Pathology in the selection of patients for pouch surgery. Dr Bryan F Warren Consultant Gastrointestinal Pathologist, Honorary Senior Lecturer, Fellow of Linacre College, Oxford M62 Course 2006
Dec 24, 2015
Pathology in the selection of patients for pouch surgery.
Dr Bryan F WarrenConsultant Gastrointestinal Pathologist, Honorary Senior
Lecturer, Fellow of Linacre College, Oxford
M62 Course 2006
Biopsy – severe UC
Crypts rupture downwards to involve superficial submucosaMimic CD
Distribution and context!
Biopsy pathology UC
• Crypt architectural distortion takes 6 weeks
• Diffuse changes-• Architecture, mucin depletion,
chronic inflammation, acute inflammation
• Rectum most severe• Distribution of changes in a
biopsy and in a biopsy series.• Catch-patchiness-post treatment
or at junction of diseased and normal, or in caecal patch.
• IF BIOPSIES ALL IN SAME POT - HARD TO REPORT!!
Early disease-diffuse Chronic inflammationand basal plasma cells
UC after treatment
Crohn’s colitis
Schiller KFR, Cockel R, Hunt RH, Warren BF. 2001An atlas of gastrointestinal endoscopy and related pathology
Crohn’s colitisFocal erosions and Focal inflammation
Perineural chronic inflammationand granuloma.
Aphthous ulcerGranuloma in relation to ruptured crypt-notall CD
Cryptolytic granulomasLee FD, Maguire C, Obeiat W,
Russell RI.Importance of cryptolytic
granulomas in inflammatory bowel disease. J Clin Pathol 1997;50: 148-152
• 14 patients with non specific inflammatory changes and pericryptal granulomas on biopsy
• 10 were found to have Crohn’s disease
Quiescent/ treated UC
May have only architectural distortion, =/-paneth cells,may return to ‘normal’-review original biopsies ? Infection.
Polyp
Flat mucosa`patchy mimics CDRectal sparing
DON’T JUST BIOPSY THE POLYP
Follow up/ post treatment biopsies in IBD
• Is it still IBD/UC/Crohn’s disease
• Has it got better? Was it IBD after all?
• Is it now complicated by infection/PMC?
• Go back to the original pretreatment series!
Crohn’s large bowel biopsy.
• May be normal
• May mimic UC
• Patchiness is most reproducible feature
• Mucosal granulomas – may mislead
Pathology in pouch surgery
• Two stage and three stage
Colectomy!
• Three stage– Colectomy– Rectal stump
Crohn’s colitis
Transmural inflammation in the form of lymphoid aggregatesThe pathologist cannot see this on a biopsy - help him - context
Crohn’s colitis-terminal ileal disease.
Backwash ileitis in UC or Crohn’s disease? Ileal biopsies maybe difficult.
Biopsies after surgery
• Ileostomy end - non specific changes may misinterpret as Crohn’s disease
• Anastomotic biopsies in Crohn’s
• Diversion– CD may mimic UC– UC may mimic CD
Diversion in UC• Transmural inflammation
• Granulomas
• PMC like change
• Mimics Crohn’s
• It is UC and not a contraindication to pouch surgery.
• Seen as part of the three stage pouch procedure.
• Comforting if this occurs-helps confirm pouch has been made in UC! PUT THE BIOPSIES IN CONTEXT FOR THE PATHOLOGIST!
When is it difficult to differentiate CD colitis and UC?
• Fulminant colitis
• After treatment of UC
• When rare variants of UC are not recognised.
Skip lesions in UC
Acceptable ones:
• Appendix –Davison and Dixon
• Caecal patch – D‘Haens
Not contraindications to pouch surgery.
Caecal patch in UC
Courtesy of Dr Axel von Herbay
Tell the pathologist What you sawPlease label biopsy SitesNot all in same pot!
Indeterminate or unable to tell for the wrong reasons?
Referral to an expert!
Pass on/ share the decision making - good but…
Biopsies minus information
Resection - must be easy, histology must give all the answers!
Photo -absent/poor
Macroscopic description - length of colon only
Slides four from unknown sites around the colon
Remains undiagnosable - not true indeterminate
Working Party clinical classificationIndeterminate Colitis:
use and abusecontroversies and consensus
(WCOG)Séverine Vermeire, MD, PhD (Leuven, Belgium)
Robert Riddell, MD, PhD (Toronto, Canada)Bryan Warren, FRCPath(Oxford, UK)
Karel Geboes, MD, PhD (Leuven, Belgium)
Introduction
• Population-based studies from Scandinavia showed that 5-20% of IBD patients affected by colonic involvement only cannot be definitively diagnosed with CD or UC using available diagnostic tools
indeterminate colitis (IC)
• Incidence of IC estimated at 1.6-2.4/100.000
• What are they calling “IC”
Moum Gut 1997, Hildebrand J Pedriatr Gastroenterol Nutr 1991, Stewenius Scand J Gastroenterol 1995
Definition of IC:evolution of diagnostic criteria
1978: introduction of ‘colitis indeterminate’ by Ashley Price
(J Clin Pathol 1978)
• based on surgical specimens
• features of both CD and UC
Wide-spread use of endoscopy and biopsies
• evolution towards diagnosis based on clinical features + endoscopy +Bxclinical features of chronic IBD, without small bowel involvement; endoscopy non-conclusive ;microscopy active-patchy chronic inflammation with crypt distortion (>10%) and absence of diagnostic features for CD or UC
1978 1980 …………………………………………. 2000 2005
• IC = Temporary diagnosis
• Majority of patients prove to have either CD or UC during follow up
• Is IC distinct disease within IBD?
• Data from epidemiological observations in patients with IC (Stewenius et al J Eur J Surg 1996; McIntyre et al Dis Colon Rectum 1995; Atkinson et al Am J Surg 1994; Stewenius et al Dis Colon Rectum 1996; Stewenius et al Int J Colorectal Dis 1995)
– clinical course– Prognosis
CD, UC or IC: does it matter?
worse compared to UC, especially concerning risk for and outcome of
surgery
“Can I do a pouch?”
• Conflicting data (Dayton Mt 2002, Wells AD 1991, Brown CJ 2005))
– patients operated at St Mark’s London (1960-1983), with diagnosis of IC performed well and were unlikely to develop CD
– Toronto: although greater risk for pouchitis in IC (43%) vs UC (21%), no increased risk for pouch failure with excision (10% vs 6%)
Proposed classification for patients with chronic inflammatory colitis
Diagnosis based on surgical specimen
Diagnosis based on endoscopy with biopsies
• chronic IBD with inflammation restricted to colon and no small bowel involvement.
• non-conclusive endoscopy
• microscopy: active patchy chronic inflammation with minimal or moderate architectural distortion and no diagnostic features for CD or UC. No infectious colitis
overlapping features of both CD and UC
indeterminate colitisUpper GI evaluation (G-scope, double
balloon and/or videocapsule) useful
Colonic IBD Type Unclassified (IBDU)