Recognition of Crohn disease on incidental gastric biopsy in childhood

Clinicopathological Characteristics and Etiological Factors of Granulomatous Gastritis

AIMS

To examine the clinicopathological characteristics of granulomatous gastritis (GG) among different etiologies, particularly Crohn disease (CD), and determine the contribution of H. pylori and the clinical significance of isolated GG.

METHODS/RESULTS

We identified 269 GG cases overall (0.19% prevalence): 220 had an underlying granulomatous disease (CD, sarcoidosis, tuberculosis) and only 8 of these (3.6%) had H. pylori, fewer than the 10.3% rate among non-GG biopsies (p<.001). Conversely, among 49 GG cases without known cause (foreign body, undetermined, idiopathic), 13 (26.5%) had H. pylori, more than background (p=.001). Most patients (n=185/68.8%) had CD and these were more likely male (p<.001), younger (p<.001), white (p<.001), and had single (p=.010), smaller (p=.005), antral (p=.027) granulomas, amid inflammation (p=.005), compared to non-CD GG cases; younger age was independently associated with CD (p=.003; OR=1.13, 95% CI: 1.04-1.22). Among CD patients, younger age (p=.003; OR=1.04, 95% CI: 1.01-1.07) and upper gastrointestinal (GI) symptoms (p=.017; OR=2.53, 95% CI: 1.18-5.43) were associated with new (vs. established) diagnosis, whereas multiple gastric granulomas (p=.003; OR=4.67, 95% CI: 1.67-13.04) and lack of upper GI symptoms (p<.001; OR=6.75, 95% CI: 2.94-15.49) were associated with lower GI granulomas. Of 86 isolated GG cases (i.e., no prior diagnosis or lower GI granulomas), 51 (59.3%) were eventually diagnosed with CD, and this was independently associated with younger age (p=.014; OR=1.11, 95% CI: 1.02-1.21) and upper GI symptoms (p=.033; OR=19.27, 95% CI: 1.27-293.31). The positive predictive value of finding isolated GG towards a CD diagnosis in patients <30 years-old was 91%, increasing in males (93%), with single (94%), antral (97%) granulomas, or upper GI symptoms (94%).

CONCLUSIONS

GG does not correlate with H. pylori in patients with granulomatous disease, but may be associated with the organism when such diagnosis is lacking. In CD patients with GG, younger age and upper GI symptoms are associated with a new CD diagnosis, whereas multiple gastric granulomas and lack of upper GI symptoms correlate with lower GI granulomas. GG, including in isolated cases with no prior clinical history or granuloma, likely signifies CD, particularly in younger, male patients, or those with single, antral granulomas, or upper GI symptoms.

Addition of Histology to the Paris Classification of Pediatric Crohn Disease Alters Classification of Disease Location

OBJECTIVES

The aim of the study was to investigate the value of microscopic findings in the classification of pediatric Crohn disease (CD) by determining whether classification of disease changes significantly with inclusion of histologic findings.

METHODS

Sixty patients were randomly selected from a cohort of patients studied at the Pediatric Inflammatory Bowel Disease Clinic at the University of California, San Francisco Benioff Children's Hospital. Two physicians independently reviewed the electronic health records of the included patients to determine the Paris classification for each patient by adhering to present guidelines and then by including microscopic findings.

RESULTS

Macroscopic and combined disease location classifications were discordant in 34 (56.6%), with no statistically significant differences between groups. Interobserver agreement was higher in the combined classification (κ = 0.73, 95% confidence interval 0.65-0.82) as opposed to when classification was limited to macroscopic findings (κ = 0.53, 95% confidence interval 0.40-0.58). When evaluating the proximal upper gastrointestinal tract (Paris L4a), the interobserver agreement was better in macroscopic compared with the combined classification.

CONCLUSIONS

Disease extent classifications differed significantly when comparing isolated macroscopic findings (Paris classification) with the combined scheme that included microscopy. Further studies are needed to determine which scheme provides more accurate representation of disease extent.

The association between Helicobacter pylori infection and inflammatory bowel disease based on meta-analysis

BACKGROUND

In humans there are epidemiological data suggesting a protective effect of Helicobacter pylori (H. pylori) infection against the development of autoimmune diseases and in addition, there are laboratory data illustrating H. pylori's ability to induce immune tolerance and limit inflammatory responses. Thus, numerous observational studies have examined the association between H. pylori infection and inflammatory bowel disease (IBD) with various results.

OBJECTIVE

We performed a meta-analysis of available studies to better define the association of H. pylori infection and IBD.

METHODS

Medical literature searches for human studies were performed through September 2014, using suitable keywords. In each study the risk ratio (RR) of H. pylori infection in IBD patients vs controls was calculated and pooled estimates were obtained using fixed- or random-effects models as appropriate. Heterogeneity between studies was evaluated using Cochran Q test and I(2) statistics, whereas the likelihood of publication bias was assessed by constructing funnel plots.

RESULTS

Thirty-three studies were eligible for meta-analysis, including 4400 IBD patients and 4763 controls. Overall 26.5% of IBD patients were positive for H. pylori infection, compared to 44.7% of individuals in the control group. There was significant heterogeneity in the included studies (Q = 137.2, df (Q) =32, I(2) ( )= 77%, p < 0.001) and therefore the random-effects model of meta-analysis was used. The obtained pool RR estimation was 0.62 (95% confidence interval (CI) 0.55-0.71, test for overall effect Z = -7.04, p < 0.001). There was no evidence of publication bias.

CONCLUSION

The results of this meta-analysis showed a significant negative association between H. pylori infection and IBD that supports a possible protective benefit of H. pylori infection against the development of IBD.

Investigation of potential early Histologic markers of pediatric inflammatory bowel disease

Background

Early manifestations of pediatric inflammatory bowel disease (IBD) can be relatively nonspecific. Initial mucosal biopsies may not be conclusive, delaying the diagnosis until subsequent biopsies demonstrate typical histologic features of IBD. We hypothesized that certain inflammatory cell types may be utilized as early histologic indicators of IBD in children.

Methods

A retrospective analysis compared histologic findings from initially inconclusive or negative endoscopic studies in 22 patients who were subsequently diagnosed with IBD (after diagnostic endoscopy) to those of 20 comparison patients with functional abdominal pain matched for age, gender, and study type. A pediatric pathologist, blinded to study group, reviewed biopsies for histologic abnormalities. Eosinophil densities were obtained from the stomach, duodenum, and rectosigmoid areas. Immunohistochemistry (IHC) staining for tumor necrosis factor-α (TNF-α) and matrix metalloproteinase-9 (MMP-9) was performed on the stomach and rectosigmoid areas.

Results

Gastritis and colonic crypt distortion were present in the IBD group at a greater rate (61 % vs. 22 %, p = 0.020; 34 % vs. 4 %, p = 0.008, respectively). Peak and mean eosinophil densities in the rectosigmoid area were greater in the IBD group (17.0/hpf vs. 5.0/hpf, p = 0.0063; 12.3/hpf vs. 4.2/hpf, p = 0.0106, respectively). TNF-α and MMP-9 staining did not reveal any significant differences.

Conclusions

Our data suggests that significantly greater inflammation in the stomach, crypt distortion in the colon, and eosinophilia in the rectosigmoid distinguished the IBD group from the comparison group at the time of the initial endoscopic evaluation.

Relationship between Helicobacter pylori infection and Crohn's disease: A Meta-analysis

AIM: To evaluate the relationship between Helicobacter pylori (H. pylori) infection and Crohn's disease (CD).

METHODS: Keyword and MeSH searches of Pubmed, Embase, the Cochrane Database, Science Citation Index, Full-text Database of Chinese Journals, the Database of Chinese Science Journals and Wanfang Database from January 2002 to December 2012 were performed to identify all available case-control studies. Two independent reviewers assessed studies for inclusion and exclusion based on methodological quality criteria, and then conducted Meta-analysis of the relative risk (RR) using Review Manager 5.2 software.

RESULTS: Thirteen case-control studies were included, involving 938 patients with CD and 65918 controls. Compared to the control group, the estimated RR of H. pylori infection in CD patients was 0.54 (95%CI: 0.42-0.70, P < 0.05).

CONCLUSION: There is a negative association between H. pylori infection and CD. H. pylori infection may have a protective effect against the development of CD.

Disseminated sarcoidosis presenting as granulomatous gastritis: a clinical review of the gastrointestinal and hepatic manifestations of sarcoidosis

Commonly considered a pulmonary disease, sarcoidosis is actually a multisystemic granulomatous disorder of unclear etiology. There is a wide range of organ system involvement, with gastrointestinal being among the rarest. We describe the diagnostic challenge of a patient presenting with gastritis without pulmonary complaints who was later found to have extrathoracic disseminated sarcoidosis. This case highlighted both the variability in the presentation of the disease and difficulties in its diagnosis. We performed a literature review to identify studies published on gastrointestinal and hepatic sarcoidosis to better understand the characteristics of this disease and help in the differentiation between other commonly encountered disorders that may be mimicked in presentation. We have also created a diagnostic approach that can be applied when endoscopic or hepatic biopsies reveal granulomas. We anticipate that this review may be useful for clinicians who face these diagnostic dilemmas and management decisions for this complex and variable condition.

Upper Gastrointestinal Tract in Inflammatory Bowel Disease

Involvement of the upper gastrointestinal tract by inflammatory bowel disease was long held to be a feature of Crohn's disease, whereas ulcerative colitis was considered to be limited to the colon. It is now recognized that ulcerative colitis associated inflammation can involve the upper gastrointestinal tract, primarily the stomach. In addition to aphthoid esophageal ulcers in Crohn's disease, eosinophilic esophagitis and so-called lymphocytic esophagitis occur in association with ulcerative colitis and Crohn's disease. Possible immune mechanisms behind these conditions are presented. The differential diagnosis of inflammation in each site is discussed.

Association between Helicobacter pylori infection and inflammatory bowel disease: a meta-analysis and systematic review of the literature

BACKGROUND

Epidemiologic data suggest a protective effect of Helicobacter pylori infection against the development of autoimmune disease. Laboratory data illustrate H. pylori's ability to induce immune tolerance and limit inflammatory responses. Numerous observational studies have investigated the association between H. pylori infection and inflammatory bowel disease (IBD). Our aim was to perform a systematic review and meta-analysis of this association.

METHODS

Medline, EMBASE, bibliographies, and meeting abstracts were searched by 2 independent reviewers. Of 369 abstracts reviewed, 30 promising articles were reviewed in detail. Twenty-three studies met our inclusion criteria (subject N = 5903). Meta-analysis was performed with the metan command in Stata 10.1.

RESULTS

Overall, 27.1% of IBD patients had evidence of infection with H. pylori compared to 40.9% of patients in the control group. The estimated relative risk of H. pylori infection in IBD patients was 0.64 (95% confidence interval [CI]: 0.54-0.75). There was significant heterogeneity in the included studies that could not be accounted for by the method of IBD and H. pylori diagnosis, study location, or study population age.

CONCLUSIONS

These results suggest a protective benefit of H. pylori infection against the development of IBD. Heterogeneity among studies and the possibility of publication bias limit the certainty of this finding. Further studies investigating the effect of eradication of H. pylori on the development of IBD are warranted. Because environmental hygiene and intestinal microbiota may be strong confounders, further mechanistic studies in H. pylori mouse models are also necessary to further define the mechanism of this negative association.

Pathology of inflammatory bowel disease

Inflammatory bowel disease in childhood refers to ulcerative colitis, Crohn's disease, and colitis of an indeterminate type. Their gross and microscopic features are discussed along with the differential diagnosis from other childhood conditions associated with bloody diarrhea.

Differentiating ulcerative colitis from Crohn disease in children and young adults: report of a working group of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the Crohn's and Colitis Foundation of America

BACKGROUND

Studies of pediatric inflammatory bowel disease (IBD) have varied in the criteria used to classify patients as having Crohn disease (CD), ulcerative colitis (UC), or indeterminate colitis (IC). Patients undergoing an initial evaluation for IBD will often undergo a series of diagnostic tests, including barium upper gastrointestinal series with small bowel follow-through, abdominal CT, upper endoscopy, and colonoscopy with biopsies. Other tests performed less frequently include magnetic resonance imaging scans, serological testing, and capsule endoscopy. The large amount of clinical information obtained may make a physician uncertain as to whether to label a patient as having CD or UC. Nevertheless, to facilitate the conduct of epidemiological studies in children, to allow the entry of children into clinical trials, and to allow physicians to more clearly discuss diagnosis with their patients, it is important that clinicians be able to differentiate between CD and UC.

METHODS

A consensus conference regarding the diagnosis and classification of pediatric IBD was organized by the Crohn's and Colitis Foundation of America. The meeting included 10 pediatric gastroenterologists and 4 pediatric pathologists. The primary aim was to determine the utility of endoscopy and histology in establishing the diagnosis of CD and UC. Each member of the group was assigned a topic for review. Topics evaluated included differentiating inflammatory bowel disease from acute self-limited colitis, endoscopic and histological features that allow differentiation between CD and UC, upper endoscopic features seen in both CD and UC, ileal inflammation and "backwash ileitis" in UC, patchiness and rectal sparing in pediatric IBD, periappendiceal inflammation in CD and UC, and definitions of IC.

RESULTS

Patients with UC may have histological features such as microscopic inflammation of the ileum, histological gastritis, periappendiceal inflammation, patchiness, and relative rectal sparing at the time of diagnosis. These findings should not prompt the clinician to change the diagnosis from UC to CD. Other endoscopic findings, such as macroscopic cobblestoning, segmental colitis, ileal stenosis and ulceration, perianal disease, and multiple granulomas in the small bowel or colon more strongly suggest a diagnosis of CD. An algorithm is provided to enable the clinician to differentiate more reliably between these 2 entities.

CONCLUSIONS

The recommendations and algorithm presented here aim to assist the clinician in differentiating childhood UC from CD. We hope the recommendations in this report will reduce variability among practitioners in how they use the terms "ulcerative colitis," "Crohn disease," and "indeterminate colitis." The authors hope that progress being made in genetic, serological, and imaging studies leads to more reliable phenotyping.

Inflammatory bowel disease in exclusively breast-fed infants

Inflammatory bowel disease is uncommon in infants. We present the clinical, endoscopic and pathologic findings for two exclusively breast-fed infants with a diagnosis of inflammatory bowel disease. We emphasize that although inflammatory bowel disease is rare in infants, chronic bloody diarrhea must be a sufficiently alarming symptom to consider a differential diagnosis of inflammatory bowel disease in young infants is considered, even when they are exclusively breast-fed.