Is Ileoscopy With Biopsy Worthwhile in Patients Presenting With Symptoms of Inflammatory Bowel Disease?

Objective : To assess the value of adding ileoscopy with biopsy to colonoscopy, hence increasing the indications for ileoscopy in patients presenting with symptoms of inflammatory bowel disease. Methods : Two hundred fifty-seven patients with persistent diarrhea and 43 patients with sporadic colonic polyps were studied prospectively. The final diagnosis based on clinical and follow-up data, the histology of multiple ileal biopsies, and endoscopic findings were analyzed. Results : Endoscopic lesions of the terminal ileum were found in 123 of 300 patients. In the 43 patients with colonic polyps, no ileal lesions were seen. Ileal disease without colonic involvement was present in 44 of 123 patients. Microscopic lesions of the ileum were present in 125 of 300, or in 125 of 257 (49%) with symptoms of diarrhea. Two of these had a normal endoscopy. Thirteen patients had a diffuse colitis and 11 had a predominantly left-sided colitis, both originally suggestive of ulcerative colitis. Crohn's disease was diagnosed in 88 patients and infectious disease in 17. Ileal biopsies were essential for the diagnosis in 15 patients and were contributive in 53. Granulomas, solitary giant cells, pseudopyloric gland metaplasia, eosinophils, and a disturbed villous architecture were the most important lesions observed in Crohn's disease and were contributive for this diagnosis. Conclusions : Ileoscopy with biopsy is useful in carefully selected patients presenting with symptoms of inflammatory bowel disease. The main indications are diagnosis of isolated ileal disease in the presence of a normal colon and differential diagnosis in patients with pancolitis and predominantly left-sided colitis. Multiple biopsy specimens show definite pathology in almost half of the patients.     

Routine colonic mucosal biopsy and ileoscopy increases diagnostic yield in patients undergoing colonoscopy for diarrhea

BACKGROUND AND AIMS: In patients undergoing colonoscopy for diarrhea, when the examination is normal, the role of routine mucosal biopsy remains controversial, particularly in the open-access setting. It is uncertain whether routine ileoscopy adds anything to colonoscopy alone. We aimed to assess the yield of mucosal biopsy and ileoscopy in patients with diarrhea. METHODS: We retrospectively reviewed all colonoscopies performed for diarrhea over a 9-year period in a tertiary referral center with an open-access service. We then selected cases where the examination was normal and biopsies were performed. The histopathology reports of these selected cases were then reviewed. RESULTS: There were 1131 cases identified. The mucosal examination was normal in 465 cases (41%); 362 of these had colonic biopsies performed. Histology was normal in 316 cases (87%) and was non-specific in 28 cases (8%). Significant histopathology was present in 18 cases (5%) with a significantly higher prevalence of microscopic colitis in patients above 60 years old. Ileoscopy was performed in 508 cases and was abnormal in 26 cases (5%). The abnormality on ileoscopy was the sole abnormality in 13 cases (3%). CONCLUSIONS: Routine colonic mucosal biopsy and ileoscopy each identify significant additional pathology in 5% of cases when investigating patients with diarrhea, and are recommended as routine practice in this setting. We found ileal biopsy unhelpful when ileoscopy was normal.     

Prospective comparison of small bowel meal with pneumocolon versus ileo-colonoscopy for the diagnosis of ileal Crohn's disease

BACKGROUND AND AIMS: Both endoscopy and barium radiography are used routinely to diagnose terminal ileal (TI) Crohn's disease (CD). A prospective study was undertaken to compare ileoscopy with biopsy to small bowel meal with pneumocolon (SBMP) in patients with suspected TI CD. METHODS: A cohort of outpatients investigated for diarrhea with features of TI disease underwent SBMP followed by colonoscopy with ileal intubation and biopsy within 21 days. All results were reported in a standardized, sequential format to assign SBMP TI diagnoses by the duty radiologist and by dual reading with consensus, ileoscopy by the attending endoscopist, and ileoscopy with biopsy by a blinded panel of endoscopists and pathologists. Reference standard TI diagnoses were determined by a consensus panel with full access to medical records. RESULTS: Among 120 subjects, the reference standard TI diagnosis was normal in 47 (39.1%), lymphoid nodular hyperplasia (LNH) in 24 (20.0%), CD in 48 (40.0%), and NSAID enteropathy in 1 (0.9%). Colonoscopy provided TI images and/or biopsies in 97 cases (80.8%), while SBMP provided TI images in 119 (99.1%). When ileoscopy with biopsy succeeded, its accuracy was similar to SBMP with dual reading (89.7%vs 89.9%, p = NS) but superior to SBMP if interpreted only by the duty radiologist (80.0%, p < 0.05). Biopsy improved the accuracy of ileoscopy, while dual reading improved that of SBMP. Both ileoscopy with biopsy and SBMP with dual reading are highly accurate for diagnosing TI CD. Choice of initial test should reflect local expertise and availability, and the likelihood of associated disease in the proximal small bowel or colon.     

Diagnosing inflammatory bowel disease and differentiating it from potential mimics

The initial diagnosis of inflammatory bowel disease (IBD) requires multiple diagnostic modalities; however, endoscopic evaluation as a diagnostic test is considered the gold standard. Endoscopic evaluation includes colonoscopy with ileoscopy, esophagogastroduodenoscopy, enteroscopy, and capsule endoscopy. IBD encompasses Crohn’s disease, ulcerative colitis, and IBD unclassified. Colonoscopy with ileoscopy along with biopsy collection is essential in most IBD cases for diagnosis and to rule out alternative findings that may mimic IBD including ischemia, diverticulitis, segmental colitis associated with diverticulosis, neoplasia, radiation enteritis, and drug-induced colitis. Esophagogastroduodenoscopy, enteroscopy, and capsule endoscopy are used in the initial workup of specific groups of patients with IBD. The role of endoluminal diagnostic studies in the initial diagnosis of IBD is discussed in detail in this article.     

Colonoscopic and histologic features of colonic Crohn's disease in Chinese patients

OBJECTIVE: An attempt was made to provide a better insight into endoscopic and histological features and to enhance the understanding of the diagnostic value of colonoscopy combined with biopsy for colonic Crohn's disease. METHODS: As presented in our 27 cases of colonic Crohn's disease (Crohn's colitis), the endoscopic findings and histological changes of biopsy specimens were analyzed. As collated with correspondent results of biopsy and surgical specimens, the diagnostic accuracy of endoscopy was evaluated. RESULTS: Of these patients, 26 involvements of the colon (often combined with other sites of the bowel) were observed (96.3%). However, involvements limited to the colon alone were seen in only four cases (14.8%). Endoscopically, diverse patterns of multi‐staged‐segmental distributed and multi‐sited inflammatory lesions, both destructive and proliferative/regenerative changes were observed in the bowel of the same patient. The diaganostic accuracy of colonoscopy, as confirmed by the histological examination of biopsy and resected specimens, was 66.7%. The major characteristic features of mucosal biopsy were the focal distribution of inflammatory infiltration and lymphoid aggregate. Otherwise, it may include edematous and widened submucosa, deep fissuring ulcers and hyperplasia, fibrosis and granulomas (detected in 30% of the group), among others. CONCLUSION: The colonic involvement of Crohn's disease was common. Colonoscopy may be valuable in establishing a diagnosis and in assessing the extent and severity of such colonic involvement. Biopsy is helpful to confirm a diagnosis conducted by colonoscopy. Colonoscopy combined with biopsy may replace radiology as the initial test of choice in many clinical situations.     

Gastral antral biopsy in the differentiation of pediatric colitides

OBJECTIVES: Differentiation of Crohn's disease (CD) from ulcerative colitis (UC) is problematic, primarily when inflammation is confined to the colon. In a historical cohort study, we evaluated the usefulness of baseline gastric antral biopsies in the differentiation of pediatric chronic colitides. METHODS: During initial investigation for suspected inflammatory bowel disease, 39 children and adolescents with colitis but normal small bowel radiography underwent pretreatment upper endoscopy concurrently with colonoscopy. Two reviewers assigned a colonoscopic diagnosis (colonic CD, UC, or indeterminate colitis) based on the macroscopic and microscopic appearances of the colonic mucosa. Antral histological findings were compared between groups using Fisher's exact test. RESULTS: Five (14%) of colonoscopic diagnoses (four indeterminate, one UC) were changed to CD by the finding of granulomatous inflammation in antral biopsies. Nonspecific antral gastritis was found in similar proportions of children and adolescents with Crohn's colitis and UC (92% vs 75%). Focal antral gastritis was more common in patients with Crohn's colitis than UC (52% vs 8%). CONCLUSIONS: Nonspecific antral gastritis is common in all forms of chronic colitis. Nevertheless, upper gastrointestinal endoscopy with biopsy is useful in the differentiation of inflammatory bowel disease confined to the colon, particularly when colonoscopic findings are indeterminate.     

Colonoscopy and SeHCAT for investigation of chronic diarrhea

BACKGROUND/AIMS: Chronic diarrhea is a common problem. Colonoscopy is the investigation of choice for diagnosis. Even a macroscopically normal mucosa on endoscopy can have abnormalities such as microscopic colitis and bile acid malabsorption (BAM). The aim of this study was to establish the value of colonoscopy with biopsies in patients with chronic diarrhea and to evaluate the additive value of a SeHCAT test for diagnosing BAM in these patients. METHODS: All patients who underwent a colonoscopy between November 1999 and December 2000 were included. Patient files, colonoscopy and pathology reports and SeHCAT test results were reviewed. RESULTS: 205 patients were included. The most common diagnoses were diarrhea-predominant IBS (n = 76) and IBD (n = 38). 158 patients had non-bloody diarrhea, 113 (72%) of them had a macroscopically normal appearing mucosa. In 40 (35%) of these patients, a histological diagnosis could be made and microscopic colitis was the most common diagnosis (n = 27). SeHCAT test was performed in 36 patients and 15 (42%) of them had BAM. In the 47 patients with bloody diarrhea, IBD was the main diagnosis (n = 23). CONCLUSION: Colonoscopy with biopsies must be performed when investigating chronic diarrhea and BAM should be excluded.     

The prevalence, anatomic distribution, and diagnosis of colonic causes of chronic diarrhea

BACKGROUND: The prevalence of chronic diarrhea from a colonic disease and the optimal method of its diagnosis have not been ascertained. METHODS: Eight hundred nine patients with chronic non-bloody diarrhea unassociated with human immunodeficiency virus (HIV) infection underwent colonoscopy with biopsy specimen taken from throughout the colon and, if reached, the terminal ileum. The prevalence and anatomic distribution of ileocolonic histopathology and whether flexible sigmoidoscopy or colonoscopy represents the safest and most cost-effective test for diagnosis were determined. RESULTS: 122 of 809 patients (15%) had colonic histopathology (microscopic colitis in 80 patients, Crohn's disease in 23, melanosis coli in 8, ulcerative colitis in 5, other forms of colitis in 5, and nodular lymphoid hyperplasia in 1). A correct assessment of colonic histology (normal or abnormal) could have been made from biopsies of the distal colon in 99.7% of patients. CONCLUSION: In a referral setting, colonic histopathology occurs in 15% of patients with chronic diarrhea without HIV infection. According to this prevalence and the nearly universal diffuse anatomic distribution of colonic disease in these patients, a diagnostic investigation for chronic colonic diarrhea using a 60 cm flexible sigmoidoscope is highly efficient and cost-effective.     

Colonoscopy in inflammatory bowel disease. Diagnostic accuracy and proposal of an endoscopic score

Colonoscopy is used in the differential diagnosis of inflammatory bowel disease but its accuracy and the "weight" of the various endoscopic signs have not been assessed. In a prospective study 357 patients with 606 colonoscopies, in whom the endoscopic appearances were those of ulcerative colitis, Crohn's colitis, or indeterminate colitis, were followed-up for an average period of 22 mo. A final, definite, endoscopy-independent diagnosis was reached by means of autopsy, surgery, or histology on biopsy in 71% of patients. Accuracy of colonoscopy was 89%, with 4% errors and 7% indeterminate diagnoses. Errors were more frequent in severe inflammatory activity (9%). The most useful endoscopic features in this differential diagnosis were discontinuous involvement, anal lesions, and cobblestoning of mucosa for Crohn's disease, and erosions or microulcers and granularity for ulcerative colitis. After selecting the endoscopic features with best predictive value, an "endoscopic score" was calculated by means of "likelihood ratios."     

Histological diagnosis of chronic inflammatory bowel disease in childhood.

One hundred and four children were initially assessed by clinical, radiological, and endoscopic criteria as chronic inflammatory bowel disease. All were assessed independently using precise histological diagnostic criteria. Fifty eight patients were diagnosed as Crohn's disease, 25 as ulcerative colitis, 15 remained provisionally categorised as indeterminate colitis and six proved to be normal. Diagnostic granulomas were found in 36% of endoscopic biopsies from the 58 children with Crohn's disease. This appears to be an underestimate as only four of 14 children with granulomatous Crohn's disease operated on had granulomas on endoscopic biopsy. This study shows that there is a spectrum of histological appearances in endoscopic biopsies in chronic inflammatory bowel disease in childhood ranging from definite Crohn's disease to definite ulcerative colitis with indeterminate features in between. Accurate histological diagnosis of chronic inflammatory bowel disease is dependent upon either multiple endoscopic biopsies or assessment of a surgically resected specimen.     

Diagnostic value of high resolution sonography in Crohn's disease and ulcerative colitis]

OBJECTIVE: To evaluate the diagnostic accuracy of high resolution sonography in patients with inflammatory bowel disease (MICI). PATIENTS AND METHODS: In patients with Crohn's disease (n = 48), ulcerative colitis (n = 23), indeterminate colitis (n = 3), inflammatory (n = 21) and non-inflammatory (n = 23) controls, high resolution sonography was performed and compared to colonoscopy (+/- retrograde ileoscopy) and/or baryum studies of the small bowel and the colon. RESULTS: Diagnosis of intestinal inflammation or not was correct in 69/74 MICI patients (sensitivity: 94.4%, specificity: 66.7%, global accuracy: 93.2%). Segment location was accurate in 58/74 (sensitivity: 80.3%, specificity: 66.7%, global accuracy: 79.7), more frequently in Crohn's disease, than in ulcerative colitis. Five out of six complications of Crohn's disease were diagnosed. In Crohn's disease, the method was more accurate in case of colonic or ileocolonic involvement. CONCLUSION: High resolution sonography is a reliable diagnostic tool for the detection of intestinal inflammation and related complications in MICI. In can be of value in the follow-up and seems particularly interesting in the case of temporary contraindication of invasive methods.     

Utility of a Rapid Fecal Latex Agglutination Test Detecting the Neutrophil Protein, Lactoferrin, for Diagnosing Inflammatory Causes of Chronic Diarrhea

Objective: The utility of tests for fecal neutrophils in the setting of chronic diarrhea has not been established. The purpose of this study was to determine the causes of chronic diarrhea associated with fecal neutrophils.
Methods: One fecal specimen from each of 10 normal subjects, 26 patients with known microscopic colitis, 13 with celiac sprue, eight with Crohn's disease, four with ulcerative colitis, and 103 with chronic diarrhea of unknown origin, as well as 10 fecal specimens from a patient with chronic nongranulomatous enterocolitis were analyzed blindly for the presence of a neutrophil granule protein called lactoferrin using a commercial latex agglutination kit. Diagnostic evaluation of the 103 patients with chronic diarrhea was carried out to determine the diagnostic accuracy of this test for chronic inflammatory bowel disease.
Results: None of the normal control subjects, three of 39 patients with microscopic colitis or celiac sprue, all 10 specimens from the patient with enterocolitis, and all 12 control patients with ulcerative colitis or Crohn's disease had a positive fecal lactoferrin test. Eleven of 103 patients with chronic diarrhea presenting without a diagnosis had a positive test, and all were diagnosed with an inflammatory condition of the colon (five-, ulcerative colitis; four-, Crohn's disease; one-, ischemic colitis; and one-, microscopic colitis). Only one patient with inflammatory bowel disease had a negative lactoferrin test. The sensitivity, specificity, and positive and negative predictive values of the fecal lactoferrin test for ulcerative or Crohn's colitis were 90%, 98%, 82%, and 99%, respectively.
Conclusion: The major cause of fecal neutrophils in patients with chronic diarrhea is chronic inflammatory bowel disease of the colon. The latex agglutination test for fecal lactoferrin offers a highly sensitive, specific, and simple means for detection of fecal neutrophils in these patients.     

The clinical significance of focal enhanced gastritis in adults with isolated ileitis of the terminal ileum

BACKGROUND: Isolated chronic ileitis in the terminal ileum, without accompanying chronic colitis, is not an uncommon finding present in biopsy specimens from patients being evaluated for chronic diarrhea. Among the many entities that should be included in the differential diagnosis are Crohn's disease and nonsteroidal antiinflammatory drugs (NSAIDs)-induced enterocolitis. In high-prevalence Crohn's disease populations, focal enhanced or active gastritis (FEG) may be a good predictor of Crohn's disease; however, this criterion may not apply in a general clinical setting. Our goal was to determine if FEG is a pathological marker of Crohn's disease in patients with isolated chronic ileitis in the terminal ileum. METHODS: We examined 46 consecutive cases of isolated chronic ileitis with concurrent stomach biopsies. These patients did not have evidence or previous history of inflammatory bowel disease. The diagnostic criteria of chronic ileitis included crypt distortion and inflammation, plasmacytosis in the lamina propria, ulceration, and/or pyloric gland metaplasia. RESULTS: Of the 46 cases reviewed, 25 (54%) cases were diagnosed with Crohn's disease later, confirmed by clinical manifestations and/or biopsies with a follow-up of up to 4 years. The stomach biopsies of these patients were either normal or demonstrated a spectrum of histological findings, including FEG, chronic gastritis with or without Helicobacter pylori organisms, chemical gastropathy, and normal tissues. FEG was more commonly present in Crohn's disease patients (36%) than in non-Crohn's disease patients (5%) (P < 0.01). CONCLUSIONS: The presence of FEG is a good indicator for the diagnosis of Crohn's disease in adult patients with isolated chronic ileitis.     

Diagnostic Yield of Routine Ileoscopy

Intubation of the ileum during colonoscopy, although well described, is not routinely performed. It can establish the completeness of colonoscopic examinations and is useful in the diagnosis of inflammatory bowel disease. However, the diagnostic utility of routine ileoscopy during all colonoscopic procedures has not been well studied. We prospectively evaluated ileal intubations in 138 patients undergoing colonoscopy. The incidence of a positive diagnosis from ileoscopy was 2.7% in asymptomatic patients undergoing surveillance colonoscopy, and 29% of patients complained of diarrhea (18% in non-HIV patients, 67% in HIV-positive patients). We feel ileal intubation is an important adjunct to colonoscopy, especially in patients with diarrhea.     

Routine ileoscopy at colonoscopy: a prospective evaluation of learning curve and skill-keeping line

BACKGROUND: Ileoscopy is the criterion standard for mucosal lesions of terminal ileum but is performed in 5% of colonoscopy activity, and the need for training is undefined. OBJECTIVE: To assess the learning curve and skill-keeping line of ileoscopy. DESIGN: Prospective randomized study. SETTING: Single GI endoscopy unit. PATIENTS: Adult outpatients referred for colonoscopy. INTERVENTIONS: Patient randomization to ileocolonoscopy by trainees and seniors. MAIN OUTCOME MEASUREMENTS: Ileoscopy skill was divided into the following: ileocecal valve (ICV) intubation (success rate, time) and ileal exploration (length, time). Consecutive blocks of 10 procedures were used to calculate the learning curve and the skill-keeping line. Variables considered to influence ICV intubation were the following: endoscopist experience, ICV morphology, patient age, gender, body mass index, diverticular disease, and preceding abdominal/pelvic surgery. RESULTS: Learning curve showed that competency in ICV intubation (80% success rate) and ileal exploration (16 cm) was achieved after 50 procedures. The skill-keeping line showed that ileoscopy was easy (97% success rate), fast (1 minute), and well accepted up to 45 cm of the ileum. Thin-lipped and volcanic ICV are the most difficult and easiest to intubate, respectively. Crohn's disease and adenomas of the proximal edge of ICV were diagnosed in 2.2%. CONCLUSIONS: Training in ileoscopy is recommended to achieve competency, and endoscopists should consider practicing ICV intubation to maintain and increase their skill. Ileoscopy can be difficult when the ICV is thin lipped or single bulged, and easy when it has a volcanic morphology.     

A Case of Diclofenac-Induced Colitis with Focal Granulomatous Change

We report a case of severe colitis from dielofenac (Voltaren), one of a number of nonsteroidal anti-inflammatory drugs (NSAIDs) that can cause colonic injury. The patient, a 68-yr-old woman, presented with acute onset of Moody diarrhea, having taken dielofenac for more than 2 yr. Colonoscopy revealed deep ulcerations in the transverse colon and erythema and erosions scattered elsewhere. Biopsy findings included crypt distortion, cryptitis, hemorrhage, and some fibrosis. Also, in one biopsy taken from an area of deepest ulceration, a large, non-foreign body-type granuloma was seen, raising the specter of Crohn's colitis. All symptoms subsided within 24 h after discontinuation of the dielofenac, and follow-up colonoscopy 17 days later showed complete endoscopic and histological resolution. Patients and physicians should be aware of the possibility of colitis from NSAIDs. In rare cases, some will show granulomatous change that may be confused with Crohn's disease. Early recognition and discontinuation of NSAIDs is crucial to prevent clinical worsening that could lead to colectomy or even prove fatal.     

Retrograde ileoscopy in chronic nonbloody diarrhea: a prospective,case-control study

OBJECTIVE: Chronic nonbloody diarrhea (CND) is a frequent intestinal disorder, with a relevant economic impact. Besides colonic diseases, alterations of the terminal ileum could be involved in CND pathogenesis. The aim of this study was to assess the role of retrograde ileoscopy with biopsy in CND patients. METHODS: Patients complaining of CND and matched control subjects were enrolled in the study. Retrograde ileoscopy with biopsy was attempted in all cases. Endoscopic and histological features of Crohn's disease, nonspecific ileitis, and nodular lymphoid hyperplasia were recorded for each patient. Exclusion criteria were presence of any colonic alterations at either endoscopy or histology as well as failure of ileal intubation. RESULTS: Overall, 156 patients were recruited. Ileal intubation was successful in 149 (95.5%), but 11 (7%) patients were excluded because colonic diseases were detected at histology. At endoscopy, alterations of the terminal ileum were significantly more frequent in patients than in controls (47/138 vs 15/138; p < 0.0001). Crohn's disease (9/138 vs 0/138; p = 0.007) and nonpecific ileitis (18/138 vs 2/138; p = 0.0009) were significantly more frequent in patients than in controls as well as nodular lymphoid hyperplasia (33/138 vs 16/138; p = 0.008). A final diagnosis of Crohn's disease was achieved on the basis of both endoscopic and histological findings in eight (5.8%) patients. CONCLUSIONS: Retrograde ileoscopy is an useful procedure in CND because of its ability to detect alterations in the terminal ileum. Its inclusion in diagnostic workup should be considered.     

5 Colonoscopy and biopsy

The place of colonoscopy in the management of ulcerative colitis is restricted to clinical situations where the information provided will change clinical management. The information provided will be answers to the questions ?inflammatory bowel disease, or, in the patient with known colitis: inflammatory bowel disease ?type ?activity ?extent ?dysplasia. Biopsy is pivotal to the diagnosis and provides the certainty of tissue diagnosis, assessment of activity and detection of dysplasia. p]Sigmoidoscopy is sufficient for providing information for clinical management in most circumstances, but colonoscopy is important where clinical features are disproportionate to sigmoidoscopic findings and systemic parameters of inflammatory activity; to determine type and extent of inflammatory bowel disease and when surveillance needs to start; and for biopsy to detect dysplasia. Ileoscopy is an important aspect of colonoscopy for differential diagnosis, and is the unique definer of total colonoscopy.     

A prospective study of the technical feasibility of ileoscopy at colonoscopy

BACKGROUND: Despite a well-documented diagnostic yield, ileoscopy at colonoscopy is not performed routinely. This is due to the perceived difficulty in intubating the ileocaecal valve, added procedure time and a lack of acceptance regarding diagnostic yield. Therefore, we conducted a study to investigate the technical feasibility of ileoscopy at colonoscopy. METHODS: Ileoscopy was studied prospectively in 120 patients undergoing diagnostic colonoscopy. After identification of the caecum, ileoscopy was attempted by one of four techniques. The time taken to pass from caecum to terminal ileum, the patient position, use of Hyoscine-n-butyl bromide and any ileal abnormalities were recorded in each case. RESULTS: Ileoscopy was successful in 117/120 (97%) cases with a median time of 55 s taken to intubate the ileo-caecal valve. A 'down and left' technique was used in most cases (74.4%). Switching the patient to supine aided ileoscopy in 24 cases (20.4%) and Hyoscine-n-butyl bromide was considered helpful in 25 (21.4%). Overall, the terminal ileum was abnormal in 24 of 117 (20.5%) patients. CONCLUSIONS: Ileoscopy can be achieved in nearly all patients undergoing diagnostic colonoscopy and the added procedure time is short. Added time, technical difficulty and limited yield are not valid reasons for choosing not to perform ileoscopy.     

Endoscopic mucosal biopsies are useful in distinguishing granulomatous colitis due to Crohn's disease from tuberculosis

BACKGROUND: Intestinal tuberculosis and Crohn's disease are chronic granulomatous disorders that are difficult to differentiate histologically. AIMS: To characterise distinctive diagnostic features of tuberculosis and Crohn's disease in mucosal biopsy specimens obtained at colonoscopy. METHODS: Selected histological parameters were evaluated retrospectively in a total of 61 biopsy sites from 20 patients with tuberculosis and 112 biopsy sites from 20 patients with Crohn's disease. The patients were chosen on the basis of clinical history, colonoscopic findings, diagnostic histology, and response to treatment. RESULTS: The histological parameters characteristic of tuberculosis were multiple (mean number of granulomas per section: 5.35), large (mean widest diameter: 193 microm), confluent granulomas often with caseating necrosis. Other features were ulcers lined by conglomerate epithelioid histiocytes and disproportionate submucosal inflammation. The features characteristic of Crohn's disease were infrequent (mean number of granulomas per section: 0.75), small (mean widest diameter: 95 microm) granulomas, microgranulomas (defined as poorly organised collections of epithelioid histiocytes), focally enhanced colitis, and a high prevalence of chronic inflammation, even in endoscopically normal appearing areas. CONCLUSIONS: The type and frequency of granulomas, presence or absence of ulcers lined by epithelioid histiocytes and microgranulomas, and the distribution of chronic inflammation have been identified as histological parameters that can be used to differentiate tuberculosis and Crohn's disease in mucosal biopsy specimens obtained at colonoscopy.