Study Of Clinicopathologic Features Of Crohn’s Disease, Primary Intestinal Lymphoma And Intestinal Tuberculosis

BackgroundThere are many Similarities on clinical manifestations and results of assistantexaminations among Crohn’s disease, primary intestinal lymphoma and intestinaltuberculosis, but significant differences in treatment and prognosis. So it is a difficultproblem to differential diagnosis yet to be resolved. There is little data available onclinicopathologic features of them，using surgical pathology as the golden standard.Therefore there is urgent need to list and analyze the features of surgical pathology, thenlook for the key information on differential diagnosis.Epithelial-mesenchymal transition is associated with chronic injury repair, tissueregeneration and organic fibrosis. There were studies done by foreign scholarsconfirmed that, epithelial-mesenchymal transition was associated with anal fistula andintestinal fistula of patients with Crohn’s disease, animal models and in vitro ofintestinal fibrosis of Crohn’s disease. There is no any report in domestic.ObjectivesTo investigate morphological and clinicopathologic features of lesions, providingclues for differential diagnosis among Crohn’s disease, primary intestinal lymphomaand intestinal tuberculosis, using surgical pathology as the golden standard. To investigate status of intestinal fibrosis of surgical samples of patients withCrohn’s disease, and whether there is epithelial-mesenchymal transition phenomenon.MethodsClinical data of41cases with primary intestinal lymphoma and27cases withCrohn’s disease who accepted surgical therapy between January2000and December2010were collected. The differences in surgical pathology and imaging signs betweenprimary intestinal lymphoma and Crohn’s disease were compared, using unifiedmorphological description standards of lesions.Clinical data of27cases with Crohn’s disease and13cases with intestinaltuberculosis who accepted surgical therapy between January2000and December2010were collected. The samples were done acid-fast staining to look for acid-fast bacillus,hematoxylin eosin staining to measure sizes of granulomas, masson staining to observestatus of fibrous tissue proliferation of intestine, immunohistochemistry method todetect the expression of cytokeratins and E-cadherin.ResultsThe mean age of patients with Crohn’s disease was significantly younger[(39.5±12.5) vs (51.4±18.2), P=0.002], the median course was longer than primaryintestinal lymphoma (P=0.036). Data of surgical pathology showed that, small intestinewas the most frequently involved site (51.9%) in Crohn’s disease, and multiple regularulcerative lesions, cobblestoning appearance, rigidity of mucosal folds and intestinalstricture were more common (P<0.05). The most commonly involved site was ileocecalregion (48.8%) in primary intestinal lymphoma, and single protruding lesions andmesenteric lymph nodes were more common (P<0.05). Data of preoperative imagingshowed that, Crohn’s disease had signs of mural stratification (P=0.074) andenhancement (P=0.008); In contrast, primary intestinal lymphoma had signs of mucosal damage and interrupted (P=0.010) and soft tissue mass (P=0.001). There wereadvantages in detection of locations of lesions (58.9%vs40%), non-continuousdistribution (66.7%vs30.8%), intestinal stricture (50%vs0%) for barium imaging, andthere were advantages in bowel wall thickening (100%vs0%), abdominal lymph nodesenlargement (25%vs0%) for CT scan.The median course of Crohn’s disease was longer than intestinal tuberculosis(182.5d vs20d，P=0.016). Evidence of tuberculosis on chest X ray of intestinaltuberculosis was more common than Crohn’s disease（4/10vs0/27，P=0.003）. Data ofsurgical pathology showed that, transmural inflammation was more common in Crohn’sdisease(χ~2=7.965，P=0.005), the rates of detection(χ~2=17.425，P=0.000) and fusion ofgranuloma (χ~2=23.742，P=0.000)of intestinal tuberculosis were higher than Crohn’sdisease. The maximum granuloma of intestinal tuberculosis [(846±249)μm]was largerthan Crohn’s disease[(579±190)μm](P=0.018). The sensitivity and specificity ofacid-fast staining to intestinal tuberculosis was30.8%,100%, respectively.There were significant fibrous tissue proliferation of surgical samples of patientswith Crohn’s disease, the expression of cytokeratins and E-cadherin weakened.Conclusions(1)Multiple regular ulcerative lesions, cobblestoning appearance, rigidity ofmucosal folds and intestinal stricture were more common in Crohn’s disease. It hadsigns of mural stratification and enhancement during CT scan.While single protrudinglesions and mesenteric lymph nodes, signs of mucosal damage and interrupted and softtissue mass during barium opacification were more common in primary intestinallymphoma.(2)As to intestinal surgical pathology, transmural inflammation was morecommon in Crohn’s disease, and the maximum granuloma was smaller. In contrast, therates of detection and fusion of granuloma were higher in intestinal tuberculosis, and the maximum granuloma was larger than Crohn’s disease.(3)There were advantages in detection of locations of lesions, non-continuousdistribution, intestinal stricture for barium imaging; while there were advantages indetection of bowel wall thickening, abdominal lymph nodes enlargement for CT scan.(4) There was tendency of epithelial-mesenchymal transition in Crohn’s disease,it may play some effect in intestinal fibrosis.