There are a number of exceptions to the classic principles of IBD pathology that may lead to diagnostic confusion . Difficulty in distinguishing UC from CD, which leads to a diagnosis of IC, can be related to the presence of fulminant or refractory colitis, chronic colitis, prolonged medical treatment and earliest stages of colitis. The most frequent scenario is fulminant or refractory colitis requiring urgent colectomy. In this case, the histologic distinction of UC from CD is difficult because of histologic feature overlap. Granulomas and transmural lymphoid hyperplasia are the two most specific indicators of CD in specimens from patients with fulminant colitis. Relative rectal sparing, intermittent ulceration, regular glandular pattern and lack of mucin depletion , which are usually typical of CD, can be found in IC cases subsequently proved to be UC . Even superficial fissuring-type ulcers may be present in patients with fulminant colitis and should not lead to a diagnosis of IC or CD .
Medical treatment can deeply modify the mucosal histology with a variable effect depending on time and type of treatment and disease severity. Usually, patchiness of disease can be found in patients treated with long-term oral or topical therapy (i.e. sul-phasalazine) [13, 15]. Focal healing, including rectal healing, can be observed in all forms of treatment. Finally, patchiness of the disease or rectal sparing can be present in the early stages of the disease, especially in children [16,17].
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