{"paper_id":"72eb57d3-ba77-49f8-8c94-48eee4750300","body_text":"Confocal laser endomicroscopy for the diagnosis\nof diversion colitis\nConfocal laser endomicroscopy (CLE) and\nvirtual chromoendoscopy (VCE) are\nadvanced endoscopic imaging techniques.\ni-Scan (Pentax, Japan) is a contrast-en-\nhancing computed program [1], while\nCLE enables in vivo histological examina-\ntion [2, 3].\nStudies from our group described the di-\nagnostic utility of CLE and VCE, such as\nfor Crohn ’s disease [4 – 6]. However, data\nregarding the applicability of VCE and\nCLE for the diagnosis of diversion colitis\nhave not been provided so far.\nHere, we describe the case of a 33-year-\nold woman who underwent an ileocecal\nresection and colorectal diversion 4 years\npreviously because of a complicated ileo-\ncecal and rectal endometriosis with poor\npostoperative wound healing and the\noccurrence of a rectovaginal fistula. She\nreported diarrheic stools, which were still\nabundant (12 – 15 occurrences of diar-\nrhea/day) even after a therapeutic at-\ntempt with high-dose steroids and anti-\nbiotics.\nHigh definition endoscopy (EPK- i, Pentax,\nJapan) showed a highly inflamed and fri-\nable mucosa with large ulcerations, loss\nof haustration, spontaneous bleeding,\nand mucus mixed with pus in the lumen\n(\n●\" Fig. 1 a) of the diverted colorectum.\nSubsequent examination of the same area\nby CLE (Pentax EC -3870 CIFK, Japan) upon\nintravenous administration of fluorescein\nas a contrast agent, revealed a pro-\nnounced crypt rarefaction, hypervascular-\nization with moderate leakage, and typi-\ncal crypt abscesses (\n●\" Fig. 1 b).\nSubsequent histopathological evaluation\n(hematoxylin and eosin stain) of conven-\nFig. 1 a High definition white-light endoscopy reveals a highly inflamed and friable mucosa with large ulcerations, loss of haustration, and mucus mixed wit h\npus, in the lumen of the sigmoid colon. b Confocal laser endomicroscopy of the same colonic area shows rarefied crypts with large lumens which are invaded by\na dense polymorph infiltrate (crypt abscesses), as well as hypervascularization with mild leakage in the lamina propria.\nFig. 2 a Conventional hematoxylin and eosin stain of a biopsy sample from the same area as in ●\" Fig. 1 shows similar crypt abscess findings (cross-sectioned\ncrypt marked by green arrowheads, and longitudinal sectioned crypt highlighted by yellow arrowheads) confirming the endomicroscopic diagnosis. b A high\ndefinition virtual chromoendoscopy image ( i-Scan) of an improved colonic mucosa with deposits (but without ulcerations) in the same patient after 10 weeks\nof topical salicylate therapy. (The intense erythematous aspect is due also to the contrast enhancement of the i-Scan mode.)\nUCTN – Unusual cases and technical notesE358\nHundorfean G et al. Confocal laser endomicroscopy for the diagnosis of diversion colitis … Endoscopy 2012; 44: E358 –E359\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\ntional biopsies taken from the same loca-\ntion confirmed the endomicroscopic find-\nings (\n●\" Fig. 2 a). There was no evidence of\ncytomegalovirus with the specific stain.\nAs a therapeutic consequence, the patient\nreceived topical therapy with salicylates.\nIn a control colonoscopy with i-Scan, per-\nformed approximately 10 weeks later, we\nsaw an endoscopic improvement of the\ncolitis (\n●\" Fig. 2 b), a fact that confirmed\nour diagnosis and choice of specific ther-\napy.\nIn conclusion, this article reports the first\ndescription and in vivo diagnosis of diver-\nsion colitis after surgery, by virtual chro-\nmoendoscopy and fluorescein-guided\nCLE, respectively.\nEndoscopy_UCTN_Code_CCL_1AD_2AD\nCompeting interests: None\nG. Hundorfean, M. T. Chiriac,\nJ. Siebler, M. F. Neurath, J. Mudter\nMedical Clinic I, University of\nErlangen-Nuremberg, Erlangen, Germany\nAcknowledgment\n!\nWe thank M. Vieth, Institute of Pathology,\nKlinikum Bayreuth, Bayreuth, Germany,\nfor providing the histologic image\n(\n●\" Fig. 2 a) and for helpful discussions.\nReferences\n1 Kodashima S , Fujishiro M . Novel image-en-\nhanced endoscopy with i-scan technology.\nWorld J Gastroenterol 2010; 16: 1043\n2 Kiesslich R , Goetz M , Hoffman A , Galle PR .\nNew imaging techniques and opportunities\nin endoscopy. Nat Rev Gastroenterol Hepa-\ntol 2011; 8: 547 – 553\n3 Inoue H , Kudo SE , Shiokawa A . Technology\ninsight: laser-scanning confocal microscopy\nand endocytoscopy for cellular observation\nof the gastrointestinal tract. Nat Clin Pract\nGastroenterol Hepatol 2005; 2: 31 – 37\n4 Hundorfean G, Agaimy A, Atreya R et al. Con-\nfocal laser endomicroscopy for characteriza-\ntion of Crohn ’s disease-associated duodeni-\ntis. Endoscopy 2012; 44: E80\n5 Hundorfean G , Agaimy A , Hartmann A et al.\nIn vivo diagnosis and characterization of\ngastric Crohn’s disease using endomicrosco-\npy and virtual chromoendoscopy. Endosco-\npy 2012 (in press)\n6 Neumann H , Vieth M , Atreya R et al. Assess-\nment of Crohn ’s disease activity by confocal\nlaser endomicroscopy. Inflamm Bowel Dis\n2012: DOI: 10.1002/ibd.22907\nBibliography\nDOI http://dx.doi.org/\n10.1055/s-0032-1310019\nEndoscopy 2012; 44: E358 –E359\n© Georg Thieme Verlag KG\nStuttgart · New York\nISSN 0013-726X\nCorresponding author\nG. Hundorfean, MD\nMedical Clinic I\nUniversity of Erlangen-Nuremberg\nUlmenweg 18\n91054 Erlangen\nGermany\nFax: +49-9131-8535102\ngheorghe.hundorfean@uk-erlangen.de\nHundorfean G et al. Confocal laser endomicroscopy for the diagnosis of diversion colitis … Endoscopy 2012; 44: E358 –E359\nUCTN – Unusual cases and technical notes E359\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.","source_license":"public-domain-us","license_restricted":false}