Recommended Approach to Diagnosis

Ulcerative colitis and Crohn's disease have, in many cases, quite distinguishing histopathological features with typical investigative findings and clinical features; however, this is not universal and in many cases these features might overlap. Common histological changes might be absent or the changes may lack the characteristic features, therefore the findings usually need to be analysed more meticulously in the all-important clinical pathological conferences (CPCs). Despite all the efforts, there are cases where it is not possible to give a definite diagnosis and which might need further investigation [25, 26-29].

In previous reports [30, 31], our group has maintained that, in addition to good biopsy samples, there are three important factors which help in reaching a more accurate histopathological diagnosis and making appropriate clinical decisions. These are:

1. Adequate information for histopathologist

2. Standard definition of histological terms

3. Maintenance of communication between clinician and histopathologist

It is very important for the clinician to remember that the pathologist's aim is to come to a diagnosis with the help of information derived from other different subspecialties and therefore coordination is essential. Similarly it is important for the pathologist to follow a clear and standard reporting system that is understood by the clinicians and all members of the IBD team who must work in absolute harmony and understanding in dealing with these diseases [32-41].

The diagnosis of IBD is confirmed by clinical evaluation and a combination of biochemical, endoscop-ic, radiological, histological and sometimes nuclear medical investigations as stated earlier. It is inappropriate to expect the pathologists to make a diagnosis of IBD in general and specifically to differentiate UC from CD without providing enough information regarding clinical suspicion, endoscopic findings and previous investigations.

Information required by the pathologist:

1. History and clinical examination: a summary of history with the symptoms, their duration, recent travel, medication, smoking and family history. The presence of intestinal manifestations—for example diarrhoea, mucous, blood etc.—their duration and a brief clinical examination finding is indispensable.

2. Investigations (laboratory and radiological): abnormal routine investigations such as blood count, CRP, liver function tests and the results of microscopical examination of stool and culture help in coming to a diagnosis. Infections and conditions that mimic IBD can be excluded based on this information as sometimes inflammation such as Clostridium and other infections can be easily diagnosed. Previous positive and negative radiological investigations help in reaffirming diagnosis and identifying subtle changes in light of the investigative findings. It is important to realise that sometimes there is super imposition of infection on IBD. Indeed some of the flare-up cases of IBD reported lately are due to superimposed CMV infection [42].

3. Endoscopies (sigmoidoscopy/colonoscopy): the diagnosis of IBD is greatly dependent upon the presence of visible endoscopic changes such as vascular pattern, mucosal viability and ulcerations and/or presence of polyps. The signs of involvement and whether it is continuous or discontinuance and other findings are of significant help. In certain cases, visual microscopic appearance, as in pseudo-membranous colitis, gives a better idea of the colonic disease than histological examination. In our unit, we regard the endoscop-ic changes of such importance that we routinely receive a copy of the endoscopy report with the request form for the histological examination. It is also important to realise that normal endoscopy is not synonymous with normal structure. We therefore recommend that 'normal' looking areas between abnormal ones be biopsied in patients suspected of IBD.

4. Others: the use of different treatments, the stage of the disease, its duration and if there are any previous biopsies, as their interpretations are greatly helpful to the pathologist in correlating the findings. A clear and definitive diagnosis makes it easy for the clinician to understand and interpret the results and to manage the patient appropriately. Standard histological terms should be used in reporting as it not only makes it easier to understand them but also helps in the exchange of information between different members of the team involved in the management of the patient as well as for research and auditing purposes [43].

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