Endoscopy in Inflammatory Bowel Disease

Stool filling of an intestinal duplication cyst at the ileocecal valve triggers colonic intussusception: a case report

Background

Intestinal duplication, a congenital malformation, is considered a rare condition, particularly in adults. Although it affects young children, a minority of patients remains asymptomatic until adulthood. Here, we describe a case of an intestinal duplication cyst that caused intussusception by a unique mechanism.

Case presentation

A 19-year-old man was admitted to our hospital for intermittent abdominal pain. Computed tomography revealed colonic intussusception induced by a nodular mass in the ileocecal region. Urgent ileocecal resection was performed because of the risk of colonic ischemia. The resected material comprised a stool-filled noncommunicating cyst that protruded into the enteric lumen at the ileocecal valve. Histological analyses revealed that the inner wall of the cyst was lined with colonic mucosa and that the muscle layer of the cyst was shared with that of the original enteric wall; furthermore, the cyst had a vestige of an opening site in the wall. We concluded that the cyst was an intestinal duplication that poured stool into its lumen through the tiny orifice, thereby triggering intussusception.

Conclusions

The present case suggests that stool-pouring can cause intussusception into the space of an intestinal duplication lesion.

An Innocent Esophageal Mucosal Bridge: Case Report and Literature Review

An esophageal mucosal bridge is a rare finding that is seldom encountered on upper endoscopy. They most commonly present secondary to an underlying inflammatory disorder and cause chest pain and dysphagia, among other symptoms. More rarely, they present asymptomatically with no identifiable inflammatory conditions. Our case consists of a 31-year-old woman who presented with an asymptomatic, noninflammatory mucosal bridge of the esophagus. To our knowledge, this makes the third such case. The rarity of this condition coupled with the lack of epidemiologic data available make this case worthy for literature review.

Repeated coaxial colonic stenting in the palliative management of benign colonic obstruction

In inflammatory bowel disease, strictures of the colon, causing bowel obstruction, is not uncommon. Usually an operative procedure can deal with these strictures. We describe a case of an unfit patient with pulmonary malignancy having a Crohn's stricture of the recto-sigmoid junction in which repeated coaxial placement of self-expanding metallic stents eliminated the need to perform an operation. This is the first report of multiple coaxial colonic stenting. It shows that there is a place for stents in selected cases of inflammatory bowel disease with a limited life expectancy and that repeated colonic stenting makes colonic stenting possible also in patients requiring stents for longer time periods.

Therapeutic options in the management of strictures in Crohn's disease

Intestinal strictures are a commonly encountered problem in patients with Crohn's disease. Endoscopic management with hydrostatic balloon dilation is an effective alternative to surgery in patients with endoscopically accessible lesions that are shorter than 7-8 cm. Endoscopic balloon dilation is the preferred initial modality in anastomotic strictures. The presence of inflammation near the stricture should not be considered a contraindication to dilation, and intralesional steroid injection should be considered in these patients with inflammation present in the area of the stricture. Further technological developments in endoscopes and balloon dilators may allow for broader application of these techniques.

Interobserver variation of colonoileoscopic findings in Crohn's disease

BACKGROUND

Colonoileoscopy is increasingly used to evaluate Crohn's disease, but the reproducibility of endoscopic findings is not clear.

METHODS

The interobserver variation of endoscopic findings and the influence of experience on assessments were investigated in 82 colonoileoscopies in Crohn's disease.

RESULTS

In colonic assessment there was excellent agreement for most endoscopic features (kappa values > 0.75; p < 0.001). In ileal assessment agreement was excellent with regard to detection of large ulcers and strictures and endoscopic staging on the basis of ulcer size and stricture (kappa > 0.76; p < 0.001). Observer experience was an important factor in ileal assessments: agreement was excellent for 13 features within experienced pairs, compared with 3 when only 1 of a pair was experienced. In colonic assessment experience was less important.

CONCLUSION

The study showed that acceptable agreement can be obtained on some well-defined inflammatory lesions in Crohn's disease even when investigator experience is limited. Endoscopic staging on the basis of ulcer size and stricture, being excellently reproducible, can serve as a simple summarizing assessment.

Perioperative endoscopy of the whole small bowel in Crohn's disease

The aim of this study was to search for small bowel lesions by means of a perioperative endoscopy in 20 patients operated on for Crohn's disease. Seven women and 13 men (mean age 29 years) had a total retrograde exploration to the angle of Treitz during an ileocolectomy (16 of 20 patients) or a colonic or ileal resection (four of 20 patients). Endoscopic exploration was completed, through an enterotomy, from the surgical area to the angle of Treitz. Periendoscopic biopsy samples were taken on macroscopic lesions and every 20 cm systematically. In 13 of 20 cases, various lesions scattered over the whole small intestine were found. These were aphthoid ulcerations (10 patients), superficial ulcerations (seven patients), mucosal oedema (three patients), non-ulcerative stenosis (three patients), erythema (two patients), pseudopolyps (two patients), deep ulcerations (two patients), and ulcerative stenosis (one patient). In seven patients none of the lesions detected at perioperative endoscopy had been recognised by preoperative evaluation or surgical inspection of the serosal surface. A typical granuloma was found at biopsy of lesions identified by endoscopy in three cases and at biopsy of an apparently healthy area in one case. Thus 65% of patients operated on for Crohn's disease had lesions of the small intestine detected by endoscopy, which were unrecognised before surgery in more than half of the cases.

Frequency and significance of chronic ulcerative colitis in severe corticosteroid-treated autoimmune hepatitis

To assess the prevalence and significance of chronic ulcerative colitis in patients with severe autoimmune hepatitis and to determine the frequency of cholangiographic and histologic features of primary sclerosing cholangitis in those with colitis, 105 patients who had been screened by annual proctoscopic examination were studied. Patients with features of colitis were compared to counterparts without colitis who had been matched by age, sex, disease severity and treatment regimen. Seventeen patients (16%) had findings of chronic ulcerative colitis. Twelve of these underwent cholangiography and five (42%) had features of primary sclerosing cholangitis. Patients with and without cholangiographic abnormalities were indistinguishable by clinical, laboratory, immunoserologic, and histologic features. Fibrous obliterative cholangitis was present in only two patients, including one with normal cholangiography. Patients with colitis entered remission less frequently (59 vs. 94%, p less than 0.05), failed treatment more commonly (41 vs. 6%, p less than 0.05) and progressed to cirrhosis more frequently (75 vs. 25%, p less than 0.05) than counterparts without colitis. Patients with colitis but normal cholangiography, however, responded satisfactorily to therapy. We conclude that chronic ulcerative colitis can coexist with severe autoimmune hepatitis in the absence of primary sclerosing cholangitis or hepatitis C infection. Under such circumstances its presence does not adversely influence treatment outcome. Primary sclerosing cholangitis cannot be excluded by routine examinations and its presence is associated with a poor treatment response. Cholangiography should be considered in all patients with autoimmune hepatitis and colitis, especially in those recalcitrant to therapy.

Endoscopy in inflammatory bowel disease: indications and differential diagnosis

Colonoscopy with multiple biopsies adds a considerable amount of information to the overall clinical approach to the patient with inflammatory bowel disease. Because colonoscopy is an invasive procedure requiring a vigorous bowel clean-out, it is not a first-line investigative procedure for patients with inflammatory bowel disease. However, in certain indicated circumstances, colonoscopy can assist greatly in the management and diagnosis of patients with inflammatory bowel disease.

Does primary sclerosing cholangitis occurring in association with inflammatory bowel disease differ from that occurring in the absence of inflammatory bowel disease? A study of sixty-six subjects

Primary sclerosing cholangitis often occurs in association with inflammatory bowel disease, particularly ulcerative colitis but also Crohn's disease of the colon either with or without terminal ileal disease. Little data exist as to the effect of inflammatory bowel disease on the presenting symptoms, radiological features, response to liver transplantation, and potential risk of bile duct carcinoma in individuals with primary sclerosing cholangitis. In an effort to answer these questions, 66 patients with primary sclerosing cholangitis were studied. The definitive diagnosis of primary sclerosing cholangitis in each was accomplished using cholangiography, which in each case demonstrated characteristic beading, ectasia and stricturing of the intrahepatic and extrahepatic bile ducts. Inflammatory bowel disease was present in 47 (71.2%) patients. Thirty nine (59.1%) had ulcerative colitis; their mean age was 42.5 +/- 11.6 yr (mean +/- SD), and the male/female ratio was 2.9:1. In addition, eight patients (12.1%) had Crohn's colitis; their mean age was 40.5 +/- 6.5 yr, and the male/female ratio of this group was 1:1. Nineteen patients (28.8%) had primary sclerosing cholangitis without any inflammatory bowel disease; their mean age was 42.0 +/- 12.1 yr, and the male/female ratio in this group was 0.72:1. Seventy-two percent of the patients without inflammatory bowel disease had either jaundice, pruritus or fatigue at presentation compared with 41% of the patients with inflammatory bowel disease (p less than 0.05). In contrast, abnormal liver function tests were more common as the first manifestation of liver disease in the latter group (38% vs. 11%; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Survey of the use of colonoscopy in inflammatory bowel disease

In a survey of patients with inflammatory bowel disease (IBD), colonoscopy with multiple biopsies has been shown to be superior to either colonoscopy alone or barium studies in assessing disease extent. Thus, of a total of 149 patients, 23 (15%) were considered to have total colitis on barium enema, 51 (34%) on macroscopic colonoscopy appearance compared to 92 (62%) on biopsy. Furthermore, radiological assessment of "skip lesions" was shown to be unreliable. Although it remains to be seen whether the more accurate delineation of disease extent achieved by endoscopy is advantageous in terms of clinical management, it may have implications for our understanding of the disease.

The value of ileoscopy with biopsy in the diagnosis of intestinal Crohn's disease

Studies to determine the diagnostic value of ileoscopy and biopsy are not available. In an attempt to clarify the role of this technique in the diagnosis of intestinal Crohn's disease, 110 patients with a radiological diagnosis of inflammatory disease of the terminal ileum were examined in a prospective study. Suspicion of Crohn's disease was rejected in 28 patients. In 18 patients the terminal ileum was normal, while 10 patients had lymphoid nodular hyperplasia. Endoscopic lesions with a predictive value of 0.96 were found in 25 of 48 patients with the final diagnosis of Crohn's disease. Diagnostic granulomas were only found in 4 patients, but lesions consistent with Crohn's disease were present in the pathology sections of 17 patients. It was concluded that ileoscopy with biopsy is a valuable tool in the diagnosis of inflammatory ileal disease and can provide useful information about the nature and extent of the inflammation.

Colonoscopic diagnosis of inflammatory bowel disease

The indications and limitations of colonoscopy in the diagnosis of inflammatory bowel disease are well defined. The endoscopic examination is usually easily performed and well tolerated by the patient, but, since endoscopic examination of the colon is an invasive procedure (and potentially dangerous), colonoscopy should only be performed in those patients in whom the indication is clear and the benefits identifiable. Colonoscopy may provide valuable information in the diagnosis and may help outline the course of therapy in patients with inflammatory bowel disease.