Solitary Rectal Ulcer Syndrome

- [F| 12.9 Recurrent CD near anastomosis following ileal resection

Rectal Ulcer Syndrome Ileum Linear Ulcer

Stenosed ileocolonic anastomosis of ileum and ascending colon, not passable with instrument. Inflammatory changes (aphthae, mini-ulcers) visible in and around the stenosis. This is a frequent occurrence; changes are not usually limited to scarring in this region, and are most likely after intense immunosuppression.

b, c Typical attack in the neoterminal ileum. b Stenosed ileocolonic anastomosis of ileum and ascending colon. Here it is passable, elongated ulcer typical of CD. c Wide ulcer in neoterminal ileum.

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Differential Diagnosis of Chronic IBD Types and Other Forms of Inflammatory Bowel Diseases

■ Differential Diagnosis: Ulcerative Colitis vs. Crohn Disease

Tables 12.1,12.2 display major characteristics for distinguishing between the two main types of chronic IBD.

Table 12.1 Endoscopic differential diagnosis CD-UC (based on reference 8)

Factors supporting a diagnosis Factors supporting a diagnosis of CD of UC

► key finding: patchy, discontinuous and segmental spread of inflammation

► areas of normal mucosal interspersed with ulcerations; or asymmetrical distribution of ulcerations in a given segment

► rectum is spared

► ulceration surrounded by relatively normal mucosa, no marked increase in vulnerability of surrounding mucosa

► deep, widespread ulcerations

► ulcerations and stenosis or distortion of the Bauhin valve

► continuous, symmetrical, diffuse inflammation

► mucosa in affected segment noticeably different from the surrounding mucosa, sharp demarcation to proximal, uninvolved mucosa

► diffuse rectal involvement

► ulceration on a background of diffuse abnormal mucosa with reddening, vulnerability, and granularity

► attention: these factors usually support a diagnosis of UC, but there are always exceptions!

Table 12.2 Colonoscopy features for differential diagnosis of UC and CD (modified according to reference 8)

Feature

Ulcerative colitis

Crohn disease

Continuous inflammation

always*

extremely rarely

Patchy manifestation

no*

frequent

Rectal involvement

almost always

often spared

Vascular pattern

distorted or lost

often normal

Diffuse bleeding

widespread

rare

Vulnerability

widespread

uncommon

Spontaneous petechiae

widespread

rare

Granularity

widespread

less widespread

Erythema

typical

less typical

Edema

present

present

Cobblestoning

no

typical

Aphthous erosions

no

typical

Surface ulcerations

occasionally

frequent

Large ulcers > 1 cm

in severe cases

common

Long, deep ulcers

rare

common

Linear ulcers

rare

common

Serpiginous ulcers

rare

common

Pseudopolyps

not infrequent

occasionally

Mucosal bridging

occasionally

occasionally

Mucosa surrounding ulcer

abnormal

normal

Sharp demarcation (circu

yes

no

lar) to normal tisse

Stricture

no

common, frequent

► This difference is vital

for the patient: stricture

related to UC may be

malignant!

Biopsy samples are generally taken with colonoscopy forceps with and without a needle, so that mucosal layers and parts of the muscularis mucosae can be sampled. The sub-mucosa normally cannot be sampled. It is advisable to take at least two to four excisional biopsies from various bowel segments in order to increase the likelihood of differential diagnosis. Separate excision, description, and investigation of individual localizations are worthwhile, especially for differentiating between chronic and acute inflammatory bowel diseases. Granulomas characteristic of CD can be found in 30-40% of patients. Other criteria for CD include discontinuity of the inflammatory infiltrates and transmural inflammation. A diagnosis of UC is supported by multiple crypt abscesses and uniform contiguous inflammatory processes.

Surveillance strategies and endoscopic surveillance (with biopsies) for ulcerative colitis (DGVS guidelines, 2001)

For ulcerative pancolitis (< 8 years) or left-sided colitis (< 15 years):

► annual total colonoscopy with multiple biopsies (2-4 biopsies every 10-12 cm = 40-50 biopsies = (recommendation grade/level of evidence B II-2),

► discuss with the patient proctocolectomy as an option,

► more intense surveillance if PSC (recommendation grade C).

For Crohn disease, there are no recommendations for systematic endoscopic surveillance.

■ Other Differential Diagnoses

In the absence of characteristic appearances, other differential diagnoses, as described in the following, should be considered. The key to definitive diagnosis is usually clinical course of disease over time and patient medical history. Blood and bacteriological evaluation play a smaller role. Colonoscopic appearances may be the deciding factor in unclear cases. Figure 12.31 provides a schematic illustration of the varying extent of colonic involvement in different types of colitis. a 12.10 shows endoscopic features for differential diagnosis of ileitis.

Indeterminate Colitis

A certain percentage of patients (5-10%) can be successfully diagnosed as chronic IBD, but, despite chronicity, it remains impossible to determine IBD type either clinically or endoscopi-cally. These are generally cases of pancolitis, whereby the biggest difficulties in differential diagnosis occur with intermittent course.

Neoterminal Ileum

Fig. 12.31 Typical extent of colonic involvement in various types of colitis.

Fig. 12.31 Typical extent of colonic involvement in various types of colitis.

Inflammation tends to be continuous and morphology is similar to UC with evenly distributed ulcerations. The frequent occurrence of pseudopolyps (Fig. 12.32) makes differentiation even more difficult. As shown in this example, lesions may on the one hand correspond to UC (Fig. 12.33 a) but on the other to CD (Fig. 12.33 b-d). The majority of these cases develop over the years into Crohn pancolitis, without necessarily involving the small intestine. More recent serological investigations can assist in classification. The distinction is important: in Crohn disease, the attachment of an ileoanal pouch is avoided.

- |T] 12.10 Differential diagnosis: ileitis

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Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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