How to differentiate Segmental Colitis Associated with Diverticulosis and

Inflammatory Bowel Diseases?

Alessandro Armuzzi

Lead IBD Unit Complesso Integrato Columbus

Fondazione Policlinico Gemelli Università Cattolica – Rome - Italy

Disclosures

• AA served as Consultant to: Abbvie, Hospira, Ferring, Janssen, Lilly, MSD, Mundipharma, Pfizer, Samsung, Sofar, Takeda

• AA received Lectures fees from: Abbvie, Astra-Zeneca, Chiesi, Ferring, Hospira, MSD, Mundipharma, Otsuka, Takeda, Zambon

• AA received research grant from: MSD

Van Assche G, et al. JCC 2010; Dignass A, et al. JCC 2012

Courtesy of A.Papa– CIC UCSC

Endoscopy in Crohn’s disease

Radiology in CD

Endoscopy in Ulcerative colitis

IOIBD definition, D’Haens. Gastro 2007

Silverberg MS, Can J Gastroenterol 2005

Montreal classification for Crohn’s disease

Phenotypes Age, location, behaviour

Age at diagnosis

A1: < 16 yr

A2: between 17 - 40 yr

A3: > 40 yr

Location

L1: ileal

L2: colonic

L3: ilecolonic

L4: isolated upper GI

Behaviour

B1: non-stricturing and non-penetrating

B2: stricturing

B3: penetrating

p: perianal disease modifier

Silverberg MS,. Can J Gastroenterol 2005

Montreal classification for ulcerative colitis

Extent Anatomy

E1 - Ulcerative proctitis

E2 – Left-sided UC

E3 – Extensive UC

Distal to rectosigmoid junction

Distal to the splenic flexure

Proximal to the splenic flexure

Severity Definition

S0 – Clinical remission

S1 - Mild

S2 - Moderate

S3 - Severe

Asymptomatic

≤ 4 stools/day (± blood), no systemic involvement, normal ESR

≥ 4 stools/day, minimal sign of systemic toxicity

At least 6 bloody stools/day, pulse rate at least 90 bpm, T at least 37.5°C, Hb less than 10.5g/100ml, ESR >30mm/h

Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, 464–470, 2010

SCAD definition

• SCAD is “segmental colitis associated with diverticular disease’’

• It is defined as a chronic colitis confined to the diverticular segment (but with sparing of orifices!) in individuals with otherwise uncomplicated diverticular disease

• By definition, the rectum and the proximal colon are endoscopically and histologically normal

Strate LL et al, Am J Gastroenterol 2012; 107:1486–1493

• It is typically found in over 60 yrs old patients, mostly male

• It is suggested by intermittent (painless) haematochezia, lower abdominal cramps or altered bowel habits

• Very rarely: fever, leucocytosis, nausea and weight loss

• The prevalence is largely unknown, but estimated to be around 0.26%-3,8% of all patients who have had colonoscopy and 1.5-11% of patients with diverticulosis

SCAD definition

Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, 464–470, 2010

Occurrence of IBD and SCAD in gastroenterology primary care setting between 2009 and 2012

Tursi A, et al. EJIM 2013

• 176 patients/94.000 residents • Prevalence: 187.2/100.000

(95%CI 160-217) • CD: 49 • UC: 97 • IBDU: 11 • SCAD: 19

• 2009-2012: 61 new cases • Incidence: 16.2/100.000 (95%CI

3-7.7) • CD:5/100.000 (95%CI 3-7.7) • UC: 6/100.000 (95%CI 3.8-8.9) • IBDU: 1/100.000 (95%CI 0.3-2.6) • SCAD: 4/100.000 (95%CI 2.3-6.5)

Pattern A. ‘Crescentic fold disease’ (52.2%) The colonic mucosa shows swollen red patches as of 0.5 to 1.5 cm in diameter without haemorrhage or ulceration confined to the crescentic mucosal folds. The diverticular orifices are always spared

Endoscopy in SCAD

Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, 464–470, 2010 Tursi A, et al. IJCD 2012;27:179-85

Prospective study performed from January 2004 to October 2007: 6230 colonoscopies, 92 SCAD (1.48%)

Pattern B. ‘Mild-to moderate ulcerative colitis-like’ SCAD (30.4%) This is similar to that of true mild-to-moderate UC including diffuse loss of vascular pattern, mucosal oedema and hyperaemia and diffuse erosions, but differs in that it spares the diverticular orifices

Endoscopy in SCAD

Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, 464–470, 2010 Tursi A, et al. IJCD 2012;27:179-85

Prospective study performed from January 2004 to October 2007: 6230 colonoscopies, 92 SCAD (1.48%)

Pattern C. ‘Crohn’s disease colitis-like’ SCAD (10.9%) It resembles mild-to-moderate Crohn’s colitis. Scattered aphthous ulcers may be found within a normal colonic mucosa, with normal vascular pattern. The diverticular orifices are always spared

Endoscopy in SCAD

Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, 464–470, 2010 Tursi A, et al. IJCD 2012;27:179-85

Prospective study performed from January 2004 to October 2007: 6230 colonoscopies, 92 SCAD (1.48%)

Pattern D. ‘Severe ulcerative colitis-like’ SCAD (6.5%)

It resembles severe UC with diffuse loss of vascular pattern, diffuse hyperaemia and contact bleeding. Mucosal oedema with ulceration is marked. The inflammation is confined to the sigmoid colon in all cases with rectal sparing. The diverticular orifices are not always easy to recognize but they may be visible as being spared by inflammation on maximal air inflation

Endoscopy in SCAD

Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, 464–470, 2010 Tursi A, et al. IJCD 2012;27:179-85

Prospective study performed from January 2004 to October 2007: 6230 colonoscopies, 92 SCAD (1.48%, 11% in diverticulosis)

Basal plasmocytosis Cryptitis

Crypt abscess

Granulomatous inflamation Granulation

Normal Mucosa

Courtesy of dr V. Arena, anatomopathoogist, Catholic University, Rome

Ulcer and crypt distortion

Discontinue inflammation

Deep layer involvement

Histopathology of SCAD resembles IBD

Tursi A, et al, J Clin Gastroenterol 2015

Patients with SCAD compared with mild-moderate UC patients

P<0.015 P<0.026

P<0.006

P<0.033

P<0.04

crescentic fold disease SCAD

SCAD: correlation between endoscopic patterns and symptoms

UC-like SCAD CD-colitis like SCAD Severe UC-like-SCAD

Tursi et al, Colorectal Disease, 12, 464–470, 2010

Long-standing colonic inflammation is associated with a low prevalence of diverticuli in IBD patients

Lahat A, et al, IBD 2007

314 colonic IBD patients and 1023 age-matched control patients

Natural history of elderly-onset inflammatory bowel disease: a French population-based cohort study

(from 1988 to 2006: 841 IBD patients >60 yr at diagnosis)

Charpentier C, et al Gut 2014

474

Disease localisation at diagnosis Disease localisation at diagnosis

Disease behaviour

Incidence and endoscopic findings of UCD, SCAD and AUD

Tursi A, et al, APT 2011

8525 consecutive colonoscopies from January 2004 to June 2009

Endoscopic spectrum of ulcerative colitis with diverticulosis (UCD), segmental colitis associated with diverticulosis (SCAD) and acute uncomplicated diverticulitis (AUD)

0.3% 2% 2%

50 PATIENTS Progression to CD in 3 patients (6%)

Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5

Surgery in 100%

~8% ~12%

Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5

117

Crohn’s disease

(n=197)

Ulcerative colitis

(n=423)

43%

55%

32%

37%

19%

6%

3%

1%

IBD disease course over first 10 years

1. Solberg IC et al. Gastroenterol Hepatol. 2007;5:1430–8. 2. Solberg IC et al. Scan J Gastroenterol. 2009;44:431–440.

Norwegian IBSEN cohort study (1990-1994)

SCAD: 5-year follow-up of 27 patients

Tursi A, et al, IJCD 2012

SCAD B & D fail to maintain long-term remission SCAD A & C show a more benign course

Conclusion

The distinction between SCAD and IBD may be difficult 1) Combination of demographic, clinical,

endoscopic, histological and radiological features

2) Accurate disease location (e.g. rectal-sparing and no proximal extension at endoscopy and histology)

3) Follow up (e.g. after therapy, after surgery)