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home - IBD - IBD Diagnosis - UC 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

UC Histopathology

Ulcerative Colitis- HistopathologyFor a reliable diagnosis of ulcerative colitis multiple biopsies from five sites around the colon (including the rectum) and the ileum should be obtained c) Inflammatory features Epithelial cell abnormalities Paneth cell metaplasia: Paneth cells (P) uncommon distal to the splenic flexure so if present is called Paneth cell metaplasia- thought to be due to epithelial regeneration and repairMucin depletion: = reduction in number of goblet cells or depleted mucin within cells Backwash ileitis: =Ileal inflammation in UC- should be in continuity with colonic inflammation.Histopath: Active inflammation in shortened and blunted villi and in lamina propria.Focal, isolated ileal erosions, mucous gland metaplasia or patchy oedema with mild active inflammation are features suggestive of Crohn's disease Previous damage or destruction (cryptolysis) Crypt branching: Need >2 branched (bifurcated) crypts. Mucosal (crypt) distortion: Irregularities in crypt size (ie variable diameter), spacing, orientation (ie loss of paral-lelism), or shape (including branching with a cystic configuration)In some studies this includes separation from the under-lying muscularis mucosae Mucosal (crypt) atrophy and crypt density: a combination of crypt depletion (thinned-out crypts, generally recognised by a distance of more than one crypt diameter between crypts) and an increase in the distance between the muscularis mucosae and the base of the crypts.May be normal in caecum and distal rectum a) Architectural features b) Epithelial cell abnormalities are mucin depletion and Paneth cell metaplasia P P P P M Basal plasmacytosis: defined either as the presence of plasma cells around (deep 1/5th of the lamina propria) or below the crypts, alongside or penetrat-ing the muscularis mucosae Lamina propria cellularity-Overall increased cellularity not discrimi-natoryThe distribution of the lamina propria cellular inflammatory infiltrate has been divided into: i) Focal (normal background cellularity with areas of increased cellularity); ii) Patchy (abnormal background cellular-ity with variable intensity); iii) Diffuse (abnormal background cell-larity with an overall increase in density)- can be superficial or transmucosal (latter occurs in UC but also in quiescent/ resolving disease>3 neutrophils outside capillaries may be abnormal (non-specific) Basal lymphoid aggregates: Nodular collections of lymphocytes between the crypt base and mus-cularis mucosae,without germinal centres>2 = abnormal Stromal changes: diffuse thic-ening of the muscularis mucosae or a double muscularis mucosae in longstanding active and quiescent ulcerative colitis Basal plasmacytosis (can disappear in treatment. Common in Crohn’s;rare in non-IBD)Glandular abnormalitiesA heavy, diffuse transmucosal lamina propria cell increase is a good diagnostic feature in established active disease Widespread mucosal or crypt architectural distortion, mucosal atrophy and a villous or irregular mucosal surface appear later during the evolution of the disease (4 weeks or more)Paneth cell metaplasiaMucin depletion correlates with active disease Epithelial damage in association with neutrophils and basal plasmacytosis have been proposed as markers of disease activity and the prediction of relapse Early disease Established disease Written by Dr Sebastian Zeki

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