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The Importance of Recognizing Increased Cecal Inflammation in Health and Avoiding the Misdiagnosis of Nonspecific Colitis

Paski, Shirley C., M.D.1; Wightman, Robert, M.D.2; Robert, Marie E., M.D.3; Bernstein, Charles N., M.D.1,4

American Journal of Gastroenterology: October 2007 - Volume 102 - Issue 10 - p 2294–2299

BACKGROUND An inherent degree of nonpathological mild inflammation in the cecum has been described informally among pathologists. This low-grade inflammation is often reported as “nonspecific colitis,” which can confuse clinicians. Our objective was to characterize and quantify inflammatory changes in the cecum and rectum of healthy adults in a blinded study.

METHODS A total of 85 adults free of gastrointestinal symptoms and history of disease underwent colonoscopy plus cecal and rectal biopsies as part of a case control study. Slides were scored independently by two observers. Histology scores 0 (none) to 3 (severe) were assigned for: epithelial injury, crypt architecture, lamina propria cellularity, subcryptal cellularity, and cryptitis. Slides were scored in a blinded fashion. Biopsy slides of cecum and rectum from fifteen patients with ulcerative colitis were randomly distributed within our sample to limit observer bias.

RESULTS Scores for inflammation were greater in the cecum versus rectum for: epithelial injury (0.45 vs 0.26, P = 0.03), crypt architecture distortion (0.25 vs 0.09, P = 0.03), lamina propria cellularity (1.13 vs 0.34, P < 0.001), and cryptitis (0.40 vs 0.11, P < 0.001).

CONCLUSIONS Increased microscopic inflammation of the cecum is present in healthy individuals, compared to the rectum. Caution should be used when describing “colitis” in cecal biopsies. Clinicians should be cautious in their response to biopsy reports identifying patients as having clinically significant “colitis” that is limited to the cecum.

1Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; 2Department of Pathology, University of Manitoba, Winnipeg, Manitoba, Canada; 3Department of Pathology, Yale University, New Haven, Connecticut; and 4University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre, Winnipeg, Manitoba, Canada

Reprint requests and correspondence: Charles N. Bernstein, M.D., 804 F-715 McDermot Avenue, University of Manitoba, Winnipeg, Manitoba, Canada R3E 3P4.

CONFLICT OF INTEREST Guarantor of the article: Charles Bernstein, M.D.

Specific author contributions: Study design: Drs. Paski, Wightman, Robert, and Bernstein. Study conduct: Drs. Paski, Wightman, Robert. Study analysis: Drs. Paski, Wightman, Robert, and Bernstein. Initial manuscript writing: Dr. Paski. Manuscript revision and final approval: Drs. Paski, Wightman, Robert, and Bernstein.

Financial support: None.

Potential competing interests: None.

Received February 6, 2007; accepted May 1, 2007.

© The American College of Gastroenterology 2007. All Rights Reserved.
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