**4. Morphology of lesions**

Typical endoscopic lesions in **CD** are [3-5] (Fig. 1-4):


Endoscopy in Paediatric Inflammatory Bowel Disease (IBD) 241

Fig. 3. Colonic mucosa with focal aphthous ulcerations (a-b) surrounded by herythematous

mucosa (c-d-e-f) in Crohn's Disease


Inflammatory pseudopolips are less frequent in CD with respect to UC [3].

According to the mucosal and phenotypical characteristics at onset, CD is classified into inflammatory, stenosing and fistulizing.

Since CD can potentially involve the whole gastrointestinal tract, the intubation of ileum and upper gastrointestinal endoscopy are always indicated for a complete stadiation of the disease.

At the level of the strictures, the intestinal mucosa usually appears actively inflamed, frequently ulcerated and bleeding.

In the fistulizing CD phenotype, the internal orifice of the fistula can be observed on the bowel wall, generally in correspondance of inflamed areas.

Fig. 1. Gastric mucosa with focal aphthous ulcerations (a) surrounded by herythematous mucosa (b) in Crohn's Disease

Fig. 2. Gastric mucosal nodularities and cobblestone pattern in Crohn's Disease

According to the mucosal and phenotypical characteristics at onset, CD is classified into

Since CD can potentially involve the whole gastrointestinal tract, the intubation of ileum and upper gastrointestinal endoscopy are always indicated for a complete stadiation of the

At the level of the strictures, the intestinal mucosa usually appears actively inflamed,

In the fistulizing CD phenotype, the internal orifice of the fistula can be observed on the

Fig. 1. Gastric mucosa with focal aphthous ulcerations (a) surrounded by herythematous

Fig. 2. Gastric mucosal nodularities and cobblestone pattern in Crohn's Disease



disease.

inflammatory, stenosing and fistulizing.

frequently ulcerated and bleeding.

mucosa (b) in Crohn's Disease

bowel wall, generally in correspondance of inflamed areas.

Fig. 3. Colonic mucosa with focal aphthous ulcerations (a-b) surrounded by herythematous mucosa (c-d-e-f) in Crohn's Disease

Endoscopy in Paediatric Inflammatory Bowel Disease (IBD) 243

The histological findings which are more characteristic of CD are: trans-mural inflammation with infiltration and fibrosis; dilatation and sclerosis of lymphatic vessels; lymphatic aggregates; the typical non - caseating granulomata. Other possible findings include eccess of histiocytes, giant perinucleated cells (Langhan's like), mucous gland cells hyperplasia, focal criptitis, pseudopyloric metaplasia of colocites and decrease of inflammation grade

Even though the macroscopic and hystological characteristics are frequently discriminating for UC and MC, in those cases in which a differential diagnosis cannot be set, the disease is identified as Unclassified IBD, presenting intermediate characteristics between CD and UC. Infective colitis can also present a macroscopic pattern being similar to that of IBD [3]. For this reason, multiple biopsies should always be suggested at each segment for diagnosis

In UC the inflammatory process is limited to mucosa and submucosa and it spreads for

Instead in CD inflammation is trans-mural and "patchy" lesions can be found throughout the whole gastrointestinal tract; an involvement of adjacent lymphonodes and mesenther as

Fig. 5. Colonic herythematous mucosa with crispness (a) and mucosal bleeding (b) in



from the upper to the lower colon [9].

continuity from rectum to the whole colon [3].

Endoscopic characteristics in **UC** [3-5] (Fig. 5):

well as the formation of fistula and abscesses can be observed [3].

[3].

Ulcerative Colitis



Other possible findings:


potentially bleeding mucosa

Fig. 4. Colonic mucosa with extensive deep ulcerations (a, b, c, d) and cobblestone pattern (e) in Crohn's Disease

Fig. 4. Colonic mucosa with extensive deep ulcerations (a, b, c, d) and cobblestone pattern

(e) in Crohn's Disease

The histological findings which are more characteristic of CD are: trans-mural inflammation with infiltration and fibrosis; dilatation and sclerosis of lymphatic vessels; lymphatic aggregates; the typical non - caseating granulomata. Other possible findings include eccess of histiocytes, giant perinucleated cells (Langhan's like), mucous gland cells hyperplasia, focal criptitis, pseudopyloric metaplasia of colocites and decrease of inflammation grade from the upper to the lower colon [9].

Even though the macroscopic and hystological characteristics are frequently discriminating for UC and MC, in those cases in which a differential diagnosis cannot be set, the disease is identified as Unclassified IBD, presenting intermediate characteristics between CD and UC. Infective colitis can also present a macroscopic pattern being similar to that of IBD [3].

For this reason, multiple biopsies should always be suggested at each segment for diagnosis [3].

In UC the inflammatory process is limited to mucosa and submucosa and it spreads for continuity from rectum to the whole colon [3].

Instead in CD inflammation is trans-mural and "patchy" lesions can be found throughout the whole gastrointestinal tract; an involvement of adjacent lymphonodes and mesenther as well as the formation of fistula and abscesses can be observed [3].

Fig. 5. Colonic herythematous mucosa with crispness (a) and mucosal bleeding (b) in Ulcerative Colitis

Endoscopic characteristics in **UC** [3-5] (Fig. 5):


Other possible findings:


Endoscopy in Paediatric Inflammatory Bowel Disease (IBD) 245

capacity of the endoscope to overcome the stricturing tract) and overestimation of nonspecific lesions (at this level the endoscopic experience of the operator is determinant) [1]. The addition prefigures the evaluation of 5 pre-determined ileum-colonic segments: ileum (explorable portion), right colon (comprehending the ileum-cecal valve, cecum, ascendant colon, hepatic flexure), transverse colon, left colon (comprehending descendant colon, sigma, rectum-sigmoid junction), rectum. For each segment, the evaluation of four endoscopic variables is prefigured: presence of ulcers, extension of ulcerated surface, extension of the surface with lesions, presence of stenosis. For each variable, a score ranging

The classification of the ulcers for the SES-CD addition is based on their dimensions; therefore the extension of the ulcerated segment is evaluated attributing a score of 3 to those cases with a surface involvement exceeding 30%: such a proportion of extension is thus considered as the most severe pattern, since a major extension has no additional effect on

The classification of strictures for SES-CD is both descriptive and functional; in fact it is based on the capacity of the endoscope to overcome a segmental luminal narrowing [1].

*Device-assisted enteroscopy* (DAE) is a generic term for endoluminal examination of the small bowel by any endoscopic technique that includes assisted progression (e. g. by a balloon, overtube, or other stiffening device) [2]. DAE can be used to diagnose Crohn's disease,

A fundamental endoscopic application in the follow-up of IBD affected patients is the endoscopic surveillance for any dysplasia (a high-grade dysplasia evolve to invasive carcinoma in 33-100% of cases) [1]. As reported by the American Gastroenterology Society guidelines, the risk of neoplasia increases in cases of a long lasting disease with early onset, severe extension of disease, familiarity for cancer of colon-rectum, presence of backwash ileitis and history of sclerosing cholangitis [3]. Furthermore carcinogenesis correlates with

Aiming to the surveillance and early diagnosis of any arising neoplasia, the ideal number of biopsies to be taken during an endoscopic examination is 2-4 every 10 cm (and on 4 quadrants). For the paediatric age, such a surveillance schedule is indicated for cases with

Techniques like chromoendoscopy and AFI (auto-florescence imaging) increase from 2 to 5 times the sensitivity for the identification of any neoplastic lesion; on the contrary no significant advantages have been observed with NBI (narrow binding imaging) technique,

An endoscopic examination is recommended, after 2-3 months since the beginning of treatment in patients with a new diagnosis, in order to evaluate the efficacy of the ongoing

Another major role of the endoscopic examination involves those patients with IBD that undergo a surgical intervention with confectioning of ileal-pouch [3][10]. A post-surgical pouchitis is- in fact- common: it can be mild to severe and generally does not involve the last ileal oxbow (23-46% of cases at 10-11 years of age). A surveillance of the macro- and

microscopic inflammation is possible through scheduled post-operative controls.

**7. Further diagnostic applications of the endoscopic examination** 

from 0 to 3 is assigned to each segment [1].

because histological corroboration is available.

the activity of inflammation [4-5].

disease duration > 8 years [4].

therapy to get mucosal healing.

with respect to traditional endoscopy [1].

the severity of symptoms [1].


Baron and Mayo scores are the two principle indexes for the endoscopic grading of UC [3]. As regards the major histological alterations in UC, they are distorted with the disappearance of mucous glandular architecture and inflammatory infiltration of the crypts. They also have a villi-like profile of the mucosal surface, a high grade alteration of the mucosal architecture, Paneth cells metaplasia and a decrease of the inflammation and mucosal alteration grade from the upper to the lower colonic tract are seen [9].
