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Heuthorst L, Mookhoek A, Wildenberg ME, D'Haens GR, Bemelman WA, Buskens CJ. High prevalence of ulcerative appendicitis in patients with ulcerative colitis. United European Gastroenterol J 2021; 9:1148-1156. [PMID: 34750986 PMCID: PMC8672077 DOI: 10.1002/ueg2.12171] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/22/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Previous studies have indicated that the appendix may be a priming site of ulcerative colitis (UC). Appendectomy is inversely associated with the development of UC, and is suggested to have a beneficial effect on the disease course in patients with refractory disease. OBJECTIVE The aim of the current study was to assess histological features of appendices from patients with UC and their clinical relevance. METHODS Patients with UC in remission and active UC (therapy refractory) that underwent appendectomy between 2012 and 2019 were included. Histological features of UC appendices were compared to those of patients with acute appendicitis and colon carcinoma. The Robarts Histopathology Index (RHI) was used to assess appendiceal inflammation. In patients with active UC, histological and clinical characteristics were compared between patients with and without endoscopic response following appendectomy. RESULTS In total, 140 appendix specimens were assessed (n = 35 UC remission, n = 35 active UC, n = 35 acute appendicitis, n = 35 colon carcinoma). Histological features of appendices from UC patients looked like UC rather than acute appendicitis. The presence of active appendiceal inflammation was comparable between patients in remission versus active disease (53.7% vs. 46.3%, p = 0.45) and limited versus extensive disease (58.5% vs. 41.5%, p = 0.50). Endoscopic response (Mayo 0-1) following appendectomy, assessed in 28 therapy refractory patients, was more frequently seen in patients with higher RHI scores (RHI > 6: 81.8% vs. RHI ≤ 6: 9.1%, p = 0.03) and limited disease (proctitis/left sided 63.6% vs. pancolitis 36.4%, p = 0.02). CONCLUSION The presence of active appendiceal inflammation is common in UC and does not correlate with colonic disease activity. More than 50% of UC patients in remission showed active histological disease in the appendix. Favorable response to appendectomy for refractory UC was seen in cases with ulcerative appendicitis. These findings might support the role of the appendix as a pivotal organ in UC.
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Affiliation(s)
- Lianne Heuthorst
- Department of Surgery, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands
| | - Aart Mookhoek
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Manon E Wildenberg
- Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Center, The Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands
| | - Christianne J Buskens
- Department of Surgery, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands
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Ma C, Sedano R, Almradi A, Vande Casteele N, Parker CE, Guizzetti L, Schaeffer DF, Riddell RH, Pai RK, Battat R, Sands BE, Rosty C, Dubinsky MC, Rieder F, Harpaz N, Abreu MT, Bryant RV, Lauwers GY, Kirsch R, Valasek MA, Crowley E, Sandborn WJ, Feagan BG, Pai RK, Jairath V. An International Consensus to Standardize Integration of Histopathology in Ulcerative Colitis Clinical Trials. Gastroenterology 2021; 160:2291-2302. [PMID: 33610533 PMCID: PMC8851891 DOI: 10.1053/j.gastro.2021.02.035] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/31/2021] [Accepted: 02/09/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Histopathology is an emerging treatment target in ulcerative colitis (UC) clinical trials. Our aim was to provide guidance on standardizing biopsy collection protocols, identifying optimal evaluative indices, and defining thresholds for histologic response and remission after treatment. METHODS An international, interdisciplinary expert panel of 19 gastroenterologists and gastrointestinal pathologists was assembled. A modified RAND/University of California, Los Angeles appropriateness methodology was used to address relevant issues. A total of 138 statements were derived from a systematic review of the literature and expert opinion. Each statement was anonymously rated as appropriate, uncertain, or inappropriate using a 9-point scale. Survey results were reviewed and discussed before a second round of voting. RESULTS Histologic measurements collected using a uniform biopsy strategy are important for assessing disease activity and determining therapeutic efficacy in UC clinical trials. Multiple biopsy strategies were deemed acceptable, including segmental biopsies collected according to the endoscopic appearance. Biopsies should be scored for architectural change, lamina propria chronic inflammation, basal plasmacytosis, lamina propria and epithelial neutrophils, epithelial damage, and erosions/ulcerations. The Geboes score, Robarts Histopathology Index, and Nancy Index were considered appropriate for assessing histologic activity; use of the modified Riley score and Harpaz Index were uncertain. Histologic activity at baseline should be required for enrollment, recognizing this carries operational implications. Achievement of histologic improvement or remission was considered an appropriate and realistic therapeutic target. Current histologic indices require validation for pediatric populations. CONCLUSIONS These recommendations provide a framework for standardized implementation of histopathology in UC trials. Additional work is required to address operational considerations and areas of uncertainty.
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Affiliation(s)
- Christopher Ma
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alimentiv Inc (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada.
| | - Rocio Sedano
- Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Ahmed Almradi
- Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Niels Vande Casteele
- Alimentiv Inc. (formerly Robarts Clinical Trials, Inc.), London, Ontario, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, California, United States
| | - Claire E. Parker
- Alimentiv Inc. (formerly Robarts Clinical Trials, Inc.), London, Ontario, Canada
| | - Leonardo Guizzetti
- Alimentiv Inc. (formerly Robarts Clinical Trials, Inc.), London, Ontario, Canada
| | - David F. Schaeffer
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert H. Riddell
- Department of Laboratory Medicine & Pathobiology, Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Reetesh K. Pai
- Division of Anatomic Pathology, Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Robert Battat
- Jill Roberts Center for IBD, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, United States
| | - Bruce E. Sands
- Department of Medicine, The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, United States
| | - Christophe Rosty
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia,Envoi Pathology, Brisbane, Queensland, Australia
| | - Marla C. Dubinsky
- Department of Pediatrics, Division of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, United States
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Noam Harpaz
- Department of Medicine, The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, United States,Department of Pathology, Molecular and Cell-Based Medicine and Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Maria T. Abreu
- Crohn's and Colitis Center, Division of Gastroenterology, Department of Medicine, University of Miami Leonard Miller School of Medicine, Miami, Florida, United States
| | - Robert V. Bryant
- IBD Service, Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia,Faculty of Health Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Gregory Y. Lauwers
- DH. Lee Moffitt Cancer Center & Research Institute, and University of South Florida, Tampa, Florida, United States
| | - Richard Kirsch
- Department of Laboratory Medicine & Pathobiology, Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Mark A. Valasek
- Department of Pathology, University of California San Diego, La Jolla, California, United States
| | - Eileen Crowley
- Division of Pediatric Gastroenterology, Western University, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - William J. Sandborn
- Alimentiv Inc. (formerly Robarts Clinical Trials, Inc.), London, Ontario, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, California, United States
| | - Brian G. Feagan
- Alimentiv Inc. (formerly Robarts Clinical Trials, Inc.), London, Ontario, Canada,Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Rish K. Pai
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona, United States
| | - Vipul Jairath
- Alimentiv Inc. (formerly Robarts Clinical Trials, Inc.), London, Ontario, Canada,Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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