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Ali M, Ng S, Burgess P. Granulomatous Crohn's disease follows a more aggressive clinical course? SURGICAL PRACTICE 2021. [DOI: 10.1111/1744-1633.12488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Muhammad Ali
- Department of Colorectal and General Surgery Great Western Hospital Swindon UK
| | - Sherwin Ng
- Department of Colorectal and General Surgery Great Western Hospital Swindon UK
| | - Phillip Burgess
- Department of Colorectal and General Surgery Great Western Hospital Swindon UK
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Hong SW, Yoon H, Shin CM, Park YS, Kim N, Lee DH, Kim JS. Clinical significance of granulomas in Crohn's disease: A systematic review and meta-analysis. J Gastroenterol Hepatol 2020; 35:364-373. [PMID: 31522456 DOI: 10.1111/jgh.14849] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 08/18/2019] [Accepted: 08/24/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Epithelioid granuloma is one hallmark used to histologically diagnose Crohn's disease (CD). However, the clinical significance of granulomas in CD is unclear. Therefore, we performed a meta-analysis to compare the clinical features with CD according to the presence of granulomas. METHODS A literature search in PubMed, EMBASE, and Cochrane databases was performed on manuscripts published until October 2018. We included studies that met the following inclusion criteria: (i) patient: patients with CD; (ii) exposure: granulomas on the pathology; (iii) comparator: no granulomas; and (iv) outcomes: disease location, disease behavior, perianal disease, disease activity, use of biologics, and CD-associated hospitalization, surgery. RESULTS Nineteen studies met our inclusion criteria. Granulomas in CD patients were associated with a higher proportion of ileocolonic disease (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.21-1.83), a higher proportion of upper gastrointestinal disease (OR: 2.25, 95% CI: 1.28-3.95), a higher proportion of penetrating behavior (OR: 1.48, 95% CI: 1.09-2.01), a higher prevalence of perianal disease (OR: 2.15, 95% CI: 1.48-3.11), and a higher severity index at presentation (standardized mean difference: 0.20, 95% CI: 0.09-0.32). In addition, the use of biologics was significantly higher in CD patients with granulomas compared with without granulomas (OR: 1.66, 95% CI: 1.07-2.59). The presence of granulomas was significantly associated with CD-associated hospitalization (OR: 3.88, 95% CI: 1.44-10.49), but not with CD-associated surgery. CONCLUSIONS Clinical features in CD patients were significantly different according to the presence of granulomas. It may indicate a more aggressive phenotype of CD.
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Affiliation(s)
- Seung Wook Hong
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Young Soo Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Nayoung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Dong Ho Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Everhov ÅH, Sachs MC, Malmborg P, Nordenvall C, Myrelid P, Khalili H, Elmberg M, Ekbom A, Askling J, Jakobsson G, Halfvarson J, Ludvigsson JF, Olén O. Changes in inflammatory bowel disease subtype during follow-up and over time in 44,302 patients. Scand J Gastroenterol 2019; 54:55-63. [PMID: 30700170 DOI: 10.1080/00365521.2018.1564361] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM To investigate inflammatory bowel disease (IBD) register-based subtype classifications over a patient's disease course and over time. METHODS We examined International Classification of Diseases coding in patients with ≥2 IBD diagnostic listings in the National Patient Register 2002-2014 (n = 44,302). RESULTS 18% of the patients changed diagnosis (17% of adults, 29% of children) during a median follow-up of 3.8 years. Of visits with diagnoses of Crohn's disease (CD) or ulcerative colitis (UC), 97% were followed by the same diagnosis, whereas 67% of visits with diagnosis IBD-unclassified (IBD-U) were followed by another IBD-U diagnosis. Patients with any diagnostic change changed mostly once (47%) or twice (31%), 39% from UC to CD, 33% from CD to UC and 30% to or from IBD-U. Using a classification algorithm based on the first two diagnoses ('incident classification'), suited for prospective cohort studies, the proportion adult patients with CD, UC, and IBD-U 2002-2014 were 29%, 62%, and 10% (43%, 45%, and 12% in children). A classification model incorporating additional information from surgeries and giving weight to the last 5 years of visits ('prevalent classification'), suited for description of a study population at end of follow-up, classified 31% of adult cases as CD, 58% as UC and 11% as IBD-U (44%, 38%, and 18% in children). CONCLUSIONS IBD subtype changed in 18% during follow-up. The proportion with CD increased and UC decreased from definition at start to end of follow-up. IBD-U was more common in children.
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Affiliation(s)
- Åsa H Everhov
- a Department of Clinical Science and Education , Södersjukhuset, Karolinska Institutet , Stockholm , Sweden
- b Clinical Epidemiology Unit, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden
| | - Michael C Sachs
- c Institute of Environmental Medicine, Karolinska Institutet , Stockholm , Sweden
| | - Petter Malmborg
- a Department of Clinical Science and Education , Södersjukhuset, Karolinska Institutet , Stockholm , Sweden
- b Clinical Epidemiology Unit, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden
| | - Caroline Nordenvall
- d Department of Molecular Medicine and Surgery , Karolinska Institutet , Stockholm , Sweden
- e Center for Digestive Disease, Div. of Coloproctology , Karolinska University Hospital , Stockholm , Sweden
| | - Pär Myrelid
- f Division of Surgery, Department of Clinical and Experimental Medicine , Faulty of Health Sciences , Linköping, Sweden
- g University and Department of Surgery , County Council of Östergötland Linköping , Linköping, Sweden
| | - Hamed Khalili
- b Clinical Epidemiology Unit, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden
- h Gastroenterology Unit, Crohn's and Colitis Center, Massachusetts General Hospital, Harvard Medical School , Boston , MA , USA
| | - Maria Elmberg
- b Clinical Epidemiology Unit, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden
| | - Anders Ekbom
- b Clinical Epidemiology Unit, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden
| | - Johan Askling
- b Clinical Epidemiology Unit, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden
| | - Gustav Jakobsson
- i Department Medical Epidemiology and Biostatistics , Karolinska Institutet , Stockholm , Sweden
| | - Jonas Halfvarson
- j Department of Gastroenterology, Faculty of Medicine and Health , Örebro University , Örebro , Sweden
| | - Jonas F Ludvigsson
- i Department Medical Epidemiology and Biostatistics , Karolinska Institutet , Stockholm , Sweden
- j Department of Gastroenterology, Faculty of Medicine and Health , Örebro University , Örebro , Sweden
- k Department of Pediatrics , Örebro University Hospital, Örebro University , Örebro , Sweden
- l Division of Epidemiology and Public Health , School of Medicine, University of Nottingham , Nottingham , UK
- m Department of Medicine , Columbia University College of Physicians and Surgeons , New York , NY , USA
| | - Ola Olén
- a Department of Clinical Science and Education , Södersjukhuset, Karolinska Institutet , Stockholm , Sweden
- b Clinical Epidemiology Unit, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden
- n Department of pediatric gastroenterology and nutrition , Sachs' Children and Youth Hospital , Stockholm , Sweden
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4
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Sun X, Yuan L, Li Y, Shen B, Xie H, Liu X. Association of granulomas in mesenteric lymph nodes in Crohn's disease with younger age and transmural inflammation. J Gastroenterol Hepatol 2017; 32:1463-1468. [PMID: 28087973 DOI: 10.1111/jgh.13735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/05/2017] [Accepted: 01/11/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Mesenteric lymph nodes were usually removed during bowel resection surgery for Crohn's disease (CD). Mesenteric lymph node (MLN) granuloma predicted postoperative disease recurrence in patients with CD after ileocolic resection (ICR). This study was aimed to identify factors associated with MLN granulomas in a cohort of CD patients who underwent ICR. METHODS The study group consisted of 18 patients with CD who underwent the index ICR between 2004 and 2012 and had MLN granulomas. The control group included 32 cases negative for MLN granulomas, which were randomly selected from the same period. Clinicodemographic and histological features were compared in these two groups. RESULTS The presence of MLN granuloma was associated with younger age, perianal disease, and ileocolic disease. Gender, body mass index, smoking status, disease duration, extraintestinal manifestation, length of bowel resected, total number of nodes examined, medical treatment, and indications for surgery were not significantly different between the groups. The presence of MLN granuloma was associated with mural granuloma, transmural inflammation, mural abscess, hypertrophy of the muscularis propria, fibrosis of the muscularis propria, and serosal fibrosis in the small bowel. The multivariable analysis confirms that MLN granuloma was associated with age and transmural inflammation. CONCLUSIONS In CD patients who underwent the index ICR, the presence of MLN granuloma was associated with younger age and transmural inflammation. Our current results suggest that the detection of MLN granulomas may be enhanced in patients at higher risk, that is, younger patients or those with transmural inflammation on imaging or histopathology.
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Affiliation(s)
- Xingwen Sun
- Universitätsmedizin, Georg-August-University of Göttingen, Göttingen, Germany
| | - Lisi Yuan
- Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Yi Li
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Bo Shen
- Department of Gastroenterology/Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hao Xie
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Xiuli Liu
- Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Lee H, Westerhoff M, Shen B, Liu X. Clinical Aspects of Idiopathic Inflammatory Bowel Disease: A Review for Pathologists. Arch Pathol Lab Med 2017; 140:413-28. [PMID: 27128299 DOI: 10.5858/arpa.2015-0305-ra] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
CONTEXT -Idiopathic inflammatory bowel disease manifests with different clinical phenotypes showing varying behavior and risk for neoplasia. The clinical questions that are posed to pathologists differ depending on phase of the disease and the clinical circumstances. Understanding the clinical aspects of the dynamic disease process will enhance the role of pathology in optimizing the care of patients with inflammatory bowel disease. OBJECTIVE -To review clinical and surgical aspects of inflammatory bowel disease that are relevant to practicing pathologists. DATA SOURCES -The literature was reviewed. CONCLUSIONS -Diagnosis and management of inflammatory bowel disease require an integrated evaluation of clinical, endoscopic, radiologic, and pathologic features. Therefore, close interaction between clinicians and pathologists is crucial. Having this team approach improves understanding of the pertinent clinical and surgical aspects of the disease and assists in the recognition of unusual presentation of variants, as well as mimics of idiopathic inflammatory bowel disease, by pathologists.
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Affiliation(s)
| | | | | | - Xiuli Liu
- From the Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, New York (Dr Lee); the Department of Anatomic Pathology, University of Washington Medical Center, Seattle (Dr Westerhoff); and the Department of Gastroenterology/Hepatology, Digestive Disease Institute (Dr Shen), and the Department of Pathology, Immunology, and Laboratory Medicine (Dr Liu), University of Florida, Gainesville
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Odze RD. A contemporary and critical appraisal of 'indeterminate colitis'. Mod Pathol 2015; 28 Suppl 1:S30-46. [PMID: 25560598 DOI: 10.1038/modpathol.2014.131] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 07/29/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023]
Abstract
Distinguishing ulcerative colitis (UC) from Crohn's disease (CD) is normally based on evaluation of a variety of clinical, radiologic, serologic and pathologic findings, the latter in biopsy and/or resection specimens. Unfortunately, some patients with IBD show overlapping pathologic features of UC and CD, which makes definite distinction between these two disorders difficult or even impossible. In most instances of uncertainty, the patient shows clinical and pathologic features of UC, but in addition, the patient's colon resection specimen reveals one or more CD-like features. In this setting, a diagnosis of indeterminate colitis (IC) is often rendered. IC is not a distinct disease entity, and, thus, it has no diagnostic criteria. The most common causes of uncertainty in IBD pathology that may lead to a diagnosis of IC in a colon resection specimen includes the presence of fulminant (severe and toxic) colitis, insufficient radiologic, endoscopic, or pathologic information (including analysis of prior biopsies) on the patient, failure to utilize major diagnostic criteria as hard evidence in favor of CD, failure to recognize unusual variants of UC and CD that may mimic each other, failure to recognize non-IBD mimics and other superimposed diseases that cause unusual pathologic features in a resection specimen, an attempt to distinguish UC from CD in mucosal biopsies of the colon and ileum, or an attempt to change the patients diagnosis (of UC or CD) based on pouch or diversion-related complications. Details of each of these causes of uncertainty are discussed, in detail, in this review article. A diagnosis of IC should never be made clinically or by pathologists based on evaluation of pre-resection colonic mucosal biopsies. Ultimately, the majority of indeterminate cases represent UC, and, thus, most of these patient can be treated safely with a colectomy combined with an ileal pouch anal anastomosis procedure.
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Affiliation(s)
- Robert D Odze
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
BACKGROUND The relevance of granulomas in biopsy specimens from patients with Crohn's disease is largely unknown. Most previous studies have been performed on small samples and have produced conflicting results. This study was designed to compare the demographic, clinical, and histopathologic characteristics of a large cohort of documented patients with Crohn's disease with and without epithelioid granulomas. METHODS Data of all patients with Crohn's disease were extracted from a computerized database of 1.3 million subjects who underwent colonoscopy and had their biopsy specimens diagnosed by a single group of gastrointestinal pathologists. The influence of age, gender, patient symptoms, and histopathologic finding on the presence of granuloma was analyzed. RESULTS There were 10,456 patients with Crohn's disease: 952 (9%) patients harbored granulomas (cases) and 9504 (91%) patients (controls) had none. Cases were significantly younger than controls: 42.4 ± 17.9 versus 48.0 ± 16.4 years (P < 0.0001). Cases presented with more symptoms than controls (odds ratio, 95% confidence interval): diarrhea (2.29, 2.28-2.31), anemia (2.06, 2.02-2.10), vomiting (2.13, 2.07-2.19), abdominal pain (1.75, 1.72-1.78), hematochezia (1.97, 1.94-2.00), and weight loss (3.94, 3.93-3.94). In a multivariate logistic regression analysis, younger age, presence of chronic active colitis, and symptoms of weight loss remained independent statistically significant predictors for the presence of granulomas. CONCLUSIONS In colonic biopsies from patients with Crohn's disease, granulomas constitute a rare finding. Presence of granulomas is associated with younger patient age, more severe histopathologic expression of the underlying disease, and more clinical symptoms.
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Feakins RM. Ulcerative colitis or Crohn's disease? Pitfalls and problems. Histopathology 2013; 64:317-35. [PMID: 24266813 DOI: 10.1111/his.12263] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 08/21/2013] [Indexed: 12/21/2022]
Abstract
The interpretation of colorectal biopsies taken for the initial diagnosis of chronic idiopathic inflammatory bowel disease (IBD) is challenging. Subclassification of IBD as ulcerative colitis (UC) or Crohn's disease, which may be particularly difficult, is the subject of this review. Biopsies taken at first presentation are emphasised, partly because their features have not been modified by time or treatment. Aspects of longstanding disease and of resections are also mentioned. The first part of the review comprises background considerations and a summary of histological features that are discriminant, according to published evidence, between UC and Crohn's disease in initial biopsies. Pitfalls and problems associated with making the distinction between UC and Crohn's disease are then discussed. These include: mimics of IBD; inadequate clinical details; unreliable microscopic features; absence of histological changes in early IBD; discontinuity in UC; cryptolytic granulomas; differences between paediatric and adult UC; reliance on ileal and oesophagogastroduodenal histology; and atypical features in IBD resections. Avoidance by pathologists of known pitfalls should increase the likelihood of accurate and confident subclassification of IBD, which is important for optimum medical and surgical management.
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Huang HL, Miao YL, Tang ZL, Wang GY. Pathological characteristics of IBD: An analysis of 430 cases. Shijie Huaren Xiaohua Zazhi 2013; 21:1888-1892. [DOI: 10.11569/wcjd.v21.i19.1888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To summarize the pathological characteristics of inflammatory bowel disease (IBD) in hospitalized patients in Kunming by retrospectively analyzing data over the past 10 years.
METHODS: The detailed data for 430 patients with IBD, including 379 with ulcerative colitis (UC) and 51 with Crohn's disease (CD), were obtained from seven large general hospital of Kunming from January 1998 to March 2007. IBD was diagnosed based on the diagnostic and treatment criteria established in the digestion disease institute branch conference of China in 2007. The pathological characteristics of IBD were then analyzed.
RESULTS: The pathology diagnosis coincidence rate in UC and CD was 24.4% and 27.5%, respectively. Approximately 56.2% of 379 UC patients underwent pathological examination, of which 180 cases had described microscopic features. The microscopic manifestations included erosion or ulcer in 25% of cases, cryptitis and crypt abscess in 29%, cryptae twisting and branching in 1.8%, cryptae atrophy in 1.7%, fluffiness surfaces in 0.56%, goblet cells reduction in 11.1%, fundus phlogocytosis in 5.6%, gland hyperplasia in 8.9%, and atypical hyperplasia in 3.9%. Approximately 78.4% of 51 patients with CD underwent pathological examination, of which 30 cases had described microscopic features. The microscopic manifestations included active chronic inflammation in 100% of cases, non-caseating granuloma in 23.3%, and fissuring ulcer in 23.3%.
CONCLUSION: The number of cases undergoing pathological examination was not very high, and the coincidence rate was low. Pathological characteristics of UC were mainly erosion or ulcer, cryptitis and crypt abscess, while those of CD were mainly non-caseating granuloma and fissuring ulcer, both of which were in active chronic inflammation period.
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Li Y, Wu B, Shen B. Diagnosis and differential diagnosis of Crohn's disease of the ileal pouch. Curr Gastroenterol Rep 2013; 14:406-13. [PMID: 22855236 DOI: 10.1007/s11894-012-0282-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Approximately 20%-30% of patients with ulcerative colitis will eventually require colectomy despite recent advances in medical therapy. Ileal pouch-anal anastomosis has become the surgical treatment of choice. A subset of patients with ileal pouches can develop Crohn's disease or a Crohn's-disease-like condition of the ileal pouch after surgery. Diagnosis, differential diagnosis, and management of Crohn's disease of the ileal pouch have been challenging. A combined assessment of clinical history, endoscopy, histology, abdominal/pelvic imaging, and examination under anesthesia is often necessary for accurate diagnosis, disease classification, management, and prognosis. A multidisciplinary approach with gastroenterologists, colorectal surgeons, gastrointestinal pathologists, and radiologists is advocated.
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Affiliation(s)
- Yue Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
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Soucy G, Wang HH, Farraye FA, Schmidt JF, Farris AB, Lauwers GY, Cerda SR, Dendrinos KG, Odze RD. Clinical and pathological analysis of colonic Crohn's disease, including a subgroup with ulcerative colitis-like features. Mod Pathol 2012; 25:295-307. [PMID: 21841769 DOI: 10.1038/modpathol.2011.120] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Little is known regarding the clinical and, in particular, pathological manifestations of patients with isolated colonic Crohn's disease. The purpose of this study was to evaluate the clinical and pathological features of patients with Crohn's disease limited to the colon at initial presentation, and to determine whether there are any histological features that are predictive of outcome after surgery. The clinical features, outcome after surgery, and pathological features of colonic resection specimens of 73 patients who presented initially with isolated colonic Crohn's disease were evaluated and compared with 45 Crohn's disease patients who presented initially with both ileal and colonic involvement. Clinically, patients with isolated colonic Crohn's disease presented at a significantly older age at the time of diagnosis, and had a significantly shorter duration of colitis before surgical resection, than did patients with ileocolonic Crohn's disease at disease onset. Pathologically, patients with isolated colonic Crohn's disease showed a significantly higher proportion of cases with subtotal, total, or left-sided colitis, and significantly fewer strictures/stenosis, pericolonic adhesions, pyloric metaplasia, and cases with proximal worse than distal colonic disease. Overall, patients with isolated colonic Crohn's disease showed a trend toward a lower number of major microscopic Crohn's disease features. A small proportion of patients from both Crohn's disease groups (14% and 13%, respectively) showed inflammatory disease limited to the mucosa, without mural involvement, reminiscent of ulcerative colitis, and these were termed 'ulcerative colitis-like Crohn's disease'. These patients were significantly younger than those with mural involvement. Overall, 44% of patients from both Crohn's disease groups developed at least one adverse outcome, and neither the number nor the type of major Crohn's disease features correlated with adverse outcome. Patients with isolated colonic involvement have distinctive clinical and pathological features. A small subgroup of Crohn's patients shows only mucosal involvement reminiscent of ulcerative colitis.
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Affiliation(s)
- Genevieve Soucy
- Department of Pathology, Centre Hospitalier Universitaire de Montreal, Montreal, Quebec, Canada
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Shen B, Patel S, Lian L. Natural history of Crohn's disease in patients who underwent intentional restorative proctocolectomy with ileal pouch-anal anastomosis. Aliment Pharmacol Ther 2010; 31:745-53. [PMID: 20047579 DOI: 10.1111/j.1365-2036.2009.04227.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Crohn's disease is generally considered a relative contraindication for restorative proctocolectomy with ileal pouch anastomosis (IPAA). The natural history of IPAA in these patients has not well been defined. AIM To evaluate the natural history of IPAA in patients with a well-defined preoperative Crohn's disease. METHODS All patients from the Pouchitis Clinic who had a preoperative diagnosis of Crohn's disease were screened and 11 patients met the inclusion criteria. The control group (with a 1:4 ratio) consisted of IPAA patients with a preoperative diagnosis of UC. RESULTS During the follow-up period of 5.0 years, 7 of 11 (63.6%) with a preoperative diagnosis of Crohn's disease developed Crohn's disease of the pouch. Crohn's disease of the pouch developed 0.2-15 years after ileostomy closure. The remaining four patients with a preoperative diagnosis of Crohn's disease did not demonstrate signs of Crohn's disease in 2, 11, 11 and 24 years after pouch surgery, respectively. CONCLUSIONS Post-operative development of Crohn's disease of the pouch was common in patients with a preoperative diagnosis of Crohn's disease who underwent IPAA. Long-term medical therapy was often required. Large multi-centre studies are warranted to delineate further the natural history of the disease, before Crohn's disease is considered an indication for IPAA.
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Affiliation(s)
- B Shen
- Digestive Disease Institute, the Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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Abstract
PURPOSE This study used meta-analytical techniques to compare the recurrence of granulomatous vs nongranulomatous Crohn disease. METHODS Comparative studies published between 1954 and 2007 of granulomatous vs nongranulomatous Crohn disease were included. Using a random effects model, end points evaluated were the number of recurrences and reoperations, and the time to recurrence and reoperation, of granulomatous vs nongranulomatous Crohn disease. Heterogeneity was assessed and sensitivity analysis was performed to account for bias in patient selection. RESULTS Twenty-one studies (14 nonrandomized retrospective, 7 nonrandomized prospective) reported on 2236 patients with Crohn disease, of whom 1050 (47.0%) had granulomas (granulomatous group) and 1186 (53.0%) had no granulomas (nongranulomatous group). The number of recurrences and reoperations was found to be significantly higher in the granulomatous group compared to the nongranulomatous group (odds ratio 1.37, P = .04; odds ratio 2.38, P < .001; respectively), with significant heterogeneity between studies (P = .06; P < .001; respectively). The time to recurrence and reoperation was significantly shorter in the granulomatous group compared with the nongranulomatous group (hazard ratio 1.63, P = .001; hazard ratio 1.62, P = .002; respectively), with no significant heterogeneity between studies. The number of recurrences and reoperations remained significantly higher in the granulomatous group compared to the nongranulomatous group during sensitivity analysis of higher-quality studies, more recent studies, and studies with a larger group of patients. CONCLUSIONS Granulomatous Crohn disease appears to be associated with a higher number of recurrences and reoperations and a shorter time to recurrence and reoperation compared to nongranulomatous Crohn disease. Because of significant heterogeneity between studies, further studies should be undertaken to confirm these findings.
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Nasseri Y, Melmed G, Wang HL, Targan S, Fleshner P. Rigorous histopathological assessment of the colectomy specimen in patients with inflammatory bowel disease unclassified does not predict outcome after ileal pouch-anal anastomosis. Am J Gastroenterol 2010; 105:155-61. [PMID: 19755970 DOI: 10.1038/ajg.2009.510] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Abdominal colectomy has been used in patients with inflammatory bowel disease unclassified (IBDU), requiring surgery to allow histopathological evaluation of the colectomy specimen to rule out Crohn's disease (CD). We evaluated whether any histopathological feature was associated with an adverse postoperative outcome. METHODS Patients with ulcerative colitis (UC) or IBDU undergoing ileal pouch-anal anastomosis (IPAA) were prospectively examined. A checklist of 17 histopathological features atypical for UC was developed. Outcomes of acute pouchitis (AP), chronic pouchitis (CP), and de novo CD were assessed. RESULTS The 153 study patients included 119 (78%) UC and 34 (22%) IBDU patients. The following atypical features were identified (n; %): broad-based ulcer (99; 65%), appendiceal involvement (78; 51%), V-shaped ulcer (48; 31%), crypt-associated granuloma (42; 27%), isolated giant cells (39; 25%), discontinuous active inflammation (36; 24%), slit-like fissure (32; 21%), discontinuous chronic inflammation (16; 10%), ileal villous architectural distortion (12; 8%), neural hypertrophy (10; 7%), backwash ileitis (10; 7%), transmural inflammation (8; 5%), discontinuous ileitis (8; 5%), muscle hypertrophy (5; 3%), ileal ulcer (4; 3%), and ileal pyloric metaplasia (1; 1%). A total of 29 patients (19%) developed AP, 17 (11%) developed CP, and 13 patients (8%) developed de novo CD. On univariate analysis, de novo CD developed in 3 of the 10 patients (30%) with neural hypertrophy compared with only 10 of the 143 patients (7%) without neural hypertrophy (P=0.01). Multivariate regression did not show a single atypical histopathological feature, which predicted a worse outcome after IPAA. CONCLUSIONS No single atypical histopathological feature of UC, or combination of features, was associated with any adverse pouch outcome after IPAA. There seems to be no value in performing a staged IPAA in IBDU patients.
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Affiliation(s)
- Yosef Nasseri
- Cedars-Sinai Medical Center, Los Angeles, California, USA
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Abstract
Approximately 30% of patients with ulcerative colitis will eventually require surgery. Ileal pouch-anal anastomosis has become the surgical treatment of choice in ulcerative colitis patients with refractory disease or dysplasia who require proctocolectomy. A subset of patients with ileal pouches may develop Crohn's disease or a Crohn's disease-like condition of the pouch after the surgery. Diagnosis and management can be challenging. A combined assessment of endoscopy, histology, radiographic imaging and examination under anesthesia is often necessary for an accurate diagnosis, disease classification, management and prognosis. A multidisciplinary approach by a medical and surgical team, together with experienced pathologists and radiologists, is advocated.
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Affiliation(s)
- Hao Wu
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
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Melmed GY, Fleshner PR, Bardakcioglu O, Ippoliti A, Vasiliauskas EA, Papadakis KA, Dubinsky M, Landers C, Rotter JI, Targan SR. Family history and serology predict Crohn's disease after ileal pouch-anal anastomosis for ulcerative colitis. Dis Colon Rectum 2008; 51:100-8. [PMID: 18085333 PMCID: PMC2442922 DOI: 10.1007/s10350-007-9158-3] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Revised: 09/27/2007] [Accepted: 10/17/2007] [Indexed: 12/13/2022]
Abstract
PURPOSE Approximately 5 to 10 percent of patients undergoing ileal pouch-anal anastomosis with a diagnosis of ulcerative colitis are subsequently diagnosed with Crohn's disease. Preoperative predictors for Crohn's disease post-ileal pouch-anal anastomosis have not been prospectively defined. METHODS A total of 238 consecutive patients with ulcerative colitis or indeterminate colitis undergoing ileal pouch-anal anastomosis were prospectively enrolled into a longitudinal database. Clinical factors were assessed perioperatively. Serum drawn preoperatively was assayed for anti-Saccharomyces cerevisiae, antiouter membrane porin-C, anti-CBir1, and perinuclear antineutrophil cytoplasmic antibody using enzyme-linked immunosorbent assay. Crohn's disease was defined by small bowel inflammation proximal to the ileal pouch or a perianal fistula identified at least three months after ileostomy closure. Predictors were assessed in a multivariate Cox proportional hazards model to predict the rate of Crohn's disease after ileostomy closure. RESULTS Sixteen patients (7 percent) were diagnosed with Crohn's disease; median time to Crohn's disease was 19 (range, 1-41) months. Significant factors for postoperative Crohn's disease after ileal pouch-anal anastomosis included family history of Crohn's disease (hazard ratio, 8.4; 95 percent confidence interval, 2.96-24.1; P < 0.0001) and anti-Saccharomyces cerevisiae immunoglobulin-A seropositivity (hazard ratio, 3.14; 95 percent confidence interval, 1.1-9.81; P = 0.04). Crohn's disease developed in only 8 of 198 patients (4 percent) without these predictors vs. 8 of 40 patients (20 percent) in those with at least one of these factors (P = 0.002). The cumulative risk of Crohn's disease among patients with two risk factors (67 percent) was higher than in patients with either risk factor (18 percent) or neither risk factor (4 percent, P < 0.001). CONCLUSIONS Patients with ulcerative colitis and indeterminate colitis with a family history of Crohn's disease or preoperative anti-Saccharomyces cerevisiae immunoglobulin-A seropositivity are more likely to be diagnosed with Crohn's disease after ileal pouch-anal anastomosis.
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Affiliation(s)
- Gil Y Melmed
- Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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17
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Rubio CA, Orrego A, Nesi G, Finkel Y. Frequency of epithelioid granulomas in colonoscopic biopsy specimens from paediatric and adult patients with Crohn's colitis. J Clin Pathol 2007; 60:1268-72. [PMID: 17293387 PMCID: PMC2095463 DOI: 10.1136/jcp.2006.045336] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2007] [Indexed: 12/28/2022]
Abstract
AIMS To test the assumption that epithelioid granulomas found in colonoscopic biopsy specimens in patients with Crohn's colitis are markers of a different clinical behaviour. METHODS Sections from colonoscopic biopsy specimens from 352 consecutive patients (119 children and 233 adults) were investigated. RESULTS A total of 1117 colonoscopies were performed: 293 in children (mean 2.46 per patient) and 824 in adults (mean 3.53 per patient) (p<0.05). Granulomas at initial colonoscopy were recorded in 67.2% (43/64) of children and 65.9% (27/41) of adults (p>0.6), and at subsequent colonoscopies in 53.8% (64/119) of children and 17.6% (41/233) of adults (p<0.05). Surgical intervention was required in 6.3% (4/64) of the children having previous granuloma, but also in 14.5% (8/55) of those without previous granuloma, the rate for operated adults being 26.8% (11/41) and 24.5% (47/192), respectively (p>0.6). CONCLUSIONS Granulomas in entry and/or in subsequent colonoscopic biopsy specimens in patients with Crohn's colitis did not predict the need for subsequent surgical intervention. The fact that the frequency of granulomas was significantly higher in children than in adults with Crohn's colitis (despite a higher mean number of colonoscopic biopsies in adults), and that granulomas were present in colonoscopic biopsy specimens but not in the subsequent surgical specimens from 50% of the paediatric and 36% of the adult patients strengthen the conviction that granulomas in Crohn's colitis might evolve or regress at different time intervals during the course of the disease. This behaviour would reflect a particular immunological reaction, an epiphenomenon from immature tissues-as in children-when challenged by the so far elusive aetiological agent responsible for Crohn's disease.
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Affiliation(s)
- C A Rubio
- Department of Pathology, Karolinska University Hospital, Stockholm, Sweden.
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18
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Leonor R, Jacobson K, Pinsk V, Webber E, Lemberg DA. Surgical intervention in children with Crohn's disease. Int J Colorectal Dis 2007; 22:1037-41. [PMID: 17530264 DOI: 10.1007/s00384-007-0281-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2007] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Crohn's disease (CD) causes chronic inflammation of the gastrointestinal tract leading to extensive medical treatments and surgery with two thirds of patients having surgery over their lifetime. In this study, we reviewed the pediatric population at the British Columbia Children's Hospital diagnosed with CD and examined their demographics and treatments, in particular assessing those who ultimately underwent surgery. MATERIALS AND METHODS Two hundred and eighty children (median age 11.9 years [CI 11.5-12.28]) diagnosed with CD from January 1994 to December 2003 were included. Demographic data were documented including age, ethnicity, duration of symptoms before diagnosis, treatment to date and surgical parameters. Comparison was made between operative and non-operative patients including involvement of disease, medical treatment, complications and recurrence of disease leading to repeat operations. RESULTS Fifty-five (19.6%) children had surgical procedures. There was a significant increase in surgery in those patients who had not received immunomodulator therapy before surgery (odds ratio 1.95 [CI 1.02-3.73]). We also observed that those CD patients with extensive small intestinal involvement had lower likelihood of having surgery (odds ratio 0.386 [CI 0.145-1.033]). No significant difference was found between the two groups with regard to age of diagnosis (p = 0.41), duration of symptoms (p = 0.22), gender (p = 0.50) or ethnicity (p = 0.451). CONCLUSION There was an increased incidence of surgery in those patients who were not treated with immunomodulator therapy. In addition, children with extensive as opposed to isolated small intestinal disease were less likely to have surgery in childhood.
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Affiliation(s)
- R Leonor
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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19
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Steele SR. Operative management of Crohn's disease of the colon including anorectal disease. Surg Clin North Am 2007; 87:611-31. [PMID: 17560415 DOI: 10.1016/j.suc.2007.03.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Evaluation and management of the patient who has Crohn's disease of the colon, rectum, and anus is challenging for even the most experienced provider. Because of its broad spectrum of presentation, recurrent nature, and potential for high morbidity, the surgeon needs to not only treat the acute situation but also keep in mind the potential long-term ramifications. Although there are exciting new medications and treatment modalities yielding promising results, surgery continues to remain at the forefront for the care of these patients. This article reviews various surgical options for the patient who has Crohn's disease of the colon, rectum, and perianal region with emphasis on symptomatic resolution and optimization of function.
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Affiliation(s)
- Scott R Steele
- Colon & Rectal Surgery, Department of Surgery, Madigan Army Medical Center, Fort Lewis, WA 98431, USA.
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Abstract
Crohn's disease in childhood is changing. The incidence is increasing, colonic disease is becoming more prevalent in younger children, and colon reconstruction is more acceptable. Genetic phenotypes are influencing decisions for surgery, and targeted immunotherapy has renewed hope for more durable remissions following less extensive resections. The tasks facing the surgeon evaluating a child with Crohn's colitis include confirming the specific diagnostic subtype and selecting the correct procedure. This chapter will review the unique aspects of pediatric Crohn's colitis and the increased complexity of surgical choice for this most challenging presentation. Recent success with less extensive surgery offers renewed hope for children with intractable colonic disease.
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Affiliation(s)
- Christopher R Moir
- Division of Pediatric Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
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21
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von Roon AC, Reese G, Teare J, Constantinides V, Darzi AW, Tekkis PP. The risk of cancer in patients with Crohn's disease. Dis Colon Rectum 2007; 50:839-55. [PMID: 17308939 DOI: 10.1007/s10350-006-0848-z] [Citation(s) in RCA: 193] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE The risk of cancer in patients with Crohn's disease is not well defined. Using meta-analytical techniques, the present study was designed to quantify the risk of intestinal, extraintestinal, and hemopoietic malignancies in such patients. METHODS A literature search identified 34 studies of 60,122 patients with Crohn's disease. The incidence and relative risk of cancer were calculated for patients with Crohn's disease and compared with the baseline population of patients without Crohn's disease. Overall pooled estimates, with 95 percent confidence intervals, were obtained, using a random-effects model. RESULTS The relative risk of small bowel, colorectal, extraintestinal cancer, and lymphoma compared with the baseline population was 28.4 (95 percent confidence interval, 14.46-55.66), 2.4 (95 percent confidence interval, 1.56-4.36), 1.27 (95 percent confidence interval, 1.1-1.47), and 1.42 (95 percent confidence interval, 1.16-1.73), respectively. On subgroup analysis, patients with Crohn's disease had an increased risk of colon cancer (relative risk, 2.59; 95 percent confidence interval, 1.54-4.36) but not of rectal cancer (relative risk, 1.46; 95 percent confidence interval, 0.8-2.55). There was significant association between the anatomic location of the diseased bowel and the risk of cancer in that segment. The risk of small bowel cancer and colorectal cancer was found to be higher in North America and the United Kingdom than in Scandinavian countries with no evidence of temporal changes in the cancer incidence. CONCLUSIONS The present meta-analysis demonstrated an increased risk of small bowel, colon, extraintestinal cancers, and lymphoma in patients with Crohn's disease. Patients with extensive colonic disease that has been present from a young age should be candidates for endoscopic surveillance; however, further data are required to evaluate the risk of neoplasia over time.
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Affiliation(s)
- Alexander C von Roon
- Department of Biosurgery and Surgical Technology, Imperial College, St. Mary's Hospital, London, W2 1NY, UK
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22
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Yantiss RK, Odze RD. Pitfalls in the interpretation of nonneoplastic mucosal biopsies in inflammatory bowel disease. Am J Gastroenterol 2007; 102:890-904. [PMID: 17324129 DOI: 10.1111/j.1572-0241.2007.01105.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This review provides a summary of common diagnostic problems encountered by both pathologists and gastroenterologists when evaluating patients with diarrhea and in whom inflammatory bowel disease (IBD) is suspected. The two most common forms of IBD, ulcerative colitis (UC) and Crohn's disease (CD), may, in certain settings, show overlapping endoscopic and pathologic features, potentially resulting in diagnostic confusion. For instance, some cases of UC may show unusual CD-like features, such as rectal sparing, discontinuous disease, aphthous ulceration, ileal or extracolonic involvement, and granulomatous inflammation, all of which may be evident in mucosal biopsy specimens. CD may also present as a diffuse, superficial pancolitis with ileal sparing that mimics the endoscopic and histologic appearance of UC. Furthermore, other forms of colitis, such as microscopic colitis, diverticulitis, diversion colitis, and nonsteroidal anti-inflammatory drug (NSAID)-induced colonic injury may also show IBD-like changes in mucosal biopsies. The potential diagnostic pitfalls faced by physicians, as well as features that aid in the distinction among these entities, are discussed in detail in this review.
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Affiliation(s)
- Rhonda K Yantiss
- Department of Pathology and Laboratory Medicine of the Weill Medical College of Cornell University, New York, New York, USA
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Goldstein N, Dulai M. Contemporary morphologic definition of backwash ileitis in ulcerative colitis and features that distinguish it from Crohn disease. Am J Clin Pathol 2006; 126:365-76. [PMID: 16880149 DOI: 10.1309/uaxmw3428pgn9hj3] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Terminal ileum (TI) sections from 250 ulcerative colitis (UC) total colectomy specimens resected during 3 periods and endoscopic TI biopsy specimens from 100 contemporary chronic UC and 100 Crohn disease (CD) patients were reviewed. The respective proportions of cases resected during the 3 periods with moderately or markedly active cecal UC were 72%, 34%, and 2% and with moderate or marked backwash ileitis (BWI), 21%, 18%, and 0%. The activity level of BWI correlated with level of cecal UC. In contemporary initial endoscopic TI biopsy specimens, 6% of chronic UC patients had BWI, all with moderately to markedly active cecal chronic UC. In CD cases, 75% had chronic or active enteritis, consisting of patchy lamina propria edema containing mildly active inflammation, crypt disarray, and focally blunted or flattened villi. Mucous gland metaplasia was present in 27% of CD biopsy specimens. BWI should be restricted to active enteritis that involves the ileum in a contiguous pattern from the cecum that has a similar or greater degree of active inflammation. Mild BWI predominantly involves the superficial mucosa in a contiguous pattern. Focal isolated ileal erosions, mucous gland metaplasia, or patchy edema with mild active inflammation are features of CD.
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Affiliation(s)
- Neal Goldstein
- Department of Anatomic Pathology, William Beaumont Hospital, Royal Oak, MI 48073, USA
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Dalal I, Karban A, Wine E, Eliakim R, Shirin H, Fridlender M, Shaoul R, Leshinsky-Silver E, Levine A. Polymorphisms in the TNF-alpha promoter and variability in the granulomatous response in patients with Crohn's disease. Pediatr Res 2006; 59:825-8. [PMID: 16641217 DOI: 10.1203/01.pdr.0000215028.19269.94] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Granulomas may be found in 30-70% of patients with Crohn's disease (CD). The etiology of granuloma formation in CD is presently unknown. Elevated levels of TNF-alpha are found within granuloma tissue, and are required to maintain granuloma formation in animal models. TNF-alpha production has been shown to influenced by TNF-alpha promoter polymorphisms. We hypothesized that heterogeneity for granulomas in CD might be influenced by the TNF-alpha promoter genotype. Patients with confirmed CD that had undergone full colonoscopy with multiple biopsies and/or surgical resection, served as the study group. One hundred healthy individuals served as a control population for genotyping. Patients and controls underwent genotyping for four TNF-alpha polymorphisms: 238G/A, 308 G/A,857 C/T, and 863 C/A. Inclusion and exclusion criteria were met in 155 patients (1-68 y). Polymorphisms in the TNF promoter were found in 16.6% (238G/A), 14.5% (308 G/A), 36.6% (857 C/T) and 30.7% (863G/A). No significant association was found for any of the individual polymorphisms with presence or absence of granulomas. In conclusion, we did not find an association between individual polymorphisms in the TNF-alpha promoter and presence of granulomas in CD. The reason for heterogeneity in granuloma formation in patients with CD remains elusive.
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Affiliation(s)
- Ilan Dalal
- Department of Pediatrics, E.Wolfson Medical Center, Holon 58100, Isreal
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25
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Sagap I, Remzi FH. Ileal Pouch Anal Anastomosis and Crohn’s Disease. SEMINARS IN COLON AND RECTAL SURGERY 2006. [DOI: 10.1053/j.scrs.2006.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
This review summarizes some of the common diagnostic problems encountered by pathologists when evaluating patients with chronic colitis and in whom inflammatory bowel disease (IBD) is either suspected or within the differential diagnosis. Both ulcerative colitis (UC) and Crohn's disease (CD) show characteristic, but non-specific, pathological features that may overlap and result in a diagnosis of 'indeterminate colitis' (IC). However, other reasons why pathologists may entertain a diagnosis of IC include failure to recognize or accept certain 'hardcore' histological features as indicative of CD, an attempt to classify cases of chronic colitis based on mucosal biopsy material or in the absence of adequate clinical and radiographic information, and the presence of other disease processes that mask, or mimic, IBD. In addition, some cases of UC may show unusual CD-like features, such as discontinuous or patchy disease, ileal inflammation, extracolonic inflammation, granulomatous inflammation in response to ruptured crypts, aphthous ulcers, or transmural inflammation. Furthermore, other forms of colitis, such as microscopic colitis, diverticulitis and diversion colitis may, on occasion, also show IBD-like changes. The clinical and pathological features that aid in the distinction between these entities, and others, are covered in detail in this review.
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Affiliation(s)
- R K Yantiss
- Department of Pathology, Weill Medical College of Cornell University, New York, NY, USA
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Abstract
There have been many recent advances in cancer prevention, including improved understanding of cancer biology, better characterization of premalignant disease, significant advances in cancer surveillance, and identification of effective chemoprevention regimens. Despite this, surgery remains the best option for many individuals at high risk of cancer. Like all prevention modalities, surgical prevention involves balancing the factors governing cancer risk with the benefits and risks of treatment. The issues governing decision making for surgical prevention vary widely among different cancer types, and include consideration of the age and level of cancer risk of the individual, the effectiveness of cancer surveillance for the particular organ at risk, the aggressiveness of the cancer once present, and the morbidity of surgery. This article briefly reviews the use of surgery to prevent some of the most common epithelial malignancies, as well as some of the genetic cancer syndromes for which surgery plays an important role in improving survival.
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Shaoul R, Karban A, Weiss B, Reif S, Wasserman D, Pacht A, Eliakim R, Wardi J, Shirin H, Wine E, Leshinsky-Silver E, Levine A. NOD2/CARD15 mutations and presence of granulomas in pediatric and adult Crohn's disease. Inflamm Bowel Dis 2004; 10:709-14. [PMID: 15626887 DOI: 10.1097/00054725-200411000-00003] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The etiology and mechanism leading to granuloma formation in patients with Crohn's disease (CD) are presently unknown. The first susceptibility gene to be identified as a risk factor for CD is the NOD2/CARD15 gene on Chromosome 16. Mutations in NOD2 could affect the intracellular response to bacterial products and may eventually lead to granuloma formation. The association between NOD2 and granulomas has not been previously explored. We evaluated a possible association between NOD2 mutations and granuloma formation, and compared the prevalence of granulomas in both pediatric and adult cohorts. METHODS Patients were consecutively recruited through pediatric gastroenterology and adult gastroenterology programs. Patients were eligible if CD was confirmed, and they had undergone full colonoscopy with biopsy and/or surgical resection. Patients underwent genotyping for NOD2 disease-associated mutations. RESULTS A total of 230 patients were enrolled into the study, of whom 169 patients met all inclusion/exclusion criteria (Group 1, 77 patients [age range 1-16 years]; Group 2, 92 patients [age range 17-68 years]). Surgical resection was performed more often in adults (P < 0.005), and gastroscopy was performed more frequently in children (P < 0.001). Granulomas were found in 34% of the patients studied. The prevalence of granulomas did not differ by age, age group, or gender. A disease-associated NOD2 mutation was found in 37.8% of patients. Granulomas were found in 39% of patients with NOD2 mutations compared with 31% of those without NOD 2 mutations (difference was not significant). In addition, no difference was noted for the specific mutations. CONCLUSIONS We did not find any correlation between NOD2 mutations and granuloma formation. The cause of granulomas in CD remains elusive.
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