Non-Neoplastic Disorders of the Intestines
Case 10 -
Duodenal Involvement By Ulcerative Colitis
Laura W. Lamps, M.D.
Audrey J. Lazenby, M.D.
Joel K. Greenson, M.D.
A 20 year old female underwent a subtotal colectomy with ileostomy for
ulcerative colitis three years ago. Nine months after surgery, the patient became symptomatic again,
Case 10 - Figure 1 - Low magnification shows moderate blunting of duodenal villi and expansion of the lamina propria by a lymphoplasmacytic infiltrate.
Case 10 - Figure 2 - Higher magnification emphasizes architectural distortion of the duodenal glands, and the dense lymphoplasmacytic infiltrate.
Case 10 - Figure 3 - Focal cryptitis, crypt abscesses, and gland loss are noted.
At endoscopy, the duodenum showed "diffuse enteritis."
Duodenal involvement by ulcerative colitis
Traditionally, ulcerative colitis (UC) and Crohn's disease (CD) have been
distinguished clinically and histologically by anatomic distribution as well as by patterns of
inflammation associated with them. CD is classically regarded as a discontinuous disease with skip
areas, whereas UC is characterized as a diffuse mucosal disease of the colon with continuous and
symmetric involvement, virtually always involving the rectum. Other than "backwash ileitis," UC has
traditionally been regarded as sparing the small bowel completely.
Several recent publications have challenged these traditional views regarding the anatomic
distribution of UC. Several studies based on colorectal biopsies from chronic UC patients have
demonstrated rectal sparing, patchy rather than diffuse colitis, and even complete rectal healing during
the course of chronic disease. Rare case reports of patients with histologically documented UC
associated with small intestinal involvement also appear in the literature, further challenging the
classic dogma relating to the anatomic distribution of UC.
Diffuse duodenitis has now been well described in patients with confirmed diagnoses of UC. Duodenal
involvement is often diagnosed when there is persistent nausea, vomiting, and/or bloody diarrhea in
patients who have already had their colons resected for UC.
Endoscopically, findings are similar to colonic UC with diffusely
erythematous, friable mucosa. Histologically, the features are similar to UC within the large bowel,
showing diffuse mucosal inflammation with basal plasmacytosis of the lamina propria, neutrophilic
cryptitis, crypt abscesses, and mucosal crypt distortion.
The major item in the differential diagnosis, of course, is CD. No
other clinical, radiographic, or endoscopic features of CD should be present, nor should gross or
microscopic findings of CD exist in either the duodenal biopsy in question or in previous specimens. The
recognition of duodenal involvement by UC suggests that rather than automatically diagnosing CD in all
patients presenting with pancolitis and diffuse duodenitis, one should consider the possibility of UC
with an aberrant anatomic distribution as these patients may be candidates for successful re-anastomosis
or ERPT procedures.
It remains to be determined whether duodenal involvement by UC is a previously unrecognized
complication of chronic UC, a component of a variant type of UC, or possibly a completely different
concurrent disease entity. Although this type of small intestinal involvement is not typical of the
natural history of UC, it is possible that it is a rare complication of UC. As traditional views
regarding the distribution of UC are already changing, further studies are needed to better understand
and characterize the issue of upper small intestinal inflammation in UC.
Cases of duodenal involvement by UC in the literature have done well treated with
medical therapy for UC.
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- Kleer CG, Appelman HD. Ulcerative colitis: Patterns of involvement in colorectal biopsies and changes with time. Am J of Surg Pathol 22:983-989, 1998.
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