Crohn's disease of aphthous type: serial changes in intestinal lesions

Capsule Endoscopy for Ileitis with Potential Involvement of Other Sections of the Small Bowel

Ileitis is defined as inflammation of the ileum. This condition includes ulcers, aphthous ulcers, erosions, and nodular or erythematous mucosa. Various etiologies are associated with ileitis. Crohn's disease, ulcerative colitis, medications such as nonsteroidal anti-inflammatory drugs, infectious conditions, neoplasms, infiltrative disorders, vasculitides, spondyloarthritis, endometriosis, and radiation therapy-related conditions involve the ileum. However, the differential diagnosis of terminal ileitis can be difficult in many cases. Video capsule endoscopy (VCE) has become a useful tool for the diagnosis of a variety of small bowel lesions. This review describes each of the various conditions associated with ileitis and the diagnostic value of VCE for ileitis, which may help identify and evaluate these conditions in clinical practice. Based on the information provided by VCE, a definitive diagnosis could be made using the patients' medical history, clinical course, laboratory and ileocolonoscopic findings, radiologic imaging findings, and histologic findings.

The analysis of factors associated with progression of isolated terminal ileal lesions

Objective

To assess the factors associated with the progression of isolated terminal ileal lesions (ITILs) at colonoscopy in Chinese patients.

Methods

Patients diagnosed with ITILs were enrolled. The ileoscopy was performed by two experienced gastroenterologists every 52 weeks. A logistic regression analysis was used to elucidate the factors associated with Crohn's disease (CD) and mucosal healing. A log rank test was used to assess the differences of the cumulative proportion of CD and mucosal healing in different groups at different times.

Results

(1) A total of 34 patients were included and no patient had taken nonsteroidal anti-inflammatory drug in the last 6 months; eight (23.5%) patients had a clinical diagnosis of CD, 14 (41.2%) patients achieved mucosal healing, and 12 (35.3%) patients showed no significant changes in the lesions at last follow-up. (2) The logistic regression analysis showed that only abdominal pain was a factor in the ITIL disease outcomes. (3) The cumulative proportion of CD in the abdominal pain group after 3 years was statistically higher than that in the non-abdominal pain group (42.7% vs. 6.2%, χ² = 10.129, P = 0.001). However, the cumulative proportion of mucosal healing in the non-abdominal pain group was statistically higher than that in the abdominal pain group (73.3% vs. 5.6%, χ² = 5.225, P = 0.022). (4) The numbers of lesions observed on the initial colonoscopy exams and the initial histologic findings were not related to the ITIL disease outcomes.

Conclusions

Clinical symptoms may be related to ITIL disease outcomes. Patients with abdominal pain had a high likelihood of CD, whereas those without abdominal pain had a high likelihood of mucosal healing.

Evaluation of diagnostic criteria for Crohn's disease in Japan

BACKGROUND

In Japan, Crohn's disease (CD) is diagnosed according to a single, well-established set of diagnostic criteria. However, no nationwide attempt has been made to determine which specific criteria within these diagnostic criteria are used to make diagnoses.

METHODS

A questionnaire-based survey was conducted of patients given a definitive or suspected diagnosis of CD before January 2011 according to the Japanese Diagnostic Criteria for Crohn's Disease. The survey included 579 patients with a definitive diagnosis of CD and 59 patients with a suspected diagnosis of CD at 34 Japanese medical institutions.

RESULTS

A total of 87.4 % of definitive diagnoses of CD were based on the criterion in the definite category: major finding A "longitudinal ulcer (LU)" or B "cobblestone-like appearance (CSA)". A total of 30.4 % of definitive diagnoses were based on the criterion: major finding C "non-caseating epithelioid cell granuloma (NCEG)" with minor finding a "irregularshaped and/or quasi-circular ulcers or aphthous ulcerations found extensively in the gastrointestinal tract" or b "characteristic perianal lesions". Finally, 7.1 % of definitive diagnoses were made according to the criterion: all minor findings a, b and c "characteristic gastric and/or duodenal lesions". Among suspected diagnoses of CD, 74.6 % were based on the criterion in the suspected category: one or two minor findings.

CONCLUSIONS

The Japanese diagnostic criteria for Crohn's disease consist of combinations of specific morphological findings. Many of the diagnoses were based on the findings of LU or CSA.

Isolated terminal ileal ulcerations in asymptomatic individuals: natural course and clinical significance

BACKGROUND

Although isolated terminal ileal ulcerations (ITIUs) are occasionally observed on colonoscopic examination of asymptomatic individuals, their clinical course and guidelines for treatment are unclear.

OBJECTIVE

To evaluate the clinical course and significance of ITIUs in asymptomatic individuals.

DESIGN

Single-center retrospective analysis.

SETTING

University hospital.

PATIENTS AND INTERVENTIONS

All patients diagnosed with ITIUs on colonoscopy from July 2001 to December 2007 were identified. Patients with colorectal symptoms, a history of nonsteroidal anti-inflammatory drug consumption, a history of colorectal surgery, oral or genital ulcerations, and coincidental ulceration in the ileocecal valve or colon were excluded.

MAIN OUTCOME MEASUREMENTS

Colonoscopic findings and clinical courses of patients were analyzed.

RESULTS

Of the 148 included patients, 93 were followed (mean duration, 29.9 months). Of these, 62 showed resolution of ITIU on follow-up colonoscopy, including 60 who resolved without any treatment and 2 who resolved after antituberculosis medication. Follow-up colonoscopy continued to show ITIUs in the remaining 31 patients, only 1 of whom developed typical Crohn's disease, whereas the other 30 showed no significant changes in the lesions (n = 22), partial improvement (n = 6), or waxing and waning endoscopic appearance (n = 2).

LIMITATIONS

Retrospective design, relatively short-term follow-up.

CONCLUSIONS

Most ITIUs incidentally observed in asymptomatic individuals resolve without any treatment. Even if these lesions persist, it is unusual for them to progress or to cause any symptoms.

Colonoscopic differences of erosive and/or small ulcerative lesions for diagnosis of colonic inflammatory diseases

BACKGROUND AND AIMS

Various etiologies and diseases may be related to erosive and/or small ulcerative lesions without gross appearance in the colon during colonoscopy. However, few investigators report on differential diagnosis of colonic inflammatory diseases. Thus, we investigated the clinical significance of these lesions and the value of colonoscopy in the differential diagnosis of colitis.

METHODS

In 110 patients with erosive and/or small ulcerative lesions (<5 mm) who were treated in our hospital during the past 9 years, we retrospectively investigated the relationship between endoscopic morphology and clinical diagnosis. The intestinal lesions were endoscopically classified into three groups (A, hyperemic type; B, aphthous type; and C, verrucous type).

RESULTS

The lesions were mainly located in the rectum to the sigmoid colon in group A. In group C, the lesions were most frequently located in the transverse colon and deeper areas. Endoscopically, the etiology was unclear in 74.5% of group A and 73.8% of group B, however, in group C, most of them (81.0%) were associated with specific diseases. With respect to inflammatory bowel diseases, 71.4% of the patients with Crohn's disease and all patients with ulcerative colitis were assigned to group A or B.

CONCLUSION

Erosive and/or small ulcerative lesions belonging to group A or B were mainly non-specific. However, careful follow up was required in groups A and B, which included the possibility of inflammatory bowel diseases, when the symptoms or lesions were not improved.

Metastatic colon cancer mimicking Crohn's disease

A 66-year-old Japanese woman presented with intestinal obstruction and right-sided hydronephrosis. Although upper gastrointestinal endoscopy demonstrated signet-ring cell gastric carcinoma, colonoscopy and barium enema study yielded findings mimicking Crohn's disease in the colon, that is, skipping longitudinal ulcer scarlike strictures, cobblestone appearance, segmental stricture, and pseudosacculations. After total gastrectomy and right-sided hemicolectomy, the final diagnosis of gastric cancer extensively involving the colon, and not of Crohn's disease complicating gastric cancer, was established. Pathologic examination showed that anaplastic cancer with exuberant desmoplastic reaction and infiltration along the mesenteric border principally accounted for the morphological similarities noted between Crohn's disease and metastatic colon cancer in this case. The findings in the present case, together with a review of the literature, suggest that metastatic colon cancer should be considered when Crohn-like colonic findings are encountered, not only in individuals with concurrent cancer in other sites but also in those with distant history of cancer.

Peyer's Patches and M Cells as Potential Sites of the Inflammatory Onset in Crohn's Disease

Clinical observations suggest that the sites of initial inflammation in ileal Crohn's disease (CD) are the lymphoid follicles, where the aphtoid lesions originate from small erosions of the follicle-associated epithelium (FAE). Lymphoid follicles and Peyer's patches (PPs) consist of a number of B-cell follicles with intervening T cell areas. The T cell follicular area is also populated by dendritic cells (DCs) and macrophages. A single layer of epithelial cells covering each follicle forms a dome between the surrounding villi. This FAE differs from normal villus epithelium in several ways that make the epithelial cells of the FAE more exposed to the luminal contents, more accessible to antigens, and in closer contact with the immune system. The most prominent feature is the presence of specialized M cells, which are optimized for antigen adherence and transport. M cells play an important role in the surveillance of the intestinal lumen, but also provide a route of entry for various pathogens. In this article we review the current knowledge on the epithelial phenotype of the human FAE, and changes of the FAE and M cells in intestinal inflammation, leading to a hypothesis of the role of the FAE and M cells in the pathogenesis of CD.