Post on 29-May-2019
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