KaichunKaichun WuWu

Dept. of Gastroenterology, Dept. of Gastroenterology, XijingXijing HospitalHospitalFourth Military Medical UniversityFourth Military Medical University

XiXi’’anan, China, China

What do we need for diagnosis of IBD

In ChinaUC 11.6/105，CD 1.4/105

Major cause of

chronic diarrhea

Misdiagnosed Cases of IBD

Rate（％） 60.932.1

C DU C

Others 4.2%

IC67.3%

Hemorroids4.7%IBS 11.0%Colonic cancer

7.9%

Ischemic colitis4.9%

Obstruction 26.7%

Others 14.6%

Intestinal TB 30.8%Appendicitis 27.9%

What do we need for diagnosis of IBD

• Knowledge/experience

• Consensus/guideline

• New technologies

Consensus/guidelines of IBD in the West

2001

2004

2006

ACG

ACG

ECCO

CD practice guidelines

UC practice guidelines

CD consensus management

……

Consensus management of IBD in China

• by IBD Collaborative Group in CSG

• published in Chin J Gastroenterol 2007

• 2 parts(diagnosis and treatment), 4 units, 19

sections, 15 pages in total

Diagnosis of ulcerative colitis

Clinical criteria：intestinal, extraintestinal

Endoscopic criteria：distal, diffuse, continuous

Radiologic criteria：less important

Histologic criteria：superficial

Clinical presentation of UC

Intestinal symptoms:• chronic diarrhea(bloody)

• abdominal pain (crampy)

• urgency of defecation

Clinical presentation of UC

Extraintestinal manifestations: • erythema nodosum, pyoderma gangrenosum,• aphthous ulcer, uveitis, iritis, • arthritis, arthralgia, osteoporosis• hepatitis, primary sclerosing cholangitis

Colonoscopic appearance in UC1）Losing vascular transparency, edematous, fragile, fibrin

2）Erosion, bleeding, ulceration

3）Reduced haustration, pseudopolyps, mucosal bridge

Histology of ulcerative colitisMucosal biopsy：

1）Epithelial inflammation, crypt abscess

2）Crypt irregular, distorted glands, chronic infiltration

3）Acute and chronic inflammation

Radiologic appearance in UC

Ba enema: 1）Irregular, granular mucosa

2）Ulceration, filling defect3）Bowel shortened, haustration lost

Diagnostic criteria of ulcerative colitis

Chronic course(>4-6 weeks)

Typical symptoms → suspicious

Symptoms + endoscopic/Ba enema(1) → provisional

Symptoms + endoscopic/Ba enema(1) + histologic(1) → confirmed

Atypical or firstly diagnosed → 3-6 months follow-up

Endoscopic colitis ≠ ulcerative colitis

Chin J Gastroenterology, 2007

Truelove and Witts classification of UC** Moderate is between the mild and severe

>30mm/h<30mm/hESR<75%normalHb>90/minnormalPulse>37.5 (°C)normalTemperaturefrequentintermittentBleeding>6 /day<4 /dayDiarrheaSevereMild

Southerland DAI (Mayo index)Score

0 1 2 3

Diarrhea No >1~2/day >3~4/day >5/day

Bleeding No little much mainly blood

Mucosal No fragile fragile very fragile & exudation

Doctor’s evaluation

No mild moderate severe

Total score<2 remission；3~5 low ；6~10 moderate；11~12 high activity。

Diagnosis of Crohn’s disease

Clinical criteria：intestinal, perianal disease

Radiologic：segmental, stricture, fistula, longitudinal ulcer

Endoscopic：skip, stricture, longitudinal ulcer, cobble stone

Histologic：granuloma with non-caseation, fissure ulcer

Surgical: transmural, asymmetric, skip, stricture

CD

Fistula fistula and abscess

Crohn’s disease

Fistula

Peri-anal disease

Crohn’s disease radiography

CD

Crohn’s disease colonoscopy

Pale Edema

Cobble stoneBleeding

Stenosis

Ulceration

UC

Granuloma Fissure ulcer

Crohn’s disease histology

UC

CDBowel resection specimensCrohn’s disease

Diagnostic criteria of Crohn’s disease

Chronic course(>4-6 weeks)

Typical symptoms → suspicious

Symptoms + SBFT/endoscopic → provisional

Symptoms + SBFT/endoscopic + histologic(1-3) → confirmed

Atypical or firstly diagnosed → 3-6 months follow-up

Differentiating intestinal TB → 4-8 weeks diagnostic therapy

Chin J Gastroenterology, 2007

WHO recommended CD diagnosisClinical radiologic endoscopic histologic surgical

Segmental ＋ ＋ ＋

Longitudinal ulcer, cobble stone ＋ ＋ ＋

Transmural ＋mess

＋stricture

＋stricture

＋

Granuloma, non-caseative ＋ ＋

Fissure ulcer, fistula ＋ ＋ ＋

Perianal lesions ＋ ＋ ＋

*1. ①+②+③=suspicious ； 2. ①+②+③+④or⑤or⑥=confirmed ； 3. ④+ two of ①or②or③=confirmed 。

Best CDAI

CDAI<150 remission; >150 active, 150~220 mild, 220~450 moderate, >450 severe

Variants

Diarrhea（1week）Abdominal pain（1week）Overall（1week）extraintestinal（1 for 1item）OpininAbdominal messSedimentation（normal：M47，F42）100×（1-bwt/standard）Total=sum of V

Power

25720301061

Differentiation between IBD and acute self limiting colitis (ASLC)

plasma cell in base of cryptneutrophil in LPCell

infiltration

intactdistortedCrypt structure

fewer，~1.6％59％ casesPlt elevated

pathogen in 50%no pathogenStool culture

>10/day<6/dayDiarrhea

<4 weeks

started with fever

chronic, recurrent

gradual, no fever

Clinical courseOnset

ASLCIBD

Differentiation between UC and CD

terminal ileum lesion(30％)，segmental lesions，stricture/fistula/perianal lisions(75％)

granular，hyperplastic polypsGross specimens

transmural，submucosal thicken，granuloma(45％)

crypt abscess, no granulomaHistology

aphathous ulcer，cobble stone sign，longitudinal ulcer

edematous,fragile mucosaEndoscopy

＋＋＋＋＋＋Cancer risk

common，asymmetricrare，centralStricture

common fistula or abscessrare fistulaComplications

segmental, skip lesionstransmural

continuous, diffusemucosal

distribution

any parts of GI tractcolonLocation

CDUC

Endoscopic difference between UC and CD

UC CDLocation left colon right colon

rectum>95% rectum<50%

T. ileum rare common

Distribution diffuse, continuous asymmetric, skip

Mucosal ulcer irregular ulcer longitudinal, deep

hyperemia, erosion around normal mucosa around

exudation common rare

bleeding common rare

peudopolyps common rare

cobble stone rare common

Differentiation between CD and intestinal tuberculosis

Anti-TB therapy

Histology

Ulceration

effective in 4～8 weeksno effect

caseative granulomanon-caseative granuloma, mesentric lymphonodes

circumferentiallongitudinal

rarecommon

noyes

yesnoTB in other place

Perianal

Fistula

IC-TBCD

Differentiation between intestinal tuberculosis and CD in endoscopic biopsy specimens by PCR

Histology

Positive rate(%)

caseativegranuloma

non-caseativegranuloma

64.171.4(granuloma+)61.1(granuloma -)

0

IC-TBCD

Gan HT, et al. Am J Gastroenterol. 2002

Innovative diagnostic procedures

Serologic markers（1）CRP

（2）ESR

（3）platlets；albumin；sialic acid；AAG；fibrinogen； lactoferrin；

β2-microglobulin； amyloid A； α2-globulin； α1anti-typsin； OMP-C；

12-peptide

(4) pANCA for UC 60%~80%

ASCA for CD 60%~70%

Combination 87%~97%

(ASCA bacterial-driven antibody marker)

Useful for indeterminate colitis

Faecal markersCalprotectin(Cal ） , lactoferrin(Lf ） , lysozyme,

elastase, myeloperoxidase

（1）calprotectin（Cal）

（2）lactoferrin（Lf）

Correlate well with CRP, ESR, disease activity

and severity。

2003, CT ColonographyOct 1996, Barium enema

Segmental STRICTURING

CROHN’S COLITIS SUBGROUPING

IBD related cancersStart at 5～8 years from onset Malignancy in 20 years 10%～20%Correlate with disease extension, site, duration

Pancolitis prominent and early

Long history prominent

UC malignancy multi-fociDifficult to find by endoscopy/barium enema

Mucosal biopsy may help

Genetic study helpful

Endoscopic developments

1. Chromocolonoscopy

2. Confocal laser endomicroscopy

3. Narrow band imaging colonoscopy

4. Endocytoscopy

5. Wireless capsule endoscopy

6. Double-balloon enteroscopy

Chromocolonoscopy for UC

UC in remission

Mild UC

Confocal laser endomicroscopy

Narrow Band ImagingAllows better detection of vessels and small mucosal lesions

415nm 445nm 500nm 540nm 600nm

400 450 500 550 600 nm

Endocytoscopy