Backwash Ileitis

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- |T] 12.10 Differential diagnosis: ileitis

a Crohn disease: terminal ileitis.

b Crohn disease: terminal ileitis.

c Ileitis caused by 5-FU chemotherapy.

a Crohn disease: terminal ileitis.

b Crohn disease: terminal ileitis.

c Ileitis caused by 5-FU chemotherapy.

Backwash Ileitis

d Terminal ileitis related to yersiniosis.

e Backwash ileitis in ulcerative colitis.

f Backwash ileitis in ulcerative colitis.

d Terminal ileitis related to yersiniosis.

e Backwash ileitis in ulcerative colitis.

f Backwash ileitis in ulcerative colitis.

Yersiniosis
Fig. 12.32 Pronounced pseudo-polyps. These appear in UC but can also appear in CD.

Infectious Colitis

These are forms of self-limiting colitis, caused by acute microbial triggers that generally manifest with acute diarrhea. Deciding clinical factors are thus acute onset of symptoms, short time period (less than one week), sometimes rapid onset of fever, travel abroad, or local outbreak of diarrhea. Regarding diagnosis, it is important to remember that stool cultures are often negative in patients with infectious colitis. Chronic changes can be expected after six weeks. Thus, if symptoms persist and there are signs of the condition becoming chronic, surveillance colo-noscopy after three months is recommended.

Endoscopic appearances are varied. The proximal right side of the colon is usually affected, but disseminated disease also can occur. In the acute phase, there are often patchy erythemas, sometimes partly brown-red in color, intramucosal bleeding, and mucosal edema (Fig. 12.34). Vascular pattern usually remains intact or at least partially visible and erosions (including aphthous erosions) may be present. Ulcers are usually small and deep ulcers are rare. Thus, the mucosal "architecture" may seem to appear intact. Difficulties arise in that some longer term infectious colitis types can mimic IBD morphologically (Crohn disease, in particular). This is particularly true of Campylobacter jejuni colitis and amebiasis. Suspicious cases must therefore be serologically investigated. Diagnosis can also be difficult when there is a bacterial superinfection related to IBD (Fig. 12.35).

Histopathological analysis can help distinguish between acute infectious enterocolitis vs. early stages of a chronic inflammatory bowel disease. A very high degree of neutrophilic infiltration and severe edema tend to indicate infectious colitis. Severe crypt distortion is more indicative of UC, while discontinuous, focal cryptitis supports a diagnosis of CD. Granulomas may be absent with CD, but, alternatively, they may be found in tuberculosis and yersiniosis.

Normal Sigmoid Colon

Fig. 12.33 Differential diagnosis of UC-CD a High-grade fibrinous-ulcerous inflammation with granularity; this segment of the transverse colon rather supports a diagnosis of UC. b Ulcer pocket in anal canal, which does not support diagnosis of UC, rather CD. c Distorted vascular pattern and patchy erythema in rectum, but no fibrin or ulcers; also does not support diagnosis of UC (NB: no local therapy in past eight months). d In cecum, partially normal vascular pattern, bizarre, recent ulcers that better support diagnosis of CD.

Fig. 12.33 Differential diagnosis of UC-CD a High-grade fibrinous-ulcerous inflammation with granularity; this segment of the transverse colon rather supports a diagnosis of UC. b Ulcer pocket in anal canal, which does not support diagnosis of UC, rather CD. c Distorted vascular pattern and patchy erythema in rectum, but no fibrin or ulcers; also does not support diagnosis of UC (NB: no local therapy in past eight months). d In cecum, partially normal vascular pattern, bizarre, recent ulcers that better support diagnosis of CD.

Infectious Colitis

Fig. 12.34 Infectious colitis, unidentified pathogen.

a Erythema, erosions, quite continuous in right colon, clearly decreasing to left (ascending colon). b Very tiny ulcers (ascending colon). c Mucosal edema became more visible at biopsy.

d Only a few small manifestations in left colon.

Fig. 12.34 Infectious colitis, unidentified pathogen.

a Erythema, erosions, quite continuous in right colon, clearly decreasing to left (ascending colon). b Very tiny ulcers (ascending colon). c Mucosal edema became more visible at biopsy.

d Only a few small manifestations in left colon.

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