Fig. 12.14 Ileoanal pouch inflammation
(pouchitis). Acute inflammatory changes similar to UC with somewhat patchy fi-brinous plaques and significant erythema.
Fig. 12.15 Pouchitis (different segment).
The changes here are more pronounced (simultaneous radiology of this region due to carcinoma in the anal transitional zone).
Pouchitis is an inflammation in the ileal reservoir following proctocolectomy and anastomosis of an ileoanal pouch to the anus. Clinical diagnosis must be confirmed by both endoscopy and histology (7).
The most common endoscopic criteria of acute pouchitis are erythema, edema, vulnerability, petechiae, granularity, contact bleeding, fibrinous discharge, erosions, and small ulcerations, similar to UC. Not all patients exhibit these macroscopic signs of extent of inflammation; histological evaluation can reveal a more severe degree of disease activity than is endoscopically visible. Thus, a biopsy is absolutely essential. Among other things, it can be used to classify activity according to number of crypt abscesses (Figs. 12.14, 12.15).
Toxic megacolon is a contraindication for colonoscopy due to high risk of perforation.
Carcinoma can appear in various forms, ranging from a vast polypoid area with an irregular surface to a typical, depressed tumor form. (Figs. 12.16-12.18).
Early Crohn disease (preceding aphthous ulceration) presents reddened patches with distorted vascular pattern. Aphthous erosions are considered early, relatively specific signs of Crohn disease. They are flat and usually less than 5 mm in diameter, with a characteristically narrow, reddened margin and a yellowish or grayish center, i.e., a hyperemic ring surrounding a fibrinous necrosis (012.6). They present in otherwise normal appearing mucosa at some distance to severe lesions.
Normal mucosal segments are interspersed with abnormal segments. Interspersion of normal and affected segments is also referred to as a "skip lesion" (Figs. 12.19, 12.20). Ulcerations can be larger, but are still surrounded by normal mucosa (0 12.17 a). They can range from flat to depressed and some are winding and snakelike (serpigi-nous) (0 12.7b), though they are often parallel to one another longitudinally (012.7 c, e, f).
A "cobblestone" appearance is typical, but not specific, arising from the intersection of longitudinal and transverse ulcerations and fissures (Figs. 12.21,12.22). In general, cob-blestoning affects shorter segments.
Pseudopolyps occur less frequently than with UC (Figs. 12.23-12.25). Strictures are common. They can have a purely scarred appearance, but they often also appear with ulcerations arising from underlying transmural inflammation. Scarring is the result of prior inflammatory episodes (Fig. 12.26).
Fistula openings are often visible and then are usually surrounded by edema and erythema. Endoscopy provides the option of introducing contrast agents into the lumen or through a stricture, e.g., using a probe inserted through the colonoscope in order to visualize fistulous tracts by means of fluoroscopy.
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