Ibd: The Role of pathology in diagnosis and disease …...• Dearth of endoscopy and imaging tools...
Transcript of Ibd: The Role of pathology in diagnosis and disease …...• Dearth of endoscopy and imaging tools...
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IBD: THE ROLE OF PATHOLOGY IN DIAGNOSIS AND DISEASE
MONITORING
Olusegun Ojo FMCPath
Consultant Histopathologist
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HISTOLOGICAL EVALUATION IS PIVOTAL
1. Initial Diagnosis
• Is this IBD of something else?
• What else might it be?
2. Classification and Characterisation of Disease
• Which is it, Crohn’s or UC?
• Indeterminate Colitis
• Grading of disease (and ?prognostication)
3. Disease Monitoring
• Effects of therapy
• Remission and associated conundrums
• Evaluation of dysplasia
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1 .Diagnosis: Is this IBD or Something Else?
• Infectious Colitides
• Microscopic Colitis
• Degenerative (and vascular) disorders
• IBS + idiopathic disorders
• Inflammatory Bowel Disease
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1 . DIAGNOSIS: IBD Vs OTHER COLITIDES
• Histological features that are most useful in separating IBD from other
inflammatory processes are:
• Crypt distortion, crypt atrophy, and basal plasmacytosis
• Severe mononuclear cell infiltration (lymphoid follicles) and Paneth cell metaplasia
distal to the splenic flexure.
• In addition, mucosal eosinophilia is a common finding in active and quiescent disease
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1 .DIAGNOSIS: WHAT ELSE MIGHT IT BE?
• Infectious colitis, ischaemic colitis, diverticular-associated colitis, and intestinal
vasculitis
• Collagenous and lymphocytic colitis may show distal Paneth cell metaplasia and
basal plasmacytosis but the endoscopic exam is normal.
• Intestinal vasculitis
• Radiation Colitis
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• Mycobacterium tuberculosis is the pathogen in most
cases.
• Mycobacterium bovis in some parts of the world
with no pasteurization of milk.
• Mycobacterium avium intracellulare has become a
major pathogen in HIV patients.
(Nial et al., 1997)
GASTROINTESTINAL TUBERCULOSIS
PATHOGENESIS
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PATHOLOGY
Portis (1953)
Bacill in depth of mucosal glands
Inflammatory reaction
Phagocytes carry bacilli to Peyers Patches
Formation of tubercle
Tubercles undergo necrosis
Most active inflammation in submucosa.
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PATHOLOGYSubmucosal tubercles enlarge
Endarteritis & edema
Sloughing
Ulcer formation
Accumulation of collagenous tissue
Thickening & Stenosis
(Howell & Knapton, 1964)
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(Boyed, 1943)
PATHOLOGY
Lymphatic obstruction
of mesentery and bowel
Thick fixed mass
Regional lymph nodes
• Hyperplasia
• Caseation necrosis
• Calcification
Bacilli via lymphatics
Inflammatory process in submucosa penetrates to serosa
Tubercles on serosal surface
Bacilli reach lymphatics
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FORMS OF GI TB
Ulceroconstrictive
60% of patients
Highly virulent
Mostly small Intestinal
Hypertrophic
10% of patients
Chronic
Mostly Ileocoecal
Mixed 30% of patients
(Howell & Knapton, 1964)
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2. WHICH IS IT, UC OR CROHN’S
• UC
• Continuous, non segmental predominantly mucosal disease
• Rectal involvement, sometimes patchy involvement of right colon and appendix
• Lack of ileal involvement unexplainable as backwash ileitis
• Crohn’s
• Fissuring ulcers
• Transmural lymphoid aggregates
• Granulomas unrelated to infection,, crypt rupture or FBs
• Ileitis or Colitis or both associated with segmental disease, rectal sparing, upper GI
involvement
• Indeterminate Colitis
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INDETERMINATE COLITIS
• IBD with overlapping pathological features of UC and CD so that a definitive
diagnosis is difficult of impossible
• Not a disease but an interim Pathologist’s diagnosis
• No pathognomonic or diagnostic criteria
• An interim position until further info (clinical, radiological or pathological)
become available enough to allow a definite classification
Robert Odze A contemporary and Critical Appraisal of ‘Indeterminate Colitis’ Modern Pathology 28, 530 – 546 2015
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MICROSCOPIC COLITIS
• Collagenous Colitis
• Lymphocytic Colitis
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3. DISEASE MONITORING
• Assessment of Disease Activity
• Grading
• Mild, Moderate or Severe
• Dysplasia
• Flat Dysplasia
• Polypoid Dysplasia
• High-grade dysplasia
• Low-grade dysplasia
1. Engelsgjerd M. et al Polypectomy may be adequate treatment for adenoma-like dysplastic lesions ib chronic ulcerative colitis Gastroenterology 117; 1288 -1294 1999
2. Rubin PH et al Colonoscopic polypectomy in chronic colitis; conservative management after endoscopic resection of dysplastic polyps
Gastroenterology 117 1295 1300 1999
3. Blackstone M. et al Dysplasia-associated lesions or mass detected by colonoscopy in long-standing ulcerative colitis: an indication for
colectomy Gastroenterology 80, 366 – 374 1981
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CHALLENGES IN SSA
• Clinical
• Not nearly enough Gastroenterologists
• Dearth of endoscopy and imaging tools
• Dismal medical records
• Laboratory
• Other Path labs
• Microbiology
• Clinical chemistry
• Histopathology
• GIT Pathologists are few and far between
• Pathology Training in IBD could do with some assistance
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Thank you for listening