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Chapter 22 - Mimics of Inflammatory Bowel Disease

Published online by Cambridge University Press:  06 June 2020

By
Roger M. Feakins
Edited by
Roger M. Feakins
Roger M. Feakins
Affiliation:
Royal Free London NHS Foundation Trust, London, UK
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Summary

Histological support for a diagnosis of inflammatory bowel disease (IBD) requires characteristic features, e.g. basal plasmacytosis, architectural changes, and granulomas. Unfortunately, many conditions share histological features with IBD. One of the closest mimics is diverticular colitis, a process that occurs adjacent or close to diverticula. It often resembles ulcerative colitis (UC), but, unlike UC, it rarely involves the rectum. Another close mimic is diversion proctocolitis, which is easy to diagnose if the history is available but otherwise is often difficult to distinguish from IBD. Mucosal changes similar to those of IBD may be the result of various infections, e.g. lymphogranuloma venereum/syphilis, amoebiasis, and HIV. Other causes include mass lesions and drugs. Granulomas are a feature of Crohn’s disease but can occur in other settings. In tuberculosis, they are typically larger and more confluent than in Crohn’s disease and may show necrosis. Rarer potential mimics of IBD include common variable immunodeficiency, Behçet’s disease, graft-versus-host disease, endometriosis, and pneumatosis coli. Close attention to the clinical picture and a careful approach to colorectal biopsy assessment by the pathologist should help reduce the chance of misdiagnosis and incorrect management.

Keywords

inflammatory bowel diseasehistologydifferential diagnosisdiverticular diseasediversion proctocolitisinfective colitisdrug-induced colitis
Type
Chapter
Information
Non-Neoplastic Pathology of the Gastrointestinal Tract
A Practical Guide to Biopsy Diagnosis
 , pp. 357 - 387
Publisher: Cambridge University Press
Print publication year: 2020

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References

Makapugay, LM, Dean, PJ. Diverticular disease-associated chronic colitis. Am J Surg Pathol. 1996;20(1):94–102.Google Scholar
Dundas, SA, Dutton, J, Skipworth, P. Reliability of rectal biopsy in distinguishing between chronic inflammatory bowel disease and acute self-limiting colitis. Histopathology. 1997;31(1):60–6.Google Scholar
Tursi, A. Segmental colitis associated with diverticulosis: complication of diverticular disease or autonomous entity? Dig Dis Sci. 2011;56(1):27–34.CrossRefGoogle ScholarPubMed
Yantiss, RK, Odze, RD. Diagnostic difficulties in inflammatory bowel disease pathology. Histopathology. 2006;48(2):116–32.CrossRefGoogle ScholarPubMed
Sultan, K, Fields, S, Panagopoulos, G, Korelitz, BI. The nature of inflammatory bowel disease in patients with coexistent colonic diverticulosis. J Clin Gastroenterol. 2006;40(4):317–21.CrossRefGoogle ScholarPubMed
Rampton, DS. Diverticular colitis: diagnosis and management. Colorectal Dis. 2001;3(3):149–53.Google Scholar
Luceri, C, Femia, AP, Fazi, M, et al. Effect of butyrate enemas on gene expression profiles and endoscopic/histopathological scores of diverted colorectal mucosa: a randomized trial. Dig Liver Dis. 2016;48(1):27–33.CrossRefGoogle ScholarPubMed
Chetty, R, Hafezi, S, Montgomery, E. An incidental enterocolic lymphocytic phlebitis pattern is seen commonly in the rectal stump of patients with diversion colitis superimposed on inflammatory bowel disease. J Clin Pathol. 2009;62(5):464–7.CrossRefGoogle ScholarPubMed
Edwards, CM, George, B, Warren, B. Diversion colitis: new light through old windows. Histopathology. 1999;34(1):1–5.Google Scholar
Feakins, RM. Diversion proctocolitis with granulomatous vasculitis in a patient without inflammatory bowel disease. Histopathology. 2000;36(1):88–9.Google Scholar
Geraghty, JM, Talbot, IC. Diversion colitis: histological features in the colon and rectum after defunctioning colostomy. Gut. 1991;32(9):1020–3.CrossRefGoogle ScholarPubMed
Warren, BF, Shepherd, NA. Diversion proctocolitis. Histopathology. 1992;21(1):91–3.Google Scholar
Asplund, S, Gramlich, T, Fazio, V, Petras, R. Histologic changes in defunctioned rectums in patients with inflammatory bowel disease: a clinicopathologic study of 82 patients with long-term follow-up. Dis Colon Rectum. 2002;45(9):1206–13.CrossRefGoogle ScholarPubMed
Rice, AJ, Abbott, CR, Mapstone, NM. Granulomatous vasculitis in diversion procto-colitis. Histopathology. 1999;34(3):276–7.CrossRefGoogle ScholarPubMed
Gill, P, Chetty, R. Filiform polyps and filiform polyp-like lesions are common in defunctioned or diverted colorectum resection specimens. Ann Diagn Pathol. 2013;17(4):341–4.Google Scholar
Arnold, CA, Limketkai, BN, Illei, PB, Montgomery, E, Voltaggio, L. Syphilitic and lymphogranuloma venereum (LGV) proctocolitis: clues to a frequently missed diagnosis. Am J Surg Pathol. 2013;37(1):38–46.Google Scholar
Soni, S, Srirajaskanthan, R, Lucas, SB, Alexander, S, Wong, T, White, JA. Lymphogranuloma venereum proctitis masquerading as inflammatory bowel disease in 12 homosexual men. Aliment Pharmacol Ther. 2010;32(1):59–65.Google Scholar
Tse, JY, Chan, MP, Ferry, JA, et al. Syphilis of the Aerodigestive Tract. Am J Surg Pathol. 2018;42(4):472–8.Google Scholar
Arnold, CA, Roth, R, Arsenescu, R, et al. Sexually transmitted infectious colitis vs inflammatory bowel disease: distinguishing features from a case-controlled study. Am J Clin Pathol. 2015;144(5):771–81.CrossRefGoogle ScholarPubMed
Orenstein, JM, Dieterich, DT. The histopathology of 103 consecutive colonoscopy biopsies from 82 symptomatic patients with acquired immunodeficiency syndrome: original and look-back diagnoses. Arch Pathol Lab Med. 2001;125:1042–6.CrossRefGoogle ScholarPubMed
Khor, TS, Fujita, H, Nagata, K, Shimizu, M, Lauwers, GY. Biopsy interpretation of colonic biopsies when inflammatory bowel disease is excluded. J Gastroenterol. 2012;47(3):226–48.Google Scholar
Lamps, LW. Infective disorders of the gastrointestinal tract. Histopathology. 2007;50(1):55–63.CrossRefGoogle ScholarPubMed
Pulimood, AB, Amarapurkar, DN, Ghoshal, U, et al. Differentiation of Crohn’s disease from intestinal tuberculosis in India in 2010. World J Gastroenterol. 2011;17(4):433–43.CrossRefGoogle ScholarPubMed
Bulger, K, O’Riordan, M, Purdy, S, O’Brien, M, Lennon, J. Gastrointestinal sarcoidosis resembling Crohn’s disease. Am J Gastroenterol. 1988;83(12):1415–7.Google Scholar
Esmadi, M, Ahmad, DS, Odum, B, Diaz-Arias, A, Hammad, H. Sarcoidosis: an extremely rare cause of granulomatous enterocolitis. J Gastrointest Liver Dis. 2012;21(4):423–5.Google ScholarPubMed
Fries, W, Grassi, SA, Leone, L, et al. Association between inflammatory bowel disease and sarcoidosis: report of two cases and review of the literature. Scand J Gastroenterol. 1995;30(12):1221–3.Google Scholar
Richter, J, Heintges, T, Thomassen, D, Tannich, E, Haussinger, D. An unsuspected cause of chronic colitis. Gut. 2006;55(6):832–41.CrossRefGoogle ScholarPubMed
Singh, R, Balekuduru, A, Simon, EG, Alexander, M, Pulimood, A. The differentiation of amebic colitis from inflammatory bowel disease on endoscopic mucosal biopsies. Indian J Pathol Microbiol. 2015;58(4):427–32.Google Scholar
Madanagopalan, N, Subramaniam, R, Vedachalam, SP, Murugesan, RG. Rectal colonic mucosal biopsy in amebiasis and other colitis. Further studies. J Assoc Physicians India. 1968;16(6):325–32.Google Scholar
Prathap, K, Gilman, R. The histopathology of acute intestinal amebiasis: a rectal biopsy study. Am J Pathol. 1970;60(2):229–46.Google Scholar
Pai, SA. Amebic colitis can mimic tuberculosis and inflammatory bowel disease on endoscopy and biopsy. Int J Surg Pathol. 2009;17(2):116–21.CrossRefGoogle ScholarPubMed
Ustun, S, Dagci, H, Aksoy, U, Guruz, Y, Ersoz, G. Prevalence of amebiasis in inflammatory bowel disease in Turkey. World J Gastroenterol. 2003;9(8):1834–5.Google Scholar
Rampton, DS, Salmon, PR, Clark, CG. Nonspecific ulcerative colitis as a sequel to amebic dysentery. J Clin Gastroenterol. 1983;5(3):217–9.CrossRefGoogle ScholarPubMed
Gupta, J, Shepherd, NA. Colorectal mass lesions masquerading as chronic inflammatory bowel disease on mucosal biopsy. Histopathology. 2003;42:476–81.Google Scholar
Lee, RG. The colitis of Behçet’s syndrome. Am J Surg Pathol. 1986;10(12):888–93.Google Scholar
Kim, DH, Cheon, JH. Intestinal Behçet’s disease: a true inflammatory bowel disease or merely an intestinal complication of systemic vasculitis? Yonsei Med J. 2016;57(1):22–32.CrossRefGoogle ScholarPubMed
Yurdakul, S, Tuzuner, N, Yurdakul, I, Hamuryudan, V, Yazici, H. Gastrointestinal involvement in Behçet’s syndrome: a controlled study. Ann Rheum Dis. 1996;55(3):208–10.Google Scholar
Brosens, LA, Montgomery, EA, Bhagavan, BS, Offerhaus, GJ, Giardiello, FM. Mucosal prolapse syndrome presenting as rectal polyposis. J Clin Pathol. 2009;62(11):1034–6.Google Scholar
Madigan, MR, Morson, BC. Solitary ulcer of the rectum. Gut. 1969;10(11):871–81.CrossRefGoogle ScholarPubMed
Singh, B, Mortensen, NJ, Warren, BF. Histopathological mimicry in mucosal prolapse. Histopathology. 2007;50(1):97–102.Google Scholar
Lin, J, Fan, R, Zhao, Z, Cummings, OW, Chen, S. Is the presence of 6 or fewer crypt apoptotic bodies sufficient for diagnosis of graft versus host disease? A decade of experience at a single institution. Am J Surg Pathol. 2013;37(4):539–47.Google Scholar
Rowan, DJ, Hartley, CP, Carrillo-Polanco, LF, Oshima, K, Hagen, CE. Diagnostic phrasing is independently correlated with the decision to treat for graft-versus-host disease: retrospective review of colon biopsies with rare apoptosis. Histopathology. 2016;69(5):802–11.Google Scholar
Lee, FD. Importance of apoptosis in the histopathology of drug related lesions in the large intestine. J Clin Pathol. 1993;46(2):118–22.Google Scholar
Star, KV, Ho, VT, Wang, HH, Odze, RD. Histologic features in colon biopsies can discriminate mycophenolate from GVHD-induced colitis. Am J Surg Pathol. 2013;37(9):1319–28.Google Scholar
Washington, K, Jagasia, M. Pathology of graft-versus-host disease in the gastrointestinal tract. Hum Pathol. 2009;40(7):909–17.CrossRefGoogle ScholarPubMed
Nyhlin, N, Bohr, J, Eriksson, S, Tysk, C. Systematic review: microscopic colitis. Aliment Pharmacol Therap. 2006;23:1525–34.Google Scholar
Langner, C, Aust, D, Ensari, A, et al. Histology of microscopic colitis-review with a practical approach for pathologists. Histopathology. 2015;66(5):613–26.CrossRefGoogle ScholarPubMed
Geboes, K, Villanacci, V. Terminology for the diagnosis of colitis: Are indeterminate colitis and microscopic colitis useful terms? J Clin Pathol. 2005;58:1133–4.CrossRefGoogle Scholar
Warren, BF, Edwards, CM, Travis, SP. ‘Microscopic colitis’: classification and terminology. Histopathology. 2002;40(4):374–6.CrossRefGoogle ScholarPubMed
Lazenby, AJ. Collagenous and lymphocytic colitis. Semin Diagn Pathol. 2007;22:295–300.Google Scholar
Libbrecht, L, Croes, R, Ectors, N, Staels, F, Geboes, K. Microscopic colitis with giant cells. Histopathology. 2002;40(4):335–8.CrossRefGoogle ScholarPubMed
Tanaka, M, Riddell, RH, Saito, H, Soma, Y, Hidaka, H, Kudo, H. Morphologic criteria applicable to biopsy specimens for effective distinction of inflammatory bowel disease from other forms of colitis and of Crohn’s disease from ulcerative colitis. Scand J Gastroenterol. 1999;34:55–67.Google Scholar
Ayata, G, Ithamukkala, S, Sapp, H, et al. Prevalence and significance of inflammatory bowel disease-like morphologic features in collagenous and lymphocytic colitis. Am J Surg Pathol. 2002;26:1414–23.CrossRefGoogle ScholarPubMed
Kakar, S, Pardi, DS, Burgart, LJ. Colonic ulcers accompanying collagenous colitis: implication of nonsteroidal anti-inflammatory drugs. Am J Gastroenterol. 2003;98(8):1834–7.Google Scholar
Goldstein, NS, Gyorfi, T. Focal lymphocytic colitis and collagenous colitis: patterns of Crohn’s colitis? Am J Surg Pathol. 1999;23(9):1075–81.Google Scholar
Pokorny, CS, Kneale, KL, Henderson, CJ. Progression of collagenous colitis to ulcerative colitis. J Clin Gastroenterol. 2001;32(5):435–8.Google Scholar
Carroccio, A, Volta, U, Di Prima, L, et al. Autoimmune enteropathy and colitis in an adult patient. Dig Dis Sci. 2003;48(8):1600–6.Google Scholar
Akram, S, Murray, JA, Pardi, DS, et al. Adult autoimmune enteropathy: Mayo Clinic Rochester experience. Clin Gastroenterol Hepatol. 2007;5(11):1282–90.Google ScholarPubMed
Masia, R, Peyton, S, Lauwers, GY, Brown, I. Gastrointestinal biopsy findings of autoimmune enteropathy: a review of 25 cases. Am J Surg Pathol. 2014;38(10):1319–29.Google Scholar
Singhi, AD, Goyal, A, Davison, JM, Regueiro, MD, Roche, RL, Ranganathan, S. Pediatric autoimmune enteropathy: an entity frequently associated with immunodeficiency disorders. Mod pathol. 2014;27(4):543–53.Google Scholar
Casella, G, Villanacci, V, Fisogni, S, et al. Colonic left-side increase of eosinophils: a clue to drug-related colitis in adults. Aliment Pharmacol Ther. 2009;29(5):535–41.Google Scholar
Parfitt, JR, Driman, DK. Pathological effects of drugs on the gastrointestinal tract: a review. Hum Pathol. 2007;38(4):527–36.CrossRefGoogle ScholarPubMed
Goldstein, NS, Cinenza, AN. The histopathology of nonsteroidal anti-inflammatory drug-associated colitis. Am J Clin Pathol. 1998;110(5):622–8.Google Scholar
Puspok, A, Kiener, HP, Oberhuber, G. Clinical, endoscopic, and histologic spectrum of nonsteroidal anti-inflammatory drug-induced lesions in the colon. Dis Colon Rectum. 2000;43(5):685–91.Google Scholar
Geramizadeh, B, Taghavi, A, Clinical, Banan B., endoscopic and pathologic spectrum of non-steroidal anti-inflammatory drug-induced colitis. Indian J Gastroenterol. 2009;28(4):150–3.Google Scholar
Baert, F, Hart, J, Blackstone, MO. A case of diclofenac-induced colitis with focal granulomatous change. Am J Gastroenterol. 1995;90(10):1871–3.Google Scholar
Liapis, G, Boletis, J, Skalioti, C, et al. Histological spectrum of mycophenolate mofetil-related colitis: association with apoptosis. Histopathology. 2013;63(5):649–58.Google Scholar
Parfitt, JR, Jayakumar, S, Driman, DK. Mycophenolate mofetil-related gastrointestinal mucosal injury: variable injury patterns, including graft-versus-host disease-like changes. Am J Surg Pathol. 2008;32(9):1367–72.Google Scholar
Adler, BL, Pezhouh, MK, Kim, A, et al. Histopathological and immunophenotypic features of ipilimumab-associated colitis compared to ulcerative colitis. J Intern Med. 2018;283(6):568–77.Google Scholar
Washington, K, Stenzel, TT, Buckley, RH, Gottfried, MR. Gastrointestinal pathology in patients with common variable immunodeficiency and X-linked agammaglobulinemia. Am J Surg Pathol. 1996;20(10):1240–52.Google Scholar
Daniels, JA, Lederman, HM, Maitra, A, Montgomery, EA. Gastrointestinal tract pathology in patients with common variable immunodeficiency (CVID): a clinicopathologic study and review. Am J Surg Pathol. 2007;31(12):1800–12.Google Scholar
Marciano, BE, Rosenzweig, SD, Kleiner, DE, et al. Gastrointestinal involvement in chronic granulomatous disease. Pediatrics. 2004;114(2):462–8.Google Scholar
Agarwal, S, Mayer, L. Diagnosis and treatment of gastrointestinal disorders in patients with primary immunodeficiency. Clin Gastroenterol Hepatol. 2013;11(9):1050–63.CrossRefGoogle ScholarPubMed
Rowland, R, Langman, JM. Endometriosis of the large bowel: a report of 11 cases. Pathology. 1989;21(4):259–65.Google Scholar
Langlois, NE, Park, KG, Keenan, RA. Mucosal changes in the large bowel with endometriosis: a possible cause of misdiagnosis of colitis? Hum Pathol. 1994;25(10):1030–4.Google Scholar
Yantiss, RK, Clement, PB, Young, RH. Endometriosis of the intestinal tract: a study of 44 cases of a disease that may cause diverse challenges in clinical and pathologic evaluation. Am J Surg Pathol. 2001;25(4):445–54.Google Scholar
Heng, Y, Schuffler, MD, Haggitt, RC, Rohrmann, CA. Pneumatosis intestinalis: a review. Am J Gastroenterol. 1995;90(10):1747–58.Google Scholar
Boerner, RM, Fried, DB, Warshauer, DM, Isaacs, K. Pneumatosis intestinalis. Two case reports and a retrospective review of the literature from 1985 to 1995. Dig Dis Sci. 1996;41(11):2272–85.Google Scholar
Pieterse, AS, Leong, AS, Rowland, R. The mucosal changes and pathogenesis of pneumatosis cystoides intestinalis. Hum Pathol. 1985;16(7):683–8.Google Scholar
Suarez, V, Chesner, IM, Price, AB, Newman, J. Pneumatosis cystoides intestinalis. Histological mucosal changes mimicking inflammatory bowel disease. Arch Pathol Lab Med. 1989;113(8):898–901.Google Scholar
Koreishi, A, Lauwers, GY, Misdraji, J. Pneumatosis intestinalis: a challenging biopsy diagnosis. Am J Surg Pathol. 2007;31(10):1469–75.Google Scholar
Louie, CY, Gomez, AJ, Sibley, RK, Bass, D, Longacre, TA. Histologic features of gastrointestinal tract biopsies in IgA vasculitis (Henoch-Schonlein purpura). Am J Surg Pathol. 2018;42(4):529–33.CrossRefGoogle ScholarPubMed
Simsek, HD, Basyigit, S, Aktas, B, et al. Comparing the type and severity of inflammatory bowel disease in relation to IgG4 immunohistochemical staining. Acta Gastro-enterol Belg. 2016;79(2):216–21.Google ScholarPubMed
Virk, R, Shinagare, S, Lauwers, GY, Yajnik, V, Stone, JH, Deshpande, V. Tissue IgG4-positive plasma cells in inflammatory bowel disease: a study of 88 treatment-naive biopsies of inflammatory bowel disease. Mod Pathol.2014;27(3):454–9.Google Scholar
Ravi, K, Chari, ST, Vege, SS, Sandborn, WJ, Smyrk, TC, Loftus, EV Jr. Inflammatory bowel disease in the setting of autoimmune pancreatitis. Inflamm Bowel Dis. 2009;15(9):1326–30.Google Scholar
Strehl, JD, Hartmann, A, Agaimy, A. Numerous IgG4-positive plasma cells are ubiquitous in diverse localised non-specific chronic inflammatory conditions and need to be distinguished from IgG4-related systemic disorders. J Clin Pathol. 2011;64(3):237–43.Google Scholar
Bedeir, A, Jukic, DM, Wang, L, Mullady, DK, Regueiro, M, Krasinskas, AM. Systemic mastocytosis mimicking inflammatory bowel disease: a case report and discussion of gastrointestinal pathology in systemic mastocytosis. Am J Surg Pathol. 2006;30(11):1478–82.Google Scholar
Doyle, LA, Sepehr, GJ, Hamilton, MJ, Akin, C, Castells, MC, Hornick, JL. A clinicopathologic study of 24 cases of systemic mastocytosis involving the gastrointestinal tract and assessment of mucosal mast cell density in irritable bowel syndrome and asymptomatic patients. Am J Surg Pathol. 2014;38(6):832–43.Google Scholar
Sokol, H, Georgin-Lavialle, S, Grandpeix-Guyodo, C, et al. Gastrointestinal involvement and manifestations in systemic mastocytosis. Inflamm Bowel Dis. 2010;16(7):1247–53.Google Scholar
Burroughs, SH, Bowrey, DJ, Morris-Stiff, GJ, Williams, GT. Granulomatous inflammation in sigmoid diverticulitis: two diseases or one? Histopathology. 1998;33(4):349–53.Google Scholar
Gledhill, A, Dixon, MF. Crohn’s-like reaction in diverticular disease. Gut. 1998;42(3):392–5.CrossRefGoogle ScholarPubMed
Greenson, JK, Odze, RD. Inflammatory disorders of the large intestine. In Odze, RD, Goldblum, JR (eds), Surgical Pathology of the GI Tract, Liver, Biliary Tract and Pancreas. 2nd ed. Philadelphia: Saunders Elsevier; 2009, 355–94.Google Scholar
Warren, BF, Shepherd, NA, Bartolo, DC, Bradfield, JW. Pathology of the defunctioned rectum in ulcerative colitis. Gut. 1993;34(4):514–6.Google Scholar
Hoie, S, Knudsen, LS, Gerstoft, J. Lymphogranuloma venereum proctitis: a differential diagnose to inflammatory bowel disease. Scand J Gastroenterol. 2011;46(4):503–10.Google Scholar
de la Monte, SM, Hutchins, GM. Follicular proctocolitis and neuromatous hyperplasia with lymphogranuloma venereum. Hum Pathol. 1985;16:1025–32.Google Scholar
Jain, D, Warren, BF, Riddell, RH. Inflammatory disorders of the large intestine. In Shepherd, NA, Warren, BF, Williams, GT, Greenson, JK, Lauwers, GY, Novelli, MR (eds), Morson and Dawson’s Gastrointestinal Pathology. 5th ed. Oxford: Wiley-Blackwell; 2013. 552–635.Google Scholar
Kotler, DP, Weaver, SC, Terzakis, JA. Ultrastructural features of epithelial cell degeneration in rectal crypts of patients with AIDS. Am J Surg Pathol. 1986;10(8):531–8.Google Scholar
Talbot, I, Price, A, Salto-Tellez, M. Biopsy Pathology in Colorectal Disease. 2nd ed. London: Hodder Arnold; 2006.Google Scholar
Tsang, P, Rotterdam, H. Biopsy diagnosis of colitis: possibilities and pitfalls. Am J Surg Pathol. 1999;23:423–30.Google Scholar

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