Histologic and Serologic Correlates of Patients with IBD: How Helpful Is Histology?

Abstract

Diagnosis of Crohn's disease (CD) is based on a combination of location, laboratory, endoscopic and histologic findings. Although non-caseating granulomas are a hallmark of CD, focal or patchy inflammation in any area of the bowel is also considered to favor CD. Non specific histologic changes in upper GI tract can occur infrequently in ulcerative colitis (UC). Our aim was to discern if CD is overdiagnosed due to such nonspecific histologic markers when serology or endoscopy suggests UC. Methods: A retrospective chart review was performed in patients with chronic inflammatory bowel disease (CIBD) for IBD serology (ANCA and ASCA status), upper and lower endoscopy. Histology was blindly reviewed by pathologist to determine CD or UC based on changes in esophagus, stomach, duodenum and colon. Besides granulomas, lymphocytic inflammation in mucosa and submucosa or focal inflammation was considered suggestive of CD. Results: Charts of 41 patients (20 M and 21 F) were reviewed. Of these 37 were classified as CD based on histology and 4 were classified as UC, even though grossly only colon was involved in most. IBD serology was done 25/37 CD patients. Of these ASCA was positive in 6, ANCA in 11 and Omp-C in 1 patient and was negative in 7 patients. On esophageal histology only 13 had chronic focal inflammation, 20 had GER type inflammation, 2 had granulomas and 6 were normal. In the stomach, 9 had chronic inflammation, 5 acute inflammation 13 had granulomas and 11 were normal. In the duodenum 7 had chronic inflammation, 4 acute inflammation and 26 were normal. Of the 4 diagnosed to have UC, IBD serology was positive for ANCA in all. On histology, 2 had GER type changes and 2 had non-specific inflammation in esophagus. In the stomach, 3 had non-specific inflammation whereas in the duodenum, 1 had chronic inflammation, 1 had acute inflammation and 2 had normal histology. Conclusions: We conclude that minor histologic abnormalities of the upper GI tract should not be overread as being consistent with CD without clinical, endoscopic and serologic correlation, as otherwise, CD would be overdiagnosed. This has practical implications in the long-term management of medically refractory patients with UC, as stigma of CD label prevents consideration of surgery even when appropriate.