Acute ileitis

Interpretation of ileal biopsies: morphological features in normal and diseased mucosa

One of the advantages of flexible colonoscopy is that the terminal ileum can easily be reached and biopsied by an experienced operator. Thus, the pathologist will, with increasing frequency, receive ileal biopsies from patients who have or may not have ileal disease and it is therefore useful to have a good knowledge of the spectrum of ileal mucosal histology and pathology, of its normal function, and of the changes seen in different conditions. It is also desirable to be aware of diseases that occur less frequently. The ileal microscopic features are related to its absorptive function on the one hand, and to non-specific and specific defence mechanisms of the organism against potential hazardous components on the other. As a consequence the mucosa features a constant physiological and controlled inflammatory process. Part of the ileal mucosal structure is determined by the presence of the gut-associated lymphoid tissue (GALT) which plays a key role in discriminating harmless nutrients and harmful pathogens. It will be important to distinguish this normal situation from alterations seen in infectious or inflammatory pathology. Further, because of the therapeutic implications, it is necessary that acute and chronic (idiopathic) inflammation are recognized. This will in general be possible by evaluating the composition of the inflammatory infiltrate and the occurrence of epithelial and mucosal architectural changes.

Clinical and diagnostic features of Crohn's disease and ulcerative colitis in childhood

Crohn's disease and ulcerative colitis are important disorders in childhood which may present in a similar way to adult life, but the major paediatric dimension is impairment of growth and development which may occur in both disorders. Whilst the diagnosis of ulcerative colitis is usually quite quick by virtue of the pressing nature of the chief symptoms, bloody diarrhoea, the diagnosis of Crohn's disease may be significantly delayed in children as the symptoms are frequently less obvious and may not, at first, be gastrointestinal. Modern diagnosis is based upon a combination of endoscopy and radiology. Of particular importance is endoscopic biopsy which enables a definite histological diagnosis to be made. Early referral to diagnostic centres is particularly important in childhood.

Incidence and sonographic diagnosis of bacterial ileocaecitis masquerading as appendicitis

533 consecutive patients with suspected acute appendicitis or appendiceal mass were examined by ultrasonography to distinguish acute appendicitis from bacterial enteritis. In 61 (11.4%) ultrasonography revealed the characteristic picture associated with bacterial enteritis of the ileocaecal region--enlarged mesenteric lymph nodes and mural thickening of the terminal ileum and caecum--but no image of the appendix. In 41 of these a bacterial infection was confirmed: infection due to Yersinia enterocolitica in 21, Campylobacter jejuni in 15, Salmonella B in 3, Salmonella C in 1, and Yersinia pseudotuberculosis in 1. In the other 20 bacteriological tests were negative (10) or not done (10). Oral barium studies, done in 15 patients, showed thickening of the terminal ileum in all of them. Only 22 of the 61 patients had diarrhoea. Yersinia enteritis clinically simulated an appendiceal mass in 17 of 22 patients, 6 of the 61 patients underwent surgery, and in all of them the appendix removed was normal. The other 55 patients recovered with conservative treatment. In 26 a planned appendicectomy was cancelled because of the sonographic findings. Bacterial enteritis limited to the ileocaecal region (bacterial ileocaecitis) seems to be responsible for an appreciable number of unnecessary appendicetomies. It has characteristic sonographic features that distinguish it from appendicitis.

Yersinia infections in surgical practice

This article reviews the clinical manifestations of Yersinia bacteria emphasizing their recent rise in incidence and describing how Yersinia infection presents to the general surgeon. Geographical variations, patterns of disease, pathogenicity and the problems in diagnosis and management are discussed. This common but often unrecognized infection is usually self-limiting but the very young, the very old and the immunocompromised are at greater risk and prompt treatment is required to save lives.

Yersinia arthritis with erythema nodosum

A previously healthy female presented with erythema nodosum and arthritis with serological evidence of infection with Yersinia enterocolitica. Erythema nodosum following this infection has not previously been reported in Britain.

Pathology of the alimentary tract in Salmonella typhimurium food poisoning

The pathology of the alimentary tracts of nine patients dying of Salmonella typhimurium infection is reviewed. Two patients had previous gastric operations, supporting previous reports that such patients are more susceptible to food poisoning. Four had no parietal (oxyntic) cells in the gastric mucosa, suggesting hypo- or anacidity. Only one had acute gastritis. None had acute enteritis, but in half of the patients, subtle histological changes suggested an 'enteropathy'. Acute diffuse colitis with abundant crypt abscesses, without stromal abscesses in the lamina propria, was the most constant finding and reparative features started very early, and occurred in later deaths. Under ideal circumstances this crypt abscess is readily distinguished from that of idiopathic ulcerative colitis, but can be confused with the crypt abscess of acute bacillary (sonne) dysentery. While the florid colonic changes may have settled in the late deaths, active inflammation is commonly present in the appendix mucosa on histology. The pathology of the alimentary tract in S typhimurium infection differs from that of S typhi and S paratyphi infections. There is little evidence of gastroenteritis, although subtle changes occur in the stomach and small intestine. The features are those of acute diffuse colitis with histological appendicitis, distinguishable from idiopathic ulcerative colitis.