seminar on colitis

1. RECENT TRENDS IN COLITIS
Moderator : Dr Kala
Presenter: Dr Shashikala C

4. Changes in recent years include:
-Wide spread use of full colonoscopy
-greater recognition of the effects of time and treatment
-improved documentation of variations in anatomical
distribution
-better understanding of the mimics of IBD
-Significant progress in clinical management
-modifications of terminology

5. Value of biopsy assessment
 Confirmation of the diagnosis of IBD
 Distinction between UC and CD
 Exclusion of dysplasia
 Exclusion of coexistent conditions or complications
Also…..
 Disease activity
 Disease extent

6. Tissue sampling
Taken from
 Both endoscopically normal and abnormal mucosa
 Samples of - ileum
-atleast four colonic sites
-the rectum
With minimum of two biopsies from each site

7. Is the mucosa inflammed?

8. Chronic inflammatory cell infiltrate

9. Histiocyte/macrophages-
muciphages are normal findings especially in colon
Eosinophils-
normal in lamina propria
sparse intraepithelial eosinophils
Acute inflammatory cells-
A few intraepithelial neutrophils are normal[2-
3/biopsy]

10. Crypt architecture

11. Villiform/irregular mucosal surface

12. Crypt distortion and branching

13. Crypt atrophy

14. Basal plasmacytosis

15. Basal lymphoid aggregates

16. Cryptitis ,crypt abscess and granulomas

17. Mucin depletion

18. Paneth cell metaplasia

19. Distribution , Extent and Activity
Distribution of chronic inflammatory cells and crypt changes
 Between anatomical sites
 Between biopsies from the same site
 Within biopsies
Terms for distribution within biopsies and within single site:-
For chronic inflammatory infiltrate- diffuse , patchy, focal
For crypt changes and acute inflammation- diffuse , focal

20. Diffuse chronic inflammation

21. Patchy chronic inflammation

22. Terms for distribution between sites
-continuous between sites
-segmental/ discontinuous between sites
Diagnostic value :
 Distribution between sites-
continuous favours UC and discontinuous/segmental
favour CD
 Distribution within sites /within biopsies
diffuse favours UC and focal/ patchy favours CD
An increased severity from proximal to distal favours UC and
right sided predominance favours CD

24. Extent of disease
-Determined endoscopically
- Extent in UC helps to predict the risk of dysplasia
- Extent in CD is difficult to determine
- Histological extent does not always correlate with
endoscopic extent

25. Activity
Histologic activity confirmation requires
cryptitis
crypt abscesses
surface epithelial neutrophils
erosion or
ulceration

26. IBD VERSUS NON IBD
IBD vs acute infective colitis/ acute self limiting colitis/ non-
IBD colitis
History :
Infective colitis- bloody diarrhea and associated symptoms
lasts for shorter duration
no relapse
secondary to shigella, salmonella,
campylobacter

28. Features favouring infective colitis over IBD

30. IBD versus infective colitis: exceptions
▸ Crypt distortion occurs in a minority of infective coli- tides,
particularly in the healing phase or if infection is severe or
prolonged.
▸ A few infective colitis biopsies have basal plasmacytosis or
other evidence of chronic inflammation.
▸ Crypt abnormalities may be absent from IBD biopsies,
especially in early or treated disease.
▸ Some IBD biopsies have little or no basal plasmacytosis/
chronic inflammation, particularly early in the course of
disease or after treatment.

31. UC Vs CD: Histology

34. Assignment to a category

37. Effects of time and treatment

38. Pediatric UC
 Children have higher prevalence of discontinuous disease
rectal sparing and pan colitis
 Low prevalence of chronic histological changes
 Upper GI involvement more in children

40. Ileal and upper gastrointestinal biopsies
Ileal biopsies:-
 In setting of IBD ileal inflammation strongly favours CD over
UC.
 Granulomas[ non cryptolytic] in inflamed ileal biopsies help
discriminate CD from UC
Upper GI biopsies:-
 CD> UC
 GERD , H pylori to be excluded
 In a setting of IBD upper GI granuloma favours CD over UC
- may raise the possibilities of new CD but caution is
advised

42. MIMICS OF IBD
Diverticular colitis
 Usually localised to sigmoid colon
 Often older patients
 History endoscopy reqiured for diagnosis

44. Diversion proctocolitis
 May resemble UC/CD
 History required

45. Ischaemic colitis
 Basal plasma cells are absent
 Mild acute inflammation
 Hyalinisation of lamina propria and fibrosis are typical
 Clinical picture and anatomic distribution helps to make
diagnosis

46. Microscopic colitis
Collagenous colitis/ lymphocytic colitis
 Plasmacytosis, sometimes basal
 No crypt changes

49. Radiation colitis
 Crypt atrophy , distorsion and mucin depletion
 Hyalinisation, fibrosis, vascular ectasia, absence of basal
plasma cells
 Clinical history

50. GVHD
 Acute GVHD cause crypt atrophy, distortion
 Chronic inflammation is minimal
 Crypt epithelial apoptoses
 Chronic GVHD result in crypt atrophy distorsion with or
without fibrosis
 History

51. Mass lesion
Mucosa overlying intramural and subserosal mass may show
features IBD
Infections
LGV/ syphilis- may resemble CD
left sided > right
HIV/risk factors
Tuberculosis and yersinia
- -Caseous necrosis and demonstrable AFB indicate TB
- -langhans gaint cells, lymphoid cuff around granuloma and
granuloma > 4oomicrometer
- Additional to these presence of stellate abscess favours
yersinia

52. Drugs
NSAID colitis -
 IBD like changes- crypt distortion , granulomas
 Clues- epithelial cell apoptosis
increased intraepithelial lymphocytes
Mycophenolate mofetil
 Can mimic IBD
 But most often confused with GVHD than IBD

53. FOCAL ACTIVE COLITIS
Focal cryptitis/crypt abscess formation in the absence of other
changes
Represents – IBD, infection, ischaemia, drugs,other causes
It is not regarded as diagnoses

54. ILEOANAL POUCH BIOPSIES
-to assess severity of inflammation
-seek the evidence of IBD, CMV
-To exclude dysplasia
Adaptive changes- colorectal phenotype and villous atrophy
Identification and sub classification of of IBD is difficult.

56. DYSPLASIA
Clinical considerations
-pancolic dye spraying with targeted biopsies of
macroscopically abnormal areas
Or random biopsies of 2-4 per 100mm interval
Diagnosis
Low grade/ high grade/ indefinite for dysplasia

57. Features favouring high grade dysplasia over low grade:
Cytological features-
 Complete loss of nuclear polarity
 Nuclei larger, more hyperchromatic, more stratified round
ovoid rather than pencil shaped
 Mitoses is more
 Architecturul changes are severe with cribriform areas

59. DALM vs adenoma
 Depends on endoscopic features
 Whether they are located inside or outside the area of IBD
 Histology does not distinguish reliably between two
diagnoses
Dual reporting of dysplasia is recommended

61. terminologies

62. REPORTING SCHEME FOR IBD BIOPSIES (PAID) Approach
and suggested scheme
The acronym ‘PAID’ is a suggested aide memoire for the
layout of the conclusion to an IBD biopsy report.
P- Pattern: of chronic changes: presence, distribution, extent
A - Activity: maximum grade, location
I- Interpretation: probability of IBD and, if relevant, probability
of UC or CD
D- Dysplasia: location, severity

65. SUMMARY
Remember
The context when dealing with colitis
Coherence when using terminologies
Corroborate histology with endoscopic findings
Communicate the inability of being more specific
Follow the recent guidelines to screen the high risk
individuals
Pathologist should assist the clinician in diagnosis to
implement appropriate treatment

66. References
 Robbins and cotran pathologic basis of disease- 9th edition
 Inflammatory bowel disease biopsies: updated British
Society of Gastroenterology reporting guidelines
Feakins RM. J Clin Pathol 2013;0:1–22.
doi:10.1136/jclinpath-2013-201885
 Morson and dawsons gastrointestinal pathology
 Pictures from journals of AJG
Thank You