Ulcerative colitis

Ulcerative colitis
Diagnosis in short
Active colitis in a case of ulcerative colitis. H&E stain.
LM	active changes (cryptitis, crypt abscesses, erosions), chronic changes (architectural distortion, basal plasmacytosis, foveolar metaplasia, Paneth cell metaplasia), lack of granulomas, mucin depletion (common)
LM DDx	Crohn's disease, infectious colitis, ischemic colitis, diversion colitis
Site	colon
Associated Dx	primary sclerosing cholangitis, toxic megacolon
Clinical history	+/-FHx of IBD
Symptoms	+/-diarrhea +/-blood per rectum
Prevalence	uncommon
Clin. DDx	other types colitis (infectious, Crohn's disease, ischemic)
Treatment	medical and/or surgical

Ulcerative colitis, abbreviated UC, is a type of inflammatory bowel disease.

General

• May be associated with toxic megacolon.

Epidemiology:

• Associated with primary sclerosing cholangitis.
• Appendicitis is considered protective against UC.
• Smoking is protective; the opposite is true for Crohn's disease.

Gross

• Conventionally considered to be contiguous, i.e. no "skip lesions", with rectal involvement being most severe.
• Dependent on the study one reads... rectal sparing may be seen in 15% of UC patients.

Microscopic

Features:

• Inflammation:
  • Active:
    • Neutrophils:
      • Intraepithelial (cryptitis).†
      • Clusters in crypts (crypt abscesses).
      • Erosions.
  • Chronic:
    • Architectural distortion.
    • Basal plasmacytosis.
    • Foveolar metaplasia.
    • Paneth cell metaplasia (distal).
  • Lack of granulomas.
• Mucin depletion - common in UC.

Notes:

• †Neutrophils are usually numerous in the lamina propria in minimal/mild active inflammation.
• No full wall-thickness inflammation.
• Epithelial apoptosis correlated with inflammation.

DDx:

• Crohn's disease.
• Infectious colitis.
• Ischemic colitis.
• Diversion colitis.
• Diverticular disease-associated colitis restricted to areas with diverticular disease.

Images

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  UC. (WC/KGH)

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  UC. (WC/KGH)

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  UC. (WC/KGH)

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SIGMOID COLON, BIOPSY:
- MODERATE ACTIVE COLITIS WITH CHRONIC CHANGES, SEE COMMENT.
- NEGATIVE FOR DYSPLASIA.

COMMENT:
No granulomata are identified. The sampled mucosa is diffusely inflamed. Crypt drop-out and
architectural distortion are present.

The findings are consistent with inflammatory bowel disease; however, an infectious etiology
should be considered as a possibility.

SIGMOID COLON, BIOPSY:
- MILD ACTIVE COLITIS, SEE COMMENT.
- NEGATIVE FOR DYSPLASIA.

COMMENT:
No granulomata are identified.

A. RIGHT COLON, BIOPSY:
- MODERATE ACTIVE COLITIS, SEE COMMENT.
- NEGATIVE FOR DYSPLASIA.

B. LEFT COLON, BIOPSY:
- MODERATE-TO-SEVERE CHRONIC ACTIVE COLITIS, SEE COMMENT.
- NEGATIVE FOR DYSPLASIA.

COMMENT:
No granulomata are identified. The mucosa is diffusely inflamed. Architectural distortion
is present in the left colon.  The findings are consistent with ulcerative colitis;
however, an infectious etiology should be considered as a possibility.

RECTUM, BIOPSY:
- MODERATE DIFFUSE CHRONIC ACTIVE PROCTITIS.
- NEGATIVE FOR DYSPLASIA.

COMMENT:
No definite granulomata are identified. Crypt drop-out is present.
Within the proper clinical context, these are findings of 
inflammatory bowel disease.

Inactive disease

SIGMOID COLON, BIOPSY:
- CHRONIC COLITIS, SEE COMMENT.
- NEGATIVE FOR ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA.

COMMENT:
The sections show chronic changes (basal plasmacytosis, marked crypt architectural
distortion, crypt branching); however, no active colitis is present. Also, lamina propria
neutrophils, which are often easy to identify in an active colitis, are not apparent.
Appreciable numbers of lamina propria eosinophils are present and focally intraepithelial.
No granulomas are identified. Clinical correlation is required.

Surveillance

A. ASCENDING COLON, BIOPSY:
- COLONIC MUCOSA WITHOUT APPARENT PATHOLOGY.
- NEGATIVE FOR ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA.

B. TRANSVERSE COLON, BIOPSY:
- COLONIC MUCOSA WITHOUT APPARENT PATHOLOGY.
- NEGATIVE FOR ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA.

C. DESCENDING COLON, BIOPSY:
- COLONIC MUCOSA WITHOUT APPARENT PATHOLOGY.
- NEGATIVE FOR ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA.

D. SIGMOID COLON, BIOPSY:
- COLONIC MUCOSA WITHOUT APPARENT PATHOLOGY.
- NEGATIVE FOR ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA.

E. RECTUM, BIOPSY:
- RECTAL MUCOSA WITHOUT APPARENT PATHOLOGY.
- NEGATIVE FOR ACTIVE PROCTITIS.
- NEGATIVE FOR DYSPLASIA.

COMMENT:
Morphologically benign lymphoid aggregates are found focally. No granulomas are
identified. Minimal architectural changes are seen focally.

A. CECUM, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.

B. ASCENDING COLON, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.

C. COLON, HEPATIC FLEXURE, BIOPSY,
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.

D. TRANSVERSE COLON, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.

E. COLON, SPLENIC FLEXURE, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.

F. DESCENDING COLON, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.

G. SIGMOID COLON, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.

H. RECTUM, BIOPSY:
- QUIESCENT INFLAMMATORY BOWEL DISEASE.
- NEGATIVE FOR DYSPLASIA.

COMMENT:
No granulomas are identified. Mild architectural distortion is present. No active
inflammation is identified. Scattered mucosal lymphoid nodules with germinal center
formation are present.

Granulomas and inflamed crypts - clinically UC

A. CECUM, BIOPSY:
- ACTIVE CECITIS, MILD.
- SMALL MUCOSAL GRANULOMAS, SUPERFICIAL, SEE COMMENT.
- NEGATIVE FOR DYSPLASIA.

...

COMMENT - PART A:
The small granulomas are mucosal and near, but not all adjacent to, inflamed crypts; this 
finding raises the possibility of Crohn's disease. It should be noted that mucosal 
granulomas may be seen in ulcerative colitis beside inflamed crypts.

COMMENT - GENERAL:
The inflammation is diffuse and chronic changes are seen throughout. Distal paneth cell
metaplasia is present. The diffuse nature of the inflammation would be more in keeping with
ulcerative colitis. Clinical correlation is required.

Micro

The sections show focal intraepithelial neutrophils (cryptitis). No crypt abscesses are identified. Granulation tissue is present. There is focal Paneth cell metaplasia and foveolar metaplasia. No granulomata are identified.

See also

• Inflammatory bowel disease.
• Crohn's disease.
• Invisible colonic dysplasia.