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• Guidelines on Treatment of IBD
  Debashis Das
  Published on: 18 April 2016
• Terminal ileal biopsies should not be used to document extent of colonoscopic examination
  MD Rutter
  Published on: 18 April 2016

• Published on: 18 April 2016

  Guidelines on Treatment of IBD

  • Debashis Das, Consultant Gastroenterologist

  Dear Editor

  The recent guidelines for the management of inflammatory bowel disease in adults[1] have not covered a common clinical scenario where Crohn’s disease presents as a pure terminal ileal lesion and biopsies are either unobtainable or inconclusive and decision of treatment rests on interpretation of radiological findings only. Under such conditions one will have to depend on the balance of probabilities...

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  Dear Editor

  The recent guidelines for the management of inflammatory bowel disease in adults[1] have not covered a common clinical scenario where Crohn’s disease presents as a pure terminal ileal lesion and biopsies are either unobtainable or inconclusive and decision of treatment rests on interpretation of radiological findings only. Under such conditions one will have to depend on the balance of probabilities and effects of trial of empirical treatment. Terminal ileum is less accessible to endoscopic procedures than the rest of the colon even in expert hands. It is doubtful if capsule endoscopy will overcome this problem, as the procedure should not be carried out on these very patients who may have narrowing of the ileum from inflammation. A fortuitous positive histological diagnosis from blind biopsies taken from elsewhere in the alimentary canal or from the peri-anal tags cannot be relied upon as in 20% of cases of Crohn’s disease the disease activity may be restricted to the terminal ileum only. Moreover, the histological diagnosis of Crohn’s disease from blind mucosal biopsies from areas, which are not affected visibly, is difficult to interpret and can even be misleading.

  In terms of frequency of occurrence of clinical conditions affecting terminal ileum, Crohn’s disease far outweigh other conditions. Although primary non-Hodgkin’s lymphoma and stromal tumors are known to involve terminal ileum in an isolated way, the frequency of such occurrence is so rare (1% of GI tumors) that according to one study in more than 75% cases the diagnoses of these tumors were made either accidentally or at post- mortem. It is therefore not at all surprising that survival from primary malignancies have not improved during the last four decades.[2]

  There is also little information in the literature on the biological behaviour of these tumors. Whilst intestinal obstruction and bleeding brings such diagnoses to light early, some tumors can lie indolent for long periods of time only to present later as subacute obstruction or perforation. Early diagnosis of these tumors is essential as not only some of these can be removed by resection in its entirety but specific chemotherapy is also available for certain tumors eg, gastrointestinal stromal tumor (GIST).

  It is therefore imperative that those cases of Crohn’s disease where biopsy confirmation has not been achieved for one reason or another are periodically reviewed at multidisciplinary meeting with surgeons. A laparoscopic examination should be carried out where there is the slightest suspicion of a non-Crohn's illness like secondary metastasis or TB that may cause peritoneal involvement. However, if the lesion is endoluminal like Crohn’s or tumor a full laparotomy becomes the only alternative. A drastic measure though it may seem for those few who respond to steroids and hence may be reluctant to undergo surgery, it would, however, form a safeguard against misdiagnosis of an early resectable ileal tumor as Crohn’s disease.

  References

  1. Guidelines for the management of inflammatory bowel disease in adults. Carter MJ, Lobo AJ, Travis SPL. Gut;53:v1-16v

  2. The role of the physician in the late diagnosis of primary malignant tumors of the small intestine. Am J Gastroenterology 1991 Mar;86(3):304-8

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  Conflict of Interest:
  None declared.

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• Published on: 18 April 2016

  Terminal ileal biopsies should not be used to document extent of colonoscopic examination

  • MD Rutter, Consultant Gastroenterologist
  • Other Contributors:
    • MG Bramble

  Dar Editor

  We commend the BSG and the authors for the excellent recent publication of guidelines for the management of inflammatory bowel disease in adults.[1] However we feel that their recommendation for routine terminal ileal biopsying is inappropriate. Although it is important to biopsy the terminal ileum if there is macroscopic evidence of an abnormality, their statement that “a terminal ileal biopsy perfor...

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  Dar Editor

  We commend the BSG and the authors for the excellent recent publication of guidelines for the management of inflammatory bowel disease in adults.[1] However we feel that their recommendation for routine terminal ileal biopsying is inappropriate. Although it is important to biopsy the terminal ileum if there is macroscopic evidence of an abnormality, their statement that “a terminal ileal biopsy performed at colonoscopy documents the extent of examination” is not recommended practice, due to the potential risk of variant Creutzfeld-Jacob disease transmission from prion proteins which are prevalent in the lymphoid tissue of Peyer’s patches in the ileum. Although the use of disposable forceps may reduce the risk of transmission, there could still be contamination of the intubation channel of the colonoscope and prion protein is resistant to the standard endoscopic cleaning process.[2] If the extent of examination needs to be documented, then a photograph of the ileocaecal valve or ileal mucosa is preferable.

  It is worth emphasising that prion protein may be present in any part of the gastrointestinal tract [3] and random biopsy of gastrointestinal mucosa for reasons other than confirming an endoscopic abnormality or excluding microscopic colitis is not acceptable. Similarly for surveillance colonoscopy where multiple biopsy is recommended, the risk benefit ratio of this policy must be supported by the clinical indications.

  References

  1. Carter MJ, Lobo AJ, Travis SP. Guidelines for the management of inflammatory bowel disease in adults. Gut 2004; 53(suppl 5) 1.

  2. Bramble MG, Ironside JW. Creutzfeld-Jakob disease: implications for gastroenterology. Gut 2002; 50:888-90.

  3. Herzog C, Sales N, Etchegaray N et al. Tissue distribution of bovine spongiform encephalopathy agent in primates after intravenous or oral infection. Lancet 2004; 363:422-8.

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  Conflict of Interest:
  None declared.

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