Distribution of collagenous colitis: utility of flexible sigmoidoscopy.

We investigated the distribution of the collagen band in 33 patients with collagenous colitis to estimate the likelihood of the disease being diagnosed in biopsy specimens from the left side of the colon, such as those obtained using flexible sigmoidoscopy. To be included in this study patients had a subepithelial collagen band greater than or equal to 10 microns, an increase in chronic inflammatory cells in the same specimen, and diarrhoea for which there was no other apparent cause. In 17 patients undergoing full colonoscopy with a thickened collagen band, collagenous colitis was frequently patchy, even though overall the thickened collagen band was almost equally distributed throughout the colon. Rectal biopsy specimens showed a normal collagen band in 73% of patients, while a thickened collagen band was found in 82% of patients in at least one specimen from the left side of the colon. Three patients had a thickened collagen band only in the caecum. In three of eight rectal biopsy specimens with a normal collagen band there was no mucosal inflammation to raise the possibility of proximal disease, although all but one specimen with a normal collagen band from the sigmoid and descending colon were inflamed. Rectal biopsy alone is therefore a relatively poor method of making the diagnosis. Flexible sigmoidoscopy with multiple biopsy specimens from several sites is a reasonable initial investigation but not sufficient to exclude collagenous colitis when based on the presence of a thickened collagen band alone. Should left sided biopsy specimens show a normal collagen band but an inflamed mucosa, total colonoscopy with multiple specimens including the caecum may be required to establish the diagnosis.     

Collagenous gastritis and collagenous colitis: a report with sequential histological and ultrastructural findings

The case is reported of a young adult man with collagenous gastritis, an extremely rare disorder with only three case reports in the English literature, who subsequently presented with collagenous colitis. Sequential gastric biopsies showed a notable increase in thickness of the subepithelial collagen band. Ultrastructural study of gastric and rectal mucosa showed the characteristic subepithelial band composed of haphazardly arranged collagen fibres, prominent degranulating eosinophils, and activated pericryptal fibroblasts.     

Diffuse excess mucosal collagen in rectal biopsies facilitates differential diagnosis of solitary rectal ulcer syndrome from other inflammatory bowel diseases

Solitary rectal ulcer syndrome (SRUS) is sufficiently uncommon that the clinician or general pathologist may lack familiarity with the disorder and may confuse it with other inflammatory bowel diseases. To evaluate the role of collagen staining in facilitating the differential diagnosis of SRUS, an initial open review was undertaken on 1672 consecutive patients whose 4780 colorectal biopsies were stained with H&E with added saffron to demonstrate collagen. Excess mucosal collagen was present in 39 (2.3%) of these patients. Twenty patients with a diffuse excess of mucosal collagen in biopsies from rectal ulcer margins or from otherwise abnormal rectal mucosa had SRUS; in the remaining 19 patients, excess mucosal collagen was focal (seven ischemic colitis, five collagenous colitis, three adenocarcinoma, and four chronic idiopathic ulcerative colitis). Diffuse excess mucosal collagen never was seen in idiopathic inflammatory bowel disease (128 Crohn's colitis and 446 ulcerative colitis). Blinded reviews then were performed on rectal biopsies from 33 patients with a variety of diagnoses (14 SRUS and 19 controls). Diffuse excess collagen by saffron staining was consistently observed in SRUS but was absent in all 19 controls. Additional blinded reviews were carried out because the collagen staining pattern in ischemic colitis, although focal, could potentially be confused with SRUS. It was possible to differentiate these two diseases blindly from one another by using additional histologic criteria (14 SRUS and 12 ischemic colitis). We conclude that the demonstration of a diffuse excess of mucosal collagen in rectal biopsies facilitates the diagnosis of SRUS and differentiates it from idiopathic ulcerative colitis and Crohn's disease, with which SRUS is often confused, and other inflammatory bowel diseases.Supported in part by United States Public Health Service National Research Service Award AM07113 and NIH Grant PO1 AM32971.This work was presented, in part, at the Annual Meeting of the American Federation for Clinical Research (Western Section), Carmel, California, February 1986.     

Endoscopic and histopathological evaluation of collagenous colitis

Collagenous colitis (CC) is a well-known cause of chronic non-bloody diarrhea, especially in elderly women. CC is characterized histopathologically by an increase in the thickness of the subepithelial collagen layer to at least 10 μm, epithelial damage, and chronic inflammation of the lamina propria. Generally, the colonic mucosa in CC is macroscopically normal, although minor, non-specific abnormalities may be found. Due to the recent advancement of endoscopic and diagnostic technologies, however, microscopic mucosal abnormalities and specific longitudinal linear lacerations of the mucosa characteristic of CC have been identified. The association of CC with non-steroidal anti-inflammatory drugs and proton pump inhibitors has also been reported. Since definitive diagnosis of CC has to rely on pathologically documented collagen bands and mononuclear infiltration, the efficiency and precision of colonic biopsy need to be improved. Of the 29 CC patients that we have encountered at our institution, it was in 15 of 29 cases that the endoscopic finding that we performed a biopsy on was apparent. Our comparison of the endoscopic and histopathological findings of CC in the 15 patients showed that the mucosa frequently appeared coarse and nodular on the surface of the mucosa, which was also significantly thicker in collagen bands, demonstrating a strong correlation between collagen band formation and CC. Also, the coarse and nodular surface of the mucosa was most frequently seen affecting the proximal colon. The results suggest that endoscopic observation and biopsy of the proximal colon, where a coarse and nodular surface of the mucosa is often found, may be useful for confirmation of the diagnosis in patients with suspected CC.     

Allergic colitis: clinical and morphological aspects in infants with rectal bleeding

BACKGROUND: Recent studies indicate the importance of eosinophilis infiltrated in the rectal mucous which jointly with the clinical features can serve to establish the diagnostic of allergic colitis. AIM: To describe prospectively, the clinical features and morphological abnormalities of the rectal mucosa in patients with rectal bleeding and clinical diagnosis of cow's milk allergy. METHODS: Clinical features of 20 infants under 6 months of age were described. Morphological findings in rectal mucosa were compared with control group, with suspicion of congenital megacolon. RESULTS: The mean age of the patients was 97 +/- 47 days, rectal bleeding started before 120 days in 85% of them; 40% were breastfed, 60% cow's milk formula or both. The most striking morphological feature, in 18 patients, was eosinophilic infiltration in the rectal mucosa. There was a significant statistical difference when these values were compared with control group. CONCLUSIONS: The increased number of eosinophils in the rectal mucosa represent the most important characteristic of allergic colitis, in patients under 6 months, with rectal bleeding, when breastfed, cow's milk formula or both.     

Risk of residual rectal mucosa after proctocolectomy and ileal pouch-anal reconstruction with the double-stapling technique

PURPOSE: This study was designed to assess the risk of retained rectal mucosa after proctocolectomy and ileal pouch-anal anastomosis with the double-stapling technique. METHODS: A total of 113 patients underwent proctocolectomy with an ileal pouch-anal reconstruction. In 57 patients the anastomosis between pouch and proximal anal canal was performed using the double-stapling technique. In 26 patients the procedure was carried out without a protecting ileostomy. Of the remaining 31 patients with a proximal ileostomy, 15 underwent endoscopy six weeks postoperatively. Circular biopsies were taken just distal from the pouch-anal anastomosis. RESULTS: Histologic examination revealed rectal mucosa in at least one biopsy in 7 of 15 patients. At follow-up (mean 18 months) no (distal) pouchitis was clinically noticed. In one patient with familial polyposis, a few polyps, distal of the anastomosis, had to be endoscopically removed. CONCLUSIONS: Double-stapled ileal pouch-anal anastomosis has a considerable risk of residual rectal mucosa, because of combined linear transection and circular stapling with bilateral dog-ear formation of rectal mucosa. Residual rectal mucosa did not seem to influence clinical results at follow-up.     

Sequential histologic evaluations in collagenous colitis

To evaluate the histologic manifestations of collagenous colitis and correlate histologic changes with disease behavior, 14 patients who had undergone sequential evaluations during 33±6 months of follow-up were studied. Two hundred twelve tissue specimens from all anatomic regions of the colon (mean, 15±3 samples per patient) were interpretated independently under code by two pathologists. Eight patients (57%) had histologic resolution after 14±4 months of empiric therapy and in only one of these (12%) did symptoms persist. Four patients (29%) had sequential histologic examinations from the same anatomic region that varied from classical collagenous colitis to ilflamed mucosa without a thickened collagen band to normal mucosa. Eight patients (57%) had varying histologic findings from different anatomic regions during the same examination that ranged from classical collagenous colitis to increased inflammation with resolution of the collagen band to normal mucosa. Normal mucosa was found mainly in specimens from the rectosigmoid, and proctosigmoidoscopic examinations alone would have missed the diagnosis of collagenous colitis in 40% of cases. Pathologic interpretations were concordant in 171 of 212 instances (81%). We conclude that histologic resolution of collagenous colitis can occur and it is associated with loss of symptoms. The histologic features of collagenous colitis are distinctive, but they may be patchy and inconsistently sampled. Rectosigmoid biopsies underestimate the diagnosis.Data analysis was performed in part using the CLINFO Data Analysis System.Presented in part at the annual meeting of the American College of Gastroenterology, October 16, 1991, Boston, Massachusetts.     

不同分型功能性便秘患者结肠传输功能、胃肠激素以及一氧化氮合酶的研究

背景：功能性便秘（FC）是一种常见的功能性胃肠病。其病因和发病机制目前尚不明确。目的：探讨不同分型FC患者结肠传输功能、胃肠激素以及一氧化氮合酶（NOS）的变化。方法：56例符合罗马Ⅲ标准的FC患者和20名健康志愿者纳入本研究。采用不透X线标记物法行结肠传输试验．放射免疫法测定降结肠、直肠黏膜促胃动素（MTL）、P物质（SP）、生长抑素（SS）、血管活性肠肽（VIP）和NOS水平。结果：56例FC患者中,传输时间正常者19例,传输时间延长者37例,其中结肠慢传输型（STC）21例,出口梗阻型（OOC）9例,混合型（MC）7例。与正常对照组相比,传输时间正常组降结肠、直肠黏膜MTL、SP、SS、VIP和NOS水平无明显差异;STC组降结肠、直肠黏膜MTL水平显著降低（P〈0．05）：STC、MC组降结肠、直肠黏膜SP水平显著降低而NOS水平显著升高（P〈0．05）;STC、MC组降结肠黏膜SS水平显著升高（P〈0．05）;STC、OOC组降结肠、直肠黏膜VIP水平显著降低（P〈0．05）。结论：各型FC降结肠、直肠黏膜胃肠激素和NOS水平改变不同．其异常导致胃肠平滑肌功能紊乱．可能与FC的发病有关。     

Studies of lactic dehydrogenase content in rectal mucosal biopsies

The total lactic dehydrogenase (LD) content and LD isoenzyme ratios were studied in homogenized rectal mucosa from 31 patients with established non-specific mucosal ulcerative colitis and from 16 normal subjects. The total LD content was found to be significantly increased in patients with active ulcerative colitis when compared with patients with inactive colitis or with normal subjects. There was a similar though not a significant increase in the slow moving isoenzymes of LD in samples of rectal mucosa from patients with active colitis. The LD isoenzyme pattern was in the normal range in two of the three patients with histological premalignant changes in rectal biopsy specimens.There was a statistically significant linear correlation between the total lactic dehydrogenase content of rectal mucosa and the carcino-embryonic antigen levels in whole serum.Both the total content and isoenzyme ratios of LD were increased in neoplastic tissue obtained from patients with carcinoma of the colon and with tissue from benign rectal polyps.     

Fate of the rectal mucosa after rectal mucosectomy and ileoanal anastomosis

The aim of our study was to determine if the rectal mucosa regenerates after rectal mucosectomy and endorectal ileoanal anastomosis for chronic ulcerative colitis. Such regenerated rectal mucosa could be the site of recurrent disease, leading to complications of the operation, and potential malignant degeneration. Pathologic specimens of the ileoanal anastomosis, surrounded by rectal muscular cuff, were obtained from eight patients who required takedown of their ileoanal anastomosis between one and 18 months after construction. Reepithelialization of the rectal cuff was not observed. In two patients, small islets of rectal mucosa and anal glands were identified. In all patients, the rectal muscularis propria was adherent to the serosa of the ileum by fibrous reaction. Three patients were diagnosed, both clinically and pathologically, as having chronic ulcerative colitis at the original ileoanal operation, but features suggestive of Crohn's disease were noted in the subsequently resected neo-rectum. Our observations suggest that, although isolated rectal mucosal cells may remain after mucosectomy, extensive rectal mucosal regeneration does not occur, thus minimizing the risk of recurrent disease and potential malignant change. Failure of an ileoanal anastomosis is therefore most likely related either to technical factors or to the presence of unsuspected Crohn's disease.     

Does rectal mucosa regenerate after ileonal anastomosis?

Regeneration of rectal mucosa after rectal mucosectomy and ileoanal anastomosis (IAA) could jeopardize the long-term safety of the procedure. The aim of this study was to determine if rectal mucosal regeneration occurred after IAA. Pathologic specimens of the IAA and surrounding rectal muscular cuff were obtained from 29 patients who had required IAA excision 17±2 months (mean±SEM, range, 2 to 48 months) following construction. Multiple (≥6) coronal and sagittal sections of each specimen were made and examined histologically. The rectal muscle cuff was bound to ileal serosa by dense fibrous tissue. Small islets of residual rectal mucosa were identified between the denuded rectal cuff and the ileal pull-through in four patients (14 percent) and at the ileoanal anastomosis in two patients (7 percent). Active rectal muscosal disease, dysplasia, or reeplithelialization of the denuded rectal muscle were not seen. It is concluded that small islets of rectal mucosa may remain after IAA. Up to four years after IAA, however, no evidence of rectal mucosal regeneration could be documented. Read in part at the meeting of the American Society of Colon and Rectal Surgeons, Houston, Texas, May 11 to 15, 1986.     

Clinical relevance of proliferation biomarkers and p53 expression in rectal mucosa and sporadic colonic adenomas: a prospective study

BACKGROUND/AIMS: Prospective study to evaluate 1) the pattern of proliferation biomarkers and p53 expression in rectal mucosa and adenomatous tissue, and 2) the clinical relevance of these biomarkers as predictors for adenoma recurrence. METHODOLOGY: 40 patients with sporadic adenomas underwent colonoscopic polypectomy and rectal biopsies. Assessment of proliferation biomarkers--Ornithine decarboxylase, PCNA and Ki-67--was done in adenomas and rectal mucosa, while p53 was performed in adenomas. After polypectomy, 34 adenoma patients were followed for 36 months to detect metachronous polyps. 20 controls underwent colonoscopy and rectal biopsies, with assessment of proliferation biomarkers. RESULTS: Mean values of ornithine decarboxylase, PCNA and Ki-67 in rectal mucosa from adenoma patients were not significantly different when compared with the control group. The expression of these biomarkers was significantly increased in adenomas versus rectal mucosa. Only 6 (15%) out of 40 adenomas were found to overexpress p53 protein. During follow-up, recurrent polyps were detected in 12 patients (relapsing group). Mean values of ornithine decarboxylase, detected at index colonoscopy, were not significantly higher in relapsing group versus non-relapsing group. Mean values of PCNA and Ki-67 detected in adenomas at index colonoscopy were significantly higher in relapsing group when compared with non-relapsing group. Adenoma recurrence was observed in all patients with p53 overexpression. CONCLUSIONS: Ornithine decarboxylase, PCNA and Ki-67 expression in rectal mucosa did not show clinical relevance. Yet, increased expression of PCNA or Ki-67 in adenomatous tissue may be a predictor of adenoma recurrence. Positive p53 might have the same predictive value.     

Role of prostaglandins in ulcerative colitis. Enhanced production during active disease and inhibition by sulfasalazine.

Prostaglandin E2 (PGE2) level in rectal mucosa excised from 17 patients suffering from ulcerative colitis was 2-fold higher than that found in rectal mucosa of 17 normal subjects: 2.0 +/- 0.4 and 0.9 +/- 0.2 ng per mg of wet tissue, respectively. Accumulation of PGE 2 in 24-hr cultures of rectal mucosa specimens obtained from patients with ulcerative colitis was 112% higher than that observed in cultures from control subjects. Addition of sulfasalazine, sulfapyridine, and 5-aminosalicylic, acid to the culture medium of ulcerative colitis mucosa resulted in inhibition of PGE2 production by 34, 32, and 62%, respectively, compared to rectal specimens cultured in drug-free medium. These results suggest that PGE may mediate the inflammatory response in ulcerative colitis and that some of the therapeutic effect of sulfasalazine and its constituents are related to the inhibition of PGE synthesis.     

Sigmoidoscopic and microscopic appearance of the rectal mucosa in homosexual men.

The aims of the study were to determine what microscopic changes occur in the rectal mucosa of men who have had anal intercourse and to correlate the sigmoidoscopic and microscopic appearances. Histological abnormalities were found in 29 of 100 men who attended consecutively a sexually-transmitted diseases clinic. The histopathology of rectal gonorrhoea, as observed in 18 patients, is described as are the microscopic findings in the rectal mucosa of 10 patients with early syphilis. Of 70 men without any detectable rectal infection, biopsies from 15 (21.4%) were abnormal. Intestinal spirochaetosis was observed in biopsies from 36 of these 100 men. With the use of strict criteria to describe the macroscopic appearance of the rectal mucosa, the sigmoidoscopic findings correlated well with the histology.     

Endoscopic Transanal Rectal Mucosal Ablation in the Surgical Treatment of Ulcerative Colitis: Preliminary Results of a Novel Technique

PURPOSE We describe a new technique that endoscopically eradicates rectal stump mucosa after total colectomy for ulcerative colitis.METHODS Seven patients (5 males; median age, 56 (range, 36–72) years) underwent attempted endoscopic transanal rectal mucosal ablation using the 28-French-gauge urologic resectoscope, either at the time of total colectomy and ileostomy for failed medical therapy (5 patients) or as an alternative to completion proctectomy (2 patients) with rectal stump discharge. All had declined restorative proctocolectomy. Clinical, endoscopic, and histologic follow-up was undertaken during a mean of 15 (range, 3–28) months.RESULTS The operative technique evolved during these cases; mucosal ablation was successfully performed leaving a denuded muscular rectal tube in situ in six patients. Mean operative time was 45 minutes. Postoperative endoscopic surveillance has not demonstrated any viable rectal mucosa in these six patients, with only granulation tissue detected histologically. Narrowing of the rectal tube has occurred in two patients. Although all patients report insignificant rectal discharge, urinary and sexual function have remained unchanged.CONCLUSIONS Diathermy ablation of the rectal mucosa via endoscopic transanal rectal mucosal ablation avoids the complications of pelvic dissection and might offer an effective alternative to proctectomy for ulcerative colitis.Presented at the meeting of the Association of Surgeons of Great Britain and Ireland, Manchester, England, May 7 to 9, 2003.     

Lectin staining of neoplastic and normal background colorectal mucosa in nonpolyposis and polyposis patients

A lectin histochemistry approach was adopted for comparative assessment of a colon cancer risk. Binding of Ulex europaeus agglutinin-I (UEA-I), peanut agglutinin (PNA), Griffonia simplicifolia agglutinin-II (GSA-II), and Dolichos biflorus agglutinin (DBA) was investigated in tumor and background tissue from a total of 34 adenoma and 44 cancer patients and compared with reaction patterns in control and familial adenomatous pplyposis (FAP) patients. Adenoma patients with UEA-I positive rectal mucosa were found to have a 33.3 percent familial history of large bowel cancer, which was significantly higher (P <0.05) than the respective 4.0 percent figure for patients with negative rectal mucosa. In the cancer patients, an even stronger correlation was noted, with a 63.2 percent UEA-I positive family history association being recorded, as opposed to 4.0 percent in the negative rectal mucosa patients (P <0.01). Thus, the results suggest that, apparently, normal rectal background mucosa of individuals genetically at high risk for colon and rectal cancer demonstrates a specific lectin binding ability similar to that of FAP patients and that the simple method using UEA-I staining of rectal biopsy specimens can be of practical use in identification of high-risk colorectal cancer.     

Rectal peptic ulceration—A rare cause of rectal bleeding

Analysis of the 27 cases of heterotopic gastric mucosa reported in the literature and a new case described here elucidates the main features of this disease: 1) all but one asymptomatic case were diagnosed in infants or in adults under 26 years old; 2) although rectal bleeding occurred in 24 patients, rectal peptic ulceration was found in only 13; 3) six of the patients also had rectal duplication; and 4) 19 times the limited extension of the heterotopic gastric mucosa was compatible with a complete excision by a transanal approach.     

Treatment of grade 3 anal intraepithelial neoplasia by complete anal mucosal excision without fecal diversion

PURPOSE: The aim of this study was to remove completely the risk of malignant transformation without permanent or temporary fecal diversion in a patient with extensive anal intraepithelial neoplasia. METHODS: All anal canal mucosa and the lowest 1.5 cm of rectal mucosa were excised and the adjacent rectal mucosa and submucosa advanced to the anal verge skin. RESULTS: The patient achieved normal continence within a month after the operation. Multiple anal canal biopsies at 12 months after the operation revealed normal rectal mucosa. CONCLUSIONS: Total anal mucosal excision offers a relatively simple means of removing the malignant risk of anal intraepithelial neoplasia without fecal diversion in selected patients.     

胶原性胃炎一例并文献复习

目的 胶原性胃炎(coHagenous gastritis,CG)临床少见,现报道一例CG并进行文献复习.方法 患者行胃镜检查,活检组织切片分别行HE染色、Masson染色、刚果红染色及Warthin-Starry染色;分析病例临床资料并进行随访.结果 1例20岁女性患者主因无规律上腹痛4年,伴腹胀、呃逆、体重明显下降2个月就诊.胃镜检查于角切迹及窦部可见白色结节(活检).病理诊断为胶原性胃炎,上皮下胶原带厚度为16.6-120.3μm,平均厚度43.8 μm,Masson染色阳性,刚果红染色阴性.给予泼尼松(20 mg/d)4周,配合促动力和胃黏膜保护药,患者食欲好转,呃逆减轻,体重略有增加.结论 目前国外文献报道CG仅40余例,其发病机制尚不明确.综合本病例临床及组织病理学特点,符合儿童和青少年发病型CG.综合相关文献及本例治疗经验,无谷胶饮食和糖皮质激素可以有效改善患者症状.     

COLLAGENOUS COLITIS: A RECENTLY RECOGNISED REVERSIBLE CLINICOPATHOLOGICAL ENTITY

:A case of collagenous colitis is reported in an 86 year old man who presented with watery diarrhea. This case differs from previous reports in that five of the six reported cases involved women, mostly in their mid-forties, and that previously the collagenous band has been demonstrated in the mucosa of the left side of the colon only. This case is the first report to demonstrate the collagenous band in the right side of the colon as well as the left, and is the thickest band reported to date. In keeping with the two reported cases with follow-up, the subepithelial collagenous band was shown to have disappeared three months after the initial biopsy with a corresponding clinical improvement after symptomatic treatment only. The diagnosis needs to be considered in all patients presenting with watery diarrhea, and can only be confirmed after rectal or colonic biopsy. (Aust NZ J Med 1983; 13: 630–632.)