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home - IBD - IBD Diagnosis - Crohns histopathology Written by Dr Sebastian Zeki

Knows the differential diagnosis of IBD including bacterial and
amoebic infection, CMV, IBS, drug induced injury (NSAIDs)
microscopic colitis and vasculitis.

Uses appropriate investigations including blood tests, stool cultures
and intestinal imaging modalities.

Exhibits sympathy to patient, orders appropriate tests in a timely
manner, and involves members of the multidisciplinary team including
IBD nurse and surgeon as appropriate.


Knows the major differential diagnoses of IBD including infection –
viral bacterial and amoebic vasculitis ischaemia Behcet’s disease
irritable bowel syndrome etc

Knows the appropriate investigations to distinguish the above and
their limitations

Knows the differential when patient with know IBD presents with
symptoms including – active IBD bacterial overgrowth bile salt
malabsorption obstruction

Able to identify appropriate investigations to make a positive
diagnosis of IBD or to exclude it

Able to interpret the results of the above investigations
Outline to patients the possible causes of their symptoms
Explains and initiates the appropriate sequence of investigations
Can explain to patients the outcome of the investigations and their


Methods GMP
Understands the appropriate investigations for assessing disease
activity and extent including:
• inflammatory markers in blood (ESR, CRP, highly sensitive
CRP) and stool (faecal calprotectin, lactoferrin etc)
and imaging techniques, including
• upper and lower GI endoscopy, CT and MRI scanning,
capsule endoscopy, enteroscopy and barium imaging
SCE, mini-CEX, CbD 1
Understands the circumstances in which disease activity and extent
should be reassessed, and when complications should be suspected
(e.g. perforation, abscess formation, fistulisation)
SCE, CbD 1 Gastroenterology 2009 Page 106 of 155
Able to make a clinical assessment of a patient and determine the
requirement for further assessment using inflammatory markers and
SCE, mini-CEX, CbD 1
Can suspect the presence of complications appropriately and take
appropriate action in terms of investigation and management
SCE, mini-CEX, CbD 1,2
Explains the extent and activity of disease to patients, and to explain
their implications
mini-CEX, MSF 1,2,3,4,
Can liaise with IBD nurses, radiologists and other healthcare
professionals to ensure timely investigation and appropriate
management of IBD and its complications

Crohns histopathology

Histology and dysplasia-intraepithelial neoplasia 6-8 biopsies are needed to detect Crohn’s related cancerBiopsy colon at 10cm intervals and place in seperately labelled pots.Enhance pick-up by using targeted biopsies. Surgical PathologyFat wrapping has a high predic-tive value for the diagnosis of Histology and disease activity-A complete macroscopic specimen is needed.-The optimum number of samples for micro-scopic analysis has not yet been established.-A lack of activity on biopsy doesnt reflect patient inactivity.-Microscopic healing is not used to assess disease activity.-Epithelial damage in association with neutro-phils is marker of disease activity.Severe lymphocytic (and eosinophilic) infiltr-tion of the lamina propria, presence of crypt atrophy and absence of lymphocytic infiltration of the epithelium are the best variables for predicting uncomplicated disease. Non-caseating granulomas, small collections of epithelioid histiocytes, and giant cells, or isolated giant cells can be seen in infectious colitis (granulomas suggest Mycobacterium sp, Chla-mydia sp, Yersinia pseudotuberculosis, Treponema sp; microgranulomas suggest Salmo-nellas p, Campylobacter sp, Yersinia enterocol-itica; giant cells suggest Chlamydia sp) and must not be regarded as evidence for CD Macroscopic features of Crohn’sIleal diseaseSpared rectumDeep fissuresFistulasFat wrappingSkip lesionsCobblestoningStrictures Microscopic featuresAbnormalities of enteric nervous system (submucosal nerve fibre hypreplasia and ganglionitis)Unchanged epithelia-mucin preservation (goblet cells often normal) Irregular cryptsIrregular syrfaceReduced crypt numberCrypt epithelial polymorphsCrypt abscesses Transmural inflammationAggregated polymorph inflammatory pattern, transmural lymphoid hyperplasiaIncreased epithelial lymphocytes >15Focal or patchy inflamm-tion Sarcoid granulomas Submucosal thickening Fissures Epithelium: Erosion/ ulcerationMucin depletionPaneth cells distal to hepatic flexure Villus irregular-ityCrypt architec-ture irregularityUlcer associ-ated cell lineageEpithelial changes -Granulomas (ie those not associated with crypt injury; in the lamina propria -consist of epithelioid histio-cytes (monocyte/macrophage cells). No multinucle-ated giant cell/necrosis. Need a presence of granuloma and one other feature. eg:-Focal crypt irregularity -Focal or patchy chronic inflammation.-Focal inflammation or crypt irregularity.Presence of granuloma not necessary:-Increased IEL’s-Transmucosal inflammation-Focal chronic inflammation without crypt atrophy-Focal cryptitis (although reproducibility is poor)-Aphthoid ulcers-Disproportionate submucosal inflammation-Nerve fibre hyperplasia,-Proximal location of ulceration and architectural distortion Histological Diagnosis of Crohn’s Disease Number of features needed for diagnosis Non-caseating granuloma differential Microscopic features of dysplasiaArchitectural abnormalities include crowding of glands, thickening of the mucosa, lengthening and distortion of the crypts with excessive budding, and increased size.Surface and crypts are lined by tall, high columnar cells in which there is some mucus differentiation.Mucin tends to be in columnar cells rather than in the usual goblet cells.Nuclear changes are morphologically similar to those seen in tubular adenomas: hyperchromatic and enlarged nuclei, with nuclear crowding and frequent overlapping.The nuclei are also typically stratified.Mitotic figures may be present in the upper part of the crypt, and even in the surface (which is abnormal). Written by Dr Sebastian Zeki

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