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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= | |||
*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. | ||
**It is said that: ''There 's nothing like a pouch to bring out Crohn's disease''.<ref>URL: [http://www.gihealthfoundation.org/library/ppts/postcolectomypatient.pdf http://www.gihealthfoundation.org/library/ppts/postcolectomypatient.pdf]. 3 March 2011.</ref> | **It is said that: ''There 's nothing like a pouch to bring out Crohn's disease''.<ref>URL: [http://www.gihealthfoundation.org/library/ppts/postcolectomypatient.pdf http://www.gihealthfoundation.org/library/ppts/postcolectomypatient.pdf]. 3 March 2011.</ref> | ||
*People with long standing IBD have an increased risk for: | |||
**Carcinoma - usually [[colorectal carcinoma]].<ref name=pmid21640928>{{Cite journal | last1 = Claessen | first1 = MM. | last2 = Siersema | first2 = PD. | last3 = Vleggaar | first3 = FP. | title = IBD-related carcinoma. | journal = Best Pract Res Clin Gastroenterol | volume = 25 Suppl 1 | issue = | pages = S27-38 | month = Apr | year = 2011 | doi = 10.1016/S1521-6918(11)70007-5 | PMID = 21640928 }}</ref> | |||
***Small increased risk for [[small bowel]] adenocarcinoma in Crohn's disease.<ref name=pmid21640928/> | |||
**Lymphoma - in association with thiopurine use.<ref name=pmid21830262>{{Cite journal | last1 = Vos | first1 = AC. | last2 = Bakkal | first2 = N. | last3 = Minnee | first3 = RC. | last4 = Casparie | first4 = MK. | last5 = de Jong | first5 = DJ. | last6 = Dijkstra | first6 = G. | last7 = Stokkers | first7 = P. | last8 = van Bodegraven | first8 = AA. | last9 = Pierik | first9 = M. | title = Risk of malignant lymphoma in patients with inflammatory bowel diseases: A Dutch nationwide study. | journal = Inflamm Bowel Dis | volume = 17 | issue = 9 | pages = 1837-1845 | month = Sep | year = 2011 | doi = 10.1002/ibd.21582 | PMID = 21830262 }}</ref> | |||
===Extra-intestinal manifestations of inflammatory bowel disease=== | |||
Mnemonic (family-rated version) '''''e'''xcellent '''c'''ardiac '''s'''urgery '''i'''s '''p'''leasant '''a'''nd '''a'''ppreciated'': | |||
*[[erythema nodosum|'''E'''rythema nodosum]]. | |||
*[[Clubbing|'''C'''lubbing]]. | |||
*[[primary sclerosing cholangitis|'''S'''clerosing cholangitis]]. | |||
*[[Iritis|'''I'''ritis]]. | |||
*[[Pyoderma gangrenosum|'''P'''yoderma gangrenosum]]. | |||
*'''A'''phthous ulcers. | |||
*[[Arthritis|'''A'''rthritis]]. | |||
===Molecular=== | |||
*NOD2<ref name=omim605956>{{OMIM|605956}}</ref> ([[AKA]] CARD15) variants are associated with stricturing CD, early need for surgery and recurrence.<ref name=pmid16244543 >{{cite journal |author=Alvarez-Lobos M, Arostegui JI, Sans M, ''et al.'' |title=Crohn's disease patients carrying Nod2/CARD15 gene variants have an increased and early need for first surgery due to stricturing disease and higher rate of surgical recurrence |journal=Ann. Surg. |volume=242 |issue=5 |pages=693–700 |year=2005 |month=November |pmid=16244543 |pmc=1409853 |doi= |url=}}</ref> | |||
===General clinical differential diagnosis=== | ===General clinical differential diagnosis=== | ||
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*[[Irritable bowel syndrome]]. | *[[Irritable bowel syndrome]]. | ||
== | =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> | |||
==Microscopic | ===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> | #*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. | ||
#* | #*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 | # 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==== | ||
<gallery> | |||
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: Cryptitis_-_alt_--_very_high_mag.jpg | Cryptitis. (WC) | |||
Image:Crypt_branching_high_mag.jpg | Crypt branching. (WC) | |||
</gallery> | |||
===Grading=== | ===Grading=== | ||
*Several systems exists.<ref> | *Several systems exists.<ref name=Kirsch>Kirsch, R. 13 December 2010.</ref> | ||
*One that is often cited is by Gupta et al | *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> | | "A grading scheme"<ref name=Kirsch>Kirsch, R. 13 December 2010.</ref> | ||
| - | | - | ||
| cryptitis | | [[cryptitis]] | ||
| | | [[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 | ==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 | **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> | 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> | 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 | ||
|- | |- | ||
|} | |} | ||
=Sign out= | |||
===Quiescent inflammatory bowel disease=== | |||
*No accepted formal definition. | |||
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. | |||
COMMENT: | |||
No definite granulomata are identified. Mild architectural changes are present. | |||
Cryptitis is seen in several crypts. Rare crypt abscesses are present. Lamina propria | |||
plasma cells are abundant throughout the biopsy. | |||
The findings are compatible with inflammatory bowel disease or an infectious | |||
etiology. Clinical correlation is required. | |||
</pre> | |||
===Moderate inflammation=== | |||
<pre> | |||
RECTUM, BIOPSY: | |||
- RECTAL MUCOSA WITH MODERATE ACTIVE INFLAMMATION AND CHRONIC CHANGES. | |||
- NEGATIVE FOR DYSPLASIA. | |||
- SEE COMMENT. | |||
COMMENT: | |||
No definite granulomata are identified. Architectural changes, including crypt drop out, | |||
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. | |||
The findings are compatible with inflammatory bowel disease or an infectious | |||
etiology. Clinical correlation is required. | |||
</pre> | |||
=Specific diagnoses= | |||
==Ulcerative colitis== | ==Ulcerative colitis== | ||
*Often abbreviated as ''UC''. | *Often abbreviated as ''UC''. | ||
{{Main|Ulcerative colitis}} | |||
== | ==Crohn's disease== | ||
* | *Abbreviated ''CD''. | ||
{{Main|Crohn's disease}} | |||
== | =="Indeterminate colitis"== | ||
* | *"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> | ||
* | |||
===Suggested terminology=== | |||
#IBDU = IBD unclassified. | |||
#CUTE = Colitis of uncertain type or etiology. | |||
#*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=== | ===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== | |||
*Abbreviated ''DALM''. | |||
{{Main|Dysplasia-associated lesion or mass}} | |||
== | ==Pouchitis== | ||
===General=== | ===General=== | ||
* | *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. | |||
=== | Note: | ||
*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> | |||
=== | 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> | |||
* | **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= | |||
*[[Colon]]. | *[[Colon]]. | ||
*[[Colorectal tumours]]. | *[[Colorectal tumours]]. | ||
Line 205: | Line 409: | ||
*[[Gastrointestinal pathology]]. | *[[Gastrointestinal pathology]]. | ||
*[[Intestinal polyps]]. | *[[Intestinal polyps]]. | ||
*[[Diverticular disease-associated colitis]]. | |||
*[[Pseudopyloric mucous glands]]. | |||
=References= | |||
{{reflist|2}} | {{reflist|2}} | ||
=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]] |
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