Transcript Indeterminate Colitis

Colitis Indeterminate
Najib Haboubi
Professor of Health Sciences, Liver and
Gastrointestinal Pathology
Head of Surgical pathology
Trafford Healthcare Centre.
UK
Overlap in the spectrum of
non-specific IBD ;
colitis indeterminate (CI)
Ashley Price
J.Clin Path 1978
Material & Methods
 330
consecutive cases of
colectomy or proctocolectomy
for UC or CD between
1960-1973.
 30 cases of IBD which could
not be categorised further and
therefore classified as C1
27 out of 30 cases (90%)
Were
presented as acute
severe disease in comparison
to (30%) in UC and CD in
the same hospital for the
same period.
Indeterminate Colitis in the
Spectrum of Inflammatory
Bowel Disease
Ken Lee, Alan Medline & Stanley Shockey
Arch. Path & Lab Med, 1979
Confirm Price’s observation.
Classically CI
 5-15%
of colonic resectates in IBD.
 Mostly seen in the severe active
phase.
 There is histological overlap between
UC and CD.
CI Not a specific
pathological entity
 A condition
that ‘awaits final
diagnosis’ which we may never
arrive to.
 Has no specific distinguishing
pathological feature.
Dilated segment (transverse),
relative rectal sparing, thin wall,
severe mucosal ulceration
Histology



Severe inflammation.
In most the process
is continuous and
diffuse.
Islands of relatively
intact mucosa.
CI is has no diagnostic
histological features
 Knife
like
‘stab’ or V
types fissures
that may extend
to superficial
muscularis.
 Myocytolysis.
Problems
 Terminology.
 Diagnosis
 Definitions.
 Outcome.
Indeterminate Colitis
Colitis Indeterminate
 Fulminant Colitis
 Toxic Mega colon
 Disintegrative Colitis
 Acute Severe Colitis

Problems
 Terminology.
 Diagnosis
 Definitions.
 Outcome.
Shared features of CD and IC
CD
IC
 Rectal

sparing
 Deep Fissures
 True
Transmural
inflammation
Rectal sparing.
 Superficial Fissures
 False Transmural
Inflammation (in
areas of ulceration).
Rectal sparing in
genuine UC
 After
topical or systemic
treatment.
 Children at initial presentation.
Problems
 Terminology.
 Diagnosis
 Definitions.
 Outcome.
Definition 1 (Price 1978)
Acute clinical situation.
 Overlap of histological features of
CD and UC .
 Surgical Resectates.

Definition 2 St. Marks 1991
Cleveland Clinic 1992
Typically fulminant.
 Resectates.
 Overlapping features.
 Further sub classify into
CI probably UC
CI probably CD
CI ‘unspecified’

Definition 3 (Kangas 1994)
Patients who had the clinical and
macroscopical features of either CD or UC
both pre and intra operatively
AND
 The histology remained indertermined.
 They included cases in which the
diagnosis was based on mucosal biopsies.

Recommendation
Mucosal biopsies
 CIBD
with no distinguishing
histological features.
 IBD unclassified.
Definition 4 (Mayo Clinic 1995)
Unequivocal diagnosis of chronic
UC preoperatively but
 inconclusive histology on examiation of the
pathologic specimens intra operatively.

Definition 5 (Price 2 1996)
‘The inability to make a confident
diagnosis of the pattern of colitis despite
an adequate surgical resectates or
adequate mucosal biopsies from the
colon and rectum’
Resectates and mucosal biopsies
Not necessarily a surgical acute condition.
Not necessarily cases of IBD.

Definition 6 Indeterminate colitis,
Montreal Working Party 2005
Returned to original definition by Price
‘should be reserved only for those cases
where colectomy has been performed and
pathologists are unable to make a definitive
diagnosis of either Crohn’s disease or
ulcerative colitis after full examination’
Satangi J, Silverberg MS, Vermeire S and J-F Colombel. The Montreal classification
of inflammatory bowel disease: controversies, consensus and implications.
Gut 2006;55:749-753.
Problems
 Terminology.
 Diagnosis.
 Definitions.
 Outcome.
Natural History, Variable.
87% will end up with either CD or UC
(Swan et al) after time and careful review.
 Most polarise into UC. Meucci et al
80% UC.
 10-40% CD.
 Still there is a group of patients who after
long term follow up the pathologist and
the clinician can not put it into either
CD or UC.

Natural History of
Indeterminate Colitis
Wells, McMillen, Price, Ritchie & Nicholls.
Br. J. Surgery 1991.
After mean follow up of 108 months
and review of histological
radiological and clinical data
Group 1
19
Probable CD - UC (1)
Group 2
11
Probable UC - No change
Group 3
16
Indeterminate - UC (3)
CD (1)
Conclusion
Patients
continuing with a
diagnosis of IC are unlikely
to show features of CD on
long term follow-up.
Current Research and
Development
Serology: ASCA/ANCA
 Genetics.
 Gastric biopsies.
 RANTES

Ansari et al J Clin Path
2006 Bahrain
Comparison of RANTES expression in
CD and UC: an aid in the differential
diagnosis.
 Mucosal biopsies from patients with
UC have a significantly more staining
of lymphocytes and histiocytes in
UC than CD.

Outcome after IAP ; Varies
UC
like (St Marks)
CD like ( Kangas et al 1994)
Between ( Yu et al Mayo 2000)
Indeterminate Colitis – Pouch Surgery
Yu et al 2000 Mayo Clinic
82 IC patients
Pouch failure 27% IC vs. 11% UC
Pelvic sepsis 13% IC vs. 7% UC
Pouch Fistula 31% IC vs. 9% UC
15% of IC evolved into CD.
Removal of converted cases = outcome
identical between IC and UC
SUMMARY




CI constitutes a small but important subgroup
of IBD
Mostly in fulminant state.
Most patients will polarize to either CD or UC
after:
1. Good clinico-pathological correlation
AND
2. Long term follow-up.
Standardisation of definition is important for
meaningful comparison between various
studies and treatment options.
ACGBI
Glasgow
th
2-5
July
ESCP Annual General Meeting
Malta September 26-29
Pre-meeting course
Core Subject Update
Wednesday 26 September 14:00 – 17:00
ESCP Annual General Meeting
Malta September 26-29
Symposia
Imaging in Colorectal Cancer
Pelvic Floor Disorders
Laparoscopy
Pouches in Ulcerative Colitis
Debates
Haemorrhoidectomy
Rectal Prolapse
Laparoscopy
ESCP Annual General Meeting
Malta September 26-29
Keynote Lectures
Management of Large Wounds
Laparoscopy
Update on Familial Adenomatous Polyposis
Sacral Nerve Stimulation for Fecal Incontinence
Interpretation of Endpoints in Cancer Trials
Management of the Advanced Pelvic Malignancy
Consultants’ Corner
Free Paper and Oral Poster Presentations
Six Best Papers
Abstract deadline date Sunday 20
May 2007
Submissions open at
www.escp.eu.com
Future ESCP Scientific Meetings
2008: 24 – 27 September: Nantes, France
2009: 23 – 26 September
2010: 22 – 25 September
Is ‘Indeterminate Colitis’
Crohn’s Disease in Long-Term
Follow-Up?
Kangas, Matikainen & Matila.
Int. Surg. 1994.
Tampere, Finland.
Conclusion
Cases
labelled for IC show
tendency to develop CD after
a long follow-up.
Fulminant Colitis in IBD
Detailed Pathologic and Clinical
Analysis
Swan, Geogehan, O’Donoghue, Hyland
and Sheahan
Dis Col and Rectum 1998
67 FC of IBD
Disease
Original Dx After Path
review
CP
correlation
UC
40
45
45
CD
16
13
16
IC
11
9
6
Can the pathologist come off the
fence?
Yes
up .
, after a long follow
Definition 6 Montreal
Classification 2005
Satangi J et al The Montreal classification of inflammatory bowel disease:
controversies, consensus and implications. Gut 2006;55:749-753.
Back to original Price 1978 classification.
 Acute phase
 Resectate
 IBD but cannot be further categorised
histologically
