The Clinical Significance of Focally Enhanced Gastritis in Children
BACKGROUND:: Focally enhanced gastritis (FEG) was initially described in patients with inflammatory bowel disease (IBD), but subsequent reports found this to be a nonspecific finding in adults. Initial reports suggest that FEG may be more predictive of IBD in pediatric patients, but this has yet to be confirmed. The aim of our study was to characterize and determine clinical correlates of FEG in pediatric patients. MATERIALS AND METHODS:: Gastric biopsies from pediatric patients who were diagnosed with FEG at a single tertiary care center over a 5-year period were reviewed (5-y cohort study). In a subsequent study, all gastric biopsies from pediatric patients in the single center over a 1-year period were reviewed. Biopsies were reviewed in a blinded manner by 2 pathologists, and histologic data of interest were recorded. Clinical data and follow-up data were recorded from review of the electronic medical records. RESULTS:: Of the 25 patients with FEG in the 5-year cohort study, IBD was present in 19 (76%) patients. Crohn disease (CD) was more common than ulcerative colitis (UC) among these patients (68% vs. 16%). In the 1-year review study with 262 gastric biopsies, FEG was present in 31 (11%) cases. Patients with FEG were significantly more likely to have IBD than non-FEG patients (61.3% vs. 11.6%, P≤0.001). Of the 19 patients with FEG and IBD, 9 patients had CD, 9 patients had UC, and 1 had indeterminate colitis. CONCLUSIONS:: The presence of FEG is highly associated with IBD in pediatric patients. The presence of FEG does not reliably distinguish between patients with CD and those with UC.
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ABSTRACT: Accurate histopathological assessment of biopsies is important for the diagnosis, subclassification, and management of chronic idiopathic inflammatory bowel disease (IBD). British Society of Gastroenterology (BSG) guidelines for the initial histopathological diagnosis of IBD were published in 1997. Changes since then include: more widespread use of full colonoscopy; greater recognition of the effects of time and treatment; improved documentation of variations in anatomical distribution; better understanding of the mimics of IBD; significant progress in clinical management; and modifications of terminology. Accordingly, an update is required. These revised guidelines aim to optimise the quality and consistency of reporting of biopsies taken for the initial diagnosis of IBD by summarising the literature and making recommendations based on the available evidence. Advice from existing clinical guidelines is also taken into account. Among the subjects discussed are: distinguishing IBD from other colitides, particularly infective colitis; subclassification of IBD (as ulcerative colitis, Crohn's disease, or IBD unclassified); the discriminant value of granulomas; aspects of disease distribution, including discontinuity in ulcerative colitis; time-related changes; differences between paediatric and adult IBD; the role of ileal and upper gastrointestinal biopsies; differential diagnoses such as diverticular colitis and diversion proctocolitis; and dysplasia. The need to correlate the histological features with clinical and endoscopic findings is emphasised. An approach to the conclusion of an IBD biopsy report based on the acronym Pattern, Activity, Inflammation, Dysplasia (PAID) (pattern, activity, interpretation, dysplasia) is suggested. The key recommendations are listed at the end of the document.
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ABSTRACT: Although the significance of focally enhanced gastritis (FEG) as a marker of Crohn disease (CD) in adults has been contested, several studies suggest that it may be more specific of CD in pediatric patients. This study describes the detailed histologic features of FEG in pediatric inflammatory bowel disease (IBD) and clarifies its association with CD. A series of 119 consecutive newly diagnosed IBD patients (62 CD cases, 57 ulcerative colitis [UC] cases) with upper and lower gastrointestinal biopsies were evaluated. The histology of the gastric biopsies was reviewed blinded to final diagnoses and compared with age-matched healthy controls (n=66). FEG was present in 43% of IBD patients (CD 55% vs. UC 30%, P=0.0092) and in 5% of controls. Among CD patients, FEG was more common in younger patients (73% in children aged 10 y and below, 43% in children above 10 y of age, P=0.0358), with the peak in the 5- to 10-year age group (80%). The total number of glands involved in each FEG focus was higher in UC (6.4±5.1 glands) than in CD (4.0±3.0 glands, P=0.0409). Amongst the CD cohort, patients with FEG were more likely than those without FEG to have active ileitis (79% vs. 40%, P=0.0128) and granulomas elsewhere in the gastrointestinal tract (82% vs. 43%, P=0.0016). There was no correlation between FEG and other gastrointestinal findings of UC. We demonstrate that differences in FEG seen in pediatric CD and UC relate to not only their frequencies but also the morphology and relationship with other gastrointestinal lesions. Further, FEG is associated with disease activity and the presence of granulomas in pediatric CD.
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