European Gastroenterology & Hepatology Review, 2005:34-36
Longer version of article from Reference Section:
While the characteristic features of Crohn’s disease (CD) and ulcerative colitis (UC) are well known, these are not always discovered when the pathologist encounters a scenario where treatment has been instigated and the initial diagnosis is then called into question.1 It is also becoming clear that the histological features of IBD are not static.
Changes in IBD Histology with Time and Treatment
The traditional description of UC is that of a disease affecting the rectum and extending to a variable degree into the colon. Therefore, common practice in patients with colitis is often to perform only a limited examination, i.e. a flexible sigmoidoscopy and rectal biopsy. However, Kleer et al. noted that over time, both histological and endoscopic areas of UC could revert to normal mucosa.2 Similarly, Levine et al. found normal rectal histology or minor changes in 46% of asymptomatic UC patients despite previous definitive histology for UC.3 In children, an initial presentation of UC with rectal sparing has been found in up to 3% to 4% of UC patients.4 However, in adults, a de novo presentation of UC with rectal sparing has been reported, but is much rarer.5,6 Therefore, relative rectal sparing can be a presentation of UC and must not solely be taken as evidence for CD. In a situation where the pathologist is now confronted with rectal sparing, a mistaken diagnosis of CD can arise. Other features of UC that can lead to confusion with CD are its similar, patchy nature and a propensity for disease to be more severe in the proximal colon compared with the distal colon.
Kleer et al. also noted a 65% correlation between histology and endoscopic findings in UC.2 In other words, disease could be present in an area with normal endoscopic findings; hence, a biopsy of so-called ‘normal endoscopic mucosa’ should be performed to determine the extent of disease. Interestingly, in 73% of UC patients (30 of 41 patients), the maximal extent of disease was a pancolitis, but more than 80% of these patients had a lesser extent of disease over the seven-year study period. This latter finding implies that repeated colonoscopic biopsies are required to assess the extent of disease as it may not be obvious from the first presentation and may change with time.7 Langholz et al. found that, all in all, about half of patients with UC will have a change in disease extent over time.8 Two other findings in UC that can be mistaken for CD are skip lesions in the form of caecal patch or appendiceal involvement that occurs in leftsided UC.9,10
In summary, the pathologist must be aware that UC can occur in the absence of rectal disease, it may be patchy and the true extent of disease may not be obvious from the initial biopsies.
Medical Therapy and Effects on Histology in UC
In UC, administration of therapies such as rectal 5-aminosalicylic acid (5-ASA) can lead to complete resolution of acute and chronic mucosal rectal inflammation such that an inexperienced pathologist may take this to represent rectal sparing.11 This may ultimately lead to the diagnosis being changed from UC to CD. Alternatively, medical therapy may only lead to relative rectal sparing. In this setting, the histology may show reduced or absent acute and/or mucosal inflammation, architectural changes only or a persistent increase in Paneth cells. This patchiness of disease, both histologically and endoscopically, is a feature of treatment in UC.12–14 The effect of treatment may also account for skip lesions in the appendix and caecum.
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