Endoscopy in inflammatory bowel disease

Histologic Diagnosis of Inflammatory Bowel Diseases

Inflammatory bowel disease, including ulcerative colitis and Crohn disease, is an idiopathic chronic inflammatory condition of the gastrointestinal tract. Since neither the clinical manifestations nor the morphologic features of inflammatory bowel disease are pathognomonic alone, the differential diagnosis to consider is relatively broad, and it relies on the synthesis of clinical, endoscopic, and microscopic features. Long-held histologic diagnostic principles include recognizing structural and inflammatory features of chronicity, that is, architectural distortion, basal plasmacytosis, and expansion of the lamina propria lymphoplasmacytic infiltrate. In addition, evaluation of the neutrophilic inflammation and related crypt and epithelial destruction is essential to gauge the activity of the disease. Nevertheless, these features can be difficult to confirm in special settings, including at the inception of the disease or in partially treated cases. This review will explore the classic morphologic features of ulcerative colitis and Crohn disease, followed by a detailed discussion of atypical and diagnostically challenging presentations and a brief review of the clinical aspects necessary for the daily practice of pathologists.

CT Enterography score: a potential predictor for severity assessment of active ulcerative colitis

BACKGROUND

Evaluate the possibility of CT enterography (CTE) score system as a predictor in assessing active ulcerative colitis (UC) severity.

METHODS

Forty-six patients with active UC with CTE and colonoscopy were enrolled. Based on modified Mayo score, patients were divided into three groups: mild (n = 10), moderate (n = 17) and severe (n = 19). A cumulative CTE score was calculated in each patient and its correlation with modified Mayo score was analyzed. The optimal cutoff values of CTE score were determined by receiver operating characteristic (ROC) curves analysis.

RESULTS

Significant between-group differences were observed in CTE spectrums of mucosal bubbles, mural stratification, loss of haustration, enlarged mesenteric lymph nodes and engorged mesenteric vessels (P < 0.05). The cumulative CTE scores were significant difference between three groups (CTE score:4.9 ± 2.3, 7.6 ± 2.6, and 10.9 ± 2.0, respectively, P < 0.01). The cumulative CTE score showed a positive correlation with modified Mayo score (r = 0.835, P < 0.05). The optimal cut-off value for CTE score predicting moderate and severe UC was 9.5 (area under the curve [AUC]:0.847, sensitivity:78.9%, specificity:82.4%).

CONCLUSION

Disease severity assessment by CTE score demonstrates strong positive correlation with severity established modified Mayo score. CTE score system maybe a potential predictor for active UC severity assessment.

THE IMPORTANCE OF COLONOSCOPY IN INFLAMMATORY BOWEL DISEASES

INTRODUCTION

Endoscopic evaluation, particularly the macroscopic mucosal and histological results of ileocolic biopsies, is essential for the management of inflammatory bowel disease. Endoscopic appearance is not always sufficient to differentiate Crohn's disease and ulcerative colitis, but there are some characteristics that favor one or another diagnosis. Both diseases have an increased incidence of colorectal carcinoma; so, surveillance colonoscopy is important for detecting early neoplastic lesions.

OBJECTIVE

To update the importance of endoscopy in the evaluation, diagnosis and prognosis of inflammatory bowel disease.

METHOD

Search was done in the scientific literature of the TRIP database, chosen from clinical questions (PICO) with the following descriptors: "inflammatory bowel disease", "endoscopy/colonoscopy", "Crohn's disease", "ulcerative colitis" and "diagnosis/treatment".

RESULTS

Endoscopic investigation in patients with chronic colitis is quite accurate for the differential diagnosis between ulcerative colitis and Crohn's disease. Endoscopy is indicated for ulcerative colitis during severe crisis due to its prognostic value. Another accepted indication for endoscopy in inflammatory bowel disease is its use in the screening for dysplastic lesion.

CONCLUSION

Ileocolonoscopy allows an accurate diagnosis of Crohn's disease or ulcerative colitis in up to 90% of cases. The healing of the mucosa assessed by endoscopy after treatments despite not being consensus is still the gold-standard in the evaluation of remission of the disease. Colonoscopy is essential for long-term cancer surveillance and in the future the implementation of Confocal Laser Endomicroscopy seems to be very promising in assessing the initial dysplasia.

Particularities of Crohn's disease in pediatric patients: current status and perspectives regarding imaging modalities

A consensus on the best imaging modality evaluating inflammatory bowel disease in the pediatric population is lacking and it is often unclear which modality to choose in specific clinical circumstances. Children with inflammatory bowel disease are exposed to ionizing radiation from multiple imaging studies performed at initial diagnosis, throughout treatment and during the follow-up period. This paper discusses the value of different imaging techniques in pediatric patients with inflammatory bowel disease and gives a review of the literature. In addition, particular features of inflammatory bowel disease in children including the predilection of affected segments in the gastrointestinal tract are highlighted. Based on current literature knowledge, we encourage an integrative approach to the interpretation of clinical and imaging data for diagnosis and follow-up in daily clinical settings.

Endoluminal ultrasound biomicroscopy as a reliable tool for in vivo assessment of colonic inflammation in rats

PURPOSE

Endoscopic ultrasound (EUS) imaging of the colon is an important diagnostic tool for early neoplasia, although usually restricted to the rectum in inflammatory bowel disease (IBD). This study aimed to evaluate the ability of an endoluminal ultrasound biomicroscopic (eUBM) system to detect and characterize lesions simulating Crohn's disease in the colon of rats in vivo.

METHODS

Colitis was induced with trinitrobenzene sulfonic acid instillated in the distal colon. Eighteen Wistar rats were submitted to eUBM in three time points: week 1 group (18 animals examined on day 3 after colitis induction), week 2 group (12 animals on days 3 and 10), and week 3 group (7 animals on days 3, 10, and 17). This design yielded distinct inflammation intensities. Three untreated rats were used for acquisition of control images. Scores were used for comparison with histology.

RESULTS

Scores for eUBM and histology in the different moments of examination achieved a Spearman's rank correlation coefficient of 0.87 (p < 0.001). Findings of wall thickening presented positive predictive value (PPV) and sensitivity of 94 and of 100 %, respectively. Superficial and deep ulcers presented a PPV of 89 and 80 %, respectively, and negative predictive values of 100 and 85 %, respectively.

CONCLUSION

Accurate detection and analysis of the lesions was achieved. The model is essential for the clinical development of the technique and a reproducible method for the evaluation of experimental colitis. eUBM might be applicable in different segments of the gut, developing into a novel adjunct method for IBD evaluation.

Endoscopic assessment of inflammatory bowel disease: colonoscopy/esophagogastroduodenoscopy

Endoscopy plays an important role in the initial diagnosis of IBD, including the evaluation of disease severity, activity, and extent. The implications of complete mucosal healing further confirm the function of endoscopy in the follow-up of IBD patients. The use of therapeutic endoscopy, for example stricture dilatation, can avoid the need for bowel resection. Modalities such as capsule endoscopy, EUS, NBI, CE, and other emerging techniques are likely to have an increasing role in the management of IBD, particularly in the area of dysplasia surveillance and treatment.

MDCT assessment of ulcerative colitis: radiologic analysis with clinical, endoscopic, and pathologic correlation

PURPOSE

Evaluate the utility of multidetector-row computed tomography (MDCT) in assessing the severity of ulcerative colitis (UC) in comparison with clinical assessment, colonoscopy, and histopathology.

MATERIALS AND METHODS

Patients with UC evaluated with at least one abdominal contrast-enhanced CT study (CECT) within 7 days of colonoscopy with biopsy were included. CECT of 23 patients (12 male; mean age 40 years; age range, 20-72 years) were retrospectively evaluated in consensus by two radiologists. A total of 138 lower GI tract segments were evaluated by CECT and graded for the presence of bowel wall thickening, mucosal hyperenhancement, mural stratification, mesenteric hyperemia, pericolonic stranding, and lymph nodes. A cumulative CT severity score was calculated and correlated with clinical, colonoscopic, and histopathologic severity grades.

RESULTS

The cumulative CT score and individual CECT scores for bowel wall thickening, mucosal hyperenhancement, and mural stratification showed positive correlation with clinical severity (P < 0.05). All individual CECT features as well as the cumulative CT score demonstrated statistically significant correlation with colonoscopic severity (P < 0.0001). Only wall thickening on CECT demonstrated significant correlation with histopathologic severity (P = 0.01).

CONCLUSION

Disease severity assessment by MDCT demonstrates positive correlation with severity established by clinical assessment and colonoscopy. Only increasing wall thickness, as graded on MDCT, correlates with histopathologic disease severity.

Clinical application of the multigene analysis test in discriminating between ulcerative colitis and Crohn's disease: a retrospective study

METHODS

The newly described--multigene analysis test (DiBiCol) identifying 7 inflammatory bowel disease (IBD)-specific genes in colonic mucosal biopsy differentiating between ulcerative colitis (UC) and Crohn's disease (CD) with active inflammation--is a new addition to existing methods with a higher stated sensitivity and specificity. Method biopsy material from 78 patients with a complicated course diagnosed as most probably UC in 38, CD in 18 and inflammatory bowel disease unclassified (IBDU) in 22 were investigated by DiBiCol.

RESULTS

DiBiCol showed a pattern consistent with CD in 13 patients with UC and led to change of diagnosis in 3 patients and a strong suggestion of CD in 8 patients. A total of 2 patients remained as UC. DiBiCol showed a pattern of UC in 4 patients of 18 with CD leading to a changing of diagnosis to UC in 3 patients, but the fourth remained as CD. In 22 patients with IBDU DiBiCol showed a pattern consistent with UC in 7 cases and with CD in 13 cases. A new evaluation 1 year after the DiBiCol allowed the assessment of clinical diagnosis in 10 patients confirmed in 9 of 10 patients by DiBiCol. In patients with acute flare of colitis the clinical diagnosis corresponded in 10 of 12 UC and in 5 of 6 CD cases.

SUMMARY

Adopting the DiBiCol test led to a change of the primary diagnosis in a significant number of patients with the initial diagnosis of UC and CD and suggested a clinically probable diagnosis in most of the patients with IBDU and in those with an acute flare of colitis.

Cytomegalovirus enterocolitis in apparently immunocompetent hosts: evaluation of the radiologic findings and clinical features

OBJECTIVE

To describe the clinical and radiologic features of cytomegalovirus (CMV) enterocolitis in apparently immunocompetent hosts.

MATERIALS AND METHODS

Our institutional review board approved this retrospective study, and informed consent was waived. Twelve apparently immunocompetent patients (7 women and 5 men; mean age, 58 years) with pathologically proven CMV enterocolitis were included. Computed tomographic (CT) scans were retrospectively reviewed to determine the extent and the location of mural thickening, maximal mural thickness, enhancement pattern, that is, single-halo, double-halo, and homogeneous patterns, and ascites.

RESULTS

Eight patients had comorbidities potentially affecting the host immune status, whereas 4 patients were apparently healthy before presentation. On CT, all patients showed mural thickening (range, 4-11 mm) involving the colon (n = 8), the small bowel (n = 1), or both (n = 3). Segmental involvement was most common (n = 9 for colon and n = 2 for small bowel), whereas focal involvement of the rectum (n = 1) and diffuse involvement of the entire ileum (n = 1) or the entire small bowel and colon (n = 1) were also noted. Colonic lesions showed variable enhancement patterns, including the single-halo (n = 6), homogeneous (n = 3), and double-halo patterns (n = 2), whereas all small-bowel lesions in 4 patients exhibited a single-ring pattern. Ascites was present in 7 patients. Complications requiring surgery occurred in 3 patients and included refractory bleeding (n = 2) and bowel perforation (n = 1).

CONCLUSIONS

Cytomegalovirus enterocolitis in immunocompetent hosts typically develops in elderly subjects with comorbidities, although it may also affect relatively young and healthy subjects. On CT, it is characterized by mild mural thickening of the small bowel and the colon and frequently shows segmental involvement and a single-halo enhancement pattern.

[The usefulness of Doppler sonography in the assessment of disease activity of ulcerative colitis]

BACKGROUND/AIMS

disease activity in ulcerative colitis (UC) is generally assessed using symptoms, laboratory data, endoscopic findings, and histology of the biopsy specimens. In this study, we compared disease activity of UC as determined by clinical features and endoscopic findings, and aimed to assess the clinical usefulness of Doppler sonography.

METHODS

the duplex Doppler sonography of superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) of 10 patients with clinically inactive UC and 20 patients with active UC were evaluated by one radiologist who was blinded to clinical information. Peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI), and pulsatility index (PI) of the SMA and IMA were evaluated. All patients underwent biochemical and endoscopic evaluations thereafter. Correlation between disease activity by the Truelove-Witts classification and the Mayo scoring system was measured, and we compared hemodynamic parameters between active and inactive UC.

RESULTS

correlation rate of disease activity between these two scoring systems was 93.3%. Flow velocities (PSV, p<0.001 and EDV, p=0.03) and PI (p=0.03) were significantly higher in patients with active UC than inactive UC. PSVs of the SMA and IMA were also significantly correlated with disease severity. The active UC could be accurately diagnosed using Doppler sonography (AUC=0.83; 95% confidence interval 0.68-0.99).

CONCLUSIONS

in patients with UC, clinical stage was well matched with endoscopic disease activity. Doppler sonography was a readily available method, and PSV of SMA would be clinically useful in predicting of disease activity and severity.

Endoscopic evaluation of patients with inflammatory bowel disease

Endoscopy plays a critical role in the diagnosis and management of inflammatory bowel disease (IBD). This article reviews the utility of endoscopy in the diagnosis of ulcerative colitis (UC) and Crohn's disease (CD), recommendations for cancer surveillance, and the use of newer techniques for the enhanced detection of dysplasia in chronic UC. Finally, the use of endoscopy for the management of certain complications of IBD is also discussed.

TLR2, TLR4 and TLR9 polymorphisms and Crohn's disease in a New Zealand Caucasian cohort

BACKGROUND AND AIM

Toll-like receptors (TLRs) have been identified as susceptibility genes for Crohn's disease (CD) in some, but not all, studies. Here we examined the association between candidate disease-susceptibility polymorphisms in the TLR2, TLR4 and TLR9 genes and CD in a New Zealand Caucasian population.

METHODS

The frequency of gene polymorphisms was examined in 182 CD patients and in 188 ethnically matched controls by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis.

RESULTS

We could not detect any significant difference in the allele frequencies of polymorphisms in the TLR2 (R753Q, 0.029 vs 0.016, P = 0.25), TLR4 (D299G and T399I, 0.085 vs 0.071, P = 0.49; and 0.085 vs 0.082, P = 0.90), and TLR9 (-1237T/C, 0.154 vs 0.148, P = 0.82) genes between controls and patients, respectively. There was no evidence that the variant TLR alleles were associated with disease phenotype. However, combination of the datasets of published studies with our dataset confirmed that the TLR4 polymorphism 299G (P = 0.0005; OR of 1.42 [95% CI 1.17-1.74]) and the TLR9 polymorphism -1237C (P = 0.0416; OR of 1.33 [95% CI 1.01-1.75]) are associated with CD.

CONCLUSIONS

There was no evidence that the above variants of the TLR2, TLR4 and TLR9 genes are major risk factors for CD or influence disease phenotype in our New Zealand case-control study. Nevertheless, the significance of the TLR4 299G and TLR9-1237C associations with CD worldwide was confirmed by a meta-analysis test using our datasets and datasets from previously published studies.

Inflammatory bowel disease and endothelin-1: a review

Inflammatory bowel disease (IBD) appears to be an inappropriate response to an antigen that leads to chronic inflammation rather than repair. This review looks at the role of endothelin-1 (ET-1) as a proinflammatory agent in IBD. ET-1 antagonists in animal models reduce the incidence and severity of IBD. These antagonists may be useful for treatment of IBD in humans.

Proposal of a new clinical index predictive of endoscopic severity in ulcerative colitis

Assessment of disease activity by clinical parameters in ulcerative colitis is still controversial. Different clinical indexes have been proposed. Colonoscopy provides detailed information on mucosal damage. The aim of this study was to identify, among 21 clinical and laboratory parameters, which were predictive of endoscopic activity. We included 137 consecutive patients with ulcerative colitis who underwent colonoscopy, clinical examination, and blood tests within 4 weeks. Endoscopic severity was recorded using a simple score (range, 0-30). The multiple stepwise regression coefficient of each significant variable predictive of mucosal damage was used to develop a new activity index predictive of endoscopic appearance (Endoscopic-Clinical Correlation Index; ECCI). We tested the ability of our score to discriminate patients with severe endoscopic disease, calculating the area under the receiver operator characteristic curve, and we compared it to activity indexes proposed by other authors. Endoscopic severity was significantly influenced by four parameters: bloody stool, nocturnal bowel movements, body temperature >37.5 degrees C, and serum albumin. The new scoring system was calculated as ECCI = {[serum albumin x (-26)] + (bloody stool x 17) + (nocturnal bowel movements x 16) + [fever (0 or 1) x 39]} + 107. The ECCI accurately identified patients with severe endoscopic disease in our sample (sensitivity = 81%, specificity = 95%). In conclusion, the ECCI should be useful in clinical practice because it is simple and strongly related to endoscopic activity.

Management of inflammatory bowel disease

Ulcerative colitis and Crohn's disease result from an interaction between genetic and environmental factors. Only one gene, NOD2/CARD15, has been clearly identified; a minority of people with alteration of this gene develop Crohn's disease. The NOD2/CARD15 protein is thought to be involved in defence against intracellular bacteria. This supports the idea that Crohn's disease and ulcerative colitis result from altered immunological responses to the normal intestinal flora. Life expectancy is normal in ulcerative colitis and nearly so in Crohn's disease, but both conditions cause considerable morbidity. Approximately 80% of patients with Crohn's disease eventually require surgery, and about 25% of patients with ulcerative colitis require colectomy. Treatment of ulcerative colitis is generally by corticosteroids for acute disease and mesalazine for maintenance, but the range of therapies for Crohn's disease is expanding. Alternative therapies include immunosuppressives, enteral nutrition, antibiotics, anti-TNF antibody (infliximab), corticosteroids, and surgery. High dosages of corticosteroids may provide symptomatic relief in Crohn's disease but do not affect the long term natural history of the disease, and management strategies should avoid using steroids whenever possible.

Inflammatory Bowel Disease After Age 60

New-onset idiopathic inflammatory bowel disease (IBD) is not uncommon among the elderly, although more common are colonic infection, ischemia, or neoplasia, all of which may mimic IBD. Although the clinical presentation of IBD in the elderly often resembles that of younger subjects, atypical manifestations are common and may lead to difficulty in diagnosis. Much progress has been made in both medical and surgical therapy for IBD, but such therapy poses additional challenges in the elderly, who are more likely to experience adverse effects of medications or complications of surgery. The elderly generally have a favorable outcome to both medical and surgical therapy for IBD. Although concern about possible untoward effects of therapy is warranted, treatment should not be withheld because of fear of complications.