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Inflammatory bowel disease–like conditions: miscellaneous


Abbreviations

CD

Crohn’s disease

CSC

cat scratch colon

EGID

eosinophilic gastrointestinal disorders

CMUSE

cryptogenic multifocal ulcerous stenosing enteritis

IBD

inflammatory bowel disease

UC

ulcerative colitis

Introduction

A long list of conditions can present inflammation or ulcers or strictures in the gastrointestinal (GI) tract. These conditions include eosinophilic GI disorders (EGID), cryptogenic multifocal ulcerous stenosing enteritis (CMUSE), sclerosing mesenteritis, diverticular colitis, and rectal prolapse. They mimic inflammatory or fibrostenotic small bowel or large bowel Crohn’s disease (CD) or ulcerative colitis (UC). Careful endoscopic examination and documentation, along with histologic assessment, is the key for the diagnosis and differential diagnosis.

Eosinophilic gastrointestinal disorders

EGID represent a disease spectrum eosinophilic esophagitis, eosinophilic gastritis, eosinophilic gastroenteritis, enteritis, and eosinophilic colitis. The etiology of EGID is unknown, with allergic factors be contributing factors. EGID are characterized by eosinophilic infiltration, edema, and thickening of the GI tract, leading to various symptoms. There are mucosal, muscular layer, and subserosal phenotypes, which necessitate the differential diagnosis from CD and UC.

Endoscopic findings of mucosal disease are nonspecific, including nodular or polypoid mucosa, thickened (gastric) folds, loss of vascularity, erythema, mucosal erosions, and ulceration ( Figs. 32.1–32.3 ). Mucosal and transmural biopsies may be helpful. Some patients may require laparoscopic full-thickness biopsy. Of note, peripheral and tissue eosinophilia can also be present in patients with inflammatory bowel disease (IBD) .

Figure 32.1, Eosinophilic gastroenteritis. (A) Patchy erythema at the gastric body and nodularity of the gastric antrum and (B–D) similar patterns with mucosal edema and nodularity of the colon.

Figure 32.2, Eosinophilic gastroenteritis involving colon. (A) Gastritis with linear erythema and loss of vascularity of mucosa; (B and C) hyperemia, edema, and erosions of colon mucosa; and (D) histopathology showed inflammation of the lamina propria of the colon with numerous plasma cells and eosinophils.

Figure 32.3, Eosinophilic colitis. (A and B) Diffuse mild edema of the colon with patchy erythema and erosions and(C and D) diffuse infiltration of eosinophils in the colon epithelia and lamina propria on H&E histology.

Cryptogenic multifocal ulcerous stenosing enteritis

CMUSE with unknown etiology is characterized by chronic and intermittent bouts of bowel obstruction resulting from multiple short ulcerated strictures in the jejunum and/or ileum. CMUSE mainly affects middle-aged patients. CMUSE lesions are limited to the mucosa and submucosa, without granuloma formation. Overlapping is observed between CMUSE and small bowel stricturing CD (L 1 B 2 in the Montreal classification) in clinical presentation and imaging . Endoscopy may provide information for diagnosis and differential diagnosis . The role of small intestine wireless capsule endoscopy in the diagnosis of CMUSE is yet to be defined, due to the concern of retained capsule ( Figs. 32.4–32.6 ).

Figure 32.4, Cryptogenic multifocal ulcerous stenosing enteritis. (A–D) Discrete ulcerated strictures in the jejunum and ileum with normal mucosa of the small bowel segments in between.

Figure 32.5, Another patient with CMUSE in the jejunum. (A) Ulcerated stricture at the distal jejunum on capsule endoscopy; (B) a thin and circumferential stricture in the proximal jejunum on balloon-assisted enteroscopy; (C) transiently trapped capsule on CT due to the small bowel strictures; (D and E) the small bowel ring-shaped strictures on surgical resection specimen ( green arrows ); and (F) histopathology shows ulceration and infiltration of chronic inflammatory cells in the lamina propria and muscularis mucosae, in the absence of transmural inflammation. CMUSE , Cryptogenic multifocal ulcerous stenosing enteritis.

Figure 32.6, CMUSE missed by conventional ileocolonoscopy. The patient was mid-diagnosed as having Crohn’s disease of the small bowel. (A and B) Normal mucosa of the distal ileum; (C) multiple small bowel strictures with dilated small bowel loops in between; and (D) intraoperative photography showed strictured and dilated small bowel ( green arrows ). CMUSE , Cryptogenic multifocal ulcerous stenosing enteritis.

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