The diagnosis of IBD requires a multidisciplinary approach involving a team of specialists that includes gastroenterologists, nurses, radiologists and pathologists.
The histologic examination of endoscopic biopsies or resection specimens is a crucial element in the diagnostic workup of a patient with suspected IBD and assists in making a final diagnosis, differentiating between UC and CD and other forms of colitis.
An adequate number of biopsies and a careful handling of the tissue are essential for an accurate diagnosis.
KeywordsInflammatory bowel disease Ulcerative colitis Crohn’s disease Histopathology Diagnosis
The correct diagnosis of IBD requires a multidisciplinary approach where histology plays an essential part. However, histology has some limitations that should be well known. Adequate sampling and a careful handling and fixation of the tissue are critical, and optimum quality has to be guaranteed by quick immersion in fixative.
In UC the mucosa shows diffuse and continuous destructive chronic inflammation (including lymphocytes, plasma cells, eosinophils and neutrophils) with crypt distortion, which involves the rectum and spreads proximally. Cryptitis and crypt abscesses are characteristic of active disease, and basal plasmacytosis is the earliest diagnostic feature, helping in the differentiation from acute colitis.
CD shows a discontinuous pattern of inflammation that may affect any segment of the digestive tract with focal (discontinuous) chronic inflammation, focal architectural irregularity and granulomas (not related to crypt injury). The lesions are not limited to the mucosa as in UC and may affect the entire thickness of the gut wall.
Despite detailed histologic criteria used to differentiate Crohn’s colitis from ulcerative colitis in colonoscopic biopsies, no single pathognomonic lesion has been identified, and accurate discrimination between the two diseases is not always possible. The term inflammatory bowel disease unclassified (IBDU) should be used in these situations.
Infections have an important role, triggering the onset of IBD, triggering flares of disease and complicating the clinical picture. Histology may be very useful in the diagnosis of CMV infection but not C. difficile.
Histology has a very important role in the detection of dysplasia and IBD-associated carcinoma. Criteria for diagnosing dysplasia are well defined, and immunohistochemistry may be useful in difficult cases, although confirmation of dysplasia by an independent expert GI pathologist is recommended.
- Jenkins D, Balsitis M, Gallivan S, Dixon MF, Gilmour HM, Shepherd NA, Theodossi A, Williams GT (1997) Guidelines for the initial biopsy diagnosis of suspected chronic idiopathic inflammatory bowel disease. The British Society of Gastroenterology Initiative. J Clin Pathol 50(2):93–105CrossRefGoogle Scholar
- Levine A, Koletzko S, Turner D, Escher JC, Cucchiara S, de Ridder L, Kolho KL, Veres G, Russell RK, Paerregaard A, Buderus S, Greer ML, Dias JA, Veereman-Wauters G, Lionetti P, Sladek M, Martin de Carpi J, Staiano A, Ruemmele FM, Wilson DC, European Society of Pediatric Gastroenterology, Hepatology, and Nutrition (2014) ESPGHAN revised Porto criteria for the diagnosis of inflammatory bowel disease in children and adolescents. J Pediatr Gastroenterol Nutr 58:795–806PubMedGoogle Scholar
- Magro F, Langner C, Driessen A, Ensari A, Geboes K, Mantzaris GJ, Villanacci V, Becheanu G, Borralho Nunes P, Cathomas G, Fries W, Jouret-Mourin A, Mescoli C, de Petris G, Rubio CA, Shepherd NA, Vieth M, Eliakim R, European Society of Pathology (ESP), European Crohn’s and Colitis Organisation (ECCO) (2013) European consensus on the histopathology of inflammatory bowel disease. J Crohns Colitis 7(10):827–851CrossRefGoogle Scholar
- Marx A, Wandrey T, Simon P, Wewer A, Grob T, Reichelt U, Minner S, Simon R, Spehlmann M, Tigges W, Soehendra N, Seitz U, Seewald S, Izbicki JR, Yekebas E, Kaifi JT, Mirlacher M, Terracciano L, Fleischmann A, Raedler A, Sauter G (2009) Combined alpha-methylacyl coenzyme A racemase/p53 analysis to identify dysplasia in inflammatory bowel disease. Hum Pathol 40:166–173CrossRefGoogle Scholar
- Palascak-Juif V, Bouvier AM, Cosnes J, Flourié B, Bouché O, Cadiot G, Lémann M, Bonaz B, Denet C, Marteau P, Gambiez L, Beaugerie L, Faivre J, Carbonnel F (2005) Small bowel adenocarcinoma in patients with Crohn’s disease compared with small bowel adenocarcinoma de novo. Inflamm Bowel Dis. 11(9):828–832CrossRefGoogle Scholar