Ulcerative colitis with relative sparing of the rectum. Clinical features, histology, and prognosis

Characteristics and Outcomes of Left-sided Ulcerative Colitis With a Cecal/Periappendiceal Patch of Inflammation

Ulcerative colitis (UC) is characterized by continuous mucosal inflammation of the rectum, extending uninterrupted to a variable portion of the colon proximally. However, in some patients with distal colitis, a distinct pattern of skip inflammation (so-called patch) involves the cecum and/or appendiceal orifice, but data on this entity are contradictory, and its significance and prognosis are still debated. We identified 102 adult cases of left-sided UC with a cecal/periappendiceal patch and compared them to 102 controls (left-sided UC only) along clinicopathologic characteristics and disease outcomes. In multivariate analysis, patients with a patch were younger (median age: 31 vs. 41 y; P =0.004) and more likely to have rectosigmoid involvement only (58.8% vs. 28.4%; P <0.001), compared with patients without a patch. During follow-up, patients with a patch were more likely to be eventually diagnosed with Crohn disease (CD) (9.8% vs. 1.0%; P =0.022) and to show proximal extension of inflammation (35.6% vs. 10.0%; P =0.021), but showed no differences in rates of neoplasia, colectomy, or pharmacotherapy escalation. Kaplan-Meier analysis confirmed that patients with a biopsy diagnosis of cecal/periappendiceal patch were more likely to show proximal disease extension ( P <0.001) and to be diagnosed with CD ( P =0.008). In conclusion, cecal/periappendiceal skip inflammation in left-sided UC occurs more often in younger patients and in those with rectosigmoid involvement and is associated with proximal disease extension and, in a small fraction of cases, change of diagnosis to CD. However, it does not portend increased risk of neoplasia, pharmacotherapy escalation, or subsequent colectomy, compared with patients with left-sided UC only.

Clinical characteristics and prognosis of patients with ulcerative colitis that shows rectal sparing at initial diagnosis

BACKGROUND

Ulcerative colitis (UC) is characterised by mucosal inflammation from the rectum to its proximal area in a symmetric and continuous fashion. However, although uncommon, we encounter cases of UC with rectal sparing in the initial stage.

AIM

To evaluate the clinical characteristics and clinical course for rectal sparing UC compared with typical UC.

METHODS

We looked at records from 2004 to 2015, and selected patients who were newly diagnosed with UC, and who could be followed up for at least 5 years in our hospital. We then retrospectively analysed the medical records and endoscopic findings of those patients. To compare the clinical course and prognosis, we matched each patient with rectal sparing UC 1:3 with controls by age, sex, and disease extent.

RESULTS

Of 619 UC patients, 24 (3.9%) showed rectal sparing at diagnosis. During the follow-up period (median 8 years), in two (8.3%) of the 24 patients, rectal sparing remained through follow-up inspections; but for the other 22 (91.7%) patients, obvious rectal inflammation was found at follow-up endoscopy. Of the 24 patients, 8 (33.3%) were initially misdiagnosed with infectious colitis. No diagnosis was changed to Crohn’s disease. The uses of corticosteroid or biologic agents, hospitalisation rate, and colectomy rates were not different between the rectal sparing UC group and typical UC group.

CONCLUSION

Some patients with UC can reveal atypical patterns of disease distribution, such as rectal sparing in its initial stage; but despite this, the clinical course and prognosis may not differ from those of typical UC patients.

A contemporary and critical appraisal of 'indeterminate colitis'

Distinguishing ulcerative colitis (UC) from Crohn's disease (CD) is normally based on evaluation of a variety of clinical, radiologic, serologic and pathologic findings, the latter in biopsy and/or resection specimens. Unfortunately, some patients with IBD show overlapping pathologic features of UC and CD, which makes definite distinction between these two disorders difficult or even impossible. In most instances of uncertainty, the patient shows clinical and pathologic features of UC, but in addition, the patient's colon resection specimen reveals one or more CD-like features. In this setting, a diagnosis of indeterminate colitis (IC) is often rendered. IC is not a distinct disease entity, and, thus, it has no diagnostic criteria. The most common causes of uncertainty in IBD pathology that may lead to a diagnosis of IC in a colon resection specimen includes the presence of fulminant (severe and toxic) colitis, insufficient radiologic, endoscopic, or pathologic information (including analysis of prior biopsies) on the patient, failure to utilize major diagnostic criteria as hard evidence in favor of CD, failure to recognize unusual variants of UC and CD that may mimic each other, failure to recognize non-IBD mimics and other superimposed diseases that cause unusual pathologic features in a resection specimen, an attempt to distinguish UC from CD in mucosal biopsies of the colon and ileum, or an attempt to change the patients diagnosis (of UC or CD) based on pouch or diversion-related complications. Details of each of these causes of uncertainty are discussed, in detail, in this review article. A diagnosis of IC should never be made clinically or by pathologists based on evaluation of pre-resection colonic mucosal biopsies. Ultimately, the majority of indeterminate cases represent UC, and, thus, most of these patient can be treated safely with a colectomy combined with an ileal pouch anal anastomosis procedure.

Segmental distribution in refractory ulcerative colitis: a histological evaluation in pediatric and adult patients who underwent proctocolectomy

BACKGROUND

Histological segmental distribution of ulcerative colitis (UC) may represent an early finding of newly diagnosed UC, especially in pediatric patients; a sign of Crohn's disease; or a predictor of refractory UC. However, its significance remains unknown. This study was performed to compare the final pathologic findings in resected total colon and rectum specimens between pediatric and adult patients with refractory UC who underwent proctocolectomy and clarify the significance of segmental distribution in pediatric patients with UC.

METHODS

Ninety patients with medically refractory UC (14 with childhood-onset UC and 76 with adult-onset UC) who underwent a two-staged operation comprising total proctocolectomy and ileal J-pouch anal anastomosis in the first stage were included in this study. We retrospectively reviewed all patients' medical records and performed a histological evaluation of the resected total colon using Geboes' grading system for histological inflammation activity of UC and factors of Tanaka's criteria for refractory UC.

RESULTS

Histological segmental distribution was more frequently observed in the resected colon at surgery in pediatric (64%) than in adult patients (21%) with refractory UC. The administration of immunomodulators or anti-TNF-α antibody within 30 days before surgery was more frequently performed in adults than in children. Patients with refractory UC with a segmental distribution had a statistically significant relationship with shorter duration before surgery (P = 0.0009), male gender (P = 0.0342), and higher activity of disease inflammation in rectum (P = 0.0399). Multivariate analysis revealed the statistically significant relationship between segmental distribution and disease duration before surgery ≤ 6 years (P = 0.0031).

CONCLUSIONS

Endoscopists should perform biopsies of both normal and abnormal mucosa throughout the total colon and follow changes in the pathological pattern because segmental distribution is an important predictor of prognosis.

Ileorectal anastomosis and proctocolectomy with end ileostomy for ulcerative colitis

Until the development of the ileal pouch-anal anastomosis in the early 1980s, proctocolectomy with end ileostomy was the only definitive surgery for ulcerative colitis and colectomy with ileorectal anastomosis was the procedure of choice for affected patients who were reluctant to have a permanent ileostomy. Currently, ileal pouch-anal anastomosis is the most common procedure for patients with ulcerative colitis requiring surgical treatment. However, there is still a role for ileorectal anastomosis and proctocolectomy with end ileostomy for a selected group of patients. In this review, the authors summarize the current indications for ileorectal anastomosis and proctocolectomy with end ileostomy in patients with ulcerative colitis.

Rectal sparing and skip lesions in ulcerative colitis: a comparative study of endoscopic and histologic findings in patients who underwent proctocolectomy

Ulcerative colitis (UC) is generally considered an inflammatory disorder that always involves the rectum and may also involve more proximal portions of the colon, but always in a diffuse and continuous (non-segmental) fashion. Earlier biopsy studies have shown that both rectal sparing and patchy disease may occur during the natural history of UC and may, in fact, be accentuated by oral or enema therapy; but these features have never been evaluated in resection specimens. The purpose of this study was to evaluate the prevalence rates and degree of endoscopic and histologic patchiness of disease and rectal sparing in preoperative endoscopic biopsies and to compare the findings with those observed in colectomy specimens. In addition, we evaluated the effects of immunomodulators and anti-TNF-alpha therapy on normalization of mucosa. Cases of 56 UC patients, all of whom had at least 1 preoperative endoscopy with biopsies, and who subsequently underwent a colectomy for nonneoplastic complications, were collected and reviewed for a variety of inflammatory histologic features, such as patchiness of disease and rectal sparing. Both of these features were categorized as either absolute or relative according to predetermined criteria. All biopsies and resection specimens were graded for their inflammatory activity on a 5-point scale. An independent score was provided for each portion of the colon, and a mean colitis score of the entire colon was calculated by adding all inflammatory grades for each colonic segment and dividing this number by the number of segments. Endoscopic, biopsy, and resection specimen findings were correlated with each other and with clinical and demographic features, such as duration of colitis, extent of colitis, and types of medications used for at least 6 months before resection. Overall, the mean colitis score in biopsies was significantly lower than in resection specimens (2.7+/-0.9 vs. 3.2+/-0.8, P<0.01). Evidence of rectal sparing and patchy disease occurred in 32.1% and 30.4% of patients by endoscopy, and 30.4% and 25% of patients by analysis of biopsies. Only 3 patients (5.4%) showed rectal sparing, and all of these were considered "relative" after evaluation of the patients' colectomy specimens. Six (10.7%) showed patchiness of disease in the colon resection specimen, 4 of which were absolute. After evaluation of all of the patients' preresection biopsy specimens and colectomy specimens, none of the patients (0%) showed complete absence of rectal involvement (absolute rectal sparing) after all of the tissue sections were evaluated. A significant correlation was noted between endoscopic and biopsy findings and between biopsy and colectomy findings, but poor correlation was noted between the patients' endoscopic features and the pathologic features in the patients' colectomy specimens. No correlation was noted between any specific type or combination of medication use and the presence or frequency of rectal sparing or patchiness of disease. These data indicate that absolute rectal sparing does not occur in UC patients even after long-term use of antiinflammatory medications. The presence of 1 (or more) tissue sections from an IBD patient's colectomy specimen showing complete absence of histologic features of chronicity or activity, but bordered on both sides by chronic or chronic active disease, should not represent a reason to change the patient's diagnosis from UC to Crohn disease.

The endoscopic spectrum of segmental colitis associated with diverticulosis

OBJECTIVE

An endoscopic classification of 'Segmental colitis associated with diverticulosis' (SCAD) is lacking. Our aim was therefore to assess the endoscopic spectrum of SCAD, comparing it with the histological and clinical features.

METHOD

A prospective study was performed from January 2004 to October 2007. Diagnosis of SCAD was made on the basis of specific endoscopic and histological patterns.

RESULTS

A total of 6230 consecutive colonoscopies were performed during the study period. SCAD was diagnosed in 92 (1.48%) patients, with four endoscopic patterns: pattern A, 'crescentic fold disease' (52.20%); pattern B, 'Mild-to moderate ulcerative colitis-like' pattern (30.40%); pattern C, 'Crohn's disease colitis-like' pattern (10.90%); pattern D, 'Severe ulcerative colitis-like' pattern (6.50%). Most patients with patterns A (58.33%, P < 0.018) and B (89.29%, P < 0.00001) showed histological alterations resembling moderate ulcerative colitis (UC). In pattern C, larger histological variability was found (P < 0.01). All patients showing pattern D showed the typical histological alteration changes of severe UC (P < 0.0001). In pattern A (60.42%, P = n.s.) and pattern B (46.43%, P = n.s.), diarrhoea was the most common symptom whilst abdominal pain was the most frequent in pattern C (50%, P = n.s.) and pattern D (83.33%, P = n.s.) patients.

CONCLUSIONS

Endoscopic patterns of SCAD may range from mild to severe inflammation. The histopathological findings but not clinical features showed a statistically significant association with the degree of endoscopic severity.

The Asia-Pacific consensus on ulcerative colitis

Inflammatory bowel disease (IBD) is increasing in many parts of the Asia-Pacific region. There is a need to improve the awareness of IBD and develop diagnostic and management recommendations relevant to the region. This evidence-based consensus focuses on the definition, epidemiology and management of ulcerative colitis (UC) in Asia. A multi-disciplinary group developed the consensus statements, reviewed the relevant literature, and voted on them anonymously using the Delphi method. The finalized statements were reviewed to determine the level of consensus, evidence quality and strength of recommendation. Infectious colitis must be excluded prior to diagnosing UC. Typical histology and macroscopic extent of the disease seen in the West is found in the Asia-Pacific region. Ulcerative colitis is increasing in many parts of Asia with gender distribution and age of diagnosis similar to the West. Extra-intestinal manifestations including primary sclerosing cholangitis are rarer than in the West. Clinical stratification of disease severity guides management. In Japan, leukocytapheresis is a treatment option. Access to biologic agents remains limited due to high cost and concern over opportunistic infections. The high endemic rates of hepatitis B virus infection require stringent screening before initiating immune-suppressive agents. Vaccination and prophylactic therapies should be initiated on a case-by-case basis and in accordance with local practice. Colorectal cancer complicates chronic colitis. A recent increase in UC is reported in the Asia-Pacific region. These consensus statements aim to improve the recognition of UC and assist clinicians in its management with particular relevance to the region.

Review article: Management of diverticulitis

BACKGROUND AND AIM

The incidence and therefore complications of (sigmoid) diverticular disease are increasing.

METHODS

Review of current literature.

RESULTS

From all patients, 15% will develop diverticulitis, 5% complications and 5% diverticular bleeding. Diagnosis is established with computerised tomography. Colonoscopy is needed to rule out malignancy. NSAIDs increase the risk of perforation; steroids, diabetes, collagen vascular disease and immune compromised are associated with complicated disease and death. In mild diverticulitis, antibiotics are recommended. In complicated disease with abscesses, <5 cm antibiotics are sufficient. Larger abscesses are drained under computerised tomography-guidance. Peritonitis forms an indication for surgery. Diverticulitis recurrence rate is around 30%, most are uncomplicated. Recurrence after surgery is around 10%. Elective surgery is reserved for fistula closure and obstruction. The need for elective surgery to prevent recurrence has diminished because of new insights. Important is to identify risk groups. New issues are the possible relationship between diverticulitis and cancer, segmental colitis associated with diverticulitis, and treatment of diverticulitis with mesalazine and probiotics.

CONCLUSIONS

Uncomplicated diverticulitis is treated medically. Complicated diverticulitis with small abscesses is treated with antibiotics while larger abscesses are drained with computerised tomography-guided puncture. Emergency surgery is reserved for peritonitis, elective surgery for fistula/stenosis. Surgery to prevent recurrence is indicated only in selected cases (e.g. immune compromised).

Epidemiology and management of diverticular disease of the colon

The aim of this review is mainly to show the high prevalence of diverticulosis and the clinical relevance of uncomplicated and complicated diverticular disease worldwide. The prevalence of diverticular disease is directly related to the aging of the population and in western countries is diagnosed in approximately 50–65% of adult subjects. The often more frequent adoption of an incorrect dietary style, such as a low-fiber diet, and the progressive increase in the average age of western populations will increase the prevalence of this pathology and the economic burden for health systems even more so. Furthermore, the management of uncomplicated diverticular disease, segmental colitis associated to diverticula and diverticulitis, which represent the different manifestations of the symptomatic spectrum of colonic diverticulosis, are reported.

Pitfalls in the interpretation of nonneoplastic mucosal biopsies in inflammatory bowel disease

This review provides a summary of common diagnostic problems encountered by both pathologists and gastroenterologists when evaluating patients with diarrhea and in whom inflammatory bowel disease (IBD) is suspected. The two most common forms of IBD, ulcerative colitis (UC) and Crohn's disease (CD), may, in certain settings, show overlapping endoscopic and pathologic features, potentially resulting in diagnostic confusion. For instance, some cases of UC may show unusual CD-like features, such as rectal sparing, discontinuous disease, aphthous ulceration, ileal or extracolonic involvement, and granulomatous inflammation, all of which may be evident in mucosal biopsy specimens. CD may also present as a diffuse, superficial pancolitis with ileal sparing that mimics the endoscopic and histologic appearance of UC. Furthermore, other forms of colitis, such as microscopic colitis, diverticulitis, diversion colitis, and nonsteroidal anti-inflammatory drug (NSAID)-induced colonic injury may also show IBD-like changes in mucosal biopsies. The potential diagnostic pitfalls faced by physicians, as well as features that aid in the distinction among these entities, are discussed in detail in this review.

Diagnostic difficulties in inflammatory bowel disease pathology

This review summarizes some of the common diagnostic problems encountered by pathologists when evaluating patients with chronic colitis and in whom inflammatory bowel disease (IBD) is either suspected or within the differential diagnosis. Both ulcerative colitis (UC) and Crohn's disease (CD) show characteristic, but non-specific, pathological features that may overlap and result in a diagnosis of 'indeterminate colitis' (IC). However, other reasons why pathologists may entertain a diagnosis of IC include failure to recognize or accept certain 'hardcore' histological features as indicative of CD, an attempt to classify cases of chronic colitis based on mucosal biopsy material or in the absence of adequate clinical and radiographic information, and the presence of other disease processes that mask, or mimic, IBD. In addition, some cases of UC may show unusual CD-like features, such as discontinuous or patchy disease, ileal inflammation, extracolonic inflammation, granulomatous inflammation in response to ruptured crypts, aphthous ulcers, or transmural inflammation. Furthermore, other forms of colitis, such as microscopic colitis, diverticulitis and diversion colitis may, on occasion, also show IBD-like changes. The clinical and pathological features that aid in the distinction between these entities, and others, are covered in detail in this review.

Granulomatous appendicitis and the appendix in idiopathic inflammatory bowel disease

Granulomatous appendicitis is a rare condition, accounting for less than 2% of all cases of appendicitis. The initial belief that it represented a manifestation of Crohn's disease is incorrect in the great majority of cases, as only 5-10% of patients with granulomatous appendicitis develop Crohn's disease elsewhere in their gastrointestinal tract. The remaining etiologies are diverse. Unusual causes include sarcoidosis, foreign body reaction, and infection by mycobacteria, fungi, or parasites. These conditions combined explain less than 10% of cases. More recently, two etiologies have been recognized that potentially account for most of the previous "idiopathic" cases of granulomatous appendicitis. The first is infection by pathogenic Yersinia species, now demonstrated in approximately 25% of cases. The second cause may be the most common of all, namely subacute/recurrent appendicitis with interval appendectomy. This condition likely produces a granulomatous reaction in relation to a protracted secondary inflammatory response to appendicitis and temporizing measures to delay appendectomy, such as antibiotic therapy. Thus, granulomatous appendicitis only rarely represents a manifestation of Crohn's disease. Rather, the overwhelming majority of patients with this condition are cured by appendectomy alone. The appendix, however, can be involved by idiopathic inflammatory bowel disease, both Crohn's disease and ulcerative colitis. It can be involved by ulcerative colitis in patients with distal colonic involvement and sparing of the intervening colonic segment, a phenomenon known as the appendiceal "skip lesion" or "cecal patch" and this pattern of involvement does not necessarily indicate Crohn's disease. Interestingly, appendectomy has been shown to provide some protection against developing inflammatory bowel disease and in reducing its severity if performed before the onset of disease.

Efficacy of mesalazine in the treatment of symptomatic diverticular disease

We aimed to improve symptoms by means of mesalazine in symptomatic colonic diverticular disease patients. One hundred seventy outpatients (98 M, 72 F; age, 67.1 years; range, 39-84 years) were assigned to four different schedules: rifaximin, 200 mg bid (Group R1: 39 pts), rifaximin, 400 mg bid (Group R2: 43 pts), mesalazine, 400 mg bid (Group M1: 40 pts), and mesalazine, 800 mg bid (Group M2: 48 pts), for 10 days per month. At baseline and after 3 months we recorded 11 clinical variables (upper/lower abdominal pain/discomfort, bloating, tenesmus, diarrhea, abdominal tenderness, fever, general illness, nausea, emesis, dysuria), scored from 0 = no symptoms to 3 = severe. The global symptomatic score was the sum of all symptom scores. After 3 months in all schedules but Group R1, 3 of the 11 symptoms improved (P < 0.03); the global score decreased in all groups but Group R1 (P < 0.0001). Mesalazine-treated patients had the lowest global score at 3 months (P < 0.001). Mesalazine is as effective as rifaximin (higher dosage schedule) for diminishing some symptoms, but it appears to be better than rifaximin for improving the global score in those patients.

The spectrum of segmental colitis associated with diverticulosis

BACKGROUND

Segmental colitis associated with diverticulosis (SCAD) has been defined as chronic colonic inflammation surrounding diverticula with rectal sparing. Distinguishing this condition from inflammatory bowel disease may be difficult. Our aim was to evaluate the epidemiological and clinical characteristics of SCAD in our area.

METHODS

Retrospective case identification with prospective follow-up was done. Patients with endoscopic findings suggestive of SCAD were enrolled. The epidemiological, clinical, and histological characteristics of these patients were analyzed.

RESULTS

Out of 605 patients with diverticulosis, 23 cases of SCAD were identified (3.8%). Four patients had histological characteristics suggestive of ulcerative colitis, in 1 case the histology was suggestive of ischemic colitis, 6 patients had histology compatible with SCAD, and the remaining patients had either transitional mucosa or minimal lesions. Four cases were refractory to conservative treatment (mesalamine and antibiotics) and surgery was required. No cases of extension of colonic inflammation in diverticula-free areas were found.

CONCLUSIONS

Segmental colitis associated with diverticulosis is not a rare disorder. It may occur with a spectrum of clinical and histologic features and may be confused with ulcerative colitis. The majority of the cases respond to medical therapy with antibiotics and/or mesalamine, whereas few cases are refractory and need surgery. No evolution to inflammatory bowel disease was observed.

Indeterminate colitis

Indeterminate colitis (IC) originally referred to those 10-15% of cases of inflammatory bowel disease (IBD) in which there was difficulty distinguishing between ulcerative colitis (UC) and Crohn's disease (CD) in the colectomy specimen. However, IC is increasingly used when a definitive diagnosis of UC or CD cannot be made at colonoscopy, in colonic biopsies or at colectomy. The diagnostic difficulties may explain the variably reported prevalence of IC. Clinically, most patients with IC evolve to a definite diagnosis of UC or CD on follow up. The role of ancillary tests in the distinction of UC from CD is reviewed. The low sensitivity of serological markers limits their usefulness. Other tests include upper endoscopy and magnetic resonance imaging. The definition of IC may not be a purely histological one derived from resected specimens, but rather a clinicopathological one. This review offers some personal observations and viewpoints, and proposes an approach to some of the relatively more esoteric combinations of findings.

Endoscopic rectal sparing in children with untreated ulcerative colitis

BACKGROUND

Ulcerative colitis (UC) typically is associated with a confluent proctitis, whereas rectal sparing may be seen in large bowel Crohn disease (CD). A few studies have reported rectal sparing in UC and suggested that this might indicate a more severe form of the disease. This study aimed to determine the prevalence and prognostic significance of rectal sparing in children with newly diagnosed, untreated UC.

METHODS

The records of all children with untreated UC presenting to a regional pediatric gastroenterology service between January 1996 and December 2001 were retrospectively reviewed. Patients were divided into two groups according to the endoscopic appearance of the rectum: Group 1 (proctitis) and Group 2 (rectal sparing). Clinical features, intractability index (duration of active disease as a proportion of length of follow-up), response to treatment, relapse index (number of recurrences per year), and the need for surgery were compared.

RESULTS

Thirty children with untreated UC were identified. Seven (23%) had rectal sparing at initial endoscopy, but disease distribution was otherwise similar in both groups. Presenting symptoms were similar in those with and without rectal sparing. In Group 1, 20 (87%) children achieved remission with initial medical treatment, compared with 3 (43%) in Group 2 (P < 0.05). The intractability index was higher in children with rectal sparing, but the difference was not statistically significant (P = 0.22). During a median follow-up period of 2 years, one (4%) child in Group 1 and two (29%) children in Group 2 experienced primary sclerosing cholangitis, and two (29%) children with rectal sparing required colectomy, compared with none in Group 1.

CONCLUSIONS

Endoscopic rectal sparing was seen in 23% of children with newly diagnosed, untreated UC, but this feature did not correlate with presenting symptoms. However, the presence of rectal sparing may indicate more aggressive disease that is less responsive to medical treatment.

[Ulcerative colitis with segmental involvement]

INTRODUCTION

Ulcerative colitis is a chronic inflammatory disease affecting areas of the colon or the full length. From the endoscopic point of view, ulcerative colitis presents lesions that stretch continuously from the rectum to variable colon segments, a characteristic that is of great value when distinguishing it from Crohn's disease. Continuous involvement, without healthy patches, justifies ending endoscopic exploration once the distal end of the lesion has been reached.

OBJECTIVE

To retrospectively study the frequency of segmental lesions in the colonoscopies performed in patients with ulcerative colitis.

METHODS

Diagnosis of ulcerative colitis and proctitis was established by clinical, endoscopic, histologic, analytical, and radiological criteria. The indication and number of endoscopies was made on the basis of the clinical criteria of diagnosis, acute episodes, refractoriness or dysplasia screening. The extent of the examination also depended on clinical criteria: the severity of the episode, tolerance to colonoscopy or the degree of cleansing.

RESULTS

A total of 155 coloscopies were performed. In 113 colonoscopies (73%) the distal end of the lesion was reached and in 70 (45%) the cecum was reached. Of the 80 patients, 27 (33%) presented ulcerative proctitis at diagnosis. Nine of the 80 patients (11.3%) biopsies were performed in healthy colonic patches, which confirmed histological normality. Six of the 9 patients were receiving no treatment. In all patients except two, the cecum was reached in one or more of the colonoscopies. The distribution of the segmental lesions varied but these were mainly found in the periappendicular region and in the cecum in 6 of the 7 patients in whom the cecum was reached. Of the 80 patients, endoscopic evidence of rectal sparing was found in 5 (6.3%); of these, 4 were receiving systemic or topical treatment. Histological analysis confirmed the absence of inflammatory lesions in these patients. The only patient who was not receiving treatment presented microscopic lesions compatible with ulcerative colitis.

CONCLUSIONS

Endoscopic segmental lesions in ulcerative colitis were present in 11.3% of patients. Segmental lesions were most frequently found in the cecum and periappendicular region. Endoscopic and histologic evidence of rectal sparing may be the result of systemic or topical treatment.

Segmental colitis: so what?

The existence of chronic mucosal inflammation, confined to sigmoid colons that bear diverticula, is termed 'segmental colitis'. This condition often mimicks inflammatory bowel disease at histological examination. The observed rectal sparing suggests a possible form of Crohn's disease, but no other similarities between segmental colitis and Crohn's colitis are detectable. Medical treatment for segmental colitis, empirically carried out with drugs such as sulfasalazine and mesalazine, is mostly successful and, when surgery is required, post-operative recurrences are infrequent. Although the existence of segmental colitis as a true clinical entity remains questionable, it appears unlikely that this condition represents an atypical form of inflammatory bowel disease.

What is diverticular colitis?

Diverticular colitis is the term used to describe a particular pattern of active chronic inflammation in the sigmoid colon affected by diverticular disease, namely the occurrence of luminal mucosal inflammation, whether or not there is evidence of inflammation within and/or around the diverticula themselves. The pathogenesis remains uncertain but is almost certainly multifactorial. In some cases mucosal prolapse, faecal stasis and relative mucosal ischaemia have been implicated as important pathogenetic factors, whilst other cases are clearly the result of a mass effect caused by subserosal peridiverticulitis and suppuration. Symptoms and endoscopic findings are diverse. Histologically, the disease may vary from modest inflammatory changes with vascular ectasia, through classical mucosal prolapse changes, to florid active chronic inflammation, closely mimicking chronic inflammatory bowel disease, especially ulcerative colitis. Thus, accurate clinical and endoscopic correlation is vital for the attainment of the correct diagnosis. Diverticular colitis may respond well to treatment similar to that used for chronic inflammatory bowel disease, adding to the similarities of this disease, notably localised to the sigmoid colon, and ulcerative colitis. Indeed, in a few cases described in the literature, diverticular colitis may 'progress' to otherwise classical ulcerative colitis, suggesting, in some cases at least, a similar pathogenesis.

Significance of appendiceal involvement in patients with ulcerative colitis

BACKGROUND

The appendix is occasionally involved in patients with distal ulcerative colitis. This study investigated the clinical significance of patchy involvement at the appendiceal orifice in ulcerative colitis.

METHODS

Colonoscopy was performed in 40 patients with active distal ulcerative colitis of mild to moderate severity. Patients were divided into 2 groups based on the presence or absence (positive or negative) of involvement at the appendiceal orifice at colonoscopy. Clinical activity, histologic grade of inflammation, and subsequent clinical course were compared between patients who were positive (appe(+)) and negative (appe(-)).

RESULTS

Twenty-three patients had involvement at the appendiceal orifice (reddish mucosa with mucinous exudate). The proximal-most extent of involvement by ulcerative colitis, the endoscopic grade, and clinical activity were not different between appe(+) and appe(-) groups. However, histologic grade of inflammation in the ascending colon was higher in the appe(+) group than in the appe(-) group. The endoscopic remission rate at 12 months was higher in the appe(+) group than in the appe(-) group (84% vs. 40%, p < 0.05).

CONCLUSIONS

In patients with distal ulcerative colitis, involvement at the appendiceal orifice may be indicative of histologically active disease, which responds reasonably well to pharmacotherapy.

Diverticular colitis: diagnosis and management

Diverticular colitis is a recently recognized nosological entity in which a chronic focal mucosal sigmoid colitis occurs in association with diverticulosis. It usually presents with rectal bleeding and may be difficult to distinguish clinically, endoscopically and pathologically from other segmental colitides including ulcerative, Crohn's, ischaemic, infective and NSAID-induced colitis as well as diverticulitis. Uncontrolled data suggests that most patients respond satisfactorily to treatment with a high fibre diet, antibiotics and/or aminosalicylates, but a minority with persistent or recurrent symptoms require sigmoid resection. This paper reviews the literature on diverticular colitis and concludes with an algorithm suggesting the optimal management of patients who present with rectal bleeding in association with segmental sigmoid colitis and diverticulosis.

Endoscopic and histological patchiness in treated ulcerative colitis

OBJECTIVE

Traditionally, contiguous distribution of inflammation (endoscopic and histological) with rectal involvement is thought to be important in distinguishing ulcerative colitis (UC) from Crohn's disease of the colon. Little long-term data are available that prove whether this rule holds during the course of disease as it is modified by time and treatment. The aim of this study was to investigate the prevalence of endoscopic and histological patchiness and rectal sparing in treated UC over time and to correlate these findings with treatment at the time of endoscopy.

METHODS

Patients with well-established UC who underwent sequential colonoscopy or flexible sigmoidoscopy with biopsies were included in this study. Patients' medical records including endoscopy/biopsy reports and clinical status/symptoms/treatment at the time of endoscopy were reviewed retrospectively.

RESULTS

A total of 32 patients (14 men, 18 women; median age, 45 yr; median UC duration, 15 yr) underwent 175 sequential endoscopies with biopsies (161 colonoscopies, 14 sigmoidoscopies; median, five endoscopies per patient; range, 3-10). Endoscopic and/or histological patchiness was present in 20 of 175 (11%) sequential endoscopies with biopsies over time from 12 of 32 (38%) patients. Endoscopic and/or histological rectal sparing was present in 27 of 175 (15%) of sequential endoscopies with biopsies over time from 14 of 32 (44%) patients. Seven patients had both patchiness and rectal sparing. Therefore, in 47 (27%) follow-up endoscopies in 19 (59%) patients, there was either patchy disease, rectal sparing, or both sometime during the course of disease with treatment. There was no significant difference in treatment, including steroid use and rectal therapy, between those with patchiness and/or rectal sparing and those without.

CONCLUSIONS

Contrary to traditional teaching, endoscopic and histological patchiness of inflammation and rectal sparing are common during the course of disease in treated UC and seem to be unrelated to specific therapy.

Ulcerative colitis: patterns of involvement in colorectal biopsies and changes with time

Chronic inflammation, both endoscopic and histologic, in a contiguous and symmetric distribution is said to be important in distinguishing ulcerative colitis (UC) from Crohn's disease. Little is known whether this rule holds during the course of the disease and whether endoscopic/histologic correlation persists. In this study, we analyzed histologic patterns of UC in sequential sets of biopsy specimens to assess whether endoscopic and histologic findings correlate with time and treatment and to see whether distribution changes. Two hundred seventeen sets of colorectal biopsy specimens from 797 sites from 41 patients with clinical UC were studied and correlated with endoscopic findings. Each biopsy specimen was classified as definite or suspicious for chronic colitis or normal. Two histologic patterns of disease were identified: (1) diffuse, when all areas in all pieces from a biopsy segment had clear-cut colitis and (2) nondiffuse, when not all pieces were involved or single pieces had disease and normal mucosa both. Of 41 patients, the maximal extent of histologic disease was pancolitis in 30; 25 had less extensive disease at some point in the course. The maximal extent was left-sided in eight patients, seven of whom had less extent at some point. Of the three patients in whom the maximal extent was proctosigmoiditis, in one the inflammation disappeared. Seventy percent of the biopsy sites had diffuse patterns and 30% had nondiffuse. Histologic and endoscopic disease reverted to normal in 22 and 24 of 41 patients, respectively. Endoscopic and histologic findings were similar in 65% of the biopsy sites. Our results indicate that in long-standing UC (1) histologic disease may revert to normal mucosa, (2) because endoscopy alone may be insufficient to identify the mucosa as normal, biopsies should also be performed on the endoscopically normal mucosa, (3) the full extent of UC often is not established by a single set of biopsies, and (4) nondiffuse chronic inflammation and rectal sparing occurs in UC and are not necessarily markers of Crohn's disease.

Computed tomography and granulocyte scintigraphy in active inflammatory bowel disease. Comparison with endoscopy and operative findings

The accuracy of computed tomography (CT) and [99mTc]HMPAO granulocyte scintigraphy (GS) for detection of bowel localization, inflammatory activity, and complications in acute inflammatory bowel disease (IBD) was prospectively studied in 32 patients. Of each bowel segment, findings on CT and GS were scored by one blinded observer. Findings on operation or endoscopy served as the gold standard. In Crohn's disease (CD, 17 patients), CT detected bowel pathology (sensitivity 71%, specificity 98%), abscesses (sensitivity and specificity 100%), and fistulas (sensitivity 80%, specificity 100%). In CD, GS had a sensitive of 79% and a specificity of 98% for detection of inflammatory activity. The detection of complications with GS was poor. Segmental inflammatory activity correlated with endoscopy-operative findings for CT (r = 0/86, P < 0.0001) and GS (r = 0.86, P < 0.0001). In ulcerative colitis (UC, 15 patients), GS predicted proximal extension of bowel involvement better than CT. In CD, CT is Superior to GS for localization of both active and fibrostenotic bowel disease, and in detection of the abscesses and fistulas. In UC, GS showed proximal extension more accurately than CT.

Diverticular disease-associated chronic colitis

A clinical syndrome of chronic colitis unique to the sigmoid colon harboring diverticular was recently reported; its histopathological appearance has not been fully elucidated. In this study, the authors analyzed the clinical and pathological features of 23 patients (age range, 38-87 years; median age, 72 years) with diverticular disease-associated chronic colitis. Nineteen presented with hematochezia; four had abdominal pain. Colonoscopic visualization of the mucosa showed patchy or confluent granularity and friability affecting the sigmoid colon encompassing diverticular ostia. Colonic mucosae proximal and distal to the sigmoid were endoscopically normal. Mucosal biopsy specimens showed features of idiopathic inflammatory bowel disease that included plasmacellular and eosinophilic expansion of the lamina propria (100%), neutrophilic cryptitis (100%) with crypt abscesses (61%), basal lymphoid aggregates (100%), distorted crypt architecture (87%), basal plasmacytosis (61%), surface epithelial sloughing (61%), focal Paneth cell metaplasia (48%), and granulomatous cryptitis (26%). Concomitant rectal biopsies obtained in five patients demonstrated histologically normal mucosa. Fourteen patients treated with high-fiber diet or antibiotics or both improved clinically, as did nine patients administered sulfasalazine or 5-aminosalicylic acid. Five patients underwent sigmoid colonic resection, three for stricture with obstruction and two for chronic blood loss anemia. Among a control population of 23 age- and gender-matched patients with diverticular disease without luminal surface mucosal abnormality, none required resection during the same follow-up period. By Fisher's exact test, a statistically significant difference in outcome for patients with and without colitis was detected (p = 0.049). In addition, three patients developed ulcerative proctosigmoiditis 6, 9, and 17 months after the onset of diverticular disease-associted colitis. The data indicate that diverticular disease-associated chronic sigmoid colitis expresses morphological features traditionally reserved for idiopathic inflammatory bowel disease. Its clinical and endoscopic profiles permit distinction from Crohn's disease and ulcerative colitis. Patients with chronic colitis in conjunction with diverticula are at increased risk for sigmoid colonic resection. Diverticular disease-associated chronic colitis may also precede the onset of conventional ulcerative proctosigmoiditis in some cases.

Patchiness of mucosal inflammation in treated ulcerative colitis: a prospective study

Conventional wisdom dictates that ulcerative colitis affects contiguous areas of the colon and is most severe in the rectum, and that the finding of rectal sparing or patchy involvement should raise suspicions of Crohn's disease. We and others have noted occasional rectal sparing and patchy involvement in patients with ulcerative colitis. Therefore, we prospectively studied the prevalence of patchiness, including rectal sparing, in treated cases of ulcerative colitis. Consecutive patients with longstanding ulcerative colitis were studied. The left colon was divided into three zones for scoring degree of activity, and biopsy specimens from each zone were graded for histologic activity by a blinded observer. Patchiness by endoscopy or histology was defined as (1) frank rectal sparing (normal appearance endoscopically; absence of inflammation of the lamina propria and crypts histologically); (2) areas of greater inflammation proximally than distally; or (3) discrete areas of patchiness endoscopically within any one zone. Of 39 patients evaluated, 17 (44%) had endoscopic evidence of patchiness, including 5 (13%) with rectal sparing. Thirteen (33%) had histologic evidence of patchiness, including 6 (15%) with rectal sparing. Both endoscopic and histologic patchiness were seen in 9 patients (23%). The patchy and nonpatchy groups did not differ in regard to the use of rectal therapy. In patients with treated ulcerative colitis, the finding of rectal sparing or patchiness should not necessarily indicate a change in the diagnosis to Crohn's disease.

Diagnostic techniques in inflammatory bowel disease

Additional diagnostic modalities exist in the clinical laboratory, as outlined in Tables 1 through 3. In general, the usefulness of each test in determining the optimal therapy for a patient with inflammatory bowel disease is inversely related to the cost of that test, with history and physical examination ranking first. Each additional test must be ordered only if the result can answer a specific question necessary for the care of the patient.

Endoscopic crescentic fold disease of the sigmoid colon: the clinical and histopathological spectrum of a distinctive endoscopic appearance

In this paper we describe an endoscopic appearance of the sigmoid colon characterised by mucosal swelling, erythema and haemorrhage strictly localised to the crescentic mucosal folds. In a 5-year period these changes were seen in 34 (1.42%) of 2380 colonoscopies and fibreoptic sigmoidoscopies. The majority of patients were middle-aged or elderly. Diverticular disease was present in most (82%) but the abnormalities were confined to the crescentic mucosal folds with sparing of the diverticular orifices. The majority of patients presented with a history of bleeding per anum. Histologically there was a spectrum of changes varying from minor vascular congestion to florid active inflammatory disease with crypt architectural abnormalities mimicking ulcerative colitis, but rectal biopsies were invariably normal. Three patients later progressed to typical distal ulcerative colitis and two other patients presenting to us with endoscopic crescentic fold disease had a previous histologically documented history of distal ulcerative colitis. In three patients the histological features were of mucosal prolapse. About half the patients required some form of therapy to control their symptoms. Steroids and/or sulphasalazine were of value although two patients subsequently underwent sigmoid resection, one to control bleeding and the second for a diverticulosis-associated stricture. Whilst endoscopic crescentic fold disease represents a specific endoscopic appearance the clinical and histological features indicate a wide spectrum of disease.