Vasculitis, defined as a non-infectious inflammatory disorder of blood vessels, can affect vessels of any type in any organ. The gastrointestinal (GI) tract may thus also be involved. In systemic disorders as mixed connective tissue disease (MCTD) and systemic lupus erythematodes (SLE), patients may present with symptoms of gastrointestinal disfunction such as motility disorders, caused by alterations in the connective tissue. True vasculitis however also occurs in the GI tract. Severe, occlusive damage often leads to ischemia that may result in ulceration and perforation. Non-occlusive vascular disease may lead to vascular leakage resulting in oedema and haemorrhage. Those patients often present with diarrhoea or symptoms of bleeding. GI involvement is frequent in Henoch-Schönlein purpura and also often noted in polyarteritis nodosa (PAN), microscopic polyangiitis, Wegener's syndrome and Churg-Strauss syndrome. Furthermore, GI vasculitis has also been described in giant cell arteritis, Takayasu's disease, Buerger's disease and leucocytoclastic vasculitides as essential mixed cryoglubulinemia, lupus vasculitis, rheumatoid disease, MCTD, drug-induced vasculitis and Behçet's disease. The diagnosis and classification of vasculitis relies upon a combination of clinical, serological, haematological, radiological and histological findings. Establishing a precise diagnosis can be difficult but is important because treatment and prognosis can be highly variable.
Acute self-limited colitis encompasses several diagnostic possibilities such as infectious colitis, post-antibiotic colitis, drug-induced colitis and should be differentiated from acute forms of inflammatory bowel disease. Diverticular disease in the elderly patient with colonic ischaemia may also give symptoms of acute bloody mucoid rectal discharge and should be recognised, although the clinical picture is usually completely different. Recognition of the causative agent--if possible--is particularly important in the patient with a foudroyant colitis (e.g. toxic megacolon), when the clinician has to decide, whether antibiotics or corticosteroids should be given or even a resection should be performed. A short history usually indicates towards infection, but a long-standing history of inflammatory bowel disease may be complicated by a superinfection. Faecal cultures, endoscopy with colonic biopsy should be performed and results be discussed. New techniques for the assessment and follow up of difficult cases are: white cell scintigraphy, computerized tomography scanning and magnetic resonance imaging scanning. Acute self-limited colitis can usually be classified properly and treated accordingly. This review discusses the role to be played by the clinician, microbiologist and pathologist and is illustrated by several clinical examples, in which patients presented with unusual forms of acute self-limited colitis.
To assess the value of adding ileoscopy with biopsy to colonoscopy, hence increasing the indications for ileoscopy in patients presenting with symptoms of inflammatory bowel disease.Two hundred fifty-seven patients with persistent diarrhea and 43 patients with sporadic colonic polyps were studied prospectively. The final diagnosis based on clinical and follow-up data, the histology of multiple ileal biopsies, and endoscopic findings were analyzed.Endoscopic lesions of the terminal ileum were found in 123 of 300 patients. In the 43 patients with colonic polyps, no ileal lesions were seen. Ileal disease without colonic involvement was present in 44 of 123 patients. Microscopic lesions of the ileum were present in 125 of 300, or in 125 of 257 (49%) with symptoms of diarrhea. Two of these had a normal endoscopy. Thirteen patients had a diffuse colitis and 11 had a predominantly left-sided colitis, both originally suggestive of ulcerative colitis. Crohn's disease was diagnosed in 88 patients and infectious disease in 17. Ileal biopsies were essential for the diagnosis in 15 patients and were contributive in 53. Granulomas, solitary giant cells, pseudopyloric gland metaplasia, eosinophils, and a disturbed villous architecture were the most important lesions observed in Crohn's disease and were contributive for this diagnosis.Ileoscopy with biopsy is useful in carefully selected patients presenting with symptoms of inflammatory bowel disease. The main indications are diagnosis of isolated ileal disease in the presence of a normal colon and differential diagnosis in patients with pancolitis and predominantly left-sided colitis. Multiple biopsy specimens show definite pathology in almost half of the patients.
Two patients with "collagenous colitis" characterized by abdominal pain and chronic watery diarrhea are described. Colorectal biopsies showed a marked, band-like collagenous deposit under the surface epithelium. Transmission electron microscopy showed an abnormally thickened collagen table under a thickened basal lamina. Immunofluorescence showed no specific lesions. Radioimmunoassay of several gastrointestinal hormones revealed no abnormality. Examination of colorectal biopsies of a large control series (564 patients) did not show a comparable diffuse thickening of the collagen table in various types of inflammatory bowel diseases. Furthermore, no obvious age-related change of the collagen layer was found. The clinical history of our two patients is compared with three analogous cases, previously described. From our findings and those of others it can be concluded that collagenous colitis is a separate entity.
