1
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Desmedt V, Geldof J, Hoorens A, Lobaton T. Case report and review of literature: IgG4-gastroduodenitis in upper GI Crohn's disease: two separate entities or just a marker of disease severity? Front Med (Lausanne) 2024; 11:1388940. [PMID: 39099590 PMCID: PMC11294937 DOI: 10.3389/fmed.2024.1388940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/07/2024] [Indexed: 08/06/2024] Open
Abstract
A 20-year-old man was presented with ulcerative gastritis and duodenitis complicated by pyloric stenosis. Helicobacter pylori infection was excluded, and the lesions did not respond to treatment with proton pump inhibitors. No other parts of the intestinal tract showed signs of inflammation. Histopathological review showed signs of chronic inflammation with granuloma formation. A tentative diagnosis of isolated upper gastrointestinal (UGI) Crohn's disease was performed. However, additional work-up revealed significantly positive IgG4 staining as well as elevated IgG4 serum levels. Since granulomatous disease is unlikely in IgG4-related disease, an eventual diagnosis of overlapping IgG4-related disease and Crohn's disease (CD) was performed. Treatment with systemic steroids and anti-TNF in combination with azathioprine led to rapid symptomatic improvement. In this article, we review the available literature on IgG4-related gastroduodenitis, granulomatous gastritis, and upper GI CD. We suggest the possibility that IgG4-infiltration may be a marker of severely active inflammatory bowel disease rather than a separate disease entity.
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Affiliation(s)
- Valérie Desmedt
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
| | - Jeroen Geldof
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
| | - Anne Hoorens
- Department of Pathology, University Hospital Ghent, Ghent, Belgium
| | - Triana Lobaton
- Department of Gastroenterology and Hepatology, University Hospital Ghent, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
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2
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Chatelain D, Moslemi A, Dreau A, Clement M. [Inflammatory bowel diseases and upper gastrointestinal tract]. Ann Pathol 2023:S0242-6498(22)00208-5. [PMID: 36822896 DOI: 10.1016/j.annpat.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 02/23/2023]
Abstract
Inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis are inflammatory diseases with a flare-up evolution and an unknown etiology. Inflammatory lesions of the upper gastrointestinal tract are more and more often described in Crohn's disease and ulcerative colitis. The aim of this article was to review the inflammatory lesions of the esophagus, stomach and duodenum currently described in the IBD.
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Affiliation(s)
- Denis Chatelain
- Service d'anatomie pathologie CHU Amiens, Place Victor-Pauchet, 80000 Amiens, France.
| | - Amine Moslemi
- Service d'anatomie pathologie CHU Amiens, Place Victor-Pauchet, 80000 Amiens, France
| | - Axel Dreau
- Service d'anatomie pathologie CHU Amiens, Place Victor-Pauchet, 80000 Amiens, France
| | - Marine Clement
- Service d'anatomie pathologie CHU Amiens, Place Victor-Pauchet, 80000 Amiens, France
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3
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Parente P, Mastracci L, Vanoli A, Fassan M, Pastore M, Bossa F, Francalanci P, Alaggio R, Graziano P, Grillo F. Pattern-based Histologic Approach in Very Early Onset IBD: Main Features and Differential Diagnosis. Adv Anat Pathol 2022; 29:71-80. [PMID: 34620740 DOI: 10.1097/pap.0000000000000323] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Very early onset inflammatory bowel disease (VEO-IBD) is a clinical umbrella classification composed of IBD-like diseases encompassing both classic IBD (Crohn's disease and ulcerative colitis) and monogenic disorder, both arising before 6 years of age. VEO-IBD patients present significant clinical differences from IBD occurring in older children and in adults, including more severe disease, often unresponsive to conventional IBD therapy and a greater proportion of cases featuring an underlying genetic alteration. Histologic findings of gastrointestinal biopsies can show an IBD-like pattern (both Crohn's disease-like and ulcerative colitis-like pattern), an apoptotic-like and enterocolitis-like pattern. Findings of specific morphologic alterations, such as villous blunting, apoptosis, dense eosinophilic infiltrates, lack of plasma cells and severe glandular atrophy, can suggest a monogenic disorder. Moreover, individuals with monogenic disorders may develop significant problems such as primary immunodeficiency, impacting treatment options. Finally, IBD histology in childhood can differ from that in older patients and adults. This complexity makes a differential diagnosis between IBD and other pediatric diseases involving the gastrointestinal tract difficult, especially considering that histologic features can be similar between different diseases. Without an appropriate diagnosis, the clinical course of VEO-IBD has greater potential for escalated treatment regimens involving extensive surgery and more intensive medical therapies rather than specific therapy directed toward the underlying defect. For these reasons, a pattern-based histologic approach correlated with clinical and laboratory findings with a multidisciplinary approach is fundamental to reach a correct diagnosis in an adequate clinical context.
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Affiliation(s)
| | - Luca Mastracci
- Unit of Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova
- Ospedale Policlinico San Martino, IRCCS, Genova
| | - Alessandro Vanoli
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia
| | - Matteo Fassan
- Surgical Pathology Unit, Department of Medicine (DIMED), University of Padova
- Veneto Institute of Oncology (IOV-IRCCS), Padova
| | | | - Fabrizio Bossa
- Gastroenterology, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia
| | - Paola Francalanci
- Pathology Unit, Children's Hospital Bambino Gesù, IRCCS, Roma, Italy
| | - Rita Alaggio
- Pathology Unit, Children's Hospital Bambino Gesù, IRCCS, Roma, Italy
| | | | - Federica Grillo
- Unit of Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova
- Ospedale Policlinico San Martino, IRCCS, Genova
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4
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Alkhatry M, Al-Rifai A, Annese V, Georgopoulos F, Jazzar AN, Khassouan AM, Koutoubi Z, Nathwani R, Taha MS, Limdi JK. First United Arab Emirates consensus on diagnosis and management of inflammatory bowel diseases: A 2020 Delphi consensus. World J Gastroenterol 2020; 26:6710-6769. [PMID: 33268959 PMCID: PMC7684461 DOI: 10.3748/wjg.v26.i43.6710] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/15/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis and Crohn's disease are the main entities of inflammatory bowel disease characterized by chronic remittent inflammation of the gastrointestinal tract. The incidence and prevalence are on the rise worldwide, and the heterogeneity between patients and within individuals over time is striking. The progressive advance in our understanding of the etiopathogenesis coupled with an unprecedented increase in therapeutic options have changed the management towards evidence-based interventions by clinicians with patients. This guideline was stimulated and supported by the Emirates Gastroenterology and Hepatology Society following a systematic review and a Delphi consensus process that provided evidence- and expert opinion-based recommendations. Comprehensive up-to-date guidance is provided regarding diagnosis, evaluation of disease severity, appropriate and timely use of different investigations, choice of appropriate therapy for induction and remission phase according to disease severity, and management of main complications.
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Affiliation(s)
- Maryam Alkhatry
- Gastroenterology and Endoscopy Department, Ibrahim Bin Hamad Obaid Allah Hospital, Ministry of Health and Prevention, Ras Al Khaiman, United Arab Emirates
| | - Ahmad Al-Rifai
- Department of Gastroenterology, Sheikh Shakbout Medical City, Abu Dhabi, United Arab Emirates
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic, Dubai, United Arab Emirates
- Department of Gastroenterology and Endoscopy, American Hospital, Dubai, United Arab Emirates
| | | | - Ahmad N Jazzar
- Gastroenterology Division, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Ahmed M Khassouan
- Digestive Disease Unit, Rashid Hospital, Dubai, United Arab Emirates
| | - Zaher Koutoubi
- Digestive Disease Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Rahul Nathwani
- Department of Gastroenterology, Mediclinic City Hospital, Dubai, United Arab Emirates
- Department of Gastroenterology, Mohammed Bin Rashid University, Dubai, United Arab Emirates
| | - Mazen S Taha
- Gastroenterology and Hepatology, Tawam Hospital, Al Ain, United Arab Emirates
| | - Jimmy K Limdi
- Department of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester Academic Health Sciences, University of Manchester, Manchester M8 5RB, United Kingdom
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5
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Appel KL, Wang L, Xi D, Bhardwaj V. Isolated Severe Stricturing Duodenal Crohn Disease in a Pediatric Patient. JPGN REPORTS 2020; 1:e003. [PMID: 37206610 PMCID: PMC10191493 DOI: 10.1097/pg9.0000000000000003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/14/2020] [Indexed: 05/21/2023]
Affiliation(s)
- Keren L. Appel
- From the Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Los Angeles (CHLA), Los Angeles, California
| | - Linda Wang
- From the Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Los Angeles (CHLA), Los Angeles, California
| | - Dong Xi
- From the Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Los Angeles (CHLA), Los Angeles, California
| | - Vrinda Bhardwaj
- From the Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Los Angeles (CHLA), Los Angeles, California
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6
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Burgess CJ, Gillett P, Mitchell D, Hammond P, Henderson P, Wilson DC. Incidence of Paediatric Stricturing Duodenal Crohn Disease: A 19-Year Population-based Cohort Study. J Pediatr Gastroenterol Nutr 2019; 69:539-543. [PMID: 31335835 DOI: 10.1097/mpg.0000000000002444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Stricturing duodenal Crohn disease (CD) is a rare but serious presentation of CD causing significant morbidity. We aim to provide the first robust incidence data and case studies on this severe presentation in children. METHODS A regional cohort of prospectively acquired incident cases of paediatric CD diagnosed <16 years of age in South-East Scotland was captured over a 19-year period (1999-2018). A retrospective review was conducted on the medical records of all patients together with a review of the available literature and consensus guidelines. Incidence rates for all CD and for duodenal stricturing CD were calculated. RESULTS A total of 247 new cases of paediatric CD were diagnosed within the study period. Median age at diagnosis was 12.5 years with 62% male predominance. Overall paediatric CD incidence rate was 5.70/100,000/year with a specific duodenal B2 phenotype disease incidence rate of 0.05/100,000/year; representing 0.8% of incident cases at diagnosis. Two incident cases of stricturing duodenal CD presented with systemic symptoms of weight loss, abdominal pain, anorexia, and lethargy, together with persistent vomiting suggestive of obstruction. Both cases partially responded to intensive medical therapy but eventually required laparoscopic gastroduodenostomy. A detailed literature search confirmed there are no paediatric incidence data, guidelines, or case reports relating to duodenal stricture as either a presentation or complication of CD. CONCLUSIONS Duodenal structuring disease is a rare but serious presentation of CD causing significant morbidity and not currently covered in the paediatric literature or consensus guidelines. Best practice medical and surgical management remain uncertain and require further research.
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Affiliation(s)
- Christopher J Burgess
- Child Life and Health, University of Edinburgh
- Department of Paediatric Gastroenterology and Nutrition
| | - Peter Gillett
- Department of Paediatric Gastroenterology and Nutrition
| | | | - Philip Hammond
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK
| | - Paul Henderson
- Child Life and Health, University of Edinburgh
- Department of Paediatric Gastroenterology and Nutrition
| | - David C Wilson
- Child Life and Health, University of Edinburgh
- Department of Paediatric Gastroenterology and Nutrition
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7
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Schwartzberg DM, Brandstetter S, Grucela AL. Crohn's Disease of the Esophagus, Duodenum, and Stomach. Clin Colon Rectal Surg 2019; 32:231-242. [PMID: 31275069 PMCID: PMC6606321 DOI: 10.1055/s-0039-1683850] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Upper gastrointestinal Crohn's is an under-reported, under-recognized phenotype of Crohn's disease. Routine screening in the pediatric population has shown a higher prevalence compared with adults; however, most adult patients remain asymptomatic with respect to upper gastrointestinal Crohn's disease. For the patients who are symptomatic, medical treatment is the first line of management, except for cases of obstruction, perforation, or bleeding. Though most patients respond to medical therapy, mainly steroids, with the addition of immunomodulators and more recently biologics agents, surgical intervention is usually required only for obstructing gastroduodenal disease secondary to strictures. Strictureplasty and bypass are safe operations with comparable morbidity, although bypass has higher rates of dumping syndrome and marginal ulceration in the long term. Rare cases of gastroduodenal fistulous disease from active distal disease may involve the stomach or duodenum, and esophageal Crohn's disease can fistulize to surrounding structures in the mediastinum which may require the highly morbid esophagectomy.
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Affiliation(s)
- David M. Schwartzberg
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Stephen Brandstetter
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alexis L. Grucela
- Division of Colon and Rectal Surgery, New York University Langone Medical Center, New York, New York
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8
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Pimentel AM, Rocha R, Santana GO. Crohn’s disease of esophagus, stomach and duodenum. World J Gastrointest Pharmacol Ther 2019; 10:35-49. [PMID: 30891327 PMCID: PMC6422852 DOI: 10.4292/wjgpt.v10.i2.35] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/31/2019] [Accepted: 02/27/2019] [Indexed: 02/06/2023] Open
Abstract
Crohn’s disease with involvement of the esophagus, stomach and duodenum has a prevalence of 0.5% to 4% in symptomatic adult patients, but some studies have shown that these results may be underestimated, since upper gastrointestinal endoscopy is not performed routinely in the initial evaluation of the disease in adult patients, as it is in the pediatric population. In general, involvement of the upper gastrointestinal tract in Crohn’s disease occurs concomitantly with involvement of the lower gastrointestinal tract. The diagnosis depends on clinical, endoscopic, histological and radiological evaluation. The presence of aphthoid ulcers, longitudinal ulcers, bamboo-joint-like appearance, stenoses and fistulas are endoscopic findings suggestive of the disease, and it is important to exclude the presence of Helicobacter pylori infection. The primary histological findings, which facilitate the diagnosis, are the presence of a chronic inflammatory process with a predominance of lymphoplasmacytic cells and active focal gastritis. The presence of epithelioid granuloma, although less frequent, is highly suggestive of the disease in the absence of chronic granulomatous disease. Treatment should include the use of proton pump inhibitors associated with corticosteroids, immunomodulators and biological therapy according to the severity of the disease.
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Affiliation(s)
- Andréa Maia Pimentel
- Programa de Pós graduação em Medicina e Saúde, Universidade Federal da Bahia, Salvador 40110-060, Bahia, Brazil
| | - Raquel Rocha
- Departamento de Ciências da Nutrição, Universidade Federal da Bahia, Salvador 40110-060, Bahia, Brazil
| | - Genoile Oliveira Santana
- Programa de Pós graduação em Medicina e Saúde, Universidade Federal da Bahia, Salvador 40110-060, Bahia, Brazil
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9
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Ledder O, Church P, Cytter-Kuint R, Martínez-León M, Sladek M, Coppenrath E, Weiss B, Yerushalmi B, Martin de Carpi J, Duchano L, Towbin A, Assa A, Shaoul R, Mearin ML, Alex G, Griffiths A, Turner D. A Simple Endoscopic Score Modified for the Upper Gastrointestinal Tract in Crohn's Disease [UGI-SES-CD]: A Report From the ImageKids Study. J Crohns Colitis 2018; 12:1073-1078. [PMID: 29800422 DOI: 10.1093/ecco-jcc/jjy072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 03/08/2018] [Accepted: 05/24/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE There is no standardized endoscopic description of upper gastrointestinal [UGI] disease in Crohn's disease [CD]. We prospectively applied the Simple Endoscopic Score for CD [SES-CD] to the UGI tract as a planned sub-study of the multicentre prospective ImageKids study. We aimed to assess the utility of the UGI-SES-CD and its clinical significance in paediatric CD. DESIGN Patients underwent an oesophagogastroduodenoscopy [EGD], ileocolonoscopy, and magnetic resonance enterography [MRE] with explicit clinical data recorded. SES-CD was scored at each region [oesophagus, stomach body, antrum, and duodenum]. Half of the patients were followed for 18 months, when a repeat MRE was performed. RESULTS A total of 202 children were included 56% males, mean age 11.5 ± 3.2 years, median weighted Paediatric Crohn's Disease Activity Index [wPCDAI 25]). UGI-SES-CD score ranged 0-17, with 95 [47%] having a UGI-SES-CD ≥1; no narrowing was detected. UGI-SES-CD ≥1 was associated with higher: wPCDAI [32.5 vs 20; p = 0.03]; Physician's Global Assessment [PGA] of inflammation (45 mm visual analogue score [VAS] vs 30 mm VAS; p = 0.04); ileocolonoscopic SES-CD [10 vs 7; p = 0.004], faecal calprotectin [717 µg/g vs 654 µ/g; p= 0.046]; and radiological global assessment of damage by MRE [7 mm VAS vs 0; p = 0.04]. In all, 81 patients were followed for 18 months and no association was identified between initial UGI SES-CD and markers of disease course such as surgery, MRE assessment, or treatment escalation. CONCLUSION UGI-SES-CD is an easily reported objective scoring system and is associated with a more severe disease phenotype but not with disease course.
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Affiliation(s)
- Oren Ledder
- Instutute of Paediatric Gastroenterology, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peter Church
- Division of GI/Hepatology/Nutrition, SickKids Hospital, University of Toronto, Toronto, ON, Canada
| | - Ruth Cytter-Kuint
- Paediatric Radiology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Maria Martínez-León
- Department of Radiology, Hospital Regional Universitario Carlos Haya, Malaga, Spain
| | - Malgorzata Sladek
- Department of Pediatric Gastroenterology, Jagiellonian University Medical College, Krakow, Poland
| | - Eva Coppenrath
- Department of Radiology, University of Munich, Munich, Germany
| | - Batia Weiss
- Paediatric Gastroenterology and Nutrition Unit, Edmond and Lily Safra Children's Hospital, Tel Hashomer, Tel Aviv, Israel
| | - Baruch Yerushalmi
- Department of Paediatric Gastroenterology, Soroka University Medical Center and Ben Gurion University of the Negev, Beer Sheba, Israel
| | | | - Larisa Duchano
- Department of Radiology, Soroka University Medical Center and Ben Gurion University of the Negev, Beer Sheba, Israel
| | - Alexander Towbin
- Department of Radiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Amit Assa
- Department of Paediatric Gastroenterology, Schneider Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Shaoul
- Department of Paediatric Gastroenterology, Rambam Medical Center, Haifa, Israel
| | - M L Mearin
- Departments of Paediatrics, Leiden University Medical Center and Free University Medical Center, Amsterdam, The Netherlands
| | - George Alex
- Department of Paediatric Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Anne Griffiths
- Division of GI/Hepatology/Nutrition, SickKids Hospital, University of Toronto, Toronto, ON, Canada
| | - Dan Turner
- Instutute of Paediatric Gastroenterology, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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10
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Magnetic Resonance Enterography Cannot Replace Upper Endoscopy in Pediatric Crohn Disease: An Imagekids Sub-study. J Pediatr Gastroenterol Nutr 2018; 67:53-58. [PMID: 29287012 DOI: 10.1097/mpg.0000000000001869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Although magnetic resonance enterography (MRE) can accurately reflect ileal inflammation in pediatric Crohn disease (CD), there are no pediatric data on the accuracy of MRE to detect upper gastrointestinal tract (UGI) lesions. We aimed to compare MRE and esophagogastroduodenoscopy (EGD) in detecting the spectrum and severity of UGI disease in children. METHODS This is an ancillary study of the prospective multi-center ImageKids study focusing on pediatric MRE. EGD was performed within 2 weeks of MRE (at disease onset or thereafter) and explicitly scored by SES-CD modified for the UGI and physician global assessment. Local and central radiologists scored the UGI region of the MRE blinded to the EGD. Accuracy of MRE compared with EGD was examined using correlational coefficients (r) and area under receiver operating characteristic curves (AUC). RESULTS One hundred and eighty-eight patients were reviewed (mean age 14 ± 1 years, 103 [55%] boys); 66 of 188 (35%) children had macroscopic ulcerations on EGD (esophagus, 13 [7%]; stomach, 34 [18%]; duodenum, 45 [24%]). Most children had aphthous ulcers, but 10 (5%) had larger ulcers (stomach, 2 [1%]; duodenum, 8 [4%]). There was no agreement between local and central radiologists on the presence or absence of UGI inflammation on MRE (Kappa = -0.02, P = 0.71). EGD findings were not accurately detected by MRE, read locally or centrally (r = -0.03 to 0.11, P = 0.18-0.88; AUC = 0.47-0.55, P = 0.53-1.00).No fistulae or narrowings were identified on either EGD or MRE. CONCLUSIONS MRE cannot reliably assess the UGI in pediatric CD and cannot replace EGD for this purpose.
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11
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Lichtenstein GR, Loftus EV, Isaacs KL, Regueiro MD, Gerson LB, Sands BE. ACG Clinical Guideline: Management of Crohn's Disease in Adults. Am J Gastroenterol 2018; 113:481-517. [PMID: 29610508 DOI: 10.1038/ajg.2018.27] [Citation(s) in RCA: 900] [Impact Index Per Article: 128.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 01/11/2018] [Indexed: 02/06/2023]
Abstract
Crohn's disease is an idiopathic inflammatory disorder of unknown etiology with genetic, immunologic, and environmental influences. The incidence of Crohn's disease has steadily increased over the past several decades. The diagnosis and treatment of patients with Crohn's disease has evolved since the last practice guideline was published. These guidelines represent the official practice recommendations of the American College of Gastroenterology and were developed under the auspices of the Practice Parameters Committee for the management of adult patients with Crohn's disease. These guidelines are established for clinical practice with the intent of suggesting preferable approaches to particular medical problems as established by interpretation and collation of scientifically valid research, derived from extensive review of published literature. When exercising clinical judgment, health-care providers should incorporate this guideline along with patient's needs, desires, and their values in order to fully and appropriately care for patients with Crohn's disease. This guideline is intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are inflexible and rarely violated. To evaluate the level of evidence and strength of recommendations, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The Committee reviews guidelines in depth, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time.
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Affiliation(s)
- Gary R Lichtenstein
- Department of Medicine, Division of Gastroenterology, Hospital of the University of Pennsylvania, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kim L Isaacs
- Department of Medicine, Division of Gastroenterology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
| | - Miguel D Regueiro
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lauren B Gerson
- Department of Medicine, Division of Gastroenterology, California Pacific Medical Center, San Francisco, California, USA
| | - Bruce E Sands
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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12
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Abstract
Celiac disease features duodenal intraepithelial lymphocytosis with or without villous atrophy. Lymphocytosis without villous atrophy will be proven to represent celiac disease in 10% to 20% of cases. The differential diagnosis is broad: Helicobacter pylori gastritis, NSAID injury and bacterial overgrowth are considerations. Lymphocytosis with villous atrophy is very likely to be celiac disease, but there are mimics to consider, including collagenous sprue, tropical sprue, drug injury, and common variable immunodeficiency. Histologic clues to a diagnosis other than celiac disease include paucity of plasma cells, excess of neutrophils, granulomas, and relative paucity of intraepithelial lymphocytes.
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Affiliation(s)
- Thomas C Smyrk
- Department of Pathology, Mayo Clinic, Hilton 11, 200 First Street Southwest, Rochester, MN 55902, USA.
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14
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Abdalla SM, Kalra G, Moshiree B. Motility Evaluation in the Patient with Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2016; 26:719-38. [PMID: 27633599 DOI: 10.1016/j.giec.2016.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with inflammatory bowel disease (IBD) suffer frequently from functional bowel diseases (FBD) and motility disorders. Management of FBD and motility disorders in IBD combined with continued treatment of a patient's IBD symptoms will likely lead to better clinical outcomes and improve the patient's quality of life. The goals of this review were to summarize the most recent literature on motility disturbances in patients with IBD and to give a brief overview of the ranges of motility disturbances, from reflux disease to anorectal disorders, and discuss their diagnosis and specific management.
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Affiliation(s)
- Sherine M Abdalla
- Department of Medicine, Jackson Memorial Hospital, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Central Building, 600D, Miami, FL 33136, USA
| | - Gorav Kalra
- Department of Medicine, Jackson Memorial Hospital, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB, 11th Floor, Miami, FL 33136, USA
| | - Baha Moshiree
- Department of Medicine, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB Suite 971, Miami, FL 33136, USA.
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15
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Addition of Histology to the Paris Classification of Pediatric Crohn Disease Alters Classification of Disease Location. J Pediatr Gastroenterol Nutr 2016; 62:242-5. [PMID: 26334258 PMCID: PMC5357324 DOI: 10.1097/mpg.0000000000000967] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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So H, Ye BD, Park YS, Kim J, Kim JS, Moon W, Lee KM, Kim YS, Keum B, Kim SE, Kim KO, Kim ES, Lee CK, Hong SP, Im JP, Koo JS, Choi CH, Shin JE, Lee BI, Huh KC, Kim YH, Kim HS, Park YS, Han DS. Gastric lesions in patients with Crohn's disease in Korea: a multicenter study. Intest Res 2016; 14:60-8. [PMID: 26884736 PMCID: PMC4754524 DOI: 10.5217/ir.2016.14.1.60] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 10/27/2015] [Accepted: 10/28/2015] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Gastric pathology and Helicobacter pylori (H. pylori) infection among Asian patients with Crohn's disease (CD) are still unclear. We evaluated gastric histologic features and frequency of H. pylori infection in Korean patients with CD. Methods Among 492 patients with CD receiving upper gastrointestinal (GI) endoscopic evaluation in 19 Korean hospitals, we evaluated the endoscopic findings and gastric histopathologic features of 47 patients for our study. Histopathologic classification was performed using gastric biopsy tissues, and H. pylori infection was determined using the rapid urease test and histology. Results There were 36 men (76.6%), and the median age of patients at the time of upper GI endoscopy was 23.8 years (range, 14.2–60.5). For CD phenotype, ileocolonic disease was observed in 38 patients (80.9%), and non-stricturing, non-penetrating disease in 31 patients (66.0%). Twenty-eight patients (59.6%) complained of upper GI symptoms. Erosive gastritis was the most common gross gastric feature (66.0%). Histopathologically, H. pylori-negative chronic active gastritis (38.3%) was the most frequent finding. H. pylori testing was positive in 11 patients (23.4%), and gastric noncaseating granulomata were detected in 4 patients (8.5%). Gastric noncaseating granuloma showed a statistically significant association with perianal abscess/fistula (P=0.0496). Conclusions H. pylori-negative chronic active gastritis appears to be frequent among Korean patients with CD. The frequency of H. pylori infection was comparable with previous studies. An association with perianal complications suggests a prognostic value for gastric noncaseating granuloma in patients with CD.
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Affiliation(s)
- Hoonsub So
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.; Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Young Soo Park
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Kang-Moon Lee
- Department of Internal Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - You Sun Kim
- Department of Internal Medicine, Inje University College of Medicine, Seoul Paik Hospital, Seoul, Korea
| | - Bora Keum
- Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University College of Medicine, Seoul, Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Ewha Mokdong Hospital, Seoul, Korea
| | - Kyeong Ok Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Eun Soo Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Chang Kyun Lee
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Pil Im
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ja Seol Koo
- Department of Internal Medicine, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Chang Hwan Choi
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jeong Eun Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Bo In Lee
- Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Kyu Chan Huh
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Young-Ho Kim
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun-Soo Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Young Sook Park
- Department of Internal Medicine, Eulji University School of Medicine, Seoul, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University College of Medicine, Hanyang University Guri Hospital, Guri, Korea
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Langner C, Magro F, Driessen A, Ensari A, Mantzaris GJ, Villanacci V, Becheanu G, Borralho Nunes P, Cathomas G, Fries W, Jouret-Mourin A, Mescoli C, de Petris G, Rubio CA, Shepherd NA, Vieth M, Eliakim R, Geboes K. The histopathological approach to inflammatory bowel disease: a practice guide. Virchows Arch 2014; 464:511-527. [PMID: 24487791 DOI: 10.1007/s00428-014-1543-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 10/20/2013] [Accepted: 01/14/2014] [Indexed: 12/12/2022]
Abstract
Inflammatory bowel diseases (IBDs) are lifelong disorders predominantly present in developed countries. In their pathogenesis, an interaction between genetic and environmental factors is involved. This practice guide, prepared on behalf of the European Society of Pathology and the European Crohn's and Colitis Organisation, intends to provide a thorough basis for the histological evaluation of resection specimens and biopsy samples from patients with ulcerative colitis or Crohn's disease. Histopathologically, these diseases are characterised by the extent and the distribution of mucosal architectural abnormality, the cellularity of the lamina propria and the cell types present, but these features frequently overlap. If a definitive diagnosis is not possible, the term indeterminate colitis is used for resection specimens and the term inflammatory bowel disease unclassified for biopsies. Activity of disease is reflected by neutrophil granulocyte infiltration and epithelial damage. The evolution of the histological features that are useful for diagnosis is time- and disease-activity dependent: early disease and long-standing disease show different microscopic aspects. Likewise, the histopathology of childhood-onset IBD is distinctly different from adult-onset IBD. In the differential diagnosis of severe colitis refractory to immunosuppressive therapy, reactivation of latent cytomegalovirus (CMV) infection should be considered and CMV should be tested for in all patients. Finally, patients with longstanding IBD have an increased risk for the development of adenocarcinoma. Dysplasia is the universally used marker of an increased cancer risk, but inter-observer agreement is poor for the categories low-grade dysplasia and indefinite for dysplasia. A diagnosis of dysplasia should not be made by a single pathologist but needs to be confirmed by a pathologist with expertise in gastrointestinal pathology.
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Affiliation(s)
- Cord Langner
- Institute of Pathology, Medical University of Graz, Auenbruggerplatz 25, 8036, Graz, Austria,
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Abstract
While celiac disease is the most common cause of villous remodeling and intraepithelial lymphocytosis in the proximal small bowel, there are many entities that can mimic its histologic appearance. The purpose of this review is to discuss normal small bowel histology and the differential diagnosis of celiac disease. Approaches to evaluate increased intraepithelial lymphocytes are presented, followed by a detailed discussion of the pathology of celiac disease. Particular emphasis is given to those conditions that cause intraepithelial lymphocytosis in the setting of preserved villous architecture, although other important entities, such as peptic injury, idiopathic inflammatory bowel disease, medication injury, eosinophilic (allergic) gastroenteritis, autoimmune enteropathy, common variable immunodeficiency, and infections are also reviewed.
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Affiliation(s)
- Rish K Pai
- Department of Anatomic Pathology, Robert J Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio 44195.
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Magro F, Langner C, Driessen A, Ensari A, Geboes K, Mantzaris GJ, Villanacci V, Becheanu G, Borralho Nunes P, Cathomas G, Fries W, Jouret-Mourin A, Mescoli C, de Petris G, Rubio CA, Shepherd NA, Vieth M, Eliakim R. European consensus on the histopathology of inflammatory bowel disease. J Crohns Colitis 2013; 7:827-851. [PMID: 23870728 DOI: 10.1016/j.crohns.2013.06.001] [Citation(s) in RCA: 459] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 06/05/2013] [Indexed: 02/06/2023]
Abstract
The histologic examination of endoscopic biopsies or resection specimens remains a key step in the work-up of affected inflammatory bowel disease (IBD) patients and can be used for diagnosis and differential diagnosis, particularly in the differentiation of UC from CD and other non-IBD related colitides. The introduction of new treatment strategies in inflammatory bowel disease (IBD) interfering with the patients' immune system may result in mucosal healing, making the pathologists aware of the impact of treatment upon diagnostic features. The European Crohn's and Colitis Organisation (ECCO) and the European Society of Pathology (ESP) jointly elaborated a consensus to establish standards for histopathology diagnosis in IBD. The consensus endeavors to address: (i) procedures required for a proper diagnosis, (ii) features which can be used for the analysis of endoscopic biopsies, (iii) features which can be used for the analysis of surgical samples, (iv) criteria for diagnosis and differential diagnosis, and (v) special situations including those inherent to therapy. Questions that were addressed include: how many features should be present for a firm diagnosis? What is the role of histology in patient management, including search for dysplasia? Which features if any, can be used for assessment of disease activity? The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas.
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Affiliation(s)
- F Magro
- Department of Pharmacology & Therapeutics, Institute for Molecular and Cell Biology, Faculty of Medicine University of Porto, Department of Gastroenterology, Hospital de Sao Joao, Porto, Portugal.
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Panes J, Bouhnik Y, Reinisch W, Stoker J, Taylor SA, Baumgart DC, Danese S, Halligan S, Marincek B, Matos C, Peyrin-Biroulet L, Rimola J, Rogler G, van Assche G, Ardizzone S, Ba-Ssalamah A, Bali MA, Bellini D, Biancone L, Castiglione F, Ehehalt R, Grassi R, Kucharzik T, Maccioni F, Maconi G, Magro F, Martín-Comín J, Morana G, Pendsé D, Sebastian S, Signore A, Tolan D, Tielbeek JA, Weishaupt D, Wiarda B, Laghi A. Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines. J Crohns Colitis 2013; 7:556-585. [PMID: 23583097 DOI: 10.1016/j.crohns.2013.02.020] [Citation(s) in RCA: 471] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 02/20/2013] [Indexed: 12/12/2022]
Abstract
The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.
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Affiliation(s)
- J Panes
- Gastroenterology Department, Hospital Clinic Barcelona, CIBERehd, IDIBAPS, Barcelona, Spain.
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Levine A, de Bie CI, Turner D, Cucchiara S, Sladek M, Murphy MS, Escher JC. Atypical disease phenotypes in pediatric ulcerative colitis: 5-year analyses of the EUROKIDS Registry. Inflamm Bowel Dis 2013; 19:370-7. [PMID: 22570259 DOI: 10.1002/ibd.23013] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Definitive diagnosis of pediatric ulcerative colitis (UC) may be particularly challenging since isolated colitis with overlapping features is common in pediatric Crohn's disease (CD), while atypical phenotypes of UC are not uncommon. The Paris classification allows more accurate phenotyping of atypical inflammatory bowel disease (IBD) patients. Our aim was to identify the prevalence of atypical disease patterns in new-onset pediatric UC using the Paris classification. METHODS Information was collected from the EUROKIDS Registry, an inception cohort of untreated pediatric IBD patients undergoing evaluation at diagnosis. Patients with IBD-unclassified were excluded. Patients with isolated Crohn's colitis served as a control group. RESULTS Data from 898 pediatric patients (643 UC, 255 CD colitis) were included. Extensive or pancolitis was present in 77% of UC patients and macroscopic rectal sparing in 5%. Rectal sparing was inversely associated with age (mean age with rectal sparing 9.9 years vs. 11.8 without; P = 0.02). Upper gastrointestinal (UGI) involvement occurred in 4% of patients. Erosions in the stomach were present in 3.1% of children, but frank ulcerations in 0.4%; 0.8% of children had erosions or ulcerations limited to the esophagus or duodenum. The corresponding UGI involvement in Crohn's colitis was 22%. A cecal patch occurred in 2% of patients. CONCLUSIONS Extensive disease and rectal sparing are age-dependent phenotypes in pediatric UC. Rectal sparing, cecal patch, backwash ileitis, and gastric erosions are not uncommon at diagnosis, while gastric ulcerations and erosions in the duodenum or esophagus are. Recognition of atypical phenotypes in pediatric-onset UC is crucial to prevent misclassification of IBD.
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Affiliation(s)
- Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, E Wolfson Medical Center, Tel Aviv University, Holon, Israel.
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Wang Y, Bennett AE, Cai H, Lian L, Shen B. Evaluation of upper and lower gastrointestinal histology in patients with ileal pouches. J Gastrointest Surg 2012; 16:572-80. [PMID: 22052108 DOI: 10.1007/s11605-011-1766-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 10/19/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Inflammatory complications of ileal pouch-anal anastomosis (IPAA), including pouchitis and Crohn's disease (CD) of the pouch, are common in patients with restorative proctocolectomy for ulcerative colitis. It is not clear whether these inflammatory conditions can affect upper GI tract. The aim of the study was to evaluate correlation between duodenal and pouch histology in patients with healthy and diseased pouches. METHODS All IPAA patients who had esophagogastroduodenoscopy with biopsy after colectomy (N = 96) were included. H&E slides of gastric, duodenal, neo-terminal ileum, and pouch body biopsies were blindly re-reviewed by an expert GI pathologist for acute and chronic inflammation. Demographic and clinical variables and pouch outcome were analyzed. RESULTS There was a significant correlation between acute inflammation in the duodenum as measured by neutrophil infiltration score and the presence of chronic pouchitis (kappa coefficient = 0.21, P < 0.05). Intraepithelial lymphocytosis of the duodenum, though uncommon, only occurred in patients with irritable pouch syndrome, chronic pouchitis, or CD of the pouch. Crypt distortion of duodenal epithelium was only seen in patients with inflammatory or structural diseases of the pouch, including acute (18.2%) and chronic (5%) pouchitis, CD of the pouch (14.3%), and surgical complications of the pouch (14.4%). CONCLUSION Histologic evaluation of duodenal biopsy may provide additional information in patients with ileal pouches, as patients with normal histology of the pouch may have an abnormal duodenal histology.
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Affiliation(s)
- Yinghong Wang
- Victor W. Fazio, MD Center for Inflammatory Bowel Disease, Digestive Disease Institute, Cleveland, OH 44195, USA
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Levine A, Griffiths A, Markowitz J, Wilson DC, Turner D, Russell RK, Fell J, Ruemmele FM, Walters T, Sherlock M, Dubinsky M, Hyams JS. Pediatric modification of the Montreal classification for inflammatory bowel disease: the Paris classification. Inflamm Bowel Dis 2011; 17:1314-21. [PMID: 21560194 DOI: 10.1002/ibd.21493] [Citation(s) in RCA: 1125] [Impact Index Per Article: 80.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Accepted: 08/19/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Crohn's disease and ulcerative colitis are complex disorders with some shared and many unique predisposing genes. Accurate phenotype classification is essential in determining the utility of genotype-phenotype correlation. The Montreal Classification of IBD has several weaknesses with respect to classification of children. The dynamic features of pediatric disease phenotype (change in disease location and behavior over time, growth failure) are not sufficiently captured by the current Montreal Classification. METHODS Focusing on facilitating research in pediatric inflammatory bowel disease (IBD), and creating uniform standards for defining IBD phenotypes, an international group of pediatric IBD experts met in Paris, France to develop evidence-based consensus recommendations for a pediatric modification of the Montreal criteria. RESULTS Important modifications developed include classifying age at diagnosis as A1a (0 to <10 years), A1b (10 to <17 years), A2 (17 to 40 years), and A3 (>40 years), distinguishing disease above the distal ileum as L4a (proximal to ligament of Treitz) and L4b (ligament of Treitz to above distal ileum), allowing both stenosing and penetrating disease to be classified in the same patient (B2B3), denoting the presence of growth failure in the patient at any time as G(1) versus G(0) (never growth failure), adding E4 to denote extent of ulcerative colitis that is proximal to the hepatic flexure, and denoting ever severe ulcerative colitis during disease course by S1. CONCLUSIONS These modifications are termed the Paris Classification. By adhering to the Montreal framework, we have not jeopardized or altered the ability to use this classification for adult onset disease or by adult gastroenterologists.
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Affiliation(s)
- Arie Levine
- Wolfson Medical Center, Tel Aviv University, Israel
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Ebach DR, Vanderheyden AD, Ellison JM, Jensen CS. Lymphocytic esophagitis: a possible manifestation of pediatric upper gastrointestinal Crohn's disease. Inflamm Bowel Dis 2011; 17:45-9. [PMID: 20848529 DOI: 10.1002/ibd.21347] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Lymphocytic esophagitis (LE) is histologically defined by marked esophageal lymphocytosis with no or only rare intraepithelial granulocytes. This study was performed to investigate the association between LE and pediatric Crohn's disease (CD). METHODS Blinded retrospective morphologic analysis was performed on gastrointestinal biopsies from pediatric patients with an established diagnosis of CD (n = 60) and ulcerative colitis (UC; n = 30), as well as a spectrum of non-inflammatory bowel disease (IBD) patients (n = 38). The highest density of intraepithelial lymphocytes (IEL), neutrophils (IEN), and eosinophils (IEE) per high power field (hpf; 40×) were counted. LE was defined as >50 IEL/hpf and a ratio of >50:1 IEL to intraepithelial granulocytes (IEG). RESULTS LE was identified in 17/60 patients with CD, and only 2/30 patients with UC and 1/38 non-IBD control patients; P = 0.0263 (CD versus UC) and P = 0.0002 (CD versus non-CD). In all, 6/60 CD patients had esophagitis with granulomas and three of these met the diagnostic criteria for LE. There was no difference in the incidence of upper gastrointestinal (UGI) symptoms between the CD patients with LE (7/17, 41%) and CD patients with esophagitis with granulomas (3/6; P = 1.0). CONCLUSIONS The histologic diagnosis of LE is associated with pediatric CD and was found in 28% of CD patients. If LE is identified in pediatric CD, it is likely a manifestation of UGI-CD rather than esophagitis due to other etiologies or a variant of normal.
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Affiliation(s)
- Dawn R Ebach
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA.
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