Forum Member Register/Login
Forums
Monthly Archives: August 2010
Diverticular Disease
Diverticular Disease
Acquired – lack or have attenuated muscularis propria due to focal weakness in the wall
Multifactorial pathogenesis including:
-increased intraluminal pressure
-colonic wall aging
-motor dysfunction
-lack of dietary fiber
Other diverticula to be aware of:
Esophageal
Meckel’s
Angiodysplasia
Angiodysplasia
Clinical
-right colon most commonly, occasionally small intestine
-presents as chronic intestinal bleed, anemia and weight loss
- reported to be association with aortic stenosis
-fairly frequent cause of bleeding in the elderly
-3 types
-I – most common, >55yrs, right colon
-II – 20s and 30s – stomach and proximal bowel
-III – positive family hx - GI tract lesions, oral mucosa and skin lesion
Pathogenesis
-acquired.vascular ectasia due to partial intermittent occlusion of submucosal veins
Gross Appearance
-one or multiple lesion -sharply delineated red, flat or slightly raised, mucosal lesion with scalloped edges and a prominent draining vein
Histology
-dilated, tortuous submucosal veins with distended branches piercing through the muscularis mucosa, connecting with dilated capillaries between the crypts in the lamina propria
-ectatic small vessels may fill the entire mucosa
-surface mucosa erosion and acute chronic inflammation
Ischemic Colitis
Ischemic Colitis
Causes of Ischemic Colitis
-damage to colon secondary to decreased blood flow.
-patients are usually in their 7th decade
-usually atherosclerosis related
-torsion and strangulation rare as causes
-acute fulminant disease with progression to transmural necrosis is rare
-chronic ischemia may lead to progressive stenosis and obstruction
-resolution in 50%, but also high recurrence rate
Distribution of lesions
-most common sites: the splenic flexure and descending colon and sigmoid colon
-any site can be involved
-rectum is the least likely
Microscopic findings on biopsy
-superficial mucosal necrosis
-hyalinized lamina propria
-withered or atrophic crypts
-pseudomembranes
-chronic ulcers or strictures
Ischemic Colitis Differential Diagnosis
-pseudomembranous colitis
-enterohemorrhagic e.coli
-NSAID damage
-radiation colitis
Crohns Disease
Crohns Disease
-1/3 present before the age of 20, 1/5 after the age of 50
-M:F=1:1
-cramping pain , non bloody diarrhea, fever, malaise, anorexia.
-hemorrhage and hematochezia uncommon
-dyspepsia, wt loss, hypoalbuminemia and iron deficiency anemia ( upper GI tract involvement)
-anal and perianal fistulas and fissures
-extraintestinal manifestations – migratory polyarthiritis, ankylosing spondylitis, cholngitis, uveitis, erythema nodosum, amyloid.
Causes of Crohns Disease
-etiology unknown
-chornic inflammatory relapsing and remitting disease of the GI tract
- strong genetic predisposition - 17-35x the risk in siblings of patients
Crohns Disease Appearance
- inflammation anywhere from mouth to anus
creeping fat subserosal fat contracted over the areas of involvement
-areas of firm, thickened and pipelike bowel
-interloop adhesions
-aphthous erosions
-longitudinal “rake “ ulcers
-cobblestoning
-inflammatory polyps
-fissures
-fistulas
-rectal sparing
Crohns Disease Microscopic Appearance
- biopsy:
-discrete foci of inflammation and architectural changes adjacent to histologically normal crypts
-basal lymphoplasmacytic infiltrates
-aphthous lesions often associated with underlying lymphoid aggregates
-variability of inflammation within a single biopsy and among biopsy fragments from the same anatomic location
-may or may not see granuloma on biopsy
-panneth cell metaplasia
-resection ( in addition to the above):
-neural hyperplasia
-submucosal fibrosis
-transumural inflammation
-ulcers separated by histological normal mucosa
-lymphoid aggregates in subserosa and submucosa
-fissures, sinuses and fistulas
-granulomata
Crohns Disease Differential Diagnosis
Infectious colitis
- most common cause of apthous ulcers of small and large intestine
- lack of significant chronic inflammation
- absence of crypt distortion and basal lymphocytosis
- no epithelial granulomata except for TB and Yersinia, but those have to be diagnosed on clinical history
Ischemic colitis
-history is KEY – elderly patients with atherosclerosis, Left-sided distribution of lesions as the left side of the colon is more vulnerable to ischemia
-no granulomata
-lamina propria neutrophillic infiltrate but no crypt abscesses of cryptitis
-intramucosal hyalinization
Ulcerative Colitis
- involves the colon only
- transmural inflammation
Medication associated colitis
- ie. NSAIDS, penicillamine, sulfasalazine, and methyldopa
-lack active inflammation
-no mucosal architectural distortion
-may resemble Crohn’s because it also has abrupt transition between ulcerated and non ulcerated areas
Diverticular disease associated segmental colitis
-commonly in sigmoid
-diverticula seen on colonoscopy
-foreign body type granulomata, cryptitis and crypt abscesses
-colitis is seen in the distribution of the diverticula
Posted in Inflammatory Bowel Disease
Tagged , crohns, crohns disease, crohns disease symptoms, disease, Inflammatory Bowel Disease
Comments Off
Cancer
Neoplastic complications of Iinflammatory Bowel Disease
Epithelial dysplasia in Ulcerative Colitis
Mod Path 2003 : 16(4): 347-358. by Robert Odze
Ulcerative colitis associated epithelial dysplasia
-incidence increases with duration of the disease
-risk is highest with ulcerative pan-colitis – the greatest extent
-presence of sclerosing cholangitis might also be a risk factor
- softer risk factors include: early age of onset, Family History of colon cancer, folate deficiency
- patients who have had Ulcerative Colitis for 7-8 years should be entered in a screening program
- systematic, multiple mucosal biopsies increase the rate of detection
- dysplasia lesions classified as either flat or raised (DALM – dysplasia associated lesion or malignancy).
- dysplastic epithelium further classified into low and high grade dysplasia
-Management guidelies depend on probabilities of 1. coexistant carcinoma and 2. progression onto carcinoma
DALM – dysplasia associated lesion or malignancy
-flat dysplasia , if low grade, is followed. If high grade, goes to colectomy.
-DALM – dysplasia associated lesion or malignancy – is broken down to adenoma-like polypoid sporadic ( isolated polypoid lesions similar in appearance to sporadic adenoma) , adenoma like polypoid dysplastic lesion related to the underlying IBD and non adenoma like . Polypoid sporadic is treated with polypectomy, and there is increasing evidence that polypoid IBD associate lesions can also be treated with polypectomy, provided there is no associated flat dysplasia.
-non adenoma like lesions are treated with colectomy
Crohn’s Disease Cancer
-increased risk of adenocarcinoma ( 4x-20x)
- adenocarcinoma may arise in a morpholocially normal bowel, in areas of stricture and within fistula tracts, making diagnosis difficult.
-multiple synchronous and metachornous adenocarcinomas may occr and involve large and small intestines
-overall mortality in Crohn’s from cancer is high -80%
well-differentiated tumors may extend from fistula tracts and may endoscopically be misinterpreted as adenoma
-symptomatically, adenocarcinoma may mimic a Crohn’s relapse – delay in diagnosis
-unlike in ulcerative colitis there is no standard surveillance strategy due to technical diffculties in surveying the bowel
-prophylactic resection ( for dysplasia) is not recommended because of risk of post op complications
Posted in Inflammatory Bowel Disease
Tagged , Cancer, Crohn’s Disease, dalm, dysplasia, dysplasia associated lesion or malignancy, epithelial, Inflammatory Bowel Disease, prophylactic colectomy, screening, Ulcerative Colitis
Comments Off
Extraintestinal Manifestations
Inflammatory bowel disease extraintestinal manifestations
All inflammatory bowel diseases can have:
- Migratory Polyarthritis, Ankylosing spondylitis, Cholangitis, Uveitiis
Crohn’s Disease
- erythema nodosum, amyloid
Ulcerative Colitis
- primary sclerosing cholangitis
Posted in Inflammatory Bowel Disease
Tagged , Crohn’s Disease, extraintestinal manifestations, Inflammatory Bowel Disease, Ulcerative Colitis
Comments Off