acute and chronic colitis - pathpathology.ro and chronic colitis - stamm.pdf · acute and chronic...
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Acute and Chronic Colitis an approach to biopsy interpretation
Bernhard Stamm, Zürich
Endoscopist‘s questions
• Normal mucosa?
• If inflammation, self-limiting or of longer
duration?
• Any clue to etiology?
• Could it be IBD?
• Histological diagnosis based on a limited
set of mostly ambiguous mucosal
response patterns
Need of structured approach
Artefact or disease?
• Artefacts may interfere with a diagnosis of
inflammation
- Edema - density of mononuclear cells - epithelial flattening - mucin depletion - few focal neutrophils
are weak arguments for genuine inflammation
„exclusion biopsies“
• „Mild chronic non-specific inflammation“
may be misleading
In case of doupt better:
• „Minor changes, possibly artefacts“
If obvious colitis..
• Acute or chronic?
• or any of the more specific histological
patterns, likely to contribute to the clinical
workup?
Acute colitis „self-limiting“ preserved crypt architecture predominantly neutrophils epithelial damage
Chronic colitis diffuse distortion of crypt architecture predominantly mononuclear cells Paneth metaplasia
Natura non facit saltus Woman, 29 bloody diarrhea, five weeks
Pattern recognition
beside acute and chronic
Microscopic colitis
Pseudomembranous
colitis
„volcano-like“ exudate of
neutrophils and mucin
Acute ischemia
„ischemic colitis“
superficial necrosis and
hemorrhage
crypt atrophy
eosinophilic hyalinization of
lamina propria
Entero-hemorrhagic E.coli –epidemic in Southern Germany Man, 40 severe bloody diarrhea
• Other patterns: focal active colitis,
eosinophilic colitis, granulomatous
colitis.....
• Evaluation of patterns best at low
magnification!
Two additional questions always to
be kept in mind..
• Histological recognizable microorganisms?
• Adverse effect of drugs?
Intestinal spirochaetosis
Man, 39, two years history of UC
steroid-resistant relapse, necessitating colectomy
• Tourism
• Migration
• Immunosuppression
Tourism Man, 40 Flight attendant chronic diarrhea
Immigration Mendrisio reception center for asylum seekers 2004 – 2016 of 103 patients with active tuberculosis - 27 with extrapulmonary manifestations Swiss Medical Forum 2018;18:844
Immunosuppression
Man, 35, HIV infection, chronic diarrhea Cryptosporidiosis
Could it be drug related?
• Wide and for general pathologists
somehow frustrating chapter
• Any form of colo-rectal inflammation
possible
• Very few drug-specific histological patterns
Increasing likeliness of drug related
injury
• Otherwise unexplained colitis
• Unusual clinical / morphologic aspects
• Temporal coincidence
• Drug with well documented adverse
effects
• subtle histological hints (eosinophilia,
„bland“ ulcerations, increased apoptotic
activity....)
Man, 62, Anti PD-1 therapy for laryngeal carcinoma Severe diarrhea Lymphocytic expansion of the lamina propria Crypt drop out Epithelial lymphocytosis Chen JH et al. Am J Surg Pathol 2017;41:643 (8 patients)
Apoptosis
Idiopathic inflammatory bowel
disease
• Any colitis of more than 4 weeks duration
invariably raises the question of IBD
Ulcerative colitis
typically begins in the
rectum and extends
proximally
primarily a mucosal
inflammation
No spared segments
No thickening of the wall
No strictures
Crypt architectural
distortion
basal plasma cells
activity (variable)
Crohn‘s disease
in contrast to UC:
- segmental
- transmural
- rectal sparing
- ileal involvement
Patchy distribution
extension into the
submucosa
(granulomas)
Biopsy diagnosis
difficult, if isolated
Crohn‘s colitis
IBD-definition
• An idiopathic and chronic intestinal
inflammation
• manifesting as ulcerative colitis or Crohn‘s
disease
It follows that...
• final diagnosis requires correlation with
clinical findings
• the contribution of pathology is critical but
not entirely conclusive
How far can biopsy diagnosis go?
• Depends also on..
• Quality, number and localisation of
biopsies (esp. separate rectal biopsies)?
• Clinical context provided (previous
treatment, suspected infection, drugs)?
„Formulation proposals“
• No evidence of chronic colitis
• IBD must be considered
• possibly IBD
• consistent with IBD
• probable IBD
• characteristic of IBD
• highly suggestive of IBD
Further information/comments
expected from the pathologist
• UC or CD?
• Activity of the inflammatory process?
• Coexisting conditions or complications
(esp. dysplasia, CMV)?
Mimics
• Diverticular disease associated colitis
• Diversion colitis
• Drug induced chronic colitis
• Infection
• ...
• Clinical context!
man, 51 Bloody discharge since several weeks rectal ulcers
Diffuse mild crypt distortion dense transmucosal infiltrate with mononuclear predominance Chlamydia trachomatis Serovar L2