How to differentiate Segmental Colitis Associated with Diverticulosis and Inflammatory Bowel Diseases?

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1 How to differentiate Segmental Colitis Associated with Diverticulosis and Inflammatory Bowel Diseases? Alessandro Armuzzi Lead IBD Unit Complesso Integrato Columbus Fondazione Policlinico Gemelli Università Cattolica Rome - Italy

2 Disclosures AA served as Consultant to: Abbvie, Hospira, Ferring, Janssen, Lilly, MSD, Mundipharma, Pfizer, Samsung, Sofar, Takeda AA received Lectures fees from: Abbvie, Astra-Zeneca, Chiesi, Ferring, Hospira, MSD, Mundipharma, Otsuka, Takeda, Zambon AA received research grant from: MSD

3 Van Assche G, et al. JCC 2010; Dignass A, et al. JCC 2012

4 Endoscopy in Crohn s disease Courtesy of A.Papa CIC UCSC

5 Radiology in CD

6 Endoscopy in Ulcerative colitis IOIBD definition, D Haens. Gastro 2007

7 Montreal classification for Crohn s disease Phenotypes Age at diagnosis Location Behaviour Age, location, behaviour A1: < 16 yr A2: between yr A3: > 40 yr L1: ileal L2: colonic L3: ilecolonic L4: isolated upper GI B1: non-stricturing and nonpenetrating B2: stricturing B3: penetrating p: perianal disease modifier Silverberg MS, Can J Gastroenterol 2005

8 Montreal classification for ulcerative colitis Extent E1 - Ulcerative proctitis E2 Left-sided UC E3 Extensive UC Severity S0 Clinical remission Anatomy Distal to rectosigmoid junction Distal to the splenic flexure Proximal to the splenic flexure Definition Asymptomatic S1 - Mild S2 - Moderate S3 - Severe 4 stools/day (± blood), no systemic involvement, normal ESR 4 stools/day, minimal sign of systemic toxicity At least 6 bloody stools/day, pulse rate at least 90 bpm, T at least 37.5 C, Hb less than 10.5g/100ml, ESR >30mm/h Silverberg MS,. Can J Gastroenterol 2005

9 SCAD definition SCAD is segmental colitis associated with diverticular disease It is defined as a chronic colitis confined to the diverticular segment (but with sparing of orifices!) in individuals with otherwise uncomplicated diverticular disease By definition, the rectum and the proximal colon are endoscopically and histologically normal Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, , 2010 Strate LL et al, Am J Gastroenterol 2012; 107:

10 SCAD definition It is typically found in over 60 yrs old patients, mostly male It is suggested by intermittent (painless) haematochezia, lower abdominal cramps or altered bowel habits Very rarely: fever, leucocytosis, nausea and weight loss The prevalence is largely unknown, but estimated to be around 0.26%-3,8% of all patients who have had colonoscopy and % of patients with diverticulosis Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, , 2010

11 Occurrence of IBD and SCAD in gastroenterology primary care setting between 2009 and patients/ residents Prevalence: 187.2/ (95%CI ) CD: 49 UC: 97 IBDU: 11 SCAD: : 61 new cases Incidence: 16.2/ (95%CI 3-7.7) CD:5/ (95%CI 3-7.7) UC: 6/ (95%CI ) IBDU: 1/ (95%CI ) SCAD: 4/ (95%CI ) Tursi A, et al. EJIM 2013

12 Endoscopy in SCAD Prospective study performed from January 2004 to October 2007: 6230 colonoscopies, 92 SCAD (1.48%) Pattern A. Crescentic fold disease (52.2%) The colonic mucosa shows swollen red patches as of 0.5 to 1.5 cm in diameter without haemorrhage or ulceration confined to the crescentic mucosal folds. The diverticular orifices are always spared Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, , 2010 Tursi A, et al. IJCD 2012;27:179-85

13 Endoscopy in SCAD Prospective study performed from January 2004 to October 2007: 6230 colonoscopies, 92 SCAD (1.48%) Pattern B. Mild-to moderate ulcerative colitis-like SCAD (30.4%) This is similar to that of true mildto-moderate UC including diffuse loss of vascular pattern, mucosal oedema and hyperaemia and diffuse erosions, but differs in that it spares the diverticular orifices Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, , 2010 Tursi A, et al. IJCD 2012;27:179-85

14 Endoscopy in SCAD Prospective study performed from January 2004 to October 2007: 6230 colonoscopies, 92 SCAD (1.48%) Pattern C. Crohn s disease colitislike SCAD (10.9%) It resembles mild-to-moderate Crohn s colitis. Scattered aphthous ulcers may be found within a normal colonic mucosa, with normal vascular pattern. The diverticular orifices are always spared Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, , 2010 Tursi A, et al. IJCD 2012;27:179-85

15 Endoscopy in SCAD Prospective study performed from January 2004 to October 2007: 6230 colonoscopies, 92 SCAD (1.48%, 11% in diverticulosis) Pattern D. Severe ulcerative colitis-like SCAD (6.5%) It resembles severe UC with diffuse loss of vascular pattern, diffuse hyperaemia and contact bleeding. Mucosal oedema with ulceration is marked. The inflammation is confined to the sigmoid colon in all cases with rectal sparing. The diverticular orifices are not always easy to recognize but they may be visible as being spared by inflammation on maximal air inflation Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, , 2010 Tursi A, et al. IJCD 2012;27:179-85

16 Courtesy of dr V. Arena, anatomopathoogist, Catholic University, Rome Ulcer and crypt distortion Normal Mucosa Cryptitis Basal plasmocytosis Discontinue inflammation Deep layer involvement Crypt abscess Granulomatous inflamation Granulation

17 Histopathology of SCAD resembles IBD Patients with SCAD compared with mild-moderate UC patients P<0.015 P<0.026 P<0.033 P<0.04 P<0.006 Tursi A, et al, J Clin Gastroenterol 2015

18 SCAD: correlation between endoscopic patterns and symptoms crescentic fold disease SCAD UC-like SCAD CD-colitis like SCAD Severe UC-like-SCAD Tursi et al, Colorectal Disease, 12, , 2010

19 Long-standing colonic inflammation is associated with a low prevalence of diverticuli in IBD patients 314 colonic IBD patients and 1023 age-matched control patients Lahat A, et al, IBD 2007

20 Natural history of elderly-onset inflammatory bowel disease: a French population-based cohort study (from 1988 to 2006: 841 IBD patients >60 yr at diagnosis) Disease localisation at diagnosis Disease localisation at diagnosis 474 Disease behaviour Charpentier C, et al Gut 2014

21 Incidence and endoscopic findings of UCD, SCAD and AUD 8525 consecutive colonoscopies from January 2004 to June 2009 Endoscopic spectrum of ulcerative colitis with diverticulosis (UCD), segmental colitis associated with diverticulosis (SCAD) and acute uncomplicated diverticulitis (AUD) 0.3% 2% 2% Tursi A, et al, APT 2011

22 50 PATIENTS Surgery in 100% Progression to CD in 3 patients (6%) Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5

23 117 ~12% ~8% Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5

24 IBD disease course over first 10 years Norwegian IBSEN cohort study ( ) Crohn s disease (n=197) Ulcerative colitis (n=423) 43% 55% 32% 37% 19% 6% 3% 1% 1. Solberg IC et al. Gastroenterol Hepatol. 2007;5: Solberg IC et al. Scan J Gastroenterol. 2009;44:

25 SCAD: 5-year follow-up of 27 patients SCAD B & D fail to maintain long-term remission SCAD A & C show a more benign course Tursi A, et al, IJCD 2012

26 Conclusion The distinction between SCAD and IBD may be difficult 1) Combination of demographic, clinical, endoscopic, histological and radiological features 2) Accurate disease location (e.g. rectal-sparing and no proximal extension at endoscopy and histology) 3) Follow up (e.g. after therapy, after surgery)