Chronic Colitis Pattern Christina A. Arnold, M.D. The Ohio State University Wexner Medical Center Columbus, Ohio

Transcription

1 Chronic Colitis Pattern Christina A. Arnold, M.D. The Ohio State University Wexner Medical Center Columbus, Ohio

2 Identify this medication resin: A. Bile Acid Sequestrant B. Kayexalate C. Sevelamer D. Renvela 0% 0% 0% 0% A. B. C. D.

3 Chronic Colitis Pattern: Overview The chronic colitis pattern is etiologically non specific A 3 step approach will cover all cases! Utilize pertinent "clues" to uncover the etiology and direct etiologic specific management

4 A Pattern Based Approach to Colitis: Step 1: Classify Colitis Acute Chronic

5 Acute Colitis: Acute inflammation in the epithelium Cryptitis Crypt abscess Erosion Ulceration No features of chronicity Colitis: Definitions

6 Colitis: Definitions Acute Colitis: Acute inflammation in the epithelium Cryptitis Crypt abscess Erosion Ulceration No features of chronicity Chronic Colitis: Established features of chronicity Pyloric gland metaplasia Paneth cell metaplasia Increased lamina propria chronic inflammation Architectural distortion ovilliform mucosal surface oabnormal crypt configuration ocrypt drop out ocrypt shortfall obasal lymphoplasmacytosis

7 1. Biopsy Location is Important Normal Right Colon: Normal Left Colon:

8 2. Tissue Orientation is Important

9 Architectural Distortion Normal Colon: Villonodular surface, Abnormal Crypt Configuration, Crypt Shortfall, Basal Lymphoplasmacytosis:

10 A Pattern Based Approach to Colitis: Step 1: Classify Colitis Acute Chronic Active Inactive Step 2: Grade Activity Step 3: Mild Moderate Severe < 50% of > 50% of Erosion or crypts with crypts with ulcer, PMN PMN regardless of PMN See note.

11 Chronic Colitis: Checklist Inflammatory Bowel Disease Medications Infections Diversion Associated Colitis Diverticular Disease

12 Key Features Ulcerative Colitis Crohn Disease Active chronic colitis Yes Yes Depth of involvement Mucosal restricted Transmural Rectal involvement Yes No Progression pattern Diffuse, most severe distally Patchy ("skip lesions") Upper tract and small bowel involvement No Yes Pseudopolyps Yes No Pipe like" bowel wall No Yes "Creeping fat" No Yes Fissures, fistulas, strictures, sinus tracts No Yes Mucosal "cobble stone" No Yes Transmural lymphoid aggregates No Yes Transmural inflammation No Yes Granulomata Crypt Rupture Yes (poorly formed)

13 Which gross is most suggestive of UC? A. Upper B. Lower 0% 0% A. B.

14 Which is most suggestive of UC? A. Left B. Right 0% 0% A. B.

15 Active Chronic Colitis: Sample Note (Established IBD History) Rectum, biopsy: Mild active chronic proctitis. See note. Note: These findings support the established history of UC. Negative for dysplasia, granulomata, and viral cytopathic effect.

16 Active Chronic Colitis: Sample Note (No History) Colon, biopsy: Mild active chronic colitis. See note. Note: Active chronic colitis is etiologically nonspecific. The differential diagnostic considerations include chronic medication injury, chronic infection, diverticular disease, diversion associated colitis, and emerging inflammatory bowel disease, among others. Clinicopathologic correlation required. Negative for dysplasia, granulomata, and viral cytopathic effect.

17 Chronic Colitis: Checklist Inflammatory Bowel Disease Medications Infections Diversion Associated Colitis Diverticular Disease

18 Case 1: Clinical History 67 year old woman underwent emergent total colectomy for medically refractory CMV colitis Rule out IBD

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21 Medication Crystals: Differential Diagnoses Kayexalate Sevelamer Bile Acid Sequestrants (BAS)

22 Medication Crystals: Pearls & Pitfalls Active chronic colitis can be indistinguishable from IBD K ayexalate (Renal Failure): K ills, K nown to cause ulcers/ischemia, lowers K+, purple, +fish scales Sodium polystrene sulfonate Sevelamer (Renal Failure):?Injury, lowers phosphate, 2 toned, +fish scales Renvela, Renagel BAS (Diarrhea): B enign, B urnt orange, lowers B ile acids, no fish scales Colesevelam (Welchol ); Colestipol (Colestid ); Cholestyramine (LoCholest, Prevalite, Questran )

23 Case 1, Revisited: A. Kayexalate B. Sevelamer C. BAS H&E Kayexalate Sevelamer 0% 0% 0% Bile Acid Sequestrants (BAS) A. B. C.

24 BAS: Sample Note Colon, total proctocolectomy: Colorectum with severe active chronic colitis, ulcerations, CMV viral cytopathic effect, and BAS crystals. See note.

25 BAS: Sample Note Note: The history of medically refractory CMV colitis is noted. The resection specimen shows severe active chronic colitis with CMV viral cytopathic effect and BAS crystals. We favor the active chronic changes are due to the known history of chronic CMV colitis. BAS have no established role in causing mucosal injury, see reference below. If a clinical concern for IBD persists, correlation with upper tract biopsies is a consideration. Reference: Arnold MA, Swanson BJ, Crowder CD, Frankel WL, Lam Himlin D, Singhi AD, Stanich PP, Arnold CA. Colesevelam and Colestipol: Novel Medication Resins in the Gastrointestinal Tract. Am J Surg Pathol Jun 11.

26 Key Features Sevelamer Sodium polystyrene sulfonate Bile Acid Sequestrants Renagel Kayexalate Many Trademark names Renvela Target ion Phosphate Potassium Bile acids Chronic renal Chronic renal failure failure Clinical history Mucosal injury Possible Yes No Fish scale Yes Yes None Diarrhea >> Hypercholesterolemia and Pruritis H&E 2 toned pink/yellow Purple PAS/D Lavender Hot pink Bright orange to black Grey and hot pink AFB Magenta Black Dull yellow

27 Case 2: Clinical History 21 year old status post segmental colectomy after intra abdominal trauma Presents with bloody discharge Endoscopy reveals rectal ulcerations and nodularity Rule out IBD

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32 Diversion Associated Colitis: Pearls & Pitfalls Active chronic colitis can be indistinguishable from IBD Diversion colitis is an iatrogenic consequence of surgical detour of the fecal stream Red Flags: Any history of bowel resection/injury Diverticular disease, neoplasm, trauma, necrotizing enterocolitis The disease is due to a deficiency of short chain fatty acids in the excluded segment Diversion colitis is 100% curable with ostomy reversion or enemas

33 Diversion Colitis is due to a Short Chain Fatty Acid Deficiency in the Excluded Segment X

34 Diversion Associated Colitis: Sample Note Rectum, proctectomy: Segment of rectum with mild active chronic colitis. See note. Note: The history of abdominal trauma, emergent ileostomy, and prominent mucosal nodules in the excluded bowel segment is noted. The resection specimen shows active chronic colitis, in keeping with active chronic diversion associated colitis.

35 Case 3: Clinical History 81 year old with complicated diverticular disease undergoes emergent sigmoidectomy History of sigmoid ulcerations with rectal sparring Rule out Crohn disease

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37 Diverticular Disease

38 Diverticular Associated Colitis: Pearls & Pitfalls Active chronic colitis can be indistinguishable from IBD Due to the western diet / constipation Diverticular disease is very common in the sigmoid and spares the rectum Always consider diverticular disease in biopsies of the left colon Curable with proper diet, antibiotics, analgesics OR surgical resection

39 Diverticular Associated Colitis: Sample Note Sigmoid, sigmoidectomy: Segment of colon with mild active chronic colitis. See note. Note: The intra operative impression of diverticular disease is noted. The resection specimens shows active chronic colitis limited to the diverticula, in keeping with diverticular associated colitis.

40 Case 4: Clinical History 36 year old man with 2 months of progressive bloody diarrhea and severe anal pain Endoscopy shows a circumferential mass Patient consented for surgical resection

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43 Courtesy of Dr. Jana M. Ritter, CDC

44 STI Colitis: Pearls & Pitfalls Active chronic colitis can be indistinguishable from IBD STI colitis = Syphilitic and/or LGV Clinical red flags: HIV+ MSM Pathologic red flags: 1. Prominent submucosal plasma cells 2. Lack of architectural changes, including Paneth cells 3. Lack of prominent acute inflammation 4. Lack of eosinophilia Curable with antibiotics

45 STI Colitis IBD

46 STI Colitis IBD

47 STI Colitis: Sample Note Rectum (biopsy): Colonic mucosa with mild cryptitis, intense chronic inflammation, and prominent submucosal plasma cell rich inflammation. Negative for significant architectural distortion, crypt centric damage, and eosinophilia.

48 STI Colitis: Sample Note Note: The biopsy findings have been associated with syphilitic and/or LGV infections. In such cases, clinical studies provide the best means of evaluation, see below. It would be important to evaluate for *both*since identical histologic features can be seen with either agent in either isolation or in combination. A CMV immunostain and AFB and GMS special stains are negative. Syphilis: Serum RPR, RPR titer, and a treponemal specific serology LGV: Rectal swab collected in the absence of lubricant for C. trachomatis nucleic acid probe test, indirect immunofluorescence, culture, or LGV PCR Reference: Arnold CA, Limketkai BN, Illei PB, Montgomery E, Voltaggio L. Syphilitic and lymphogranuloma venereum (LGV) proctocolitis: clues to a frequently missed diagnosis. Am J Surg Pathol Jan;37(1):38 46.

49 Chronic Colitis Pattern: Summary The chronic colitis pattern is etiologically non specific A 3 step approach will cover all cases! Utilize pertinent "clues" to uncover the etiology and direct etiologic specific management Checklist: Inflammatory Bowel Disease Medications Infections Diversion Associated Colitis Diverticular Disease

50 Bonus Quiz

51 Identify this medication resin: A. Bile Acid Sequestrant B. Kayexalate C. Sevelamer D. Renvela 0% 0% 0% 0% A. B. C. D.

52 This finding was seen in an autopsy case. The clinician asks which drug may have caused the fatal ischemic colitis? A. Top left B. Bottom right A B 0% 0% A. B.

53 What is the underlying mechanism of diversion associated colitis? A. Deficiency of short chain fatty acids in the excluded bowel B. Deficiency of short chain fatty acids in the diverted bowel C. Deficiency of medium chain fatty acids in the excluded bowel D. Deficiency of long chain fatty acids in the diverted bowel 0% 0% 0% 0% A. B. C. D.

54 Diversion Colitis is due to a Short Chain Fatty Acid Deficiency in the Excluded Segment X

55 Identify the depicted gross abnormality: A. Diversion Colitis B. Syphilitic Colitis C. LGV Colitis D. Diverticular Disease 0% 0% 0% 0% A. B. C. D.

56 Select the most likely etiology: A. B. C. D. This is a normal rectal biopsy Favor IBD Favor STI colitis Favor plasma cell neoplasm 0% A. 0% B. 0% C. 0% D.

57 Which of the following is correct about syphilitic / LGV colitis? A. It is an IBD mimic B. It is curable with antibiotics C. HIV, Syphilis, and LGV testing worthwhile D. It can present as large mass lesions E. All of the above are correct 0% 0% 0% 0% 0% A. B. C. D. E.

58 Match the following red flags to the characteristic chronic colitis etiology: Red flags: Severe A constipation HIV+ C Bowel B Perforation Renal D Failure Etiologies: A. Diverticular Disease B. Diversion Associated Colitis C. Syphilitic / LGV Colitis D. Kayexalate / Sevelamer

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