Granulomatous inflammation in sigmoid diverticulitis: two diseases or one?

Accurate histopathological assessment of biopsies is important for the diagnosis, subclassification, and management of chronic idiopathic inflammatory bowel disease (IBD). British Society of Gastroenterology (BSG) guidelines for the initial histopathological diagnosis of IBD were published in 1997. Changes since then include: more widespread use of full colonoscopy; greater recognition of the effects of time and treatment; improved documentation of variations in anatomical distribution; better understanding of the mimics of IBD; significant progress in clinical management; and modifications of terminology. Accordingly, an update is required. These revised guidelines aim to optimise the quality and consistency of reporting of biopsies taken for the initial diagnosis of IBD by summarising the literature and making recommendations based on the available evidence. Advice from existing clinical guidelines is also taken into account. Among the subjects discussed are: distinguishing IBD from other colitides, particularly infective colitis; subclassification of IBD (as ulcerative colitis, Crohn's disease, or IBD unclassified); the discriminant value of granulomas; aspects of disease distribution, including discontinuity in ulcerative colitis; time-related changes; differences between paediatric and adult IBD; the role of ileal and upper gastrointestinal biopsies; differential diagnoses such as diverticular colitis and diversion proctocolitis; and dysplasia. The need to correlate the histological features with clinical and endoscopic findings is emphasised. An approach to the conclusion of an IBD biopsy report based on the acronym Pattern, Activity, Interpretation, Dysplasia (PAID) is suggested. The key recommendations are listed at the end of the document.

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“…Basal plasmacytosis and Paneth cell metaplasia are also quite common. Villous surface change and non-cryptolytic granulomas are rare 27 100…”

Section: Mimics Of Ibdmentioning

confidence: 99%

Inflammatory bowel disease biopsies: updated British Society of Gastroenterology reporting guidelines

2013

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“…In addition to other pelvic disease and to infectious or inflammatory bowel disease, special forms of inflammatory or otherwise abnormal mucosa coexisting with diverticulosis must be considered, in order to avoid a too liberal ‘definition’ of diverticulitis, e.g. NSAID colitis, ischemia [7], diverticular colitis [8,9,10,11,12], mesenteric inflammatory veno-occlusive disease [13], coexistence of Crohn’s disease and diverticulosis or diverticulitis [14,15,16,17], and prolapsing mucosal folds in diverticular disease [18,19]. Not taking care for these differentiations makes it very difficult to compare patients, rationales and results from the literature.…”

Section: What Is Recurrent Diverticulitis?mentioning

confidence: 99%

The Gastroenterologist’s View

Lembcke¹

2012

Dig Dis

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The traditional view that recurrent episodes of diverticulitis lead to progressively complicated disease resulting in a disadvantageous course, more difficult, complicated operations and lethal outcomes did not stand the test of evidence. Only a minority of patients with acute diverticulitis will ever require surgery, and if so, this occurs during or early after the first episode. Complications and recurrence of disease after surgery are enumerable. Strong indicators favoring sigmoid colectomy are major abscess, free air, and fistula, i.e. perforating disease. This occurs predominantly at the initial presentation, frequently in younger or immunosuppressed patients. Important differential diagnoses must be considered both for initial diagnosis of diverticulitis and for recurrent episodes. Conservative management of recurrent diverticulitis is safe and best guided by gastroenterological expertise. Sophisticated ultrasound experience as a part of this competence allows detailed evaluation of the local status and the best evidence in the literature for diagnosing diverticulitis is on US. In practice, however, the question of perforating diverticulitis is adequately answered by subtle CT scan. Medical therapy is usually the treatment of choice for recurrent diverticulitis. Avoidance of drugs bearing the hazard of perforation (e.g. NSAIDs) is emphasized, and smoking is strongly discouraged. A mathematical model based on published data shows that patients with recurrent diverticulitis overall (only) profit from surgery if they are hit by four episodes during the course of disease. This is where theory and reality (should) meet.

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“…[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] This pattern may be predominantly periostial in distribution or 11,18,20 Several studies have addressed the clinical and pathologic features of sigmoid colitis in patients with diverticular disease. Two, which have focused especially on the histologic features from different perspectives, are summarized below.…”

Section: Diverticulosis-associated Changes In the Nondiverticular Mucmentioning

confidence: 99%

The Pathology of Diverticulosis Coli

West

Losada²

2004

Journal of Clinical Gastroenterology

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Left-sided diverticulosis coli is a common condition in western communities, with 30% to 50% of adults over the age of 60 being affected. It predominantly involves the sigmoid colon. The diverticula (pseudodiverticula) are pockets of mucosa bounded by muscularis mucosae and invested with a thin layer of submucosa, that are forced out through weak points in the muscularis propria, the tips ending in the colonic subserosa. The weak points in the muscle coat are the sites of entry of the nutrient vessels of the colonic mucosa. Diverticulosis is attributed to increased colonic intraluminal pressure while straining at stool in individuals who eat low-fiber diets. Muscular hypertrophy, shortening of the bowel, and thickened mucosal folds due to mucosal redundancy are characteristic of this condition. Complications of diverticulosis include bleeding, diverticulitis, peridiverticular abscess, perforation, stricture, and fistula formation. However, most individuals with diverticulosis are asymptomatic, without evidence of complications. Mucosal changes in the diverticula in uncomplicated diverticulosis include an increased lymphoid infiltrate, development of lymphoglandular complexes, mucin depletion, mild cryptitis, architectural distortion, Paneth cell metaplasia, and ulceration. The mucosa of the remainder of the sigmoid colon (ie, the nondiverticular mucosa) is usually normal, but in about 1% of cases it has features that are indistinguishable from ulcerative colitis or from Crohn's disease (segmental colitis associated with diverticular disease, SCAD). Such cases pose a difficult diagnostic challenge as patients with SCAD respond to medical or surgical therapy for diverticular disease, whereas those with ulcerative colitis or Crohn's disease will develop other manifestations of their disease in time and require different treatment. In SCAD, the mucosal changes are confined to the area of diverticulosis; therefore, histologic evaluation of the rectum (which is unaffected by diverticulosis) and more proximal bowel can be helpful in the differential diagnosis.

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Granulomatous inflammation in sigmoid diverticulitis: two diseases or one?

Abstract: Granulomatous inflammation appears to be part of a spectrum of sigmoid diverticulitis. In this setting, caution should be exercised to avoid an inappropriate diagnosis of Crohn's disease.

Cited by 80 publications

References 13 publications

Inflammatory bowel disease biopsies: updated British Society of Gastroenterology reporting guidelines

Inflammatory bowel disease biopsies: updated British Society of Gastroenterology reporting guidelines

The Gastroenterologist’s View

The Pathology of Diverticulosis Coli

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