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Pathology in the selection of
patients for pouch surgery.
Dr Bryan F Warren
Consultant Gastrointestinal Pathologist, Honorary Senior
Lecturer, Fellow of Linacre College, Oxford
M62 Course 2006
Pathology in pouch surgery
• One stage
• Two stage
• Three stage
One stage-Communication and
context
What do I tell the pathologist?
Biopsy –
severe UC
Crypts rupture downwards to
involve superficial submucosa
Mimic CD
Distribution and context!
Biopsy pathology UC
• Crypt architectural distortion
takes 6 weeks
• Diffuse changes• Architecture, mucin depletion,
chronic inflammation, acute
inflammation
• Rectum most severe
• Distribution of changes in a
biopsy and in a biopsy series.
• Catch-patchiness-post treatment
or at junction of diseased and
normal, or in caecal patch.
• IF BIOPSIES ALL IN SAME
POT - HARD TO REPORT!!
UC after treatment
Early disease-diffuse
Chronic inflammation
and basal plasma cells
Crohn’s colitis
Schiller KFR, Cockel R, Hunt RH, Warren BF. 2001
An atlas of gastrointestinal endoscopy and related pathology
Crohn’s colitis
Focal erosions and
Focal inflammation
Granuloma in relation
to ruptured crypt-not
all CD
Perineural chronic inflammation
and granuloma.
Aphthous ulcer
Cryptolytic granulomas
Lee FD, Maguire C, Obeiat W,
Russell RI.
Importance of cryptolytic
granulomas in inflammatory
bowel disease. J Clin Pathol
1997;50: 148-152
• 14 patients with non specific
inflammatory changes and
pericryptal granulomas on
biopsy
• 10 were found to have Crohn’s
disease
Quiescent/ treated
UC Polyp
Flat mucosa
`patchy mimics CD
Rectal sparing
DON’T JUST BIOPSY THE POLYP
May have only architectural distortion, =/-paneth cells,
may return to ‘normal’-review original biopsies ? Infection.
Follow up/ post treatment
biopsies in IBD
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Is it still IBD/UC/Crohn’s disease
Has it got better? Was it IBD after all?
Is it now complicated by infection/PMC?
Go back to the original pretreatment series!
Crohn’s large bowel biopsy.
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May be normal
May mimic UC
Patchiness is most reproducible feature
Mucosal granulomas – may mislead
Pathology in pouch surgery
• Two stage and three stage
Colectomy!
• Three stage
– Colectomy
– Rectal stump
Crohn’s disease - fat wrapping
Crohn’s colitis
Transmural inflammation in the form of lymphoid aggregates
The pathologist cannot see this on a biopsy - help him - context
Crohn’s colitis-terminal ileal
disease.
Backwash ileitis in UC or Crohn’s disease? Ileal biopsies may
be difficult.
Biopsies after surgery
• Ileostomy end - non specific changes may
misinterpret as Crohn’s disease
• Anastomotic biopsies in Crohn’s
• Diversion
– CD may mimic UC
– UC may mimic CD
Diversion in UC
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Transmural inflammation
Granulomas
PMC like change
Mimics Crohn’s
It is UC and not a contraindication
to pouch surgery.
Seen as part of the three stage
pouch procedure.
Comforting if this occurs-helps
confirm pouch has been made in
UC! PUT THE BIOPSIES IN
CONTEXT FOR THE
PATHOLOGIST!
Diverted Crohn’s colitis
When is it difficult to differentiate
CD colitis and UC?
• Fulminant colitis
• After treatment of UC
• When rare variants of UC are not
recognised.
Skip lesions in UC
Acceptable ones:
• Appendix –Davison and Dixon
• Caecal patch – D‘Haens
Not contraindications to pouch surgery.
Caecal patch in UC
Tell the pathologist
What you saw
Please label biopsy
Sites
Not all in same pot!
Courtesy of Dr Axel von Herbay
Indeterminate or unable to tell for
the wrong reasons?
Referral to an expert!
Pass on/ share the decision making - good
but…
Biopsies minus information
Resection - must be easy, histology must give
all the answers!
Photo -absent/poor
Macroscopic description - length of colon only
Slides four from unknown sites around the
colon
Remains undiagnosable - not true
indeterminate
Working Party clinical classification
Indeterminate Colitis:
use and abuse
controversies and consensus
(WCOG)
Séverine Vermeire, MD, PhD (Leuven, Belgium)
Robert Riddell, MD, PhD (Toronto, Canada)
Bryan Warren, FRCPath(Oxford, UK)
Karel Geboes, MD, PhD (Leuven, Belgium)
Introduction
• Population-based studies from Scandinavia showed
that 5-20% of IBD patients affected by colonic
involvement only cannot be definitively diagnosed
with CD or UC using available diagnostic tools
 indeterminate colitis (IC)
• Incidence of IC estimated at 1.6-2.4/100.000
• What are they calling “IC”
Moum Gut 1997, Hildebrand J Pedriatr Gastroenterol Nutr 1991, Stewenius
Scand J Gastroenterol 1995
Definition of IC:
evolution of diagnostic criteria
1978: introduction of ‘colitis
indeterminate’ by Ashley Price
Wide-spread use of
endoscopy and biopsies
(J Clin Pathol 1978)
1978
1980
………………………………………….
• based on surgical specimens
• features of both CD and UC
• IC = Temporary diagnosis
• Majority of patients prove to have
either CD or UC during follow up
2000
2005
• evolution towards diagnosis based on
clinical features + endoscopy +Bx
clinical features of chronic IBD, without small
bowel
involvement;
endoscopy
nonconclusive ;microscopy active-patchy chronic
inflammation with crypt distortion (>10%) and
absence of diagnostic features for CD or UC
• Is IC distinct disease within IBD?
CD, UC or IC: does it matter?
• Data from epidemiological observations in patients with IC
(Stewenius et al J Eur J Surg 1996; McIntyre et al Dis Colon Rectum 1995; Atkinson et al Am J
Surg 1994; Stewenius et al Dis Colon Rectum 1996; Stewenius et al Int J Colorectal Dis 1995)
– clinical course
– Prognosis
worse compared to UC, especially
concerning risk for and outcome of
surgery
• Conflicting data (Dayton Mt 2002, Wells AD 1991, Brown CJ 2005))
– patients operated at St Mark’s London (1960-1983), with diagnosis of IC
performed well and were unlikely to develop CD
– Toronto: although greater risk for pouchitis in IC (43%) vs UC (21%), no increased
risk for pouch failure with excision (10% vs 6%)
“Can I do a pouch?”
Proposed classification for patients with chronic inflammatory colitis
Diagnosis based on
surgical specimen
overlapping features of both
CD and UC
indeterminate colitis
Diagnosis based on
endoscopy with biopsies
• chronic IBD with inflammation restricted to colon and no
small bowel involvement.
• non-conclusive endoscopy
• microscopy: active patchy chronic inflammation with
minimal or moderate architectural distortion and no
diagnostic features for CD or UC. No infectious colitis
Upper GI evaluation (G-scope, double
balloon and/or videocapsule) useful
Colonic IBD Type Unclassified
(IBDU)
Summary - Pathology in the
selection of patients for pouch
surgery.
Biopsies and resections considered in
CONTEXT
Awareness of rare variants and effects of
treatment
Consistent use of terminology
Multidisciplinary team approach