acute and chronic colitis - pathpathology.ro and... · acute and chronic colitis an approach to...
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Acute and Chronic Colitis an approach to biopsy interpretation
Bernhard Stamm, Zürich
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Endoscopist‘s questions
• Normal mucosa?
• If inflammation, self-limiting or of longer
duration?
• Any clue to etiology?
• Could it be IBD?
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• Histological diagnosis based on a limited
set of mostly ambiguous mucosal
response patterns
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Need of structured approach
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Artefact or disease?
• Artefacts may interfere with a diagnosis of
inflammation
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- Edema - density of mononuclear cells - epithelial flattening - mucin depletion - few focal neutrophils
are weak arguments for genuine inflammation
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„exclusion biopsies“
• „Mild chronic non-specific inflammation“
may be misleading
In case of doupt better:
• „Minor changes, possibly artefacts“
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If obvious colitis..
• Acute or chronic?
• or any of the more specific histological
patterns, likely to contribute to the clinical
workup?
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Acute colitis „self-limiting“ preserved crypt architecture predominantly neutrophils epithelial damage
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Chronic colitis diffuse distortion of crypt architecture predominantly mononuclear cells Paneth metaplasia
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Natura non facit saltus Woman, 29 bloody diarrhea, five weeks
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Pattern recognition
beside acute and chronic
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Microscopic colitis
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Pseudomembranous
colitis
„volcano-like“ exudate of
neutrophils and mucin
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Acute ischemia
„ischemic colitis“
superficial necrosis and
hemorrhage
crypt atrophy
eosinophilic hyalinization of
lamina propria
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Entero-hemorrhagic E.coli –epidemic in Southern Germany Man, 40 severe bloody diarrhea
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• Other patterns: focal active colitis,
eosinophilic colitis, granulomatous
colitis.....
• Evaluation of patterns best at low
magnification!
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Two additional questions always to
be kept in mind..
• Histological recognizable microorganisms?
• Adverse effect of drugs?
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Intestinal spirochaetosis
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Man, 39, two years history of UC
steroid-resistant relapse, necessitating colectomy
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• Tourism
• Migration
• Immunosuppression
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Tourism Man, 40 Flight attendant chronic diarrhea
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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
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Immunosuppression
Man, 35, HIV infection, chronic diarrhea Cryptosporidiosis
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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
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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....)
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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)
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Apoptosis
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Idiopathic inflammatory bowel
disease
• Any colitis of more than 4 weeks duration
invariably raises the question of IBD
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Ulcerative colitis
typically begins in the
rectum and extends
proximally
primarily a mucosal
inflammation
No spared segments
No thickening of the wall
No strictures
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Crypt architectural
distortion
basal plasma cells
activity (variable)
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Crohn‘s disease
in contrast to UC:
- segmental
- transmural
- rectal sparing
- ileal involvement
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Patchy distribution
extension into the
submucosa
(granulomas)
Biopsy diagnosis
difficult, if isolated
Crohn‘s colitis
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IBD-definition
• An idiopathic and chronic intestinal
inflammation
• manifesting as ulcerative colitis or Crohn‘s
disease
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It follows that...
• final diagnosis requires correlation with
clinical findings
• the contribution of pathology is critical but
not entirely conclusive
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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)?
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„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
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Further information/comments
expected from the pathologist
• UC or CD?
• Activity of the inflammatory process?
• Coexisting conditions or complications
(esp. dysplasia, CMV)?
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Mimics
• Diverticular disease associated colitis
• Diversion colitis
• Drug induced chronic colitis
• Infection
• ...
• Clinical context!
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man, 51 Bloody discharge since several weeks rectal ulcers
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Diffuse mild crypt distortion dense transmucosal infiltrate with mononuclear predominance Chlamydia trachomatis Serovar L2