Histopathology of Non-IBD Colitis. A practical approach from the Italian Group for the study of the gastrointestinal tract (GIPAD)

A Systematic Review and Metaanalysis to Examine the Utility of Histological Parameters Such as Mucosal Basal Plasmacytosis and Eosinophilia for Distinguishing Inflammatory Bowel Disease and Non-IBD-Type Colitis

Background and aim: Basic differentiation between an inflammatory bowel disease (IBD)-type colitis and a non-IBD type of colitis is the essential histological pre-requisite before further subclassifications are made. The combination of mucosal prominent eosinophilic cell infiltrate along with basal plasmacytosis is supposed to be a useful histological feature that can differentiate between IBD-type and non-IBD-type colitis. Hence, this systematic review and metaanalysis aimed to assess the reliability of mucosal basal plasmacytosis and eosinophilia for histological differentiation of IBD-type versus non-IBD-type colitis. Methods: We searched the PROSPERO, PubMed, Embase, and Scopus from January 1, 2000 to July 30, 2022 for all types of studies (prospective, cross-sectional, or retrospective studies) having histological features (including mucosal basal plasmacytosis, eosinophilia, and neutrophilic infiltration) in IBD and/or non-IBD colitis cases. Two reviewers extracted data, which were aggregated using random-effects models. Results: The 59 selected articles were evaluated for the predecided parameters. Both basal plasmacytosis and lamina propria plasmacytosis did not show any significant correlation between IBD-type and non-IBD-type colitis. The proportions for basal plasmacytosis with 95% CI were 0.50 (0.19-0.82) in IBD-type colitis and 0.46 (0.40-0.52) in non-IBD-type colitis, with a P value of .79. The proportion of lamina propria plasmacytosis with 95% CI was 0.67 (0.42-0.92) in IBD and 0.60 (0.35-0.85) in non-IBD-type colitis, with a P value being .7. Conclusions: This systematic review documented the dearth of published data on key histological features such as basal plasmacytosis and mucosal eosinophilia which are believed to differentiate between IBD-type and non-IBD-type colitis.

Anti-Inflammatory Effects of Artemisia argyi H. Fermented by Lactobacillus plantarum in the LPS-Induced RAW 264.7 Cells and DSS-Induced Colitis Model

Ulcerative colitis is a chronic inflammatory disease caused by abnormal immune responses in the intestinal mucosa and gut microorganisms. Unlike other mugworts, Artemisia argyi H. (A. argyi H.) enhances antioxidant, anti-inflammatory, and anticancer effects, but the improvement effects against gut inflammation have not yet been reported. Therefore, this study aimed to confirm the alleviation of the inflammatory state in the gut by A. argyi H. fermented with Lactobacillus plantarum (FAA), using lipopolysaccharide (LPS)-induced RAW 264.7 cells and dextran sulfate sodium (DSS)-induced colitis models. In vitro, FAA (10, 50, 100, and 200 μg/mL) was pretreated into RAW 264.7 cells, followed with LPS (100 ng/mL), which induced the cell damage. Meanwhile, in vivo, FAA (100, 200 mg/kg/day) was orally administered into 6-week-old C57BL/6N mice for 3 weeks. During the last week of FAA administration, 2.5% DSS was used to induce colitis. The results showed that FAA reduced the production of nitric oxide (p < 0.0001), tumor necrosis factor (TNF)-α, interleukin (IL)-6 (p < 0.0001), and IL-1β (p < 0.0001) in the LPS-induced RAW 264.7 cells. Moreover, in the DSS-induced colitis model, FAA alleviated clinical symptoms (p < 0.001), inhibited the inflammatory state by reducing the production of TNF-α (p < 0.0001) and interferon-γ in intestinal immune cells (p < 0.0001), and strengthened the intestinal barrier by increasing the number of goblet cells (p < 0.0001). Furthermore, the anti-inflammatory effects were confirmed by the alleviation of histological damage (p < 0.001) and down-regulation of the expression of inflammatory proteins (TLR4, p < 0.0001; MyD88, p < 0.0001; Cox-2, p < 0.0001). These results suggest the potential of FAA as a dietary ingredient for preventing inflammation in the gut.

Common Diagnostic Challenges and Pitfalls in Segmental Colitis Associated with Diverticulosis (SCAD)

Segmental colitis associated with diverticulosis (SCAD) is characterized by inflammation involving the sigmoid inter-diverticular mucosa, sparing the proximal colon and rectum. Due to the heterogeneity of clinical manifestations and endoscopic and histological findings, SCAD diagnosis might be challenging in clinical practice. This narrative review aimed to report the SCAD diagnostic criteria adopted in different studies, highlighting the current challenges and main pitfalls in its diagnosis. We analysed fourteen studies, mainly prospective observational studies. Haematochezia and rectal bleeding were the main complaints leading to diagnosis, followed by diarrhoea. An accurate endoscopic description was performed in 86% of studies, while a standardised biopsy sampling protocol (sigma, proximal colon and rectum) was scarcely adopted, being complete only in 28.5% of studies. The evaluation of concomitant drugs potentially inducing colitis was carried out in only 57% of studies. Great heterogeneity in sigmoid endoscopic (edema, erythema, erosions, ulcers, mucosal friability) and histological findings (chronic and/or acute inflammatory infiltrate) was observed. We showed that SCAD diagnosis is often based on not fully adequate macroscopic colonic description and scant biopsy protocol sampling. An accurate clinical and endoscopic evaluation, with an adequate sampling biopsy protocol, with attention to differential diagnosis, seemed to be crucial for a prompt SCAD diagnosis.

Unusual Ileocecal Ulcers after Liver Transplantation for Hepatitis B Cirrhosis and Hepatocellular Carcinoma

We presented a case demonstrating ileocecal ulcers after liver transplantation for hepatitis B cirrhosis and hepatocellular carcinoma. The patient presented 4 years post-transplant with paroxysmal right lower abdominal pain. Due to a mild increase in the leukocyte and neutrophil count, infectious diseases were initially suspected. However, probiotic treatment did not help improve the symptom. An enhanced CT scan revealed a thickening in the ileocecal region, and endoscopy later showed multiple giant and deep ulcers in the ileocecal region with polypoid hyperplasia. Histopathology of an ulcer biopsy displayed benign ulcers, and chronic inflammation with non-caseous granulomas, without signs of a fungus or parasite infection. Epithelial exfoliation with atypical hyperplasia was observed, and a tacrolimus-induced ileocecal ulcer was considered by a pathologist. Clinical manifestation, lab findings, radiology, and pathology characteristics of ulcers were not consistent with the pathogenesis of ischemia, tuberculosis, CMV, EBV, tumor, or inflammatory bowel diseases. Abdominal pain was gradually relieved and subsided with the discontinuation of tacrolimus and corticosteroid administration.

Gut inflammation induced by drugs: Can pathology help to differentiate from inflammatory bowel disease?

Drug‐induced mucosal injury (DIMI) in the gastrointestinal tract is important to recognise, partly because cessation of the culprit agent alone may result in resolution of symptoms. An ever‐growing list of medications, including newer immunotherapeutic agents and targeted therapies, can cause gastrointestinal inflammation of varying severity. However, the diagnosis of DIMI is challenging, as a single drug can induce a variety of histopathological patterns of injury including acute colitis, chronic colitis, microscopic colitis, apoptotic colopathy, and ischaemic‐type colitis. An additional consideration is the potential clinical, endoscopic and histological overlap of DIMI with gastrointestinal mucosal injury secondary to other entities such as inflammatory bowel disease (IBD). We discuss DIMI of the gastrointestinal tract with an emphasis on histological patterns that mimic IBD, histological features which may distinguish the two entities, and the diagnostic role and limitations of the pathologist.

Clinic, Endoscopic and Histological Features in Patients Treated with ICI Developing GI Toxicity: Some News and Reappraisal from a Mono-Institutional Experience

Background: Immune checkpoint inhibitors (ICIs) have widened the therapeutic scenario of different solid tumors over the last ten years. Gastrointestinal (GI) adverse events (AEs), such as diarrhea and colitis, occur in up to 50% of patients treated with ICIs. Materials and methods: We conducted a single-center retrospective analysis in patients with solid tumors treated with ICIs in a 6-year period, from 2015 to 2021, developing GI AEs, for which an endoscopic analysis was performed, with available histological specimens or surgery. Results: Twenty-one patients developed GI AEs under ICIs. The median time from the start of ICIs to the onset of GI AEs was 5 months. Diarrhea was the most frequent symptom (57.2%), upper GI symptoms presented in four patients (19%), while three patients (14.3%) had no symptoms and were diagnosed occasionally. Two patients underwent surgical resection for acute abdomen. Histological findings observed in endoscopic sampling were eosinophilic-pattern gastro-enterocolitis, apoptotic damage, IBD-like features, and ischemic-like changes. Histological damage was also documented in patients with unremarkable endoscopy. Conclusions: Under ICI therapy, GI toxicity is an expected event. Since GIAEs can mimic a broad range of primary GI diseases, a multidisciplinary approach is advocated with upper and lower GI mucosal sampling to remodel therapy and avoid complications.

Very Early Onset-IBD: evidence for the need of a multidisciplinary approach

Very early onset inflammatory bowel disease (VEO-IBD) represents approximately 25% of cases of IBD-like colitis occurring during childhood and, by definition, it is characterized by an onset prior to 6 years of age. This subgroup of patients presents significant differences from IBD occurring in older children and in adults, including a more severe clinical course, a reduced responsiveness to conventional IBD therapy, and a greater proportion of cases featuring an underlying monogenic disorder. Histological findings from gastro-intestinal (GI) biopsies are characterized by an IBD-like, apoptotic or enterocolitis-like pattern, complicating the differential diagnosis with other pediatric diseases involving GI tract. Moreover, individuals with monogenic disorders may develop significant comorbidities, such as primary immunodeficiency (PID), impacting treatment options. Without an appropriate diagnosis, the clinical course of VEO-IBD has greater potential for escalated treatment regimens involving extensive surgery, more intensive medical therapies and, even more important, inadequate recognition of underlying monogenic defect that may lead to inappropriate (sometimes fatal) therapy. For these reasons, an adequate context leading to an appropriate diagnosis is imperative, calling for a close collaboration between pediatricians, pathologists, geneticists, and immunologists.

"Stranger things" in the gut: uncommon items in gastrointestinal specimens

Organic (such as parasites or vegetable remnants) and inorganic substances may be encountered during routine pathology diagnostic work up of endoscopic gastrointestinal biopsy samples and major resections, causing possible diagnostic conundrums for the young and not so young pathologists. The main aim of this review is the description of the most frequent oddities one can encounter as foreign bodies, in gastrointestinal pathology, on the basis of the current literature and personal experience. The types of encountered substances are divided into four principal categories: parasites (helminths such as Enterobius vermicularis, Strongyloides, Schistosoma, and Anisakis, and protozoa such as Entamoeba, Giardia and some intestinal coccidia); drugs and pharmaceutical fillers (found as deposits and as bystanders, innocent or not); seeds (possibly confused with worms) and plant remnants; pollutants (secondary to post-resection or post-biopsy contamination of the sample). An ample library of images is provided in order to consent easy referencing for diagnostic routine.

Correlation Between the Transient Elevation of Peripheral Eosinophil Count During Radiotherapy and Acute Diarrhea

BACKGROUND/AIM

This study aimed to evaluate the association between the change in peripheral eosinophil count during postoperative pelvic radiotherapy and gastrointestinal (GI) toxicities in patients with cervical cancer.

PATIENTS AND METHODS

The medical records of 163 patients with cervical cancer who underwent postoperative concurrent chemoradiotherapy between 2000 and 2016 were analyzed.

RESULTS

Among the peripheral blood cell counts, transient elevation of the eosinophil count was observed during radiotherapy. Of the 163 patients, 117 developed grade ≥2 diarrhea during radiotherapy, and 25 patients developed grade ≥2 late GI toxicities. In multivariate analysis, the maximum eosinophil count and age emerged as independent predictors of grade ≥2 acute diarrhea during radiotherapy, while bowel bag V _{40 Gy} and age were predictive of grade ≥2 late GI toxicities.

CONCLUSION

Early detection of transient elevation of eosinophil may facilitate early treatment of acute diarrhea during radiotherapy.

Histopathology of IBD Colitis. A practical approach from the pathologists of the Italian Group for the study of the gastrointestinal tract (GIPAD)

Inflammatory bowel diseases (IBDs) are lifelong disorders in which an interaction between genetic and environmental factors is involved. IBDs include two entities: Crohn's disease (CD) and ulcerative colitis (UC); these can be adequately diagnosed and distinguished with a correct methodological approach based on communicating exhaustive clinical, endoscopic and laboratory information to the pathologist and performing adequate bioptic sampling and precise morphological signs including crypt architecture, distribution of inflammation and granulomas, when present. IBD needs to be distinguished from non-IBD colitis, mostly at its onset. Moreover, IBDs are associated with an increased risk of developing colorectal adenocarcinoma. In daily pathological practice, correct diagnosis of IBD and its subclassification as well as a correct detection of dysplasia is imperative to establish the best therapeutic approach.