Colitis Indeterminate

The condition known now as colitis indeterminate or indeterminate colitis (IC) was first described by Ashley Price in 1978. He found that 9% of resected colon from patients with IBD in his series did not show enough diagnostic features to enable a definitive diagnosis of UC or CD and that 90% of these cases had undergone emergency surgery [69]. Subsequent publications confirmed the condition and quoted the incidence as being between 4-15%. There are, however, two areas of possible confusion in regards to this condition. The first is the terminology, as many synonyms have been given or substituted for IC like toxic dilatation, fulminant colitis and disintegrative colitis [70]. Although these entities may be descriptive, they have been associated with conditions other than IBD such as infection and occasionally ischaemia [71]. Therefore, it is inappropriate to use them synonymously with IC.

The second problem regards that of definition. Over the years, the term IC itself has undergone changes in definition and the term has been used liberally in different situations or institutions. When it was first described by Price, it only included surgical specimens of the colon that were mostly generated from emergency procedures. Therefore, strictly speaking, it was used as a condition which usually presents as an emergency and the pathologist is unable to distinguish between UC and CD after colec-tomy due to the overlap in pathological features. Since then, Kangas et al. have defined the condition as regarding "patients who had the clinical and the macroscopical features of either CD or UC both pre-and post-operatively and the histology remains indeterminate both pre- and post-operatively". This definition refers to mucosal biopsies and not to surgical resectates in conditions which are not necessarily presenting as an emergency, and is a significant vari ance from the original definition [72]. A third definition came from the Mayo Clinic which defines IC as "the unequivocal diagnosis of UC pre-operatively but inconclusive histology on examination of the pathologic specimens intra-operatively" [73]. Prior to that, Koultun et al. [74] defined the condition as "inflammatory colitis containing features in macroscopic and microscopic evaluation of the colon that were consistent with both CD and UC". To confuse the issue further, Price has subsequently redefined the condition as "the inability to make a confident diagnosis of the pattern of colitis despite examination of adequate surgical resectates or adequate mucosal biopsy series from the colon and rectum" [75]. It is possible, therefore, to see why the outcome of these condition(s) varies from series to series as they use different diagnostic criteria. In our unit, we use the original Price definition of 1978. It has been suggested that up to two thirds of patients diagnosed initially as IC will polarise after long-time follow-up into either UC or CD after careful appraisal of all available evidence and close clinicopathological correlation [76]. Often the history, clinical correlation and further investigations like rectal stump biopsy may show diagnostic features.

There is a strong clinical need to classify patients either as UC or CD since this affects the patient's management (pouch procedure is generally unsuitable for CD patients). Recent studies showed that about 20% of IC patients develop severe pouch complications and this incidence is between that of UC (8-10%) and CD (30-40%), and the overall literature suggests that IC patients have a similar outcome as those with UC [77, 78]. It is recommended, as said previously, that the term IC be reserved for colecto-my specimens where the distinction between UC and CD is not possible, and that it not be used in endo-scopic biopsies; however, in cases where the distinction is not possible, some use the term 'IBD not yet classified' [79].

Using the original Price definition macroscopical-ly, the specimen usually shows total colitis, sometimes with macroscopic rectal sparing, and there is usually a varying degree of colonic dilatation. Microscopically, it shows severe disease with transmural inflammation, severe ulceration, fissuring or clefts, myocytolysis with intact islands of surviving mucosa showing minimal inflammation, intense congestion and a regular glandular pattern [69, 70, 72, 76, 80].

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