Endoscopic biopsy features and diagnostic challenges of adult Crohn's disease at initial presentation

Changes in clinical features and seasonal variations of Crohn's disease at diagnosis: a 10-year observational study in China

Background and aims

The clinical aspects of Crohn's disease (CD) at diagnosis determine its therapy and management. The onset of CD follows a seasonal pattern. We aimed to analyze changes in the clinical features and seasonal variations of newly CD patients over the last decade.

Methods

CD patients were divided into cohort 1 (2012-2016) and cohort 2 (2017-2021). The clinical characteristics were collected and the trends according to the year and season of diagnosis were analyzed.

Results

A total of 2038 patients were included. Cohort 1 had a considerably greater proportion of diarrhea, fever, hematochezia, weight loss and extraintestinal manifestations. The levels of platelet and C-reactive protein were higher in cohort 2 patients, but the opposite was true for albumin levels (p<0.05). The rate of increased eosinophils, increased gangliocyte and abundant lymphoplasmacytic infiltrate significantly decreased over the years. Patients with granulomas were diagnosed with CD at an earlier age (p = 0.006). Cohort 1 patients used more conventional drugs, while cohort 2 patients apply more biologics (p<0.05). The diagnosis occurred more frequently in summer and less frequently in winter. Patients diagnosed in winter had notably higher BMI, lower frequency of perianal disease and lowest incidence of asthenia and weight loss.

Conclusion

The clinical phenotype, laboratory and pathological characteristics of CD has changed over time in China. The diagnosis of CD tends to have a seasonal trend with the highest incidence in summer. CD patients diagnosed in winter appear to have a milder form of the disease.

Isolated Gastric Crohn's Disease: A Growing Tendency

Isolated gastric Crohn's disease (IGCD) is a rare manifestation of Crohn's disease confined to the stomach, unlike its more common forms that primarily affect the ileum and colon. We report the case of a 25-year-old female presenting with a one-month history of epigastric discomfort and nausea, with no other significant gastrointestinal or systemic symptoms. Upper endoscopy revealed an aphthous ulceration on the greater curvature of the stomach, with biopsies showing non-caseating granulomas consistent with Crohn's disease. The diagnosis of IGCD was confirmed through a positive ASCA test and negative p-ANCA test, alongside the absence of ileal and colonic involvement. The patient was treated with prednisone for acute symptom management, followed by infliximab for long-term maintenance. Follow-up evaluations showed no significant relapse episodes. This case highlights the diagnostic challenges and management strategies for IGCD, emphasising the need for further research to optimise treatment protocols and improve long-term outcomes.

LEARNING POINTS

This case highlights the challenges and complexities of diagnosing and managing isolated gastric Crohn's disease (IGCD), a rare manifestation of Crohn's disease confined to the stomach.Serological tests such as the anti-Saccharomyces cerevisiae antibody (ASCA) test and the perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) test help in distinguishing Crohn's disease from other conditions.This case emphasises the importance of considering IGCD in patients with unexplained gastric symptoms, and the need for individualised treatment plans due to the lack of specific guidelines for IGCD.

A Case Report and Literature Review of Rectosigmoid Crohn's Disease: A Diagnostic Pitfall Ultimately Leading to Spontaneous Colonic Perforation

Inflammatory bowel disease (IBD) is a chronic condition that affects the gastrointestinal tract, with ulcerative colitis (UC) and Crohn's disease (CD) as the two major entities. While these conditions share some similarities in clinical presentation, they have distinct histopathological features. UC is a mucosal disease affecting the left colon and rectum, while CD can affect any part of the gastrointestinal tract and all layers of the bowel wall. Accurate diagnosis of UC and CD is important for effective management and prevention of complications. However, distinguishing between the two conditions based on limited biopsy specimens or atypical clinical presentations can be challenging. We present a case of a patient diagnosed with UC based on a single endoscopic biopsy from the sigmoid colon, who later presented with colonic perforation and was found to have CD on the colectomy specimen. This case emphasizes the importance of clinical guidelines when dealing with any patient of suspected IBD, considering alternative diagnoses in patients with atypical presentations and the need for careful clinical, endoscopic, and histological evaluation to make an accurate diagnosis. Delayed or missed diagnosis of CD can lead to significant morbidity and mortality.

Significance of granuloma and granulomatous lymphangitis in the differential diagnosis of Crohn's disease

OBJECTIVE

To clarify the pathological characteristics of granuloma and granulomatous lymphangitis in patients with non-neoplastic bowel diseases and to compare their significance in the differential diagnosis of Crohn's disease (CD) and intestinal tuberculosis (ITB).

METHODS

Altogether 78 cases with CD, 11 with ITB and 33 suffering from other non-neoplastic bowel diseases were included. All patients underwent a partial enterectomy and histopathological examination. Pathological sections were reviewed retrospectively. Detailed morphological features and the distribution of granulomas and granulomatous lymphangitis in the three groups were analyzed and compared.

RESULTS

Significant differences in the features of granuloma were observed in CD compared with ITB, including the presence of Langhans giant cells, caseous necrosis, coalescence, hyaline change, onionskin changes, and their frequency and size. Granulomatous lymphangitis was significantly more frequent in CD than in other non-neoplastic bowel diseases (P < 0.0001). The rate was also higher than that of granuloma in CD (P = 0.0004). It more often manifested within the mucosal layer of the small bowel (55.4%) in CD whereas it tended to be located within the deep layers of the intestinal wall in other diseases. It can be divided into four types, but types 1 and 2 appeared relatively specific to CD.

CONCLUSIONS

Granuloma and granulomatous lymphangitis were not specific in CD. However, by combining morphology and distribution, their manifestations could assist in the differentiation of CD from other non-neoplastic bowel diseases. Furthermore, granulomatous lymphangitis showed better diagnostic performance than granulomas in the mucosal layer of the small bowel.

Microscopic features of small bowel mucosa of patients with Crohn's disease

BACKGROUND

Double-balloon enteroscopy enables performing numerous small bowel biopsies for pathologic analysis. However, most histopathological characteristics of Crohn's disease are non-specific characteristics. We aimed to explore the small bowel mucosal histopathologic characters of Crohn's disease and identify some disease-specific changes.

METHODS

We included 253 patients without tumors and grouped them into Crohn's disease, suspected Crohn's disease, and non-Crohn's disease groups. These patients underwent double-balloon endoscopy examination and small bowel biopsy at Renji Hospital, Shanghai. All histopathological sections were reviewed, and > 20 histopathological parameters were assessed. Immunohistochemistry was conducted when necessary.

RESULTS

There were different forms of granulomatous lymphangitis on the small bowel mucosa in Crohn's disease. They showed as various macrophages or epithelioid cells in the lumina of lymphatics or in the center of the villi with or without evident obstruction. These features were only observed in Crohn's disease patients. Furthermore, they were correlated with granuloma and lymphangiectasia. Additionally, 15 other features showed significant differences among the three groups, and Crohn's disease patients showed an average of almost seven histopathological characteristics.

CONCLUSIONS

We described the detailed morphologies of granulomatous lymphangitis on the small bowel mucosa and recommend it as a useful histopathological feature for the diagnosis of Crohn's disease. In terms of specificity and sensitivity, it was superior to non-caseating epithelioid granuloma.

Capsule endoscopy in small bowel Crohn’s disease and Tuberculosis

Differentiation of small bowel tuberculosis (SBTB) from Crohn’s disease (CD) is a diagnostic challenge. We studied 52 patients with suspected SBTB or CD with terminal ileal involvement, who were prospectively enrolled. After confirming patency of the gastrointestinal tract, 26 patients underwent capsule endoscopy (CE). A final diagnosis of CD was found in 18 patients and SBTB in eight patients. All SBTB patients had involvment of the ileocecal valve (ICV) with large (n = 6) and aphthous (n = 2) ulcers in the ileal segment. In CD, ICV involvement was seen in five (33%) patients. Large and aphthous ulcers were observed in seven (47%) and 15 (100%) patients, respectively. On comparison with CD, patients with SBTB had increased frequency of ICV involvement ( P = 0.002) and lesser frequency of aphthous ulcers ( P = 0.007). CE can help in differentiating CD from SBTB by the position of its involvement and the type of ulcers present.

Endoscopic and clinical responses to anti-tubercular therapy can differentiate intestinal tuberculosis from Crohn's disease

BACKGROUND

Differentiation between intestinal tuberculosis and Crohn's disease is difficult and may require therapeutic trial with anti-tubercular therapy in tuberculosis-endemic regions.

AIM

To evaluate the role of therapeutic trial with anti-tubercular therapy in patients with diagnostic confusion between intestinal tuberculosis and Crohn's disease.

METHODS

We performed retrospective-comparative (n = 288: 131 patients who received anti-tubercular therapy before being diagnosed as Crohn's disease and 157 intestinal tuberculosis patients) and prospective-validation study (n = 55 patients with diagnostic confusion of intestinal tuberculosis/Crohn's disease). Outcomes assessed were global symptomatic response and endoscopic mucosal healing.

RESULTS

In the derivation cohort, among those eventually diagnosed as Crohn's disease, global symptomatic response with anti-tubercular therapy was seen in 38% at 3 months and in 37% who completed 6 months of anti-tubercular therapy. Ninety-four per cent of intestinal tuberculosis patients showed global symptomatic response by 3 months. Endoscopic mucosal healing was seen in only 5% of patients with Crohn's disease compared with 100% of intestinal tuberculosis patients. In the validation cohort, all the patients with intestinal tuberculosis had symptomatic response and endoscopic mucosal healing after 6 months of anti-tubercular therapy. Among the patients with an eventual diagnosis of Crohn's disease, symptomatic response was seen in 64% at 2 months and in 31% who completed 6 months of anti-tubercular therapy, none had mucosal healing.

CONCLUSIONS

Disproportionately lower mucosal healing rate despite an overall symptom response with 6 months of anti-tubercular therapy in patients with Crohn's disease suggests a need for repeat colonoscopy for diagnosing Crohn's disease. Patients with intestinal tuberculosis showing significant symptomatic response after 2-3 months of anti-tubercular therapy, suggest that symptom persistence after a therapeutic trial of 3 months of anti-tubercular therapy may indicate the diagnosis of Crohn's disease.

The Challenge of Inflammatory Bowel Disease Diagnosis in Asia

Background

The current major clinical challenge relates to the accurate diagnosis of inflammatory bowel disease (IBD) in Asian countries with a high background prevalence of infections.

Summary

The diagnosis of Crohn's disease in geographical areas where tuberculosis is endemic poses a major diagnostic challenge.

Key Messages

Infections can mimic IBD and complicate the course of existing IBD. Limited availability of diagnostic modalities and health service may delay diagnosis. A multidisciplinary approach, continuous medical education, and academic activities may warrant an accurate diagnosis of IBD.

Linkage between genotype and immunological phenotype in Crohn's disease

Understanding the mechanisms that drive uncontrolled inflammation in Crohn's disease (CD) remains one of the most pressing challenges in contemporary experimental medicine. Recently, a three-phased view on the pathogenesis of CD was proposed in which following the breakdown of intestinal epithelial barrier function, CD patients fail to clear the resulting infectious debris, provoking subsequent immune responses. This view on CD is attractive in that it is testable and allows better diagnosis of disease if proven correct, apart from opening a window on new therapeutic horizons. Here we shall argue, however, that this scheme may be an oversimplification in that it ignores the genetic diversity of CD and thus does not fully take into account the nature of the intestinal epithelium, which appears a non-passive actor in this disease.

Paneth cell metaplasia in newly diagnosed inflammatory bowel disease in children

Background

Paneth cell metaplasia (PCM) is well described in adults but little is known about the distribution of colonic Paneth cells and the occurrence of PCM in a paediatric population. The aim of this study is to determine whether Paneth cell hyperplasia or metaplasia characteristically occurs in the colons of children with newly diagnosed idiopathic inflammatory bowel disease (IBD).

Methods

We retrospectively reviewed colonic series from 28 new diagnoses of paediatric IBD at a tertiary referral centre, and from a further 14 children with IBD-like symptoms whose colonic biopsies and ancillary investigations were normal. Paneth cells were counted at 6 anatomical sites in the colon, and at each site acute and chronic inflammation were assessed semi-quantitatively and the presence or absence of crypt architectural distortion and eosinophilia was documented.

Results

In control, ulcerative colitis (UC) and Crohn’s disease (CD) groups there was a gradient of decreasing Paneth cell numbers from caecum to rectum. Paneth cells were not seen in the distal colon in the control group, but they were present there in 11 of 13 patients with ulcerative colitis and 14 of 15 with Crohn’s disease. Only patients with IBD showed Paneth cell hyperplasia, assessed as more than 10 Paneth cells per 10 well-oriented crypts at any site. There was a statistically significant increase in Paneth cells in the caecum, ascending, transverse and descending colon in UC and in the ascending, transverse, descending and sigmoid colon in CD compared with controls. There was no significant difference between UC and CD. There was no correlation between the site of PCM and acute or chronic inflammation, crypt distortion or eosinophilia.

Conclusion

Paneth cells are found in the proximal but not the distal colon in otherwise normal paediatric colonic series. A high proportion of UC and CD patients show PCM in the distal colon. This is present early in the disease and does not correlate with histological features of chronicity.

'Crohn'z meanz Heinz': foreign body inflammatory mass mimicking Crohn's disease

The authors present a patient with a presumed diagnosis of Crohn's disease for 6 years turning out to be an unusual inflammatory mass caused by ileal perforation due to a foreign body. When surgical intervention became necessary for admissions with recurrent obstruction, laparoscopy revealed an inflammatory mass in the terminal ileum, exposing two pieces of plastic bearing the word 'Heinz'. Resection of the inflammatory mass led to the complete resolution of symptoms. Histology from the operative specimen showed no features of Crohn's disease. There were no granulomas and no fissuring ulcers. This case highlights that an inflammatory mass in the small intestine caused by the perforation of ingested foreign body can mimic Crohn's disease. To our knowledge, this is the first report of a synthetic plastic packaging causing ileo-caecal junctional perforation mimicking Crohn's disease.

Value of capsule endoscopy and double-balloon endoscopy in the diagnosis of small bowel tumors and Crohn's disease: an analysis of 316 cases

AIM: To evaluate the value of capsule endoscopy and double-balloon endoscopy in the diagnosis of small bowel tumors and Crohn's disease.

METHODS: A total of 316 patients who were suspected of having small bowel diseases were collected in this study. Of these patients, 178 underwent capsule endoscopy, 138 underwent double-balloon endoscopy, and 32 underwent both examinations. The detectable rates and diagnosis rates of small bowel tumors and Crohn's disease achieved using the two methods were compared.

RESULTS: The detectable rate and diagnosis rate of small bowel tumors in patients undergoing capsule endoscopy were 4.5% (8/178) and 1.1% (2/178), respectively. The detectable rate and diagnosis rate of small bowel tumors in patients undergoing double-balloon endoscopy were 18.1% (25/138) and 15.2% (21/138), respectively. There are significant differences in the detectable rate and diagnosis rate of small bowel tumors between patients undergoing capsule endoscopy and those undergoing double balloon endoscopy (both P < 0.01). The detectable rate and diagnosis rate of Crohn's disease in patients undergoing capsule endoscopy were 3.4% (6/178) and 1.7% (3/178), respectively. The detectable rate and diagnosis rate of Crohn's disease in patients undergoing double-balloon endoscopy were 15.9% (22/138) and 10.1% (14/138), respectively. There are significant differences in the detectable rate and diagnosis rate of Crohn's disease between patients undergoing capsule endoscopy and those undergoing double-balloon endoscopy (both P < 0.01). Of 32 patients who underwent both capsule endoscopy and double-balloon endoscopy, 5 patients were diagnosed with small bowel tumors by double-balloon endoscopy and confirmed by pathological examination, 1 was found with small bowel tumors by capsule endoscopy, and 3 were diagnosed with Crohn's disease by both capsule endoscopy and double-balloon endoscopy.

CONCLUSION: Double balloon endoscopy is superior to capsule endoscopy in the diagnosis of small bowel tumors and Crohn's disease. Combination of capsule endoscopy and double-balloon endoscopy can improve diagnosis and reduce misdiagnosis of small intestinal diseases.