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Gastroenterologists are from Mars and Pathologists are from Venus: �Reporting IBD Pathologic Findings��(and “Kurt’s Notes”)

Kurt Schaberg M.D.

Department of Pathology

University of California, Davis

kbschaberg@ucdavis.edu

@KurtSchaberg

Kurtsnotes.net

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Disclosures

None

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Inflammatory Bowel Disease (IBD)

A chronic, idiopathic, relapsing and remitting inflammatory disease of the gastrointestinal tract resulting from inappropriate mucosal immune activation

IBD

Ulcerative Colitis

Crohn’s Disease

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Ulcerative Colitis

UC is a severe, ulcerating inflammatory disease that almost always involves the rectum (will talk more about this later) and then spreads proximally in a continuous, diffuse manner. The small intestine is normal, although mild mucosal inflammation in the distal ileum, “backwash ileitis,” may be present.

(Backwash ileitis is only present with severe colitis in ascending colon)

Continuous, confluent, concentric

UC can proceed continuously distally, but then skip to the appendiceal orifice, which is called a “cecal patch.” This can actually be seen in up to 75% of UC cases.

There can be unusual patterns: including rectal sparing, which can be seen in up to 30% of children. Adutls can also have “relative” rectal sparing--especially with severe or “fulminant” colitis or in adults post-treatment.

UC is limited to mucosa and superficial submucosa.

Strictures are rare. The wall appears thinned (as ulcerated).

Ulcers are superficial and broad and often aligned along the long axis of the colon.

Pseudopolyps are numerous.

No perianal disease.

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Crohn‘s Disease

In contrast, Crohn's disease characteristically shows “skip” lesions with sparing of interspersed mucosa in a patchy distribution and can involve any part of the GI tract from the oral cavity to the anus.

Gastroenterologists put a lot of stock in this distribution. Rectal sparring🡪 Crohn’s

The most common sites involved at presentation are the terminal ileum, ileocecal valve, and cecum.

Inflammation is transmural and this results in a thicker-appearing bowel wall and strictures and fistulas.

Ulcers are deep and knife-like, serpentine ulcers and fissures. These can extend through the wall to become fistulas.

Combined, these findings can result in a coarsely textured “cobblestone” appearance in which the diseased tissue is depressed below the normal tissue.

Rarely circumferential. Often longituidinal.

The bowel wall becomes thick and rubbery because of transmural edema, inflammation, and submucosa fibrosis. All of these factors contribute to stricture formation. Fat wrapping is also common.

Perianal disease is common (fistulae, skin tags, fissures)

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New IBD Patient

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Colonoscopy

Chun et al. Clinical Gastrointestinal Endoscopy: A Comprehensive Atlas, 2014

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Pathology Report:

Rectum, Biopsy:

Chronic active proctitis

Rectum, Biopsy:

Active colitis with prominent basal lymphoplasmacytosis and architectural distortion

Electronically signed out by Kurt Schaberg M.D.

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New IBD Patient

Ulcerative Colitis

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New IBD Patient

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What is our endpoint for IBD treatment?

Symptoms?
Endoscopic findings?
Radiographic findings?
Lab values (e.g., fecal calprotectin or CRP)?
Histologic findings?

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Pathology Report:

Rectum, Biopsy:

Chronic active proctitis

Rectum, Biopsy:

Active colitis with prominent basal lymphoplasmacytosis and architectural distortion

Electronically signed out by Kurt Schaberg M.D.

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Activity = Acute Inflammation = Neutrophils

Neutrophilic cryptitis

Crypt abscesses

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Chronicity

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Chronicity

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Chronicity

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Chronicity

Crypt architectural distortion

Crypt foreshortening
Crypt branching
Crypt dropout
Loss of crypt parallelism

Basal lymphoplasmacytosis

Lymphocyte

Plasma cell

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Why do we care about histologic findings if there is endoscopic remission?

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76 UC patients in endoscopic remission, which they defined as a Mayo score of 0

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166 UC Patients with Mayo endoscopic score of 1

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Overall increased risk of relapse

OR 2.41; (95% CI, 1.91–3.04)

with histologic activity

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Select findings:

Histologic remission predicts lower:

risk of hospitalization,
colectomy, and
corticosteroid use.

Histologic activity may increase the likelihood of the need for colectomy for neoplastic complications.

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A brief analogy

Let’s think of the colon as some lovely California hills and IBD as a wildfire.

This Photo by Unknown Author is licensed under CC BY-NC

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Chronic and Active inflammation

Acute/Active inflammation think of as the flame🡪 It’s red, hot, and is very destructive

Chronic inflammation think of as the embers🡪 It is less eye-catching and acutely destructive, but it can easily burst into flames again and melt things.

Scarring and some architectural changes of as🡪 burnt trees

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Endoscopic vs Microscopic

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Endoscopic vs Microscopic

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Endoscopic vs Microscopic

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Endoscopic vs Microscopic

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Endoscopic vs Microscopic

Pathologist

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Pathology Report:

Rectum, Biopsy:

Chronic active proctitis

Rectum, Biopsy:

Active colitis with prominent basal lymphoplasmacytosis and architectural distortion

What do these mean?!�How much inflammation is there? Should I escalate treatment?

Electronically signed out by Kurt Schaberg M.D.

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Histopathology Scoring Indices

More than 30 systems have been proposed. Mostly for UC.
Most involve some combination of:

Architectural Change
Chronic Inflammatory Infiltrate
Lamina Propria Neutrophils
Lamina Propria Eosinophils
Epithelium Neutrophils
Crypt Destruction
Erosion/ Ulceration
Basal Plasmacytosis
Mucin depletion

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The Nancy System

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The Robart’s Histologic Index

Minimum score = 0

Maximum score = 33

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The Geboes score

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Which to use?

No current standard.
For UC, the Nancy Index and the Robarts Histopathology Index have undergone the most validation.
However, none of the currently available histologic scoring indices have been fully validated.
In CD, there are fewer systems and even less validation.
There are no systems that have been validated in both diseases.

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A “Colitis” Synoptic Checklist

	Metric	Scoring
Activity
	Lamina Propria Neutrophils *	Marked (3)
	Cryptitis/Crypt abscesses (Neutrophils in Epithelium) *	>50% crypts (3)
	Erosion/Ulcers *	Probable erosion (1)
Chronicity
	Chronic Inflammatory Infiltrate*	Mild (1)
	Basal Lymphoplasmacytosis	None (0)
	Architectural distortion and/or metaplasia	None (0)
Additional Findings
	Granulomas	Absent
	Viral cytopathic effect	Absent
	Dysplasia	Negative
	Robart’s Activity Index	15/33

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Surgeons misunderstood pathologists’ reports 30% of the time.

Surgical experience reduced but did not eliminate the problem.

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What did we find?

Participants: 9 fellows and 30 attendings.
Participants were in practice for a mean of 8.6 years and saw a mean of 12.6 IBD patients per month.
Mean accuracy scores were higher post-intervention (0.81 vs 0.86, P = 0.0005).
Mean confidence was higher post-intervention, but this was not statistically significant (3.91 vs 3.98, P = 0.242).

Post

Pre

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Conclusions

In IBD, histologic findings add useful clinical data that can predict disease relapse even in endoscopically normal patients.
Comprehension of pathology reports by clinicians is imperfect, with up to 30% of findings misinterpreted.
Reporting findings in standardized synoptic checklists appears to help with understanding reports.

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What we do now at UC Davis:

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Questions So Far?

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http://kurtsnotes.net/

Pathology

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>560 pages of guides

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>560 pages of guides!

Dual/Competing Goals

Boards studying

Concise, High-yield

Useful at the scope daily

Reference for common problems

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Users over the years:

Users in a week:

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Top Cities:

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“That is very good.”

“Kurt is proud of you.”

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What next?

Continue to update, improve, and expand existing pages
Add more cytology
Add sample gross descriptions?

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Thank you!

Questions?

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Overview

Some IBD basics
Histology as a treatment endpoint in IBD
Pathology report comprehension
Comprehension of IBD reports

Kurt’s Notes