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Critical Evaluation of Critical Evaluation of colonoscopic biopsies in colonoscopic biopsies in
Crohn’s DiseaseCrohn’s Disease
Najib Haboubi MB Ch B ,D Path, FRCPathProfessor of Health Science, Liver and
Gastrointestinal and Pathology, Universities of John Moors, Liverpool and Salford, Manchester.
Crohn, Ginzburg and Crohn, Ginzburg and Oppenhiemer 1932 JAMAOppenhiemer 1932 JAMA
‘A disease of the terminal ileum, affecting mainly young adults and characterised by……
Things have changedThings have changed
Young and old All GIT ( mostly small and large intestine)
Distinction between UC and Distinction between UC and CDCD
From a single mucosal biopsy.
Not easy!
CD Classical featuresCD Classical features
Focality Rectal sparingGranulomas.Transmural inflammation
DistalDistal UCUC is mostly is mostly
accompanied by inflammatory accompanied by inflammatory lesions of the lesions of the caecumcaecum
Geboes et al Gastroenterology 1987
Patchy Patchy CoecalCoecal Inflammation Inflammation
Associated with Associated with DistalDistal UCUC: : A Prospective Endoscopic A Prospective Endoscopic
StudyStudy D’Haens,Geboes,Peeters,Baert,Ectors, Rutgeerts. Am.J.Gasroenterol. 1997
Patchiness of mucosal Patchiness of mucosal inflammation in treated inflammation in treated
UCUC
Bernstein , Shanahan , Anton , Weinstein.
Gastrointestinal Endoscopy. 1995.
Ulcerative ColitisUlcerative Colitis
Patterns of Involvement in Colorectal Biopsies and Changes With Time.
Celina Kleer and Henry Appelman
Am.J.Surg.Path.
Material and MethodMaterial and Method
41 patients with proven chronic UC.
Sequential sets of colonic biopsies.
ResultsResultsHistologically normal
appearing mucosal biopsies do occur in established cases of CUC.
This finding is enhanced with treatment with 5 ASA.
Summary Summary In In CUCCUC
Mucosa can revert to normal with or without treatment.
Skip lesions and rectal sparing .
Classical featuresClassical features
Multi focality and Rectal sparing
Granulomas. Transmural inflammation
GranulomasGranulomas
25-90% of cases (site, specimen type,no. of slides). Seen more in early disease. Younger age group Increase yield as we travel throughout the colon. Usually related to active inflammation and
ulceration/disputed! May indicate aggressive disease (Heresbach et al Gut
2005) Specific to CD only in the setting of IBD and when they
are Sarcoid type.
Non Infective Granulomas Non Infective Granulomas
Pericryptal position can be seen in UC Diversion colitis. Diverticular disease. Sarcoidosis Chronic granulomatous disease of childhood Foreign body Pericryptal in infective colitis. Vasculitis
Infective GranulomasInfective Granulomas
TBFungal infection.Viral infection.
UCUC
Classic ViewsNever patchy No granuloma
Current viewsCan be .Pericryptal
granuloma
In practiceIn practice
The distinction between UC and CD is not always easy .
Even in the hands of the experts?
How could pathologists How could pathologists improve the initial diagnosis of improve the initial diagnosis of
colitis? colitis?
Bentley et al J Clin Path 2002,55;955-960
AimAim
1. Determine the effect of a single versus multiple biopsies on the accuracy of diagnosis.
2. Study the accuracy and reproducibility of different criteria used in the diagnosis of multiple biopsies by the experts and the non experts pathologists.
MethodsMethods
13 experts and 12 non experts examined 60 well followed up cases of CD and UC , totally blinded and in 2 rounds.
Diagnoses were made initially on rectal then full colonoscopic biopsies.
Diagnosing CDDiagnosing CD
Experts Rectal 24% Full colonoscopy 64%
Non experts Rectal 12% Full colonoscopy 60%
Diagnosing UCDiagnosing UC
Experts Rectal 64% Full colonoscopy 74%
Non experts Rectal 62% Full colonoscopy 72%
ConclusionConclusion
Full colonoscopic series are more accurate in diagnosing CD and UC
No difference between the experts and the non experts in blinded biopsies
Trafford / Manchester Trafford / Manchester approachapproach
CD is by and large a clinicopathological diagnosis.
A preliminary working pattern based report with a differential diagnosis .
The final diagnosis is made in the CPC when all the data become available.
The mutual responsibility of the clinician and the pathologist
Thanks for the invitationThanks for the invitation
Number Number
Classically UCClassically UC
A mucosal disease.The histology does not come back
to normal.In Distal disease it is Never patchy
(continuous).
UCUCMucosal. May extend into the
submucosa in acute cases and ulceration.
This is not Transmural inflammation.
Is time a good Is time a good healer?healer?
UCUC
Mucosal.
Never patchy Never come back to
normal.
May extend into the submucosa.
Yes it could .Yes it could.
Diagnostic DifficultiesDiagnostic Difficulties
There is no specific histological feature that distinguishes CUC from many other colitides.
The diagnosis has to be a team responsibility .
SystemSystemPattern based provisional report
with a working differential diagnosis.
The final diagnosis is in the CPC.No place for Non Specific Colitis
Causes of DifficultyCauses of Difficulty
1.Limited morphological response of the colonic mucosa to various injuries.
2.Incomplete morphological expression of IBD.
3. Overlap of some features.4. Clinical and histological mimicry of
IBD.
Colitis with no Colitis with no distinguishing distinguishing
histological histological featuresfeatures
Despite the legitimate Despite the legitimate pressure we cannot tell pressure we cannot tell
the differencethe difference
DilemmaDilemma
Absence of a histological parameter that is invariably present in one disease and invariably absent from the other.
ResultsResults
Infective GranulomasInfective Granulomas
Campylobacter colitis.Salmonella colitis.TBYersinia
Vienna ClassificationVienna Classification
InflammatoryStricturing , non penetrating ( stenosing)Fistulating( penetrating)
Size is not every thingSize is not every thing
Accurate reportingAccurate reporting
Full clinical storey
Classical featuresClassical features
Sarcoid type granulomas.FocalDiscontinuous.Rectal sparing.
Patchiness of mucosal Patchiness of mucosal inflammation in treated inflammation in treated
UCUC
Bernstein , Shanahan , Anton , Weinstein.
Gastrointestinal Endoscopy. 1995.
ConclusionConclusion
In patients with treated UC, the finding of rectal sparing or patchiness should not necessarily indicate a change in the diagnosis to CD.
Ulcerative ColitisUlcerative Colitis
Patterns of Involvement in Colorectal Biopsies and Changes With Time.
Celina Kleer and Henry Appelman
Am.J.Surg.Path.
Material and MethodMaterial and Method
41 patients with proven chronic UC.
Sequential sets of colonic biopsies.
ResultsResultsHistologically normal
appearing mucosal biopsies do occur in established cases of Chronic UC.
This finding is enhanced with treatment with 5 ASA.
SummarySummary
Skip lesions do occur in CUC.Mucosa can revert to normal
with or without treatment.
Granuloma specific to CDGranuloma specific to CD
Well formedIsolatedAway from areas of inflammation.Basally or submucosally situated
Frequency and significance of Frequency and significance of granulomas in a cohort of granulomas in a cohort of
incidence cases of CDincidence cases of CD
Heresbach et al Gut 2005;54: 215222
AimAim
Evaluate epitheloid granulomas occurence in incident CD.
Association between epitheloid granuloma and outcome of CD
M&MM&M
188 cases of endoscopic (upper and lower) and surgical (intestinal or colonic) procedures.
Follow up for at least 5 years.
ResultsResults
Epitheloid granulomas are associated with higher rate of surgical resections.