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How to differentiate Segmental Colitis Associated with Diverticulosis and
Inflammatory Bowel Diseases?
Alessandro Armuzzi
Lead IBD Unit Complesso Integrato Columbus
Fondazione Policlinico Gemelli Università Cattolica – Rome - Italy
Disclosures
• AA served as Consultant to: Abbvie, Hospira, Ferring, Janssen, Lilly, MSD, Mundipharma, Pfizer, Samsung, Sofar, Takeda
• AA received Lectures fees from: Abbvie, Astra-Zeneca, Chiesi, Ferring, Hospira, MSD, Mundipharma, Otsuka, Takeda, Zambon
• AA received research grant from: MSD
Van Assche G, et al. JCC 2010; Dignass A, et al. JCC 2012
Courtesy of A.Papa– CIC UCSC
Endoscopy in Crohn’s disease
Radiology in CD
Endoscopy in Ulcerative colitis
IOIBD definition, D’Haens. Gastro 2007
Silverberg MS, Can J Gastroenterol 2005
Montreal classification for Crohn’s disease
Phenotypes Age, location, behaviour
Age at diagnosis
A1: < 16 yr
A2: between 17 - 40 yr
A3: > 40 yr
Location
L1: ileal
L2: colonic
L3: ilecolonic
L4: isolated upper GI
Behaviour
B1: non-stricturing and non-penetrating
B2: stricturing
B3: penetrating
p: perianal disease modifier
Silverberg MS,. Can J Gastroenterol 2005
Montreal classification for ulcerative colitis
Extent Anatomy
E1 - Ulcerative proctitis
E2 – Left-sided UC
E3 – Extensive UC
Distal to rectosigmoid junction
Distal to the splenic flexure
Proximal to the splenic flexure
Severity Definition
S0 – Clinical remission
S1 - Mild
S2 - Moderate
S3 - Severe
Asymptomatic
≤ 4 stools/day (± blood), no systemic involvement, normal ESR
≥ 4 stools/day, minimal sign of systemic toxicity
At least 6 bloody stools/day, pulse rate at least 90 bpm, T at least 37.5°C, Hb less than 10.5g/100ml, ESR >30mm/h
Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, 464–470, 2010
SCAD definition
• SCAD is “segmental colitis associated with diverticular disease’’
• It is defined as a chronic colitis confined to the diverticular segment (but with sparing of orifices!) in individuals with otherwise uncomplicated diverticular disease
• By definition, the rectum and the proximal colon are endoscopically and histologically normal
Strate LL et al, Am J Gastroenterol 2012; 107:1486–1493
• It is typically found in over 60 yrs old patients, mostly male
• It is suggested by intermittent (painless) haematochezia, lower abdominal cramps or altered bowel habits
• Very rarely: fever, leucocytosis, nausea and weight loss
• The prevalence is largely unknown, but estimated to be around 0.26%-3,8% of all patients who have had colonoscopy and 1.5-11% of patients with diverticulosis
SCAD definition
Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, 464–470, 2010
Occurrence of IBD and SCAD in gastroenterology primary care setting between 2009 and 2012
Tursi A, et al. EJIM 2013
• 176 patients/94.000 residents • Prevalence: 187.2/100.000
(95%CI 160-217) • CD: 49 • UC: 97 • IBDU: 11 • SCAD: 19
• 2009-2012: 61 new cases • Incidence: 16.2/100.000 (95%CI
3-7.7) • CD:5/100.000 (95%CI 3-7.7) • UC: 6/100.000 (95%CI 3.8-8.9) • IBDU: 1/100.000 (95%CI 0.3-2.6) • SCAD: 4/100.000 (95%CI 2.3-6.5)
Pattern A. ‘Crescentic fold disease’ (52.2%) The colonic mucosa shows swollen red patches as of 0.5 to 1.5 cm in diameter without haemorrhage or ulceration confined to the crescentic mucosal folds. The diverticular orifices are always spared
Endoscopy in SCAD
Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, 464–470, 2010 Tursi A, et al. IJCD 2012;27:179-85
Prospective study performed from January 2004 to October 2007: 6230 colonoscopies, 92 SCAD (1.48%)
Pattern B. ‘Mild-to moderate ulcerative colitis-like’ SCAD (30.4%) This is similar to that of true mild-to-moderate UC including diffuse loss of vascular pattern, mucosal oedema and hyperaemia and diffuse erosions, but differs in that it spares the diverticular orifices
Endoscopy in SCAD
Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, 464–470, 2010 Tursi A, et al. IJCD 2012;27:179-85
Prospective study performed from January 2004 to October 2007: 6230 colonoscopies, 92 SCAD (1.48%)
Pattern C. ‘Crohn’s disease colitis-like’ SCAD (10.9%) It resembles mild-to-moderate Crohn’s colitis. Scattered aphthous ulcers may be found within a normal colonic mucosa, with normal vascular pattern. The diverticular orifices are always spared
Endoscopy in SCAD
Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, 464–470, 2010 Tursi A, et al. IJCD 2012;27:179-85
Prospective study performed from January 2004 to October 2007: 6230 colonoscopies, 92 SCAD (1.48%)
Pattern D. ‘Severe ulcerative colitis-like’ SCAD (6.5%)
It resembles severe UC with diffuse loss of vascular pattern, diffuse hyperaemia and contact bleeding. Mucosal oedema with ulceration is marked. The inflammation is confined to the sigmoid colon in all cases with rectal sparing. The diverticular orifices are not always easy to recognize but they may be visible as being spared by inflammation on maximal air inflation
Endoscopy in SCAD
Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5 Tursi et al, Colorectal Disease, 12, 464–470, 2010 Tursi A, et al. IJCD 2012;27:179-85
Prospective study performed from January 2004 to October 2007: 6230 colonoscopies, 92 SCAD (1.48%, 11% in diverticulosis)
Basal plasmocytosis Cryptitis
Crypt abscess
Granulomatous inflamation Granulation
Normal Mucosa
Courtesy of dr V. Arena, anatomopathoogist, Catholic University, Rome
Ulcer and crypt distortion
Discontinue inflammation
Deep layer involvement
Histopathology of SCAD resembles IBD
Tursi A, et al, J Clin Gastroenterol 2015
Patients with SCAD compared with mild-moderate UC patients
P<0.015 P<0.026
P<0.006
P<0.033
P<0.04
crescentic fold disease SCAD
SCAD: correlation between endoscopic patterns and symptoms
UC-like SCAD CD-colitis like SCAD Severe UC-like-SCAD
Tursi et al, Colorectal Disease, 12, 464–470, 2010
Long-standing colonic inflammation is associated with a low prevalence of diverticuli in IBD patients
Lahat A, et al, IBD 2007
314 colonic IBD patients and 1023 age-matched control patients
Natural history of elderly-onset inflammatory bowel disease: a French population-based cohort study
(from 1988 to 2006: 841 IBD patients >60 yr at diagnosis)
Charpentier C, et al Gut 2014
474
Disease localisation at diagnosis Disease localisation at diagnosis
Disease behaviour
Incidence and endoscopic findings of UCD, SCAD and AUD
Tursi A, et al, APT 2011
8525 consecutive colonoscopies from January 2004 to June 2009
Endoscopic spectrum of ulcerative colitis with diverticulosis (UCD), segmental colitis associated with diverticulosis (SCAD) and acute uncomplicated diverticulitis (AUD)
0.3% 2% 2%
50 PATIENTS Progression to CD in 3 patients (6%)
Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5
Surgery in 100%
~8% ~12%
Harpaz N and Sachar DB. J Clin Gastroenterol 2006;40:S132-5
117
Crohn’s disease
(n=197)
Ulcerative colitis
(n=423)
43%
55%
32%
37%
19%
6%
3%
1%
IBD disease course over first 10 years
1. Solberg IC et al. Gastroenterol Hepatol. 2007;5:1430–8. 2. Solberg IC et al. Scan J Gastroenterol. 2009;44:431–440.
Norwegian IBSEN cohort study (1990-1994)
SCAD: 5-year follow-up of 27 patients
Tursi A, et al, IJCD 2012
SCAD B & D fail to maintain long-term remission SCAD A & C show a more benign course
Conclusion
The distinction between SCAD and IBD may be difficult 1) Combination of demographic, clinical,
endoscopic, histological and radiological features
2) Accurate disease location (e.g. rectal-sparing and no proximal extension at endoscopy and histology)
3) Follow up (e.g. after therapy, after surgery)