 
COMMENT:
The sections show patchy transmural inflammation and skip lesions. Submucosal fibrosis is
present. Focal ulceration and abscess formation is identified. No granulomas are identified.
 
The findings are consistent with Crohn's disease.
</pre>
 
<pre>
ILEUM, COLON, ILEO-COLIC RESECTION:
- SEVERE FOCAL ILEITIS WITH ULCERATION AND TRANSMURAL INFLAMMATION.
- BENIGN STRICTURE ASSOCIATED WITH A LARGE LYMPHOID AGGREGATE.
- FIBROUS ADHESION.
- COLON WITHIN NORMAL LIMITS.
- ONE LYMPH NODE NEGATIVE FOR MALIGNANCY ( 0 POSITIVE / 1 ).
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
 
COMMENT:
The findings are consistent with chronic, active Crohn's disease.
</pre>
 
==See also==
*[[Inflammatory bowel disease]].
**[[Ulcerative colitis]].
 
==References==
{{Reflist|2}}


[[Category:Diagnosis]]
[[Category:Diagnosis]]
[[Category:Gastrointestinal pathology]]
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