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Hayashi T, Terashima T, Nishitani M, Orita N, Miyazawa M, Seki A, Nakagawa H, Nio K, Iida N, Yamada S, Takatori H, Shimakami T, Yamashita T. Gastroduodenitis Associated with Active Ulcerative Colitis Treated with Infliximab: Different Clinical Course in the Colon and Gastroduodenal Lesions. Intern Med 2024; 63:929-935. [PMID: 37495533 PMCID: PMC11045365 DOI: 10.2169/internalmedicine.2047-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/12/2023] [Indexed: 07/28/2023] Open
Abstract
A 29-year-old man with severe ulcerative colitis and gastroduodenitis was initially treated with oral mesalamine and high-dose intravenous steroid therapy; however, his epigastralgia and vomiting did not improve. After initiating infliximab, the patient experienced prompt improvement in symptoms and inflammation. Although steroids were effective for the colon, they proved ineffective for gastroduodenal lesions, highlighting the necessity for molecular-targeted agents, such as infliximab, in these cases. The timing for administering such agents should be carefully considered.
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Affiliation(s)
- Tomoyuki Hayashi
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | | | - Masaki Nishitani
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Noriaki Orita
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Masaki Miyazawa
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Akihiro Seki
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | | | - Kouki Nio
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Noriho Iida
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Shinya Yamada
- Endoscopy Center, Kanazawa University Hospital, Japan
| | | | | | - Taro Yamashita
- Department of Gastroenterology, Kanazawa University Hospital, Japan
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Sun Y, Zhang Z, Zheng CQ, Sang LX. Mucosal lesions of the upper gastrointestinal tract in patients with ulcerative colitis: A review. World J Gastroenterol 2021; 27:2963-2978. [PMID: 34168401 PMCID: PMC8192286 DOI: 10.3748/wjg.v27.i22.2963] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/10/2021] [Accepted: 04/21/2021] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis (UC) is a chronic, nonspecific, relapsing inflammatory bowel disease. The colorectum is considered the chief target organ of UC, whereas upper gastrointestinal (UGI) tract manifestations are infrequent. Recently, emerging evidence has suggested that UC presents complications in esophageal, stomachic, and duodenal mucosal injuries. However, UC-related UGI tract manifestations are varied and frequently silenced or concealed. Moreover, the endoscopic and microscopic characteristics of UGI tract complicated with UC are nonspecific. Therefore, UGI involvement may be ignored by many clinicians. In addition, no standard criteria have been established for patients with UC who should undergo fibrogastroduodenoscopy. Furthermore, specific treatment recommendations may be needed for patients with UC-associated UGI lesions. Herein, we review the esophageal, gastric, and duodenal mucosal lesions of the UC-associated UGI tract, as well as the potential pathogenesis and therapy.
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Affiliation(s)
- Yan Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China
| | - Zhe Zhang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China
| | - Chang-Qing Zheng
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China
| | - Li-Xuan Sang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China
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Kohyama A, Watanabe K, Sugita A, Futami K, Ikeuchi H, Takahashi KI, Suzuki Y, Fukushima K. Ulcerative colitis-related severe enteritis: an infrequent but serious complication after colectomy. J Gastroenterol 2021; 56:240-249. [PMID: 33155079 DOI: 10.1007/s00535-020-01742-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM After colectomy for ulcerative colitis (UC), very severe and sometimes lethal enteritis can develop. However, the clinical features remain uncertain because of the low incidence, diversity of symptoms, and undefined diagnostic criteria. The aim of this study was to define postoperative ulcerative colitis-related severe enteritis (UCRSE) and to investigate its clinical features. METHODS A retrospective multicenter study was performed as a survey of major medical facilities utilizing surgical supplies for inflammatory bowel disease in Japan from 2001 to 2014. UCRSE was defined as a case with massive intestinal bleeding, intestinal perforation, high-output stoma, and/or a requirement for medications, such as steroids and biologics. Patients with gastroduodenal lesions or pouchitis alone were excluded. The incidence, symptoms, involvement of bacteria, cytomegalovirus reactivation, treatment, and prognosis were examined for patients with UCRSE after colectomy. RESULTS Forty-two (0.8%) out of 5284 cases met the criteria for UCRSE. Major symptoms were massive intestinal bleeding (76.2%), which required a median of 3850 (560-18900) mL blood transfusion; high-output stoma (38.1%) with excretion of fluid of 5000 (2000-7800) mL/day; and intestinal perforation (7.1%). Hypovolemic shock (35.7%) and/or disseminated intravascular coagulation (31.0%) developed as serious complications. Tests for cytomegalovirus reactivation were positive in 26.2% of cases. The presence of pathogenic bacteria was confirmed in only 5 cases. Corticosteroids or infliximabs were effective in half of the patients. Thirteen cases (31.0%) were treated surgically and 22 cases (56.4%) required maintenance therapy. The mortality rate was 11.9%. CONCLUSION UCRSE is a rare but serious complication after colectomy and is sometimes life-threatening.
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Affiliation(s)
- Atsushi Kohyama
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Kazuhiro Watanabe
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Akira Sugita
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Kitaro Futami
- Department of Surgery, Fukuoka University, Chikushi Hospital, Fukuoka, Japan
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Yasuo Suzuki
- Inflammatory Bowel Disease Center, Toho University Sakura Medical Center, Sakura, Japan
| | - Kouhei Fukushima
- Division of Surgical and Molecular Pathophysiology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Laboratory of Gastrointestinal Tract Reconstruction, Tohoku University Graduate School of Biomedical Engineering, Sendai, Japan
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Gastroduodenal Ulcerative Colitis in Association with Ulcerative Pancolitis. Case Rep Gastrointest Med 2021; 2021:6684806. [PMID: 33628535 PMCID: PMC7895600 DOI: 10.1155/2021/6684806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/27/2021] [Accepted: 02/03/2021] [Indexed: 12/11/2022] Open
Abstract
Ulcerative colitis (UC) is a chronic inflammatory bowel disease, traditionally regarded as being limited to the colorectum. Although several gastroduodenal lesions have been reported in cases of UC, in general, duodenal lesions in UC are believed to be uncommon and gastric lesions in UC are a rare presentation. In this report, we presented a 66-year-old lady with upper GI presentation with gastroduodenal ulcerative colitis accompanying pancolonic UC.
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Monif GRG. Is ulcerative colitis a disease of a dysfunctional microbiota? Med Hypotheses 2019; 131:109300. [PMID: 31443761 DOI: 10.1016/j.mehy.2019.109300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/17/2019] [Accepted: 07/03/2019] [Indexed: 01/07/2023]
Abstract
Using the gross pathology literature and the prior decoupling of Crohn's disease from inflammatory bowel disease, IDI's White Paper puts into question the current understanding of what ulcerative colitis is and how it can be therapeutically addressed. The pathology literature, when coupled with the ability of fecal enema therapy to achieve a remission rate significantly superior to those documented for biologics, puts focus on the dominant role of the gastrointestinal microbiota in both disease induction and its recovery. The concept of endogenous enterotoxogenesis is introduced.
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Affiliation(s)
- Gilles R G Monif
- Infectious Diseases Incorporated, 17121 Lakewood Drive, Bellevue, NE 68123-3954, United States.
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Abstract
RATIONALE Ulcerative colitis (UC) is a chronic, nonspecific, inflammatory disease of the colon. Colorectal is the main target organ of UC, while other digestive tract involvement is rare. This report describes 2 rare cases of duodenal mucosa lesions in patients with UC after total colectomy. PATIENT CONCERNS In case 1, a patient of 45-year-old with intermittent diarrhea and bloody mucosanguineous feces who was diagnosed as UC, revealed diffuse erosive ulcers in the descending duodenum through gastroscopy after total colectomy. In case 2, a 55-year-old Chinese female with UC, aggravated to colon cancer and received total colectomy. Eighteen months after surgery, the patient was admitted to hospital following upper abdominal pain and acid regurgitation. A gastroscopy found inflammation in the descending part of the duodenum. DIAGNOSIS UC, duodenal mucosa lesions INTERVENTIONS:: In case 1, the patient was treated with oral mesalazine (1 g/tid) and hydrocortisone (0.3 g/d) but symptoms did not improve, and the treatment was changed to oral methylprednisolone (0.6 g/d) and a hydrocortisone enema (0.1 g/late). Finally, the patient underwent a total colectomy and ileostomy. In case 2, the patient was treated with sulfasalazine, mesalazine, and intermittent hormone enemas. A total colectomy and ileostomy were performed with the patient after diagnosed as colon cancer. After surgery, the patient received N1-(2 tetrahydrofuryl)-5-fluorouracil (FT-207), 8 g, 300 mg, and 100 mg oxaliplatin chemotherapy, and biologic therapy. OUTCOMES In case 1, the patient presented with duodenal necrosis and died of septic shock. In case 2, the patient recovered well without recurrence by taking proton pump inhibitor. LESSONS The occurrence of UC related ulcerative gastroduodenal mucosal lesions may be associated with progressing UC or total colitis that does not respond to hormone therapy, leading to requirement of total colectomy.
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Affiliation(s)
| | | | | | - Hai Qin
- Department of Colorectal Surgery
| | - Yang Shi
- Department of Colorectal Surgery
| | | | - Yongjie Zhao
- Department of General Surgery, Tianjin Union Medical Center, Tianjin, China
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Choi YS, Kim JK, Kim WJ, Kim MJ. Remission of diffuse ulcerative duodenitis in a patient with ulcerative colitis after infliximab therapy: a case study and review of the literature. Intest Res 2019; 17:273-277. [PMID: 30739436 PMCID: PMC6505096 DOI: 10.5217/ir.2018.00122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/07/2018] [Indexed: 12/12/2022] Open
Abstract
Although ulcerative colitis (UC) is confined to colonic and rectal mucosa in a continuous fashion, recent studies have also demonstrated the involvement of upper gastrointestinal tract as diagnostic endoscopy becomes more available and technically advanced. The pathogenesis of UC is not well established yet. It might be associated with an inappropriate response of host mucosal immune system to gut microflora. Although continuous and symmetric distribution of mucosal inflammation from rectum to colon is a typical pattern of UC, clinical feature and course of atypically distributed lesions in UC might also help us understand the pathogenesis of UC. Herein, we report a case of duodenal involvement of UC which successfully remitted after infliximab therapy. Endoscopic and pathologic findings before and after administration of anti-tumor necrosis factor suggest that the pathogenesis of upper gastrointestinal involvement of UC may be similar to that of colon involvement.
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Affiliation(s)
- Yong-Sung Choi
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | - Jong Kyu Kim
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | - Wan Jung Kim
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | - Mi-Jung Kim
- Department of Pathology, Daehang Hospital, Seoul, Korea
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Ninomiya K, Hisabe T, Okado Y, Takada Y, Yamaoka R, Sato Y, Kishi M, Takatsu N, Matsui T, Ueki T, Yao K, Hirai F. Comparison of Small Bowel Lesions Using Capsule Endoscopy in Ulcerative Colitis and Crohn's Disease: A Single-Center Retrospective Analysis. Digestion 2018; 98:119-126. [PMID: 29698945 DOI: 10.1159/000487796] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/16/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Capsule endoscopy (CE) has allowed the characterization of small bowel lesions. However, small bowel lesions in ulcerative colitis (UC) have not been elucidated and no studies have compared between UC and Crohn's disease (CD). AIM The objective of this study was to investigate the small bowel lesions in UC, and to characterize UC lesions by comparison with CD. METHODS Subjects comprised 54 UC patients and 39 CD patients who underwent CE. We retrospectively investigated characteristics of small bowel lesions in UC. We also compared endoscopic findings and degree of inflammation between UC and CD. RESULTS The incidence of small bowel lesions in UC was 27.8%. The group with small bowel lesions exhibited higher endoscopic activity in the colon than without small bowel lesions (p = 0.002). Comparing small bowel lesions between UC and CD, significantly more ulcerative lesions, notched appearance, longitudinal tendency of lesions, and cobblestone appearance were seen in CD. The Lewis score was significantly higher in CD than UC in the second and third tertiles (205 ± 379 vs. 73 ± 223, p = 0.01; 358 ± 449 vs. 105 ± 333, p < 0.001). CONCLUSIONS Small bowel lesions in UC were linked to colonic activity. UC and CD differ in terms of the morphology and distribution of small bowel lesions.
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Affiliation(s)
- Kazeo Ninomiya
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Takashi Hisabe
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Yuki Okado
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Yasumichi Takada
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Rino Yamaoka
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Yuho Sato
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Masahiro Kishi
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Noritaka Takatsu
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Toshiharu Ueki
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Kenshi Yao
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Fumihito Hirai
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Fukuoka, Japan
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Okabayashi S, Kobayashi T, Sujino T, Ozaki R, Umeda S, Toyonaga T, Saito E, Nakano M, Tablante MC, Morinaga S, Hibi T. Steroid-refractory extensive enteritis complicated by ulcerative colitis successfully treated with adalimumab. Intest Res 2017; 15:535-539. [PMID: 29142523 PMCID: PMC5683986 DOI: 10.5217/ir.2017.15.4.535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/11/2017] [Accepted: 01/16/2017] [Indexed: 12/22/2022] Open
Abstract
Extracolonic involvement of the gastrointestinal tract is extremely uncommon in ulcerative colitis (UC) and rarely found in the upper gastrointestinal tract or in postoperative cases since it typically responds to steroids. Here we report a case of UC complicated by extensive ileal inflammation that was refractory to steroids. A 20-year-old man was diagnosed with UC of typical pancolitis without ileal involvement and started treatment with pH-dependent mesalazine and oral prednisolone. Although his symptoms transiently resolved, the condition flared when the steroid dose was tapered down. Computed tomography revealed marked thickening of the ileal wall, and capsule endoscopy and balloon-assisted enteroscopy found diffuse mucosal inflammation with ulcers in the ileum. On the contrary, the inflammation in the colon and rectum was improving. Since the response to the second steroid course was inadequate, treatment with adalimumab and 6-mercaptopurine was initiated and finally achieved clinical and endoscopic remission. The investigation of small intestinal lesions is necessary in patients with UC whose clinical deterioration cannot be explained by colonic lesions.
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Affiliation(s)
- Shinji Okabayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Tomohisa Sujino
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Ryo Ozaki
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Satoko Umeda
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Takahiko Toyonaga
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Eiko Saito
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Masaru Nakano
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Maria Carla Tablante
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Shojiroh Morinaga
- Department of Diagnostic Pathology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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Sullivan KJ, Wei M, Chernetsova E, Hallani S, de Nanassy J, Benchimol EI, Mack DR, Nasr A, El Demellawy D. Value of upper endoscopic biopsies in predicting medical refractoriness in pediatric patients with ulcerative colitis. Hum Pathol 2017; 66:167-176. [PMID: 28652148 DOI: 10.1016/j.humpath.2017.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/30/2017] [Accepted: 06/10/2017] [Indexed: 12/13/2022]
Abstract
Refractory ulcerative colitis (UC) occurs in patients who experience a severe disease manifestation that is unresponsive to medical therapy. The assessment of upper endoscopic microscopic findings and its correlation with refractory UC has not been fully studied in pediatric patients and is the focus of this study. Medical records of UC patients treated at a tertiary pediatric center between 2000 and 2014 were reviewed. Endoscopic biopsies of the upper gastrointestinal (GI) tract of patients meeting a priori inclusion criteria were compared between refractory UC patients and nonrefractory UC patients for active inflammation. Statistically significant differences were determined between groups, and tissues shown to have significant differences were further evaluated for their diagnostic performance. A total of 52 patients were included, 26 in each group. Significant differences were observed in intraepithelial neutrophil infiltration and percentage involvement of crypts/glands for the antrum, body, and duodenal bulb (P ≤ .001, .005, and .01 [intraepithelial neutrophil infiltration] and P = .001, .009, and .015 [% involvement], respectively). Microabscesses of mucosal glands/crypts were also experienced in a greater number of refractory UC patients in the stomach (ie, antrum and/or body of stomach; P = .005) and duodenum (ie, duodenum and/or duodenal bulb; P = .023). The sensitivity and specificity of upper GI tissues to predict refractory UC were moderate, with sensitivities ranging from 38% to 67% and specificities ranging from 81% to 100%. Our results suggest that children with refractory UC are more likely to have active inflammation in the upper GI tract, and thus, this may represent a predictor of responsiveness to current medical therapy.
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Affiliation(s)
- Katrina J Sullivan
- Department of Pathology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada K1H 8L1.
| | - Mike Wei
- Faculty of Medicine, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8M5.
| | - Elizabeth Chernetsova
- Faculty of Medicine, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8M5.
| | - Soufiane Hallani
- Faculty of Medicine, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8M5.
| | - Joseph de Nanassy
- Department of Pathology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada K1H 8L1; Faculty of Medicine, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8M5.
| | - Eric I Benchimol
- Faculty of Medicine, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8M5; Department of Pediatrics, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8M5; Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada K1H 8L1; School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8M5; Institute for Clinical Evaluative Sciences, Veterans Hill Trail, Toronto, ON, Canada M4N 3M5.
| | - David R Mack
- Faculty of Medicine, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8M5; Department of Pediatrics, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8M5; Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada K1H 8L1.
| | - Ahmed Nasr
- Faculty of Medicine, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8M5; Department of Surgery, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada K1H 8L1.
| | - Dina El Demellawy
- Department of Pathology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada K1H 8L1; Faculty of Medicine, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8M5.
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11
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Clinical features and treatment of ulcerative colitis-related severe gastroduodenitis and enteritis with massive bleeding after colectomy. Int J Colorectal Dis 2014; 29:239-45. [PMID: 24105365 DOI: 10.1007/s00384-013-1779-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2013] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Ulcerative colitis (UC) has been recognised as a systemic immune disorder that is not as restricted as colitis. UC-related gastrointestinal lesions with bleeding can develop soon after colectomy and can progress rapidly. Therefore, we considered the clinical features and treatment of these UC-related lesions. METHODS We reviewed the patient data in our UC surgery database to evaluate its prevalence and features. RESULTS We found 7/1,100 patients with UC-related lesions between January 2000 and April 2013. These lesions developed at a mean of 24 (range 8-480) days after colectomy. Six of the seven patients suffered from gastrointestinal bleeding as an initial symptom that rapidly developed into massive bleeding or perforations. All of the patients were diagnosed with pancolitis; at the time of colectomy, fulminant, severe, moderate, and mild colitis were presented by four, one, one, and one patients, respectively. All patients with enteritis had consecutively developed other infectious complications, including anastomotic leakage, pyoderma gangrenosum, wound infection, and pneumonia. Although patients with bleeding did not respond to treatment with corticosteroids, they responded well to infliximab soon after its administration. Although six of the seven patients showed cytomegalo virus re-activation in blood or pathological examinations, ganciclovir was not effective in its elimination. CONCLUSION Although UC-related lesions with an unknown aetiology can occur after colectomy, immediate examination and treatment are required if gastrointestinal bleeding is found after surgery. Because gastrointestinal bleeding from UC-related lesions can worsen rapidly and may be related to mortality, early potent immunosuppressive therapy should be considered.
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12
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Saito K, Katsuno T, Nakagawa T, Minemura S, Oyamada A, Kanogawa N, Saito M, Yoshihama S, Maruoka D, Matsumura T, Arai M, Tohma T, Miyauchi H, Matsubara H, Yokosuka O. Severe diffuse duodenitis successfully treated with intravenous tacrolimus after colectomy for ulcerative colitis. Intern Med 2014; 53:2477-81. [PMID: 25366006 DOI: 10.2169/internalmedicine.53.1910] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
We encountered a rare case of severe diffuse duodenitis associated with ulcerative colitis (UC). A 23-year-old man underwent total proctocolectomy with ileal J-pouch anal anastomosis for UC. He suffered from severe abdominal pain, fever and bloody diarrhea for six months after the surgery. Upper double-balloon enteroscopy disclosed severe diffuse duodenitis, of which the findings were endoscopically and histologically similar to those of colonic lesions of UC. Although the administration of prednisolone was ineffective, treatment with intravenous tacrolimus markedly improved the clinical findings. This is the first report of the successful treatment of severe UC-associated diffuse duodenitis with intravenous tacrolimus.
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Affiliation(s)
- Keiko Saito
- Department of Gastroenterology and Nephrology (K1), Graduate School of Medicine, Chiba University, Japan
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13
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Chiba M, Ono I, Wakamatsu H, Wada I, Suzuki K. Diffuse gastroduodenitis associated with ulcerative colitis: treatment by infliximab. Dig Endosc 2013; 25:622-5. [PMID: 24164601 DOI: 10.1111/j.1443-1661.2012.01398.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Accepted: 09/06/2012] [Indexed: 01/21/2023]
Abstract
Diffuse gastroduodenitis resembling ulcerative colitis in respect to macro- and microscopic findings occurs in ulcerative colitis, although it is rare. Reports of gastroduodenitis associated with ulcerative colitis treated with infliximab are rare. A 58-year-old man had tarry stool in March 2011. He had a history of ulcerative colitis that was diagnosed in 1984. He underwent subtotal colectomy in 1991. Endoscopy and radiography revealed diffuse friable mucosa throughout the duodenum and an ulcer in the middle of the descending portion, resulting in a narrow portion.In the stomach, numerous small aphthae were observed in the antrum. Biopsy specimens of the duodenum and antrum showed marked inflammatory cell infiltration in both areas and cryptitis in the duodenum. Standard induction therapy of infliximab was started in April. The ulcer in the descending portion became a scar without diffuse mucosal friability in September 2011.
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Affiliation(s)
- Mitsuro Chiba
- Division of Gastroenterology, Nakadori General Hospital
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Hoentjen F, Hanauer SB, Hart J, Rubin DT. Long-term treatment of patients with a history of ulcerative colitis who develop gastritis and pan-enteritis after colectomy. J Clin Gastroenterol 2013; 47:52-7. [PMID: 22858512 PMCID: PMC3874322 DOI: 10.1097/mcg.0b013e3182582c1d] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ulcerative colitis (UC) is generally described as a superficial diffuse inflammation restricted to the colon and rectum. However, several case reports have described a distinct and rare type of UC-related pan-enteritis, typically occurring after colectomy. Corticosteroids are effective for induction of remission of this condition, but it is not clear how these patients should be managed long term. GOALS To further describe and define the entity of UC-related pan-enteritis and to investigate the efficacy of azathioprine for maintenance of remission. RESULTS We describe 5 patients with superficial diffuse ulcerative inflammation of the stomach, small bowel, and pouch if present. Four of the 5 patients developed enteritis after colectomy for ulcerative pancolitis. Pathology showed severe mucosal inflammation with infiltration of neutrophils and plasma cells from the stomach to the ileum. Video capsule endoscopy in 1 patient confirmed the presence of mucosal inflammation throughout the small bowel. All patients were started on a standardized treatment with intravenous corticosteroids for induction of remission and azathioprine for maintenance therapy. The conditions of all the patients rapidly improved, and subsequently, 4 patients were in full remission on azathioprine monotherapy, despite failure of this UC therapy before surgery, whereas 1 patient continues to have a steroid-dependent disease. CONCLUSIONS The outcomes of 5 cases of UC-related pan-enteritis as described in this report support a role for azathioprine in remission maintenance. Future research is needed to improve our understanding of this rare but distinct intestinal inflammatory disorder.
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Affiliation(s)
- Frank Hoentjen
- Inflammatory Bowel Disease Center, University of Chicago Medical Center, Chicago, USA,Inflammatory Bowel Disease Center, Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stephen B. Hanauer
- Inflammatory Bowel Disease Center, University of Chicago Medical Center, Chicago, USA
| | - John Hart
- Department of Pathology, University of Chicago Medical Center, Chicago, USA
| | - David T. Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medical Center, Chicago, USA
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Two cases of diffuse duodenitis associated with ulcerative colitis. Case Rep Gastrointest Med 2012; 2012:396521. [PMID: 23119193 PMCID: PMC3483663 DOI: 10.1155/2012/396521] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 09/30/2012] [Indexed: 01/02/2023] Open
Abstract
The upper gastrointestinal tract is not generally considered a target organ in ulcerative colitis (UC). However, several cases showing upper gastrointestinal involvement in UC have been reported. In this report, we present 2 rare cases of diffuse duodenitis accompanying pancolonic UC. Case patient 1 was a 44-year-old man who developed diffuse duodenitis shortly after colectomy and was successfully treated with mesalazine. Case patient 2 was a 25-year-old woman who developed diffuse duodenitis under a steroid-free condition and was successfully treated with prednisolone. The 2 patients had Helicobacter pylori-negative duodenitis that resembled colonic lesions of UC in both the endoscopic and histological findings. No evidence of Crohn's disease was found in these cases. We diagnosed both cases as typical UC-associated diffuse duodenitis. The occurrence of gastrointestinal involvement in UC has been attracting attention because such lesions could potentially open a new window for studying the etiology and pathogenesis of UC. Further studies involving a large number of patients are needed to clarify whether the upper gastrointestinal tract is a target organ in UC.
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Hisabe T, Ninomiya K, Matsui T, Karashima Y, Sato Y, Nagahama T, Takaki Y, Hirai F, Yao K, Higashi D, Futami K, Iwashita A. Small bowel lesions detected with wireless capsule endoscopy in patients with active ulcerative colitis and with post-proctocolectomy. Dig Endosc 2011; 23:302-9. [PMID: 21951090 DOI: 10.1111/j.1443-1661.2011.01149.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although rare, duodenal lesions have been reported in association with ulcerative colitis (UC); however, there have been very few reports on small bowel lesions, and many aspects of their pathology and frequency remain unknown. This study determined whether small bowel lesions are present in UC by using wireless capsule endoscopy (WCE). PATIENTS AND METHODS WCE was performed on 20 patients with active UC and 10 who had undergone proctocolectomy. RESULTS Small bowel lesions (e.g. edema or ulcers) were observed in 11 of the 30 patients (36.6%): in eight (40%) of the 20 patients with active UC and in three (33.3%) of the 10 post-proctocolectomy patients. Ulcers that extended over a long segment or whole tertile of the small bowel were observed in five patients, and the disease type was extensive colitis in three of these and pouchitis in the other two. Age at onset was significantly lower in the 20 active UC patients that had small bowel lesions. CONCLUSION WCE revealed the presence of ulcers that extended over a long segment or a whole tertile in the small bowel in active extensive colitis and pouchitis. In future, it will be necessary to assess the clinical significance of small bowel lesions in UC in detail.
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Affiliation(s)
- Takashi Hisabe
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka 818-8502, Japan.
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Hisabe T, Matsui T, Miyaoka M, Ninomiya K, Ishihara H, Nagahama T, Takaki Y, Hirai F, Ikeda K, Iwashita A, Higashi D, Futami K. Diagnosis and clinical course of ulcerative gastroduodenal lesion associated with ulcerative colitis: possible relationship with pouchitis. Dig Endosc 2010; 22:268-74. [PMID: 21175478 DOI: 10.1111/j.1443-1661.2010.01006.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Ulcerative colitis (UC) is not only characterized by pathological lesions localized to colonic mucosa, but also to various complications involving other organs, including postoperative pouchitis. Among these complications, diffuse gastroduodenitis with lesions resembling colonic lesions has been reported, albeit rarely.The aim of the present study was to attempt to characterize the lesions of the upper gastrointestinal tract occurring as a complication of UC, and to assess the frequency and clinical course of these lesions. METHODS A total of 322 UC patients who had undergone upper gastrointestinal endoscopy were retrospectively analyzed. We assessed the frequency of endoscopic findings, including diffuse gastroduodenal lesions resembling colonic lesions. Ulcerative gastroduodenal lesion (UGDL) associated with UC was diagnosed if lesions satisfied the following criteria: (i) improvement of the lesions with treatment of UC; and/or (ii) resemblance to UC in pathological findings. RESULTS UGDL satisfying the aforementioned criteria was found in 15 (4.7%) of 322 patients. All the 15 patients had UGDL accompanied by pancolitis or after proctocolectomy. Frequency in 146 patients with pancolitis was 6.2% (nine patients) and that in 81 patients who had undergone proctocolectomy was 7.4% (six patients). Four patients with diffuse ulcerative upper-gastrointestinal mucosal inflammation (DUMI) had pouchitis. In all patients except one, the lesions resolved easily with medical treatment. CONCLUSIONS In more than half of the post-proctocolectomy patients, UGDL was related to the occurrence of pouchitis. The existence of characteristic UGDL must be taken into account in the diagnosis and treatment of UC, and UGDL is possibly related to the occurrence of pouchitis.
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Affiliation(s)
- Takashi Hisabe
- Department of Gastroenterology Pathology Surgery, Fukuoka University, Fukuoka, Japan.
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Vidali F, Di Sabatino A, Broglia F, Cazzola P, Biancheri P, Viera FT, Vanoli A, Alvisi C, Perego M, Corazza GR. Increased CD8+ intraepithelial lymphocyte infiltration and reduced surface area to volume ratio in the duodenum of patients with ulcerative colitis. Scand J Gastroenterol 2010; 45:684-9. [PMID: 20201621 DOI: 10.3109/00365521003663662] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Recent evidence suggests the involvement of the upper gastrointestinal tract in ulcerative colitis (UC). By conducting a prospective controlled study, we explored the immunological abnormalities in the duodenal mucosa of UC patients. METHODS Duodenal and colonic biopsies were collected from 24 corticosteroid-free UC patients and 21 controls. Colonization by Helicobacter pylori and positivity for anti-endomysial antibodies was an exclusion criteria. The severity of duodenal and colonic inflammation was determined by endoscopic and histologic scores. Morphometry was performed to measure the surface area to volume ratio (SV). Duodenal CD3(+) and CD8(+) intraepithelial lymphocytes (IELs) and lamina propria mononuclear cells (LPMCs) were detected by immunohistochemistry. RESULTS Fifteen UC patients and 14 controls were Helicobacter pylori and anti-endomysial antibody negative and were thus included in the study. Microscopic duodenitis was reported in 4 of the 15 UC patients (26.6%), and in none of the controls. A significantly higher number of CD3(+) and CD8(+) IELs and LPMCs was found in UC patients than in controls. A significant positive correlation between the percentage of both CD3(+) and CD8(+) IELs and disease activity was found in UC patients. SV was significantly reduced in UC patients compared to controls, and inversely correlated with the percentage of CD8(+) IELs. CONCLUSIONS The duodenum of UC patients is infiltrated by a higher number of CD8(+) IELs which correlates with the degree of villous flattening and disease activity, but not with extent of the colonic lesions. Further studies are needed to clarify whether the duodenum is a target organ in UC.
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Affiliation(s)
- Francesca Vidali
- First Department of Medicine, Centro per lo Studio e la Cura delle Malattie Infiammatorie Croniche Intestinali, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Diffuse enteritis after colectomy for ulcerative colitis: two case reports and review of the literature. Eur J Gastroenterol Hepatol 2009; 21:710-5. [PMID: 19282770 DOI: 10.1097/meg.0b013e32831bc400] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Ulcerative colitis (UC) is an inflammatory disease of the colon. Involvement of the small bowel is limited to backwash ileitis or pouch-related conditions. Here, we report two men with UC who presented with small bowel inflammation and even perforation, within 1 month after subtotal colectomy. Endoscopy showed diffuse enteritis. Histology showed marked apoptosis of epithelial cells in both cases. One patient responded to steroids and the other to a calcineurin inhibitor. Both patients had no evidence of Crohn's disease in the small intestine before this event. Several more cases of small intestinal lesions in patients with well-established UC have been reported. The majority typically presented shortly after colectomy and responded well to steroids. The pathogenesis of this enteritis is unknown, but seems to be distinct from Crohn's disease and may be associated with UC and colectomy.
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21
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Hori K, Ikeuchi H, Nakano H, Uchino M, Tomita T, Ohda Y, Hida N, Matsumoto T, Fukuda Y, Miwa H. Gastroduodenitis associated with ulcerative colitis. J Gastroenterol 2008; 43:193-201. [PMID: 18373161 DOI: 10.1007/s00535-007-2143-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2007] [Accepted: 11/07/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ulcerative colitis (UC) is regarded as confined to the colorectum; however, there are several case reports showing upper gastrointestinal involvement. The aim of this study was to examine the prevalence and characteristics of gastroduodenitis associated with UC (GDUC). METHODS Esophagogastroduodenoscopy with biopsies was prospectively performed on 250 UC patients (134 men, 116 women; mean age, 42 years; 162 with colectomy, 163 with pancolitis). Criteria for GDUC were created on the basis of endoscopic and histological comparisons with non-UC controls, and the prevalence and characteristics were statistically analyzed. RESULTS GDUC was defined endoscopically as friable mucosa (erosive or ulcerative mucosa with contact or spontaneous bleeding), granular mucosa (multiple white spots almost without a red halo), or, conditionally, multiple aphthae (multiple white spots surrounded by a red halo, clinically excluding other disorders such as Crohn's disease). The prevalence of GDUC was 19/250 (7.6%). The clinical characteristics included more extensive colitis, lower dose of prednisolone, higher prevalence of pouchitis, and longer postoperative period. In our population, the presence of pancolitis and a lower dose of prednisolone were significant risk factors for developing GDUC in multivariate analysis. CONCLUSIONS The high prevalence of GDUC suggests that the gut inflammatory reaction in UC may not be restricted to the large intestine. Administered steroids might conceal GDUC, and more aggressive UC such as active pancolitis may be related to the development of GDUC.
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Affiliation(s)
- Kazutoshi Hori
- Department of Endoscopy Center, Hyogo College of Medicine, Nishinomiya, 663-8501, Japan
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22
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Abstract
Intestinal malabsorption results from a wide variety of causes, which can most easily be organized into three groups. Maldigestion arises from problems with mixing or with digestive mediators, and includes post-gastrectomy patients and those with deficiencies of pancreatic or intestinal enzymes, or of bile salts. Mucosal and mural causes of malabsorption are abundant, and include gluten-sensitive enteropathy, tropical sprue, autoimmune enteropathy, and HIV/AIDS-related enteropathy, as well as mural conditions such as systemic sclerosis. Finally, microbial causes of malabsorption include bacterial overgrowth, Whipple's disease, and numerous infections or infestations that are most frequently seen in immunocompromised patients. An overview of the most common and interesting entities in each of these categories follows, along with a discussion of current concepts. Mucosal conditions and microbial causes of malabsorption are given special attention.
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Affiliation(s)
- S R Owens
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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23
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Godart B, Beau P, Benchellal Z, Bumsel F, Metman E. [Ulcerative colitis associated with rectocolitis hemorrhagic: successful treatment with infliximab]. ACTA ACUST UNITED AC 2007; 31:88-90. [PMID: 17273137 DOI: 10.1016/s0399-8320(07)89332-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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Ikeuchi H, Hori K, Nishigami T, Nakano H, Uchino M, Nakamura M, Kaibe N, Noda M, Yanagi H, Yamamura T. Diffuse gastroduodenitis and pouchitis associated with ulcerative colitis. World J Gastroenterol 2006; 12:5913-5. [PMID: 17007066 PMCID: PMC4100681 DOI: 10.3748/wjg.v12.i36.5913] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We experienced a very rare case of ulcerative colitis (UC) accompanied with analogous lesions in the stomach, duodenum, and ileal J -pouch. Ileal J-pouch anal anastomosis was performed on a 29-year old woman in 1996. Six years later, she was admitted again to our hospital because of epigastralgia, nausea, watery diarrhea and low fever. Based on the results of endoscopic examination, we diagnosed it as pouchitis. Moreover, on hypotonic duodenography, expansion of the duodenal bulb and the descending portion were poor. Kerckring folds disappeared with typical lead-pipe appearance. The pathogenesis of the gastric and duodenal lesion in this patient was similar to that of the colonic lesions of UC. For the gastroduodenal lesions in this patient, symptomatic remission was obtained following administration of crushed mesalazine tablets (1500 mg/d) for 14 d with continuous administration of omeprazole. Firstly we used ciprofloxacin to treat pouchitis. On the fifth day, she got a fever because of catheter infection. In the catheter culture, methicillin-resistant Staphylococcus aureus (MRSA) was detected. Therefore we changed ciprofloxacin to vancomycin hydrochloride (Vancomycin®). Vancomycin was very effective, and the stool frequency dramatically improved in three days. Now she continues to take mesalazine, but her condition is stable and there has been no recurrence of pouchitis.
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Affiliation(s)
- Hiroki Ikeuchi
- Second Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan.
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25
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Ludeman L, Shepherd N. Problem areas in the pathology of chronic inflammatory bowel disease. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.cdip.2006.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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26
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Abstract
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.
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Affiliation(s)
- R K Yantiss
- Department of Pathology, Weill Medical College of Cornell University, New York, NY, USA
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27
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Maeda K, Okada M, Seo M, Aoyagi K, Yamaguchi M, Sakisaka S. Evaluation of gastroduodenal mucosal lesions in patients with Crohn's disease and ulcerative colitis. Dig Endosc 2004. [DOI: 10.1111/j.1443-1661.2004.00343.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Rubenstein J, Sherif A, Appelman H, Chey WD. Ulcerative colitis associated enteritis: is ulcerative colitis always confined to the colon? J Clin Gastroenterol 2004; 38:46-51. [PMID: 14679327 DOI: 10.1097/00004836-200401000-00011] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ulcerative colitis (UC) is a chronic inflammatory disease of the colon whose etiology is unknown. Small bowel involvement in UC is extraordinarily rare, and should make the clinician question the diagnosis. However, we present a case of a 38-year-old man with voluminous diarrhea following colectomy for well-documented UC; he was found to have ulcerative enteritis with histologic features identical to UC. Also, for the first time, we present an inclusive review of another 11 cases of UC associated enteritis (UCAE) reported in the literature, and discuss the significance of the entity. We conclude that UC is rarely accompanied by enteritis that is distinct from Crohn disease, frequently presents shortly after colectomy, and usually is responsive to traditional therapies for inflammatory bowel disease (IBD).
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Affiliation(s)
- Joel Rubenstein
- Division of Gastroenterology, University of Michigan Medical Center, 3912 Taubman Center, Box 0362, Ann Arbor, MI 48109-0362, USA
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Abstract
Dyspepsia is a common clinical problem. Its causes include peptic ulcer disease, gastroesophageal reflux, and functional (nonulcer) dyspepsia. A detailed clinical description of pain does not reliably differentiate the cause. Approximately 80% of gastroscopies are performed for the investigation of dyspepsia. "Gastritis" is diagnosed endoscopically in 59% of all stomachs, although in only 3% are the changes severe. Pathologic examination of unselected gastric biopsy specimens reveals that abnormalities are present in 62-73%, but there is only a weak correlation between endoscopic and histologic findings. For these reasons, it is recommended that endoscopic examination should always be accompanied by biopsy. Ideally, biopsies should be taken in a systematic fashion to include sampling of antrum and corpus. Recent evidence suggests that gastric infection by Helicobacter pylori initially presents as a superficial gastritis. Later it may become atrophic with development of intestinal metaplasia. The onset of atrophic changes may be related to the duration of infection, the strain of the infecting organism, associated dietary factors, or as-yet undefined host factors related to immunity. Persistent superficial gastritis predisposes to duodenal ulcer and gastric mucosa-associated lymphoid tissue lymphoma. Atrophic gastritis predisposes to gastric ulcer and adenocarcinoma. Evidence is accumulating that in some patients, pernicious anemia may be an end result of H. pylori-induced atrophic gastritis. Reactive gastropathy is a relatively common finding in gastric biopsies; in most instances it is associated with either reflux of duodenal contents or therapy with nonsteroidal anti-inflammatory drugs. Lymphocytic gastritis, eosinophilic gastritis, and the gastritis associated with Crohn's disease are distinct morphologic entities. Lymphocytic gastritis and eosinophilic gastritis have a variety of clinical associations. Carditis is a controversial topic: currently opinions are divided as to whether it is the result of gastroesophageal reflux or a proximal extension of H. pylori infection from the remainder of the stomach.
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Affiliation(s)
- David A Owen
- University of British Columbia, Vancouver, British Columbia, Canada.
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30
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Abstract
This review summarizes current diagnostic problems and advances with regard to patterns of inflammation and dysplasia in ulcerative colitis and Crohn's disease. Ulcerative colitis and Crohn's disease have a variety of characteristic but non-specific pathologic features. In approximately 5% of inflammatory bowel disease cases, a definite diagnosis of ulcerative colitis or Crohn's disease cannot be established, in which case the term "indeterminate" colitis is used. Most cases of indeterminate colitis are related to fulminant colitis, a condition in which the classic features of ulcerative colitis or Crohn's disease may be obscured by severe ulceration with early superficial fissuring ulceration, transmural lymphoid aggregates, and relative rectal sparing. Approximately 20% of patients with indeterminate colitis develop severe pouch complications, which is intermediate in frequency between ulcerative colitis (8-10%) and Crohn's disease (30-40%). In order to establish a diagnosis of ulcerative colitis or Crohn's disease, it is important to evaluate pathologic material in conjunction with clinical, laboratory, radiologic, and endoscopic features and to recognize the variety of changes that may be seen in fulminant ulcerative colitis. There are a number of exceptions to the classic principles of inflammatory bowel disease pathology that may lead to diagnostic confusion. For instance, apparent skip lesions on biopsy analysis may occur in patients with ulcerative colitis in the following settings; long term oral or topical therapy, focal ascending colon, cecum and/or appendiceal involvement in patients with left sided ulcerative colitis, upper gastrointestinal involvement in patients with ulcerative colitis, and at initial presentation of ulcerative colitis in pediatric patients. In all of these circumstances, the finding of patchy disease and/or rectal sparing should not be misinterpreted as either evidence against a diagnosis of ulcerative colitis, or as representing skip areas characteristic of Crohn's disease. Patients with ulcerative colitis and Crohn's disease are at increased risk for the development of dysplasia and carcinoma. Recent studies suggest that given a similar duration and extent of disease, patients with Crohn's disease have a similar risk of dysplasia and cancer as patients with ulcerative colitis. Dysplasia in ulcerative colitis may be classified as flat or elevated (dysplasia associated lesion or mass [DALM]). Patients with flat high grade dysplasia are generally treated with colectomy. However, there is recent evidence to suggest that patients with flat low grade dysplasia, particularly if detected at the time of initial endoscopic exam, or if its multifocal or synchronous, should also be treated with colectomy. Elevated lesions in ulcerative colitis (DALM) are subdivided into "adenoma-like" and "non-adenoma-like" lesions based on their endoscopic appearance. Recent data suggests that adenoma-like lesions, regardless of the grade of dysplasia, or the location of the lesion (i.e., inside or outside areas of established colitis) may be treated adequately by polypectomy if there are no other areas of flat dysplasia in the patient. Although there are some histologic and molecular features that can help differentiate sporadic adenomas from adenoma-like polypoid dysplastic lesions related to ulcerative colitis, none of these adjunctive techniques can help distinguish these lesions definitively in any single patient. Patients with a non-adenoma-like DALM, (irregular, broad based, or strictured lesion) should be treated with colectomy because of the high probability of adenocarcinoma. The surveillance and treatment options for patients with flat and elevated dysplasia in ulcerative colitis are reviewed in detail.
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Affiliation(s)
- Robert Odze
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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31
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Papadakis KA, Tabibzadeh S. Diagnosis and misdiagnosis of inflammatory bowel disease. Gastrointest Endosc Clin N Am 2002; 12:433-49. [PMID: 12486937 DOI: 10.1016/s1052-5157(02)00005-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Several diseases can mimic IBD clinically, but careful and repeated evaluations, if necessary, will dramatically decrease the likelihood of misdiagnosis. A careful consideration of patient's clinical, radiographic, endoscopic, and histopathologic features will establish the correct diagnosis in the majority of cases.
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Affiliation(s)
- Konstantinos A Papadakis
- Department of Medicine, Division of Gastroenterology and Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, UCLA School of Medicine, 8700 Beverly Boulevard, D-4063, Los Angeles, CA 90048, USA.
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Abstract
Ulcerative colitis (UC) is a chronic inflammatory disease of the colon of unknown etiology. There are varied manifestations in the natural course of UC. However, duodenum is not generally considered a target organ of UC. Here, we report two patients with steroid-responsive ulcerative duodenitis with colitis that was consistent with UC, but not with Crohn's disease. We also reviewed six cases of ulcerative duodenitis with UC. Duodenal lesion with UC may be a more common phenomenon, although infrequently clinically manifested under steroid therapy. Upper gastrointestinal tract inflammation in UC warrants further studies to ascertain whether the duodenum is a target organ in UC, especially in steroid-free conditions.
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Affiliation(s)
- S Terashima
- First Department of Surgery, Fukushima Medical University, Japan.
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33
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Valdez R, Appelman HD, Bronner MP, Greenson JK. Diffuse duodenitis associated with ulcerative colitis. Am J Surg Pathol 2000; 24:1407-13. [PMID: 11023103 DOI: 10.1097/00000478-200010000-00011] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Backwash ileitis and postcolectomy pouchitis are well-recognized complications of ulcerative colitis (UC), whereas inflammation of the proximal small intestine is not. In contrast, small intestinal disease at any level is common in Crohn's disease (CD). Despite this well-established and accepted dogma, rare cases of histologically proven diffuse duodenitis (DD) associated with UC appear in the literature. In this study, we report our experience with similar cases exhibiting this unusual inflammatory phenomenon. Routine histologic sections from four cases of DD associated with well-documented UC were reviewed and the findings correlated with all available medical records. Multiple endoscopic biopsies showing histologic features of UC and colectomy specimens confirming severe ulcerative pancolitis were available for all cases. Varying degrees of active chronic inflammation and architectural mucosal distortion identical to UC were observed in pre- and postcolectomy duodenal biopsies of one of four and four of four cases, respectively. Similar inflammatory patterns were present postoperatively in the ileum in three of four cases and in the jejunum in one case. Endorectal pull-through (ERPT) procedures were performed in three of four patients and an end-to-end ileorectal anastomosis was done in one patient. Despite extensive upper gastrointestinal tract involvement, none of the patients developed postsurgical Crohn's-like complications during a follow-up period of 12 to 54 months. This suggests that patients with pancolitis and DD do not necessarily have CD, but rather may have UC and, most importantly, that successful ERPT procedures may be performed in these patients.
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Affiliation(s)
- R Valdez
- University of Michigan Health System, Department of Pathology, Ann Arbor 48109-0054, USA
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