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Thread: Normal Colon and Ileum Pictures - Atlas of Colon and Ileum

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    Default Normal Colon and Ileum Pictures - Atlas of Colon and Ileum

    The terminal ileum is the most distal segment of the small intestine and hosts many toxic substances, including bacteria, viruses, parasites, and digested food. Therefore, it is lined by a specialized lymphoid tissue of the immune system. Increases in lymphocytes, macrophages, and mast cells in response to luminal antigens are observed physiologically . Diseases involving the terminal ileum may be classified as the inflammatory bowel diseases (IBD), infectious and parasitic diseases, and more rarely, neoplasia. In cases of suspected IBD, terminal ileum endoscopy and biopsy represent the gold standard in the differential diagnosis of the infectious, inflammatory, and non-inflammatory disorders that mimic IBD in symptoms and findings. In addition, conducting a terminal ileum biopsy during colonoscopy is a significant criterion that is indicative of completion of the colonoscopy. However, biopsies may sometimes fail in establishing a diagnosis. On the other hand, biopsy-associated hemorrhages and perforations, and variant prion infections that can colonize the terminal ileum due to its lymphoid dominant structure, such as the Creutzfeldt-Jakob disease that is resistant to sterilization of the endoscopic forceps, have been reported . Due to all these reasons, performing a biopsy of an endoscopically normal terminal ileum is controversial . Previous studies had reported rates of abnormal histological findings in 0.6 − 5.2% of biopsies taken from endoscopically normal terminal ilea . Among the literature studies assessing the normal-appearing terminal ileum biopsy results, no study could be detected that evaluated the procedure indication, pre-procedure laboratory data, and the number of samples collected at the same time. We performed this study to compare the histopathological results of ileal biopsies taken from endoscopically normal-appearing terminal ilea based on the procedure indication and the pre-procedure laboratory data, thereby determining the factors affecting the diagnostic value of the biopsies from the normal-appearing terminal ilea. In brief, we organized this study to answer the question ‘In which patients would it be beneficial to obtain a biopsy of the terminal ileum even if it appeared normal?’.

    Methods
    A total of 297 patients between 18 and 65 years of age who presented to the Sisli Etfal Education and Research Hospital, Gastroenterology Endoscopy Unit, between January 2009 and December 2011 and found to have a completely normal colon mucosa and a normal ileal mucosa or less than five aphthous ulcers in the terminal ileum were included in the study. Colonoscopy procedures were performed by the same gastroenterologist using an Olympus colonoscope (Olympus GIF-180, Tokyo, Japan). The patients’ demographics, procedure indications, colonoscopy reports, ileal biopsy sample numbers, and the ileal biopsy pathology results were all recorded. Pathology preparations were re-assessed by an experienced pathologist. Complete blood count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), ferritin, albumin, vitamin B12, and stool test results were retrospectively collected by accessing the laboratory records obtained not more than 2 weeks before the procedure.
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    Histopathological findings were classified as normal, lymphoid hyperplasia, chronic ileitis and others. Cases with preserved villus and crypt structures; intact arteriole, venule, and lymphatic capillary structures; and normal number and distribution of cells were included in the normal group. The others group included cases with non-IBD diseases such as increased neutrophil count in the lamina propria, necrotizing granulomatous inflammation, and non-specific findings. The presence of distorted villous architecture (such as enlargement, blunting, broadening, atrophy, and irregular or diffuse shortening), branching, shortened or atrophic crypts, mixed inflammatory infiltrates in the lamina propria clearly distinct from the lymphoid follicles, and neutrophils infiltrating the epithelium were considered chronic ileitis.

    Cases with more than five aphthous ulcers, deep ulcers, strictures or cobblestone finding at the terminal ileum, and with marked hyperemia, edema, fragility, and ulceration at colonoscopy were not included. Patients with malignancy, chronic renal failure, and liver failure, as well as patients without pre-procedure laboratory results were excluded from the study.
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    Statistical methods
    Data were analyzed using SPSS version 15 software. Pearson Chi-square test and Student's t-test were used for comparison of the categorical data and numeric data, respectively. The correlation analysis was demonstrated by Pearson and Spearman test while the independent efficacies of the parameters were demonstrated by linear regression analysis. Receiver operating characteristic curve (ROC) analysis was performed for the parameters that were found to be significant. All the statistical assessments were made at the 95% confidence interval; p<0.05 was considered to be statistically significant.

    General analyses
    The mean age of the study group was 42±13.9 years. A total of 297 patients meeting the pre-specified criteria who underwent terminal ileum biopsy, including 142 females and 155 males, were included in the study. A hundred and three patients (34.7%) underwent colonoscopy due to chronic diarrhea and this was the most common indication in the whole study population (Table 1). The other frequent indications were chronic diarrhea together with abdominal pain (19%) and anemia (15%).
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    The histopathological evaluation detected chronic ileitis in 49 (16.5%) of the 297 patients. The diagnosis of chronic ileitis was found to be statistically significant more frequently in the indications of anemia, known IBD, and chronic diarrhea together with abdominal pain compared to all other indications (p<0.01).

    Group analysis for endoscopically normal terminal ileum
    Two hundred (67%) of the patients had endoscopically normal terminal ileum and 97 (33%) of the patients had aphthous ulcer in the terminal ileum. There was no significant difference between the two groups with respect to age and gender.

    The most common colonoscopy indication in the endoscopically normal terminal ileum group was also chronic diarrhea. Eighty-five of 200 patients (42.5%) underwent colonoscopy because of chronic diarrhea. Twenty-six (13%) patients underwent colonoscopy due to chronic diarrhea together with abdominal pain, (10.5%) for anemia, (8.5%) for abdominal pain,(6.5%) for positive radiologic finding, and 13 (6.5%) for known IBD. Twenty-five (12.5%) patients who had colonoscopy for other reasons, such as constipation, meteorism, or colon cancer screening, were used as control.

    The histopathological assessment of biopsies of endoscopically normal terminal ileum patients revealed normal findings in 156 of the 200 patients (78%), while patients (13.5%) had findings consistent with lymphoid hyperplasia. Chronic ileitis was determined in (5.5%) patients. Chronic ileitis was significantly more common in the groups of known IBD (15.4%), anemia (9.5%), and chronic diarrhea together with abdominal pain (7.7%) than in the other groups (p<0.05) (Table 2, Fig. 3). Two of the chronic ileitis patients were known IBD patients. Six (66%) of the remaining nine patients were diagnosed with Crohn's disease (CD) after further evaluation or during follow-up. One patient was lost from follow-up and the last two patients remained undiagnosed.
    Normal Colon Ileum Pictures Atlas attachment.php?s=2c50b2f1ff079d054243c7e64337c6bf&attachmentid=2267&d=1442519737

    phthous ulcer group analyses
    While 11 of the 200 patients (5.5%) with a normal terminal ileum were diagnosed with chronic ileitis, 38 of the 97 patients (39.2%) with aphthous ulcer were found to have chronic ileitis. Chronic ileitis rate was significantly higher in the aphthous ulcer group relative to the endoscopically normal group (p<0.01). In the aphthous ulcer group, none of the abdominal pain cases and 14% of the control cases had chronic ileitis. In all of the remaining groups, chronic ileitis rate was 40% on average (Table 3, Fig. 4). Five of the 38 chronic ileitis patients were known IBD patients. Twenty-five (75%) of the remaining patients were diagnosed with CD after further evaluation or during follow-up. Two patients were lost from follow-up and the other six patients remained undiagnosed.

    References:
    How does a biopsy of endoscopically normal terminal ileum contribute to the diagnosis? Which patients should undergo biopsy?











    Last edited by Medical Photos; 09-17-2015 at 07:55 PM.

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