The importance of clinicopathological correlation in the diagnosis of inflammatory conditions of the colon: histological patterns with clinical implications

Histopathological characterization and grading of chronic enterocolitis in Sulawesi crested macaques (Macaca nigra)

Sulawesi crested macaques (Macaca nigra) (SCMs) are critically endangered and frequently suffer from chronic intestinal disease in captivity. Often, despite routine diagnostic investigations and confirmation of intestinal inflammation, an aetiology cannot be identified, leading to a non-specific categorization as chronic enterocolitis rather than an aetiological diagnosis. This study evaluates the histological features of gastrointestinal tissues from 23 SCMs, comparing animals with a clinical history suggestive of chronic enterocolitis (n = 14) with those without gastrointestinal clinical signs (n = 9). Tissues were graded according to the Nancy index (NI), a scoring system used in human medicine to evaluate disease activity in ulcerative colitis, a common form of human inflammatory bowel disease (IBD). Additionally, inflammatory cells in the colonic lamina propria were visually identified by type, counted and subsequently compared between diseased and control animals. Moderate to severe lymphoplasmacytic inflammation and structural changes were most common in the colons of affected SCMs, whereas histopathological changes were absent or mild in all examined small intestine (n = 17) and stomach (n = 11) tissues. The colonic NI had a significant positive correlation with clinical disease severity and 57% (n = 8) of animals with clinical signs had a NI grade of ≥2, consistent with moderate to severe, active IBD. Half of SCMs with recurrent rectal prolapse (n = 6) had a NI grade of 0, suggesting that intestinal inflammation is not always part of this condition's pathogenesis. The numbers of colonic lymphocytes, plasma cells, neutrophils, macrophages and total leucocytes were significantly higher in diseased animals. This study validated the use of the NI in SCMs, enabling a more standardized histopathological evaluation of the colon in this species.

The diagnostic performance of serum αvβ6 autoantibodies for ulcerative colitis: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Currently, there is no single golden standard for diagnosing ulcerative colitis (UC). Now serum αvβ6 autoantibodies have shown promise as a diagnostic tool for UC. Here the aim was to determine the diagnostic performance of serum αvβ6 autoantibodies for UC.

METHODS

PubMed, the Cochrane Library, the Embase, and the Web of Science were searched comprehensively. STATA software was utilized to analyze the relevant data.

RESULTS

9 studies from 6 articles with 1827 subjects were eligible. The summary sensitivity and specificity of serum αvβ6 autoantibodies to diagnose UC were 0.82 (95 % confidence interval (CI): 0.65-0.92) and 0.94 (95 % CI: 0.90-0.97) with an area under the summary receiver operating characteristic curve of 0.96 (95 % CI: 0.94-0.97). Subgroup analysis was conducted owning to substantial heterogeneity between studies (I2 = 97 % and P < 0.001). The aggregate sensitivity and specificity to diagnose UC in adults were 0.75 (95 % CI: 0.61-0.86) and 0.95 (95 % CI: 0.90-0.97), and when using a threshold of mean control+3SD, 0.80 (95 % CI: 0.60-0.91) and 0.96 (95 % CI: 0.90-0.99), respectively. Additionally, to differentiate UC from healthy participants, non-inflammatory bowel disease, and Crohn's disease, the overall specificity was 0.96, 0.88, and 0.80, respectively.

CONCLUSIONS

serum αvβ6 autoantibodies, as a non-invasive tool, demonstrated good diagnostic accuracy for UC. However, their application may be limited in some immune-related disorders, and further studies are needed for validation.

Definitions of Histological Abnormalities in Inflammatory Bowel Disease: an ECCO Position Paper

Histological assessment of endoscopic biopsies in inflammatory bowel disease [IBD] plays an important role in clinical management, investigative studies, and clinical trials. Scoring schemes consisting of multiple histological items and offering considerable precision are widely available. However, definitions of histological abnormalities are often inconsistent. Furthermore, interobserver variability for their recognition and assessment may be high. The European Crohn's and Colitis Organisation [ECCO] formed an expert panel to explore definitions of histological abnormalities in IBD, with the aim of improving the quality of diagnosis and facilitating development of scoring schemes. The process confirmed that the current definitions often have no evidence base and vary between sources. Using available evidence and expert knowledge, the panel produced a series of ECCO consensus position statements on histological features in IBD.

Effects of four food hydrocolloids on colitis and their regulatory effect on gut microbiota

Hydrocolloids are important food additives and have potential regulatory effects on gut microbiota. The development of colitis is closely related to changes in gut microbiota. The effect of food hydrocolloids on the structure of the gut microbiota and their impact on colitis has not been well investigated. Therefore, this study investigated the effects of four hydrocolloids (carrageenan, guar gum, xanthan gum, and pectin) on colitis, and explored their regulatory effects on gut microbiota. The results indicated that pectin and guar effectively alleviated body weight loss and disease activity index, reduced inflammatory cytokine levels, and promoted short-chain fatty acids (SCFAs) production. They increased the abundance of Akkermansia muciniphila, Oscillospira, and Lactobacillus, and Akkermansia abundance had a negative correlation with the severity of colitis. In contrast, carrageenan and xanthan gum did not significantly improve colitis, and carrageenan reduced the production of SCFAs. Both carrageenan and xanthan gum increased the abundance of Ruminococcus gnavus, and Ruminococcus abundance was positively correlated with the severity of colitis. These findings suggest that food additives have an impact on host health and provide guidance for the diet of patients with colitis.

The Histology-Driven Differential Diagnosis in Bowel Inflammatory Conditions Is Not All That Obvious: Evidence from a Survey Based on Digital Slides

(1) Background: when the pathologist faces histologic slides from colonoscopies in daily practice, given the large number of entities and etiologies under inflammatory bowel conditions, in-depth definition of the histological spectrum and the recommendations of current guidelines are often not enough to conclusively define a diagnostic framework. Histological patterns should be organized hierarchically in flowcharts that consider the correlation with clinical data. We conducted an online survey asking a group of gastroenteropathologists to apply a pattern classification based on the most significant lesions in colitis differential diagnosis: crypt distortion and activity. (2) Methods: digital slides from 20 endoscopy samples were analyzed by twenty pathologists and classified according to the occurrence of crypt distortion (nondestructive-destructive colitis) and subsequently to the evidence of activity (ND1-2-3, D1-2). (3) Results: in 8 out of 20 (40%) cases, the participants reached a full agreement regarding the evaluation of crypt distortion (5 cases: nondestructive colitis; 3 cases: destructive colitis). The calculated agreement was k = 0.432. In the second-level quiz (ND1-2-3 and D1-2), full agreement between participants was achieved for 7 of the 28 (25%) possible classifications, with k = 0.229. (4) Conclusions: The findings from this survey are indicative of an unexpectedly low consensus, even among dedicated pathologists, about the recognition of histological changes that are commonly considered critical lesions in the histologic identification of bowel non-neoplastic diseases. In our opinion, these divergences imply a significant risk of misdiagnosis of bowel inflammatory conditions, hampering the usefulness of histological assessment.

Linked mutations within the pathogenicity locus of Clostridioides difficile increase virulence

BACKGROUND

The clinical manifestations of Clostridioides difficile infections range from diarrhoea to pseudomembranous colitis (PMC) and death. We evaluated the association between gene content in C. difficile clinical isolates and disease severity.

METHODS

Fifty-three C. difficile isolates were subjected to Sanger sequencing, clinical data were used to analyse the association of gene content with disease severity, and 83 non-duplicate isolates were collected to confirm the results. Virulence was further examined by functional in vitro and in vivo experiments.

RESULTS

Among the 53 C. difficile isolates, ribotypes 017 (n = 9, 17.0%) and 012 (n = 8, 15.1%) were predominant. Fifteen strains exhibited a correlation between mutations of pathogenicity locus genes (tcdB, tcdC, tcdR, and tcdE) and were named linked-mutation strains. Ribotypes are not associated with clinical PMC and Linked-mutation strains. The proportion of patients with PMC was higher in the group infected with linked-mutation strains than in the non-linked-mutation group (57.14% vs. 0%, p < 0.001). The linked-mutation rate of C. difficile was higher in patients with PMC than in patients without PMC (89.47% vs. 7.8%, p < 0.0001). Linked-mutation strains showed greater cytotoxicity in vitro and caused more severe tissue damage in a mouse model.

CONCLUSIONS

Linked-mutation strains are associated with high virulence and PMC development. This result will help monitor the clinical prognosis of C. difficile infection and provide key insights for developing therapeutic targets and monoclonal antibodies.

Clinicopathologic comparison between sporadic and syndromic Peutz-Jeghers polyps

Peutz-Jeghers polyps (PJPs) are hamartomatous polyps that may define patients with Peutz-Jeghers syndrome (PJS), a rare inherited polyposis syndrome with high cancer risk. However, the clinical significance of 1-2 sporadic PJPs (without other PJS stigmata) regarding malignant potential and identification of new PJS probands is still unclear. We identified 112 patients with 524 histologically confirmed PJPs and categorized them based on polyp number into syndromic (n = 38) if ≥3 PJPs or diagnosed PJS, solitary (1 PJP, n = 61), and intermediate (2 PJPs, n = 13). Clinicopathologic features, including presence of dysplasia in the polyp and development of neoplasia in the patient, were compared on a per-patient and per-polyp basis. Whereas patients with solitary and intermediate PJPs were not different from each other, patients with syndromic PJPs were, in multivariate analysis, younger (P = .001) and more likely to develop neoplasia (P = .02) over a 62.6-months median follow-up than patients with sporadic PJPs. On an individual polyp basis, syndromic PJPs were more likely, in multivariate analysis, to occur in the small intestine (P < .001), but less likely to harbor metaplasia (P = .03) or dysplasia (P = .001), than sporadic PJPs. Dysplasia and metaplasia were more likely in larger PJPs, by multivariate analysis (P = .007 and P < .001, respectively). These data suggest that strict criteria for PJS (including ≥3 PJPs), as currently used, stratify patients into distinct groups with significant differences in clinicopathologic parameters, particularly regarding risk of neoplasia. However, sporadic PJPs exhibit characteristics such as dysplasia and are thus important to recognize and diagnose but perhaps as heralding only a forme fruste PJS.

Olfactomedin-4 + neutrophils exacerbate intestinal epithelial damage and worsen host survival after Clostridioides difficile infection

Neutrophils are key first responders to Clostridioides difficile infection (CDI). Excessive tissue and blood neutrophils are associated with worse histopathology and adverse outcomes, however their functional role during CDI remains poorly defined. Utilizing intestinal epithelial cell (IEC)-neutrophil co-cultures and a pre-clinical animal model of CDI, we show that neutrophils exacerbate C. difficile -induced IEC injury. We utilized cutting-edge single-cell transcriptomics to illuminate neutrophil subtypes and biological pathways that could exacerbate CDI-associated IEC damage. As such, we have established the first transcriptomics atlas of bone marrow (BM), blood, and colonic neutrophils after CDI. We found that CDI altered the developmental trajectory of BM and blood neutrophils towards populations that exhibit gene signatures associated with pro-inflammatory responses and neutrophil-mediated tissue damage. Similarly, the transcriptomic signature of colonic neutrophils was consistent with hyper-inflammatory and highly differentiated cells that had amplified expression of cytokine-mediated signaling and degranulation priming genes. One of the top 10 variable features in colonic neutrophils was the gene for neutrophil glycoprotein, Olfactomedin 4 (OLFM4). CDI enhanced OLFM4 mRNA and protein expression in neutrophils, and OLFM4 + cells aggregated to areas of severe IEC damage. Compared to uninfected controls, both humans and mice with CDI had higher concentrations of circulating OLFM4; and in mice, OLFM4 deficiency resulted in faster recovery and better survival after infection. Collectively, these studies provide novel insights into neutrophil-mediated pathology after CDI and highlight the pathogenic role of OLFM4 + neutrophils in regulating CDI-induced IEC damage.

One Sentence Summary

Utilizing single-cell transcriptomics, IEC-epithelial co-cultures, and pre-clinical models of CDI, we have identified a subset of neutrophils that are marked by OLFM4 expression as pathogenic determinants of IEC barrier damage after CDI.

A Review of Colonoscopy in Intestinal Diseases

Since the development of the fiberoptic colonoscope in the late 1960s, colonoscopy has been a useful tool to diagnose and treat various intestinal diseases. This article reviews the clinical use of colonoscopy for various intestinal diseases based on present and future perspectives. Intestinal diseases include infectious diseases, inflammatory bowel disease (IBD), neoplasms, functional bowel disorders, and others. In cases of infectious diseases, colonoscopy is helpful in making the differential diagnosis, revealing endoscopic gross findings, and obtaining the specimens for pathology. Additionally, colonoscopy provides clues for distinguishing between infectious disease and IBD, and aids in the post-treatment monitoring of IBD. Colonoscopy is essential for the diagnosis of neoplasms that are diagnosed through only pathological confirmation. At present, malignant tumors are commonly being treated using endoscopy because of the advancement of endoscopic resection procedures. Moreover, the characteristics of tumors can be described in more detail by image-enhanced endoscopy and magnifying endoscopy. Colonoscopy can be helpful for the endoscopic decompression of colonic volvulus in large bowel obstruction, balloon dilatation as a treatment for benign stricture, and colon stenting as a treatment for malignant obstruction. In the diagnosis of functional bowel disorder, colonoscopy is used to investigate other organic causes of the symptom.

Gastrointestinal health: changes of intestinal mucosa and microbiota in patients with ulcerative colitis and irritable bowel syndrome from PM2.5-polluted regions of Ukraine

Here, clinical studies of patients were conducted to assess changes in patients with ulcerative colitis (UC) and irritable bowel syndrome (IBS) associated with air pollution by PM. A comparative study of 100 patients with UC and 75 with IBS from highly (HPRs) and low (LPRs) PM_2.5-polluted regions of Ukraine was conducted. Biopsy of the intestinal mucosa of patients with UC from HPRs showed severe cellular infiltration. Patients with IBS from HPRs had changes in the superficial epithelium (focal desquamation), and inflammatory-cellular infiltration of mucous membrane of the colon. In patients with UC, changes in mucus production were found, which were more significant in HPR patients. PAS response did not depend on the residence; the level of MUC2 was significantly lower in HPR patients with UC (1.12 vs 2.15 au). In patients with UC from HPRs, a decrease in Bacteroidetes (34.0 vs. 39.0 small intestinal bacterial overgrowth (SIBO), ppm) and an increase in Proteobacteria compared to LPRs were shown. In IBS patients, significant differences were found in the level of Proteobacteria, which was higher in HPRs. The level of regulatory flora Akkermansia muciniphila and Faecalibacterium prausnitzii reduced in patients with UC from HPRs. In patients from LPRs, the level of Akkermansia muciniphila raised above normal (2.8 vs 4.7 SIBO, ppm). Similar changes of regulatory flora have been identified in patients with IBS from different regions. Therefore, a more severe course of the disease (more pronounced cellular infiltration and violation of the microbiota) was shown in patients with UC from HPRs as compared to LPRs.

A Rare Case of Pseudomembrane-Associated Ulcerative Colitis

Ulcerative colitis (UC) is a chronic, life-long inflammatory bowel disease that normally presents with bloody diarrhea, fever, abdominal pain, and leukocytosis. Diagnosis is usually based on clinical presentation, endoscopy with biopsy, and exclusion of alternative diagnoses. In very rare cases, pseudomembranes may be found on colonoscopy in patients with an early UC flare. Historically, the objective finding of pseudomembranes has been exclusively used to diagnose a Clostridioides difficile infection (CDI); however, diagnostic testing must be correctly utilized to confirm whether a CDI is truly the cause of the presence of pseudomembranes, and not an alternative etiology, such as UC. In this case, we discuss a 43-year-old female who presented to the hospital with worsening chronic bloody diarrhea after being seen in the outpatient clinic for a questionable CDI. She underwent endoscopic evaluation revealing pseudomembranous colitis; however, C. difficile testing showed one positive gastrointestinal (GI) pathogen panel and multiple negative antigens and toxin enzyme immunoassays (EIA). With a clinical suspicion of early UC, the patient was treated with mesalamine enemas and improved clinically before discharge. Several months later, she underwent endoscopic evaluation with biopsy, which showed findings consistent with a diagnosis of UC.

Pattern-based Histologic Approach in Very Early Onset IBD: Main Features and Differential Diagnosis

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.

A worldwide systematic review and meta-analysis of bacteria related to antibiotic-associated diarrhea in hospitalized patients

INTRODUCTION

Antibiotic-associated diarrhea (AAD) is a major hospital problem and a common adverse effect of antibiotic treatment. The aim of this study was to investigate the prevalence of the most important bacteria that cause AAD in hospitalized patients.

MATERIALS AND METHODS

PubMed, Web of Science and Scopus databases were searched using multiple relevant keywords and screening carried out based on inclusion/exclusion criteria from March 2001 to October 2021. The random-effects model was used to conduct the meta-analysis.

RESULTS

Of the 7,377 identified articles, 56 met the inclusion criteria. Pooling all studies, the prevalence of Clostridioides (Clostridium) difficile, Clostridium perfringens, Klebsiella oxytoca, and Staphylococcus aureus as AAD-related bacteria among hospitalized patients were 19.6%, 14.9%, 27%, and 5.2%, respectively. The prevalence of all four bacteria was higher in Europe compared to other continents. The highest resistance of C. difficile was estimated to ciprofloxacin and the lowest resistances were reported to chloramphenicol, vancomycin, and metronidazole. There was no or little data on antibiotic resistance of other bacteria.

CONCLUSIONS

The results of this study emphasize the need for a surveillance program, as well as timely public and hospital health measures in order to control and treat AAD infections.

A Novel Nanomedicine Ameliorates Acute Inflammatory Bowel Disease by Regulating Macrophages and T-Cells

Ramulus mori polysaccharide (RMP), one of the most important active components of R. mori, has been attracting increasing interest because of its potent bioactive properties, including anti-inflammatory, antitumor, and antidiabetic effects. Despite the great therapeutic potential of RMP, its inherent properties of low bioavailability and brief biological half-life have limited its applications to the clinic. Thus, RMP was packaged by poly(lactic-co-glycolic acid) (PLGA) nanoparticles to develop a novel anti-inflammatory nanomedicine (PLGA-RMP) in this study. The nanoparticles were synthesized via a double-emulsion solvent evaporation technique, and the average diameter of PLGA-RMP was about 202 nm. PLGA-RMP nanoparticles reduced the expression of inflammatory cytokines while promoting the production of IL-10, and boosted the phenotypic shift in macrophages in vitro. Furthermore, lipopolysaccharide (LPS)-induced inflammatory bowel disease (IBD) in mouse was used to examine the anti-inflammatory effect of PLGA-RMP in vivo. Oral administration of PLGA-RMP in LPS-induced IBD mice substantially mitigated the intestinal inflammation compared to treatment with LPS alone, as evidenced by attenuation of disease activity index scores and inflammatory damage in the intestine. Meanwhile, PLGA-RMP suppressed the expression and secretion of specific inflammatory cytokines including TNF-α, IL-6, IL-1β, and PGE2 in the inflamed intestine while inhibiting the activation of CD3⁺CD8⁺ T-cells and increasing the number of activated T_regs in the intestine. These results indicated that PLGA-RMP deserves further consideration as a potential therapeutic nanomedicine to treat various inflammatory diseases, including IBD.

Cytomegalovirus-associated pseudomembranous colitis in a kidney transplant recipient

Pseudomembranous colitis (PMC) is classically associated with Clostridium difficile infection. We report a rare case of cytomegalovirus (CMV)-associated PMC in a 52-year-old female patient who had undergone kidney transplantation more than 20 years ago and was on low dose prednisolone and ciclosporin. She presented with an acute history of fever, lethargy, vomiting and diarrhoea on admission. Computed tomography of the abdomen showed extensive colitis, and colonoscopy revealed extensive pseudomembrane formation. Multiple tests for Clostridium difficile and other common microbiological causes of colitis were negative. CMV DNAemia and colonic biopsies confirmed the diagnosis of CMV colitis. The patient responded to prompt CMV treatment, as demonstrated by clinical, endoscopic, and histological response. While CMV is a common pathogen in the solid organ transplant population that is familiar to most transplant physicians, it may present atypically as PMC. Here, we review the literature on CMV-associated PMC and its relevance to solid organ transplant recipients. To our knowledge, this is the first reported case of CMV-associated PMC in a kidney transplant recipient.

Atractylenolide III Ameliorates TNBS-Induced Intestinal Inflammation in Mice by Reducing Oxidative Stress and Regulating Intestinal Flora

The present study aimed to explore the therapeutic effects of the main active ingredients of Atractylodes macrocephala on the 2,4,6-trinitrobenzenesulfonic acid (TNBS)-induced mouse colitis model. TNBS-induced colitis was established in mice, which were treated with 8-β-Hydroxyasterolide (Atractylenolide III) for 14 days. The body weight of the mice in the middle and high dose groups of Atractylenolide III was increased compared with that of the model group. The disease activity index score was significantly reduced. The activity levels of myeloperoxidase were significantly decreased following increase in the dosage of Atractylenolide III, as determined by histological analysis. Moreover, Atractylenolide III downregulated the expression levels of the inflammatory factors interleukin-1β and tumor necrosis factor-α, and greatly suppressed the levels of the pro-oxidant markers, reactive oxygen species and malondialdehyde, while enhancing the expression levels of the antioxidant enzymes catalase, superoxide dismutase and glutathione peroxidase. The protein expression levels of formyl peptide receptor 1 (FPR1) and nuclear respiratory factor 2 (Nrf2) were upregulated in the colonic tissues of TNBS-treated mice. This effect was effectively reversed by Atractylenolide III treatment. In vivo studies indicated that TNBS alone induced a decrease in the abundance of lactobacilli and in the biodiversity of the colon. In conclusion, the present study suggested that Atractylenolide III attenuated TNBS-induced acute colitis by regulating oxidative stress via the FPR1 and Nrf2 pathways and by affecting the development of intestinal flora.

Large prolapse-related lesions of the sigmoid colon

BACKGROUND

Large prolapse-related lesions (LPRL) of the sigmoid colon have been documented histologically but may not be readily recognized endoscopically.

METHODS

Colonic lesions referred for endoscopic mucosal resection (EMR) were enrolled prospectively. Endoscopic features were carefully documented prior to resection. Final diagnosis was made based on established histologic criteria, including vascular congestion, hemosiderin deposition, fibromuscular hyperplasia, and crypt distortion.

RESULTS

Of 134 large ( ≥ 20 mm) sigmoid lesions, 12 (9.0 %) had histologic features consistent with mucosal prolapse. Distinct endoscopic features were: broad-based morphology; vascular pattern obscured by dusky hyperemia; blurred crypts of varying size and shape; and irregular spacing of sparse crypts. Focal histologic dysplasia was identified in 6 of 12 lesions (50.0 %).

CONCLUSIONS

LPRL of the sigmoid colon exhibit a distinct endoscopic profile. Although generally non-neoplastic, dysplasia may be present, warranting consideration of EMR.

Discrimination between Human Colorectal Neoplasms with a Dual-Recognitive Two-Photon Probe

Colorectal cancer is a major cause of cancer-related deaths worldwide. Histologic diagnosis using biopsy samples of colorectal neoplasms is the most important step in determining the treatment methods, but these methods have limitations in accuracy and effectiveness. Herein, we report a dual-recognition two-photon probe and its application in the discrimination between human colorectal neoplasms. The probe is composed of two monosaccharides, d-glucosamine and β-d-galactopyranoside, in a fluorophore for the monitoring of both glucose uptake and β-gal hydrolysis. In vitro/cell imaging studies revealed the excellent selectivity and sensitivity of the probe for glucose transporter-mediated glucose uptake and β-gal activity. Cancer-specific uptake was monitored by increased fluorescence intensity, and additional screening of cancer cells was achieved by changes in emission ratio owing to the higher activity of β-gal. Using human colon tissues and two-photon microscopy, we found that the plot of intensity versus ratio can accurately discriminate between colorectal neoplasms in the order of cancer progression (normal, adenoma, and carcinoma).

Optimal cut-off value of fecal calprotectin for the evaluation of ulcerative colitis: An unsolved issue?

INTRODUCTION

There is variability in the fecal calprotectin (FCP) cut-off level for the prediction of ulcerative colitis (UC) disease activity and differentiation from irritable bowel disease (IBS-D). The FCP cut-off levels vary from country to country.

AIMS

We aimed to assess FCP as a marker of disease activity in patients with UC. We determined the optimal FCP cut-off value for differentiating UC and IBS-D.

METHODS

In a prospective study, we enrolled 76 UC and 30 IBS-D patients. We studied the correlation of FCP with disease activity/extent as well as its role in differentiating UC from IBS-D. We also reviewed literature regarding the optimal FCP cut-off level for the prediction of disease activity and differentiation from IBS-D patients.

RESULTS

Sensitivity, specificity, positive predictive value, and negative predictive value of FCP (cut-off level, 158 μg/g) for the prediction of complete mucosal healing (using Mayo endoscopic subscore) were 90, 85, 94.7, and 73.3%, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value of FCP (cut-off level, 425 μg/g) for the prediction of inactive disease (Mayo Score ≤ 2) were 94.3, 88.7, 86.2, and 95.4%, respectively. We also found a FCP cut-off value of 188 μg/g for the differentiation of UC from IBS-D.

CONCLUSIONS

The study reveals the large quantitative differences in FCP cut-off levels in different study populations. This study demonstrates a wide variation in FCP cut-off levels in the initial diagnosis of UC as well as in follow-up post-treatment. Therefore, this test requires validation of the available test kits and finding of appropriate cut-off levels for different study populations.

Heme Oxygenase-1 as a Modulator of Intestinal Inflammation Development and Progression

Heme Oxygenase 1 (HMOX1) is an enzyme that catalyzes the reaction that degrades the heme group contained in several important proteins, such as hemoglobin, myoglobin, and cytochrome p450. The enzymatic reaction catalyzed by HMOX1 generates Fe2+, biliverdin and CO. It has been shown that HMOX1 activity and the by-product CO can downmodulate the damaging immune response in several models of intestinal inflammation as a result of pharmacological induction of HMOX1 expression and the administration of non-toxic amounts of CO. Inflammatory Bowel Diseases, which includes Crohn's Disease (CD) and Ulcerative Colitis (UC), are one of the most studied ailments associated to HMOX1 effects. However, microbiota imbalances and infections are also important factors influencing the occurrence of acute and chronic intestinal inflammation, where HMOX1 activity may play a major role. As part of this article we discuss the immune modulatory capacity of HMOX1 during IBD, as well during the infections and interactions with the microbiota that contribute to this inflammatory disease.

Cambogin suppresses dextran sulphate sodium-induced colitis by enhancing Treg cell stability and function

Background and Purpose

Inflammatory bowel disease (IBD) is a chronic and relapsing inflammatory disorder of the gastrointestinal tract, and an impaired immune response plays a critical role in IBD. The current drugs and therapies for IBD treatment are of limited use, therefore, there is a need to find novel drugs or therapies for this disease. We investigated the effect of cambogin in a mouse model of dextran sulphate sodium (DSS)‐induced colitis and whether cambogin attenuates inflammation via a Treg‐cell‐mediated effect on the immune response.

Experimental Approach

Chronic colitis was established in mice using 2% DSS, and cambogin (10 mg·kg⁻¹, p.o.) was administered for 10 days. Body weight, colon length and colon histology were assessed. Cytokine production was measured using elisa and quantitative real‐time PCR. To evaluate the mechanism of cambogin, human CD4⁺CD25^hiCD127^lo Treg cells were isolated from peripheral blood mononuclear cells. Major signalling profiles involved in Treg cell stability were measured.

Key Results

Cambogin attenuated diarrhoea, colon shortening and colon histological injury and IL‐6, IFN‐γ and TNF‐α production in DSS‐treated mice. Cambogin also up‐regulated Treg cell numbers in both the spleen and mesenteric lymph nodes. Furthermore, cambogin (10 μM) prevented Foxp3 loss in human primary Treg cells in vitro, and promoted USP7‐mediated Foxp3 deubiquitination and increased Foxp3 protein expression in LPS‐treated cells.

Conclusions and Implications

The effect of cambogin on DSS‐induced colitis is expedited by a Treg‐cell‐mediated modification of the immune response, suggesting that cambogin could be applied as a novel agent for treating colitis and other Treg cell‐related diseases.

The Apoptotic Crypt Abscess: An Underappreciated Histologic Finding in Gastrointestinal Pathology

OBJECTIVES

To differentiate apoptotic crypt abscesses (ACAs) from neutrophilic crypt abscesses (NCAs).

METHODS

Cases with crypt abscesses were classified as containing ACAs, NCAs, or mixed crypt abscesses (MCAs) by H&E staining. Sections were stained with cleaved caspase 3 and myeloperoxidase and recategorized.

RESULTS

Fifty-nine cases were reviewed: inflammatory bowel disease (IBD; n = 33), acute cellular rejection (n = 5), graft vs host disease (GVHD; n = 14), cytomegalovirus (n = 5), and drug reaction (n = 2). Concordance was seen in 59%, with most reclassifications resulting from a change of ACAs to MCAs. When cases were classified as having NCA vs those with apoptosis (ACA and MCA), there was 85% agreement (P < .01). NCAs were present in IBD (96%) and not in GVHD or drug injury. Crypt abscesses with apoptosis were seen in 18% of IBD and 96% of non-IBD cases.

CONCLUSIONS

ACAs and MCAs can be distinguished from NCAs and may be a diagnostically useful finding.

An Italian case of intestinal anisakiasis with a presurgical diagnosis: Could this parasite represent an emerging disease?

Anisakiasis is a parasitic infection caused by the consumption of raw fish containing larvae of the Anisakis species. Since the first description in 1960 of a patient suffering from this pathogen, in the Netherlands, most of the cases have been reported in Japan, where consumption of raw fish is common, but the number of cases is increasing worldwide. The first case identified in Italy dates back to 1996 and a few cases have been reported since then. In Italy the intestinal form occurs almost as frequently as the gastric form, which is far more frequent in Japan. Intestinal Anisakiasis represents a diagnostic challenge as it is clinically misdiagnosed and most of the patients require surgery due to the occurrence of complications such as bowel occlusion or perforation. Practically no cases of the intestinal form are diagnosed preoperatively. We report the first case, to our knowledge, of intestinal Anisakiasis in which surgery was avoided, due to a prompt diagnosis suspected on intestinal biopsies. A literature review of Anisakiasis cases reported in Italy is also carried out.

Dosimetric parameters correlate with duodenal histopathologic damage after stereotactic body radiotherapy for pancreatic cancer: Secondary analysis of a prospective clinical trial

PURPOSE

Prospectively assess relationships between dosimetric parameters and histopathologic/clinical duodenal toxicities in patients on a phase I trial for pancreatic cancer.

METHODS

Forty-six borderline resectable/unresectable patients were enrolled on a prospective trial testing neoadjuvant gemcitabine/5-fluorouracil followed by SBRT (5 daily fractions of 5-8Gy) and concurrent nelfinavir. Post-SBRT surgery was performed in 13 resectable patients, which constituted the patient population herein. Pathologic duodenal damage was assessed using predetermined criteria: 1, no/minimal; 2, moderate; and 3, marked damage. Clinical toxicities were assessed per the Clinical Terminology Criteria for Adverse Events (CTCAE). Duodenal dosimetric parameters included V5-V40 and mean/maximum doses. Spearman correlation and linear regression evaluated associations between dosimetric parameters and clinical/pathologic duodenal toxicity.

RESULTS

The median duodenal mean and maximum doses were 20 and 37Gy. Median duodenal V5-V40 were 64, 62, 52, 39, 27, 14, 5 and 0cc, respectively. The median duodenal damage score was 2 (four 1, eight 2, and one 3). Higher duodenal damage scores correlated with higher duodenal mean doses (r=0.75, p=0.003), V35 (r=0.61, p=0.03), V30 (r=0.67, p=0.01), V25 (r=0.68, p=0.01), V20 (r=0.56, p=0.05), and the planning target volume (PTV) mean (r=0.59, p=0.03) and maximum (r=0.61, p=0.03) doses. Clinical toxicities did not correlate with dosimetric parameters or duodenal pathologic damage.

CONCLUSIONS

Duodenal histologic damage correlates with mean duodenal dose, V20-V35, and PTV mean/maximum doses.

Molecular characterisation of Klebsiella oxytoca strains isolated from patients with antibiotic-associated diarrhoea

BACKGROUND AND STUDY AIM

Colitis is a common complication after treatment with antibiotics such as β-lactams, quinolones, and aminoglycosides. Recently, Klebsiella oxytoca has been implicated in this type of diarrhoea. The prevalence and characterisations of K. oxytoca isolated from patients with antibiotic-associated diarrhoea were investigated. The K. oxytoca isolates were also tested for cytotoxin production.

PATIENTS AND METHODS

This study was conducted from May 2011 to Dec 2013. Faecal samples were collected from hospitalised patients receiving antibiotic treatment. Initial cultivation was performed on specific media. The clinical isolates were confirmed by polymerase chain reaction (PCR) using the specific K. oxytoca polygalacturonase (pehX) gene. The double-disc diffusion test was used to detect extended-spectrum beta-lactamase (ESBL)-producing strains. Tracking of ESBL-encoding genes was performed via PCR. The organism was cultured on Hep-2 cell lines for cytotoxin production.

RESULTS

Out of 331 samples collected from patients, 40 were confirmed molecularly to be clinical isolates of K. oxytoca. Fourteen (35%) ESBL-producing strains were isolated using the double-disc diffusion method. Among the molecularly confirmed K. oxytoca isolates, seven (17.5%) tested positive for the blaSHV gene, 12 (30%) for blaTEM, 10 (25%) for blaCTX-M, three (7.5%) for blaOXA, nine (22.5%) for blaCTX-M-15, and seven (17.5%) for blaTEM-1. Five (12%) isolates showed cytotoxin activity below 30%, 12 (30%) strains showed moderate cytotoxin activity between 30% and 60%, and 23 (58%) strains showed cytotoxin activity ⩾60%.

CONCLUSIONS

The cytotoxin-producing K. oxytoca is found to be one of the causes of antibiotic-induced colitis. Discontinuing treatment and allowing normal intestinal flora to be established or prescribing appropriate medication after antibiogram can help patients with antibiotic-induced haemorrhagic colitis in a timely manner.

Fecal calprotectin and ulcerative colitis endoscopic activity index as indicators of mucosal healing in ulcerative colitis

Ulcerative colitis (UC) is a chronic, idiopathic, inflammatory large bowel disease with recurrent variable periods of exacerbation. The aim of the current study is to evaluate the correlation of UCEIS with fecal calprotectin (FC) level to assess disease activity in UC patients in order to determine whether FC can prognosticate clinical outcome and disease activity of UC instead of colonoscopic evaluation. Our endoscopic investigations revealed the extension of UC as the following: proctitis (11.6%), procto-sigmoiditis (18.5%), left-sided colitis (15.8%), extensive colitis (11.7%), and normal endoscopy (42.4%). Conclusively, we suggest that FC can be used as a reliable tool to evaluate disease activity in ulcerative colitis patients. Moreover, our findings indicate a significant correlation between FC level and mucosal healing.

Inflammatory bowel disease-like colitis pathology in a patient with common variable immune deficiency

Common variable immunodeficiency (CVID) can show variant histological patterns in the gastrointestinal system. We present a case of an 11-year-old boy who has been followed up with a diagnosis of CVID since he was 6 months old. He presented with abdominal pain and diarrhoea. Colonoscopic biopsy showed crypt destructive colitis, severe decrease and focal absence of plasma cells. Three months later he suffered from abdominal pain, vomiting and bloody diarrhoea. Macroscopic examination of small intestinal resection material revealed multiple perforation areas, ulcers. Histopathology showed mild-moderate active enteritis with aphthous ulcers, purulent peritonitis, decrease in plasma cells and loss of primary follicles in lymph nodes. Histopathological findings were consistent with inflammatory bowel disease (IBD)-like CVID. Although in 6-10% of patients with CVID an IBD-like presentation is observed, this highly aggressive form is rarely seen. We present this case because of its extraordinary presentation displaying perforating active enteropathy.

Pseudomembranous Colitis: Not Always Caused by Clostridium difficile

Although classically pseudomembranous colitis is caused by Clostridium difficile, it can result from several etiologies. Certain medications, chemical injury, collagenous colitis, inflammatory bowel disease, ischemia, and other infectious pathogens can reportedly cause mucosal injury and subsequent pseudomembrane formation. We present the case of a middle-aged woman with vascular disease who was incorrectly diagnosed with refractory C. difficile infection due to the presence of pseudomembranes. Further imaging, endoscopy, and careful histopathology review revealed chronic ischemia as the cause of her pseudomembranous colitis and diarrhea. This case highlights the need for gastroenterologists to consider non-C. difficile etiologies when diagnosing pseudomembranous colitis.

Clinical and pathologic characteristics of inflammatory bowel disease

AIM: To investigate the clinical and pathological characteristics of inflammatory bowel disease to raise the early diagnosis of this disease.

METHODS: One hundred and twenty-two cases of inflammatory bowel disease including 101 cases of ulcerative colitis and 21 cases of Crohn's disease were analyzed.

RESULTS: Non-necrotizing granuloma, fissure ulcer and chronic inflammation were morphological features of Crohn's disease. Massive inflammatory cell infiltration in the lamina propria, destroyed glands and reduced secretion, and polyangitis were the hallmarks of ulcerative colitis.

CONCLUSION: The diagnosis of inflammatory bowel disease should be made based on endoscopic, macroscopic and clinical findings. Awareness of the clinical and pathologic features of inflammatory bowel disease can help make an early diagnosis of this disease.

Prevalence of graft versus host disease and cytomegalovirus infection in patients post-haematopoietic cell transplantation presenting with gastrointestinal symptoms

BACKGROUND

There is lack of consensus regarding whether both upper and lower endoscopic examinations are required for diagnosis of gastrointestinal acute graft versus host disease (GI-AGVHD).

AIM

To evaluate the impact of endoscopic procedures on the diagnosis of GI-AGVHD.

METHODS

We performed a retrospective case-control study of recipients of allogeneic haematopoetic cell transplant (HCT) from 2000 to 2011, who presented with GI symptoms between 20 and 125 days post-HCT. GI-AGVHD status was based on the National Institutes of Health (NIH) clinical grading system.

RESULTS

One hundred and twenty-nine clinical GI-AGVHD cases and 184 controls underwent endoscopic examinations. Diarrhoea was present in 73% of cases and 38% of controls (P < 0.0001); 99% of patients with nausea ± vomiting and diarrhoea underwent bidirectional endoscopy. Histology had a sensitivity of 92% and specificity of 91% compared to the clinical criteria. The sensitivity for GI-AGVHD was 80% or greater when upper endoscopy (EGD) was performed with either sigmoidoscopy or colonoscopy, or if lower endoscopic examinations were performed alone. The sensitivity of EGD alone was only 48% (P = 0.003). Sensitivity was highest with biopsy of the terminal ileum (79%), followed by the ascending (74%), transverse/descending (73%) and sigmoid colons (69%). Diagnostic yield for cytomegalovirus (CMV) infection was equivalent for biopsies from both upper and lower GI tracts. Patients found to have concurrent GI-AGVHD and CMV infection (N = 18) had a poorer overall prognosis.

CONCLUSION

In patients post-HCT with GI symptoms, sigmoidoscopy alone had equivalent diagnostic yield for GI-AGVHD and CMV infection, compared with the addition of EGD or performance of full colonoscopy.

Pathological characteristics of IBD: An analysis of 430 cases

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.

Probe-based confocal laser endomicroscopy: a new method for quantitative analysis of pit structure in healthy and Crohn's disease patients

BACKGROUND

Probe-based confocal laser endomicroscopy enables microscopic examination of the digestive mucosa.

AIMS

(1) To identify and validate quantitative endomicroscopic criteria for evaluation of the colonic mucosa and (2) to compare these criteria between healthy and Crohn's disease patients in clinical remission.

METHODS

Six healthy controls and ten Crohn's disease patients in clinical remission were included in this prospective study. Methylene blue-stained biopsies of the right colon and corresponding endomicroscopic images were analyzed. Major axis, minor axis, and major axis/minor axis ratio of crypt lumens were quantified.

RESULTS

Quantitative assessment was performed on 21 ± 4 crypt lumens per patient. Major axis/minor axis ratio values measured with endomicroscopy or methylene blue-stained biopsies were linearly correlated (r=0.63, p=0.01). All macroscopically inflamed mucosa had values of major axis/minor axis ratio higher than the median of controls. Interestingly, 50% (3/6) of Crohn's disease patients with macroscopically normal mucosa had also a higher ratio than pooled controls. Histological analysis showed that 6/7 patients with major axis/minor axis ratio superior to 1.7 had microscopic inflammation.

CONCLUSION

Probe-based confocal laser endomicroscopy allows quantitative analysis of colonic pit structure. Endomicroscopic analysis of major axis/minor axis ratio allows the detection of microscopic residual inflammation with greater accuracy than standard endoscopy in Crohn's disease patients in clinical remission.

Atypical presentation of pseudomembranous colitis localized in adenomatous polyps

The most frequent cause of pseudomembranous colitis is Clostridium difficile (C. difficile) infection. This type of colitis is characterized by an endoscopic pattern of numerous small, yellowish or whitish plaques diffusely distributed, which typically compromises the rectum extending to proximal colon. Occasionally, the pseudomembranes compromise only the transverse or right colon, but their exclusive localization over polyps has not been reported. In this case report we have described a patient with symptoms compatible with C. difficile infection and positive for C. difficile toxigenic culture. Colonoscopy examination showed two small polyps with a whitish surface, and histopathological analysis confirmed them to be pseudomembranes over tubular adenomas. The rest of the colonic mucosa was normal and no other cause was demonstrated. We suggest that this particular distribution might be due to a higher affinity for dysplastic cells such as adenomatous polyps of colon by C. difficile and/or its toxins.

Interplay between T(h)1 and T(h)17 effector T-cell pathways in the pathogenesis of spontaneous colitis and colon cancer in the Gαi2-deficient mouse

Gαi2-deficient mice spontaneously develop colitis. Using xMAP technology and RT-PCR, we investigated cytokine/chemokine profiles during histologically defined phases of disease: (i) no/mild, (ii) moderate, (iii) severe colitis without dysplasia/cancer and (iv) severe colitis with dysplasia/cancer, compared with age-matched wild-type (WT) littermates. Colonic dysplasia was observed in 4/11 mice and cancer in 1/11 mice with severe colitis. The histology correlated with progressive increases in colon weight/cm and spleen weight, and decreased thymus weight, all more advanced in mice with dysplasia/cancer. IL-1β, IL-6, IL-12p40, IL-17, TNF-α, CCL2 and CXCL1 protein levels in colons, but not small intestines increased with colitis progression and were significantly increased in mice with moderate and severe colitis compared with WT mice, irrespective of the absence/presence of dysplasia/cancer. CCL5 did not change during colitis progression. Colonic IL-17 transcription increased 40- to 70-fold in all stages of colitis, whereas IFN-γ mRNA was gradually up-regulated 12- to 55-fold with colitis progression, and further to 62-fold in mice with dysplasia/cancer. IL-27 mRNA increased 4- to 15-fold during the course of colitis, and colonic IL-21 transcription increased 3-fold in mice with severe colitis, both irrespective of the absence/presence of dysplasia/cancer. FoxP3 transcription was significantly enhanced (3.5-fold) in mice with moderate and severe colitis, but not in mice with dysplasia/cancer, compared with WT mice. Constrained correspondence analysis demonstrated an association between increased protein levels of TNF-α, CCL2, IL-1β, IL-6 and CXCL1 and dysplasia/cancer. In conclusion, colonic responses are dominated by a mixed T(h)1/T(h)17 phenotype, with increasing T(h)1 cytokine transcription with progression of colitis in Gαi2(-/-) mice.

A histopathologic scoring system as a tool for standardized reporting of chronic (ileo)colitis and independent risk assessment for inflammatory bowel disease

Pathologists regularly evaluate for the presence of chronic (ileo)colitis in lower gastrointestinal mucosal biopsies, for which a major differential diagnosis is inflammatory bowel disease. Although the histologic features of chronic (ileo)colitis are clearly defined, there is no standard, experimentally derived and validated terminology to document these findings in pathology reports and to convey the likelihood of inflammatory bowel disease in a compact, consistent style. This study had 2 retrospective and 1 prospective phases. In phase 1, we developed a histopathologic scoring system for chronic (ileo)colitis and measured the agreement in scoring between pathologists. In phase 2, we emulated the surgical pathology practice by scoring mucosal biopsies of 164 patients who had undergone lower gastrointestinal endoscopies for clinical suspicion of (ileo)colitis. The cases were matched to 6 different groups based on clinical diagnoses. In phase 3, we prospectively assessed accuracy and ease of application of the scoring system in our practice. The scoring system showed low interobserver variability (correlation coefficient, 0.94-0.96) and distinguished chronic (ileo)colitis from negative cases. In addition, it enabled us to provide probabilistic diagnostic statements based on total scores and their positive predictive values, conveying the likelihood of inflammatory bowel disease as low (<20%), intermediate (∼50%), and high (∼90%). In conclusion, this histopathologic scoring system might be a useful approach to report the findings of lower gastrointestinal mucosal biopsies and to provide measured opinion regarding chronic (ileo)colitis independent of available clinical information. In addition, a defined set of diagnostic statements with regard to likelihood of inflammatory bowel disease would reduce interpretive variability.

Biopsy interpretation of colonic biopsies when inflammatory bowel disease is excluded

The interpretation of colonic biopsies related to inflammatory conditions can be challenging because the colorectal mucosa has a limited repertoire of morphologic responses to various injurious agents. Only few processes have specific diagnostic features, and many of the various histological patterns reflect severity and duration of the disease. Importantly the correlation with endoscopic and clinical information is often cardinal to arrive at a specific diagnosis in many cases.

Clinical application of the multigene analysis test in discriminating between ulcerative colitis and Crohn's disease: a retrospective study

METHODS

The newly described--multigene analysis test (DiBiCol) identifying 7 inflammatory bowel disease (IBD)-specific genes in colonic mucosal biopsy differentiating between ulcerative colitis (UC) and Crohn's disease (CD) with active inflammation--is a new addition to existing methods with a higher stated sensitivity and specificity. Method biopsy material from 78 patients with a complicated course diagnosed as most probably UC in 38, CD in 18 and inflammatory bowel disease unclassified (IBDU) in 22 were investigated by DiBiCol.

RESULTS

DiBiCol showed a pattern consistent with CD in 13 patients with UC and led to change of diagnosis in 3 patients and a strong suggestion of CD in 8 patients. A total of 2 patients remained as UC. DiBiCol showed a pattern of UC in 4 patients of 18 with CD leading to a changing of diagnosis to UC in 3 patients, but the fourth remained as CD. In 22 patients with IBDU DiBiCol showed a pattern consistent with UC in 7 cases and with CD in 13 cases. A new evaluation 1 year after the DiBiCol allowed the assessment of clinical diagnosis in 10 patients confirmed in 9 of 10 patients by DiBiCol. In patients with acute flare of colitis the clinical diagnosis corresponded in 10 of 12 UC and in 5 of 6 CD cases.

SUMMARY

Adopting the DiBiCol test led to a change of the primary diagnosis in a significant number of patients with the initial diagnosis of UC and CD and suggested a clinically probable diagnosis in most of the patients with IBDU and in those with an acute flare of colitis.

A Case of Oral-contraceptive Related Ischemic Colitis in Young Woman

Ischemic colitis is generally considered a disease of the elderly. The causes of ischemic colitis include low-flow states due to cardiac dysfunction or hypovolemia and certain medications including estrogen. Here we report a case of ischemic colitis in a 26-year-old woman. She had no specific medical history except taking oral-contraceptives for a long time. The mechanism of estrogen-induced ischemic colitis is not clearly understood. But we recommend that oral-contraceptives should be considered as a cause of ischemic colitis in young women.

[Bacterial colitis]

The question of whether there are inflammatory changes in colorectal biopsy specimens is frequently asked, especially when the patient reports diarrhea or when the mucosa is reddened on endoscopy. The pathologist first has to find out whether there is, in fact, an increase in the inflammatory infiltrate of the colorectal mucosa which warrants the diagnosis of inflammation. If so, the second challenge is to ascertain the etiology of these inflammatory changes, in particular to differentiate between infectious and non-infectious causes. In principle, we can distinguish forms of colitis with distinct morphological hallmarks confirming the diagnosis (e.g. microscopic detection of the causative organism, as well as lymphocytic or collagenous colitis) from other forms of colitis which have a characteristic pattern of findings not necessarily allowing to deduce the etiology (e.g. infectious colitis without microscopic evidence of the germ vs. inflammatory bowel disease). The present article discusses the pathomorphology and differential diagnosis of the most important forms of bacterial colitis.

Histopathologic diagnosis of eosinophilic conditions in the gastrointestinal tract

Eosinophils, a constitutive component of the columnar-lined gastrointestinal tract, play an essential role in allergic responses and parasitic infections. The tissue density of these cells also increases in a variety of conditions of uncertain etiology. With the exception of the esophageal squamous epithelium, in which no eosinophils are normally present, the population of normal eosinophils in the remainder of the luminal gut is poorly defined. Therefore, histopathologists must rely on their subjective judgment to determine when a diagnosis of eosinophilic gastritis, enteritis, or colitis should be rendered. Eosinophilic esophagitis is currently the best defined and most studied eosinophilic condition of the digestive tract; therefore, the confidence in accurate diagnosis is increasing. In contrast, the characteristic clinicopathologic features of eosinophilic conditions affecting other parts of the digestive tract remain somewhat elusive. This review was designed to present pathologists with simple and practical information for the biopsy-based histopathologic diagnosis of eosinophilic esophagitis, gastritis, enteritis, and colitis. It was prepared by critically reviewing more than 200 articles on the topic, along with incorporating evidence accumulated through our own collective experience. We anticipate that by increasing pathologists' confidence in reporting these abnormal but often nameless eosinophilic infiltrates, we can help better define and characterize their significance.

Differential effects of TNF (TNFSF2) and IFN-γ on intestinal epithelial cell morphogenesis and barrier function in three-dimensional culture

Background

The cytokines TNF (TNFSF2) and IFNγ are important mediators of inflammatory bowel diseases and contribute to enhanced intestinal epithelial permeability by stimulating apoptosis and/or disrupting tight junctions. Apoptosis and tight junctions are also important for epithelial tissue morphogenesis, but the effect of TNF and IFNγ on the process of intestinal epithelial morphogenesis is unknown.

Methods/Principal Findings

We have employed a three-dimensional cell culture system, reproducing in vivo-like multicellular organization of intestinal epithelial cells, to study the effect of TNF on intestinal epithelial morphogenesis and permeability. We show that human intestinal epithelial cells in three-dimensional culture assembled into luminal spheres consisting of a single layer of cells with structural, internal, and planar cell polarity. Exposure of preformed luminal spheres to TNF or IFNγ enhanced paracellular permeability, but via distinctive mechanisms. Thus, while both TNF and IFNγ, albeit in a distinguishable manner, induced the displacement of selected tight junction proteins, only TNF increased paracellular permeability via caspase-driven apoptosis and cell shedding. Infliximab and adalumimab inhibited these effects of TNF. Moreover, we demonstrate that TNF via its stimulatory effect on apoptosis fundamentally alters the process of intestinal epithelial morphogenesis, which contributes to the de novo generation of intestinal epithelial monolayers with increased permeability. Also IFNγ contributes to the de novo formation of monolayers with increased permeability, but in a manner that does not involve apoptosis.

Conclusions

Our study provides an optimized 3D model system for the integrated analysis of (real-time) intestinal epithelial paracellular permeability and morphogenesis, and reveals apoptosis as a pivotal mechanism underlying the enhanced permeability and altered morphogenesis in response to TNF, but not IFNγ.

Prebiotic treatment in experimental colitis reduces the risk of colitic cancer

BACKGROUND AND AIM

  Germinated barley foodstuff (GBF) is a prebiotic product that reduces colonic mucosal inflammation and the clinical symptoms observed in ulcerative colitis (UC). The risk of contracting colorectal cancer is higher in patients with UC than in that of the general population. The aim of this study is to apply this prebiotic approach to control chronic colitis and to reduce the incidence of colitic cancer.

METHODS

  Repeated and intermitted dextran sulfate sodium administration to male Sprague-Dawley rats was used for the chronic and subacute colitis models. GBF was added as the diet (10% w/v). The incidence of adenomatous high-grade dysplasia, and pathophysiological observations, including the proliferative cell nuclear antigen (PCNA) labeling index, and clinical score, cecal organic acid profile, and the accompanying β-glucosidase activity were determined.

RESULTS

  In the chronic phase, the incidence of adenomatous dysplasia was only confirmed in the control group, and the GBF group had no dysplasia in the entire colon; the stratified squamous epithelium area of GBF was significantly lower than that of the controls. GBF treatment significantly lowered the cecal succinate content and significantly increased β-glucosidase activity compared to the controls. In addition, colonic mucosal inflammatory damage was comparable between the two groups, while the PCNA labeling index of the colonic mucosa in the GBF group was significantly lower than that of the control group. However, in the subacute phase, the mucosal damage score of GBF was significantly attenuated, and the PCNA labeling index of the colonic mucosa in the GBF group was significantly higher than that of the control group.

CONCLUSION

  This preliminary study demonstrated that GBF effectively prevents colitis-related dysplasia and inflammatory change in chronic and subacute colitis models by modulating the intestinal environment as a prebiotic. This prebiotic might contribute to the prevention of mucosal damage, to show different proliferative effects on the epithelium in the regeneration and steady states.

Chronic idiopathic inflammatory bowel diseases: the histology report

The incidence of chronic idiopathic inflammatory bowel diseases (IBD) is growing in western countries, making their histological diagnosis an everyday task for all pathologists. Reviews from the literature strongly suggest that such diagnosis cannot be performed on the histological ground alone but requires a clinical-pathological approach. Moreover, bewildering variations can be observed in the terminology employed to report either individual lesions or diagnostic categories. The aim of the present paper is to suggest a practical diagnostic algorithm summarizing the main data from the literature. Particular emphasis has been placed on minimum clinical information required and the accurate definition of individual lesions. Diagnostic categories to employ and to avoid in daily practice have furthermore been stressed.

The diagnostic value of the duodenal biopsy: a clinico-pathologic analysis of 28,000 patients

BACKGROUND

Duodenal biopsies are frequently obtained to investigate malabsorption, diarrhoea, and anemia. The proportion of patients who have duodenal biopsies and their diagnostic yield are unclear.

AIMS

To determine what proportion of patients undergoing esophagogastroduodenoscopy in a private setting has duodenal biopsies and to evaluate the diagnostic yield relative to clinical indications and endoscopic findings.

METHODS

Records of patients who had duodenal biopsies diagnosed at a United States gastrointestinal pathology laboratory in a single year were analysed.

RESULTS

28,210 patients with and 75,175 without duodenal biopsies were studied. Duodenal biopsy patients were younger (52 years versus 58 years, p<0.001) and more likely to be female (OR 1.46; p<0.0001); 87% of children and 27% of adults had duodenal biopsies. Suspicion of malabsorption or sprue, diarrhoea, anemia, and weight loss were strong predictors of duodenal biopsy. More than 80% of patients had normal duodenum, except those biopsied for sprue, 64% of whom had normal findings. Marsh II-IIIc lesions were diagnosed in 23% of patients with suspected sprue, but in 3.0% of those with diarrhoea, weight loss, or anemia, and in 1.5% of patients with dyspepsia or GERD.

CONCLUSIONS

A clinical suspicion of sprue produces the highest yield of histopathologic abnormalities; women are biopsied more often than men despite having less duodenal pathology.

Clinical significance of serum α1-acid glycoprotein level in patients with ulcerative colitis

AIM: To study the clinical significance of serum α1-acid glycoprotein (α1-AGP) level in patients with ulcerative colitis.

METHODS: Immunonephelometry was used to measure the levels of α1-AGP in serum from 100 patients with ulcerative colitis and 40 controls. Erythrocyte sedimentation rate (ESR) was also measured. The disease activity of UC was determined according to Mayo criteria.

RESULTS: Serum α1-AGP level was significantly higher in patients with active UC than in those with inactive UC and controls (1 446.0 mg/L ± 543.6 mg/L vs 857.2 mg/L ± 310.9 mg/L and 653.7 mg/L ± 308.9 mg/L, respectively; both P < 0.01). Serum α1-AGP level was significantly higher in patients with inactive UC than in controls (P < 0.05). In patients with active UC, significant differences were also found in serum α1-AGP levels among patients with mild, moderate and severe disease. A positive correlation was noted between serum α1-AGP level and the disease activity index of UC (r = 0.777, P < 0.001).

CONCLUSION: The change in serum α1-AGP level accurately reflects the severity of UC and may be used for assessing UC activity.

Stem cells as potential therapeutic targets for inflammatory bowel disease

The incidence and prevalence of Crohn's disease and ulcerative colitis, the two major forms of inflammatory bowel disease (IBD), are rising. According to some estimates >1 million new cases of IBD arise in the United States annually. The conventional therapies available for IBD range from anti-inflammatory drugs to immunosuppressive agents, but these therapies generally fail to achieve satisfactory results due to their side effects. Interest in a new therapeutic option, that is, biological therapy, has gained much momentum recently due to its focus on different stages of the inflammatory process. Stem cell (SC) research has become a new direction for IBD therapy due to our recent understanding of cell populations involved in the pathogenic process. To this end, hematopoietic and mesenchymal stem cells are receiving more attention from IBD investigators. The intestinal environment, with its crypts and niches, supports incoming embryonic and hematopoietic stem cells and allows them to engraft and differentiate. The above findings suggest that, in the future, SC-based therapy will be a promising alternative to conventional therapy for IBD. In this review, we discuss SCs as potential therapeutic targets for future treatment of IBD.

Costimulation of Th17 cells: Adding fuel or putting out the fire in the inflamed gut?

Inflammatory bowel disease, typified by Crohn's disease and ulcerative colitis, is a common disorder characterized by recurrent and serious inflammation of the gastrointestinal tract. It is well documented that T cells play a pivotal role in the development of inflammatory bowel disease. Th17 cells are a unique T cell subpopulation implicated in inflammatory bowel disease and many other autoimmune/inflammatory diseases. However, the regulatory mechanism of Th17 activation and proliferation has not been defined completely. Recent studies have shown that the ligation of several costimulatory receptor-ligand pairs contributes to the activation, differentiation, and proliferation of T lymphocytes including the Th17 subset. In this review, we will discuss the emerging evidence on the role of Th17 cells in inflammatory bowel disease pathogenesis as well as the effect of costimulatory molecules on Th17 development and consider if the need for such costimulation of T lymphocytes provides a target for the development of novel therapeutic strategy.