Patchiness of mucosal inflammation in treated ulcerative colitis: a prospective study.Gastrointest Endosc. 1995 Sep;42(3):232-7.

Conventional wisdom dictates that ulcerative colitis affects contiguous areas of the colon and is most severe in the rectum, and that the finding of rectal sparing or patchy involvement should raise suspicions of Crohn's disease. We and others have noted occasional rectal sparing and patchy involvement in patients with ulcerative colitis. Therefore, we prospectively studied the prevalence of patchiness, including rectal sparing, in treated cases of ulcerative colitis. Consecutive patients with longstanding ulcerative colitis were studied. The left colon was divided into three zones for scoring degree of activity, and biopsy specimens from each zone were graded for histologic activity by a blinded observer. Patchiness by endoscopy or histology was defined as (1) frank rectal sparing (normal appearance endoscopically; absence of inflammation of the lamina propria and crypts histologically); (2) areas of greater inflammation proximally than distally; or (3) discrete areas of patchiness endoscopically within any one zone. Of 39 patients evaluated, 17 (44%) had endoscopic evidence of patchiness, including 5 (13%) with rectal sparing. Thirteen (33%) had histologic evidence of patchiness, including 6 (15%) with rectal sparing. Both endoscopic and histologic patchiness were seen in 9 patients (23%). The patchy and nonpatchy groups did not differ in regard to the use of rectal therapy. In patients with treated ulcerative colitis, the finding of rectal sparing or patchiness should not necessarily indicate a change in the diagnosis to Crohn's disease.

Are dysplasia and colorectal cancer endoscopically visible in patients with ulcerative colitis?Gastrointest Endosc. 2007 Jun;65(7):998-1004. Epub 2007 Apr 23.

BACKGROUND: Dysplasia and colorectal cancer (CRC) in ulcerative colitis (UC) develop via pathways distinct from sporadic CRC and may occur in flat mucosa indistinct from surrounding tissue. Surveillance guidelines, therefore, have emphasized the approach of periodic endoscopic examinations and systematic random biopsies of involved mucosa. Given the imperfect nature of this random approach, recent work has focused on improved surveillance techniques and suggests that neoplasia is endoscopically visible in many patients. OBJECTIVE: To assess the endoscopic visibility of dysplasia and CRC in UC. DESIGN: This was a retrospective review that used the University of Chicago Inflammatory Bowel Disease Registry and the clinical administrative database. All cases of dysplasia or CRC in UC between November 1994 and October 2004 were identified. The approach to surveillance in these patients included both random biopsies at approximately 10-cm intervals throughout the involved colon and directed biopsies of polypoid lesions, masses, strictures, or irregular mucosa distinct from surrounding inflamed tissue. Findings on endoscopy were compared with pathologic findings from biopsy or surgical specimens. Visible dysplasia was defined as a lesion reported by the endoscopist that led to directed biopsy and that was confirmed by pathology. Invisible dysplasia was defined as dysplasia diagnosed on pathology but not described on endoscopy. Per-lesion and per-patient sensitivities were determined. SETTING: Tertiary referral center. PATIENTS: Database of patients with inflammatory bowel disease seen at the University of Chicago. MAIN OUTCOME MEASUREMENTS: Endoscopically visible neoplasia. RESULTS: In this database, there were 1339 surveillance examinations in 622 patients with UC. Forty-six patients were found to have dysplasia or CRC at a median age of 48 years and with median duration of disease of 20 years. Of these patients, 77% had pancolitis, 21% had left-sided colitis, and 2% had proctitis. These patients had 128 surveillance examinations (median 3 per patient; range, 1-9 per patient), and, in 51 examinations, 75 separate dysplastic or cancerous lesions were identified (mean, 1.6 lesions per patient; standard deviation, 1.3). Thirty-eight of 65 dysplastic lesions (58.5%) and 8 of 10 cancers (80.0%) were visible to the endoscopist as 23 polyps and masses, 1 stricture, and 22 irregular mucosa. The per-patient sensitivities for dysplasia and for cancer were 71.8% and 100%, respectively. The overall per-lesion and per-patient sensitivities were 61.3% and 76.1%, respectively. LIMITATIONS: Retrospective review of clinical databases and medical records. CONCLUSIONS: Dysplasia and cancer in UC are endoscopically visible in most patients and may be reliably identified during scheduled examinations. Future surveillance guidelines should incorporate this information.

Diffuse duodenitis associated with ulcerative colitis.Am J Surg Pathol. 2000 Oct;24(10):1407-13.

Backwash ileitis and postcolectomy pouchitis are well-recognized complications of ulcerative colitis (UC), whereas inflammation of the proximal small intestine is not. In contrast, small intestinal disease at any level is common in Crohn's disease (CD). Despite this well-established and accepted dogma, rare cases of histologically proven diffuse duodenitis (DD) associated with UC appear in the literature. In this study, we report our experience with similar cases exhibiting this unusual inflammatory phenomenon. Routine histologic sections from four cases of DD associated with well-documented UC were reviewed and the findings correlated with all available medical records. Multiple endoscopic biopsies showing histologic features of UC and colectomy specimens confirming severe ulcerative pancolitis were available for all cases. Varying degrees of active chronic inflammation and architectural mucosal distortion identical to UC were observed in pre- and postcolectomy duodenal biopsies of one of four and four of four cases, respectively. Similar inflammatory patterns were present postoperatively in the ileum in three of four cases and in the jejunum in one case. Endorectal pull-through (ERPT) procedures were performed in three of four patients and an end-to-end ileorectal anastomosis was done in one patient. Despite extensive upper gastrointestinal tract involvement, none of the patients developed postsurgical Crohn's-like complications during a follow-up period of 12 to 54 months. This suggests that patients with pancolitis and DD do not necessarily have CD, but rather may have UC and, most importantly, that successful ERPT procedures may be performed in these patients.