About uncertainty in IBD histological diagnosis
Dear Prof. Feakins,
First of all we wish to express our congratulations for your excellent reporting guidelines about the diagnosis of IBD on biopsies published in JCP, September 2013.
About this important matter, we would like to make some comments based on our personal experience. Regarding the terminology in the histological diagnosis of IBD, it was stated (section "Probability" in the paragraph "Terminology") that "unfortunately, there are no universal agreed of terms to describe the various levels of certainty or uncertainty encountered by the histopathologists and the clinicians, unless the diagnosis is definite". In this meaning, the "level of uncertainty" of diagnosis defines the category of cases that do not satisfy the conventional criteria for a definite diagnosis of IBD or non IBD colitis, due to inadequate clinical information, as well as to inadequate number and quality of biopsies or unclear microscopic pattern (absence of IBD -specific lesions). This group of histological diagnoses with a significant level of uncertainty is relevant in IBD management for various reasons:
1) It represents a large portion of the patients that underwent endoscopy with a clinical suspicion of IBD, given the frequent inadequacy of the prerequisites of diagnosis in clinical practice, as stated in your recent paper, published in this journal. We confirmed this trend in a recent study of our group, based on the evaluation the clinical/endoscopic information, the sampling procedures and the histological characteristics of 353 histological reports collected from 13 of the most representative gastroenterological centres in Piedmont (Italy), that evidenced a low rate of adequacy (5% adequate clinical/endoscopic information, 13% adequate sampling and no case with a correct orientation of the samples). (The first results will be presented at the Congress of the Italian Pathologists Society - SIAPEC Rome October 2013 and then published).
2) The nomenclature of this category of cases is still heterogeneous, as well described in your paper, and often equated with a definite diagnosis in clinical practice.
3) There is no clear indication about the management of patients with this typology of histological diagnosis. In our opinion, the effect of these anomalies is often inappropriate treatment for these patients, with the consequent modifications of the endoscopic pattern, that reduces the chance of a further diagnostic setting. Moreover, these diagnoses may be misleading in the case studies. Thus, we think it might be useful to consider this item in the management of IBD patients and to improve the quality of the histological diagnosis in the first evaluation of patients with clinical/endoscopic pattern suggestive of IBD (see also our letter to the editor [World J Gastroenterol 2013 January 21; 19(3): 426-428]) by:
1. implementing a minimum mandatory set of clinical information and histological sampling that could fit with an appropriate diagnostic process in histology and using an univocal nomenclature for histological diagnosis that does not meet these requirements, with the goal of reducing the number of inconclusive or inappropriate diagnoses.
2. adopting the repetition of the endoscopy (after a brief discussion with the clinical staff) for all the cases with a significant "level of uncertainty" in histological diagnosis.
We hope that you agree with the need to obtain a more definite diagnosis for the patients, and we are strongly interested in your opinion about this topic. Thank you for your attention.
We look forward to your kind response,
Conflict of Interest: