SCAD: diverticular inflammation or IBD in diverticular ...

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DIPAR

UOC d

SCAD: diverticul
o

IBD in divertic

Franco Scaldaferri, MD, Ph

[email protected]

TO DI PATOLOGIA SPECIALE MEDICA
RTIMENTO DI MEDICINA INTERNA

di Medicina Interna e Gastroenterologia
direttore Prof. A. Gasbarrini

lar inflammation
or
cular disease?

hD

SC

Tursi et al, Colorectal Disease, 12, 464–470, 2010

CAD definition

Lisa L et al, Am J Gastroenterol 2012; 107:1486–1493

SC

Tursi et al, Colorectal Disease, 12, 464–470, 2010

CAD definition

Lisa L et al, Am J Gastroenterol 2012; 107:1486–1493

SC

• SCAD is “segmental colitis
associated with diverticular
disease’’

• defined as a chronic colitis
confined to the diverticular
segment (but with sparing of
orifices!) in individuals with
otherwise uncomplicated
diverticular disease

• By definition, the rectum and
the proximal colon are
endoscopically and
histologically normal

Tursi et al, Colorectal Disease, 12, 464–470, 2010

CAD definition

Lisa L et al, Am J Gastroenterol 2012; 107:1486–1493

SC

• It is typically found in over

• It is suggested by intermitt
haematochezia, lower abd
bowel habit

• Very rarely fever, leucocyto

• The prevalence is unknown
around 0.26%-1,48% of all
colonoscopy and 3.8-11%
diverticulosis

Tursi et al, Colorectal Disease, 12, 464–470, 2010

CAD definition

r 60, mostly male

tent painless
dominal cramps or altered

osis, nausea and weight loss

n, but estimated to be
l patients who have had
of patients with

0

ULCERATIVE
COLITIS

• Continuous chronic
inflammation of the colonic
mucosa

• Prevalence 7.6-246.0 cases
per 100,000 in young adult
and lower pick in elderly

• Atipical presentations:
- backwash ileitis
- rectal sparing (children)
- Inflmmation of the
appendix area

IBD

CROHN’S
DISEASE

• Transmural inflammation
of the intestine

• Potentially interested
every segment of the GI
tract, as segmental o
regional inflammation

• Pick of incidece at 15-40
years, second pick at 60s

• Granuloma are often
found in histology

• Perianal disease and/or
fistulizing disease

ULCERATIVE
COLITIS

• Continuous chronic

inflammation of the colonic

mucosa

• Prevalence 7.6-246.0 cases

per 100,000 in young adult INDETER
and lower pick in elderly COLI
• Atipical presentations:
5-10% of t

- backwash ileitis

- rectal sparing (children)

- Inflmmation of the

appendix area

IBD

RMINATE CROHN’S
ITIS DISEASE

the cases • Transmural inflammation
of the intestine

• Potentially interested
every segment of the GI
tract, as segmental o
regional inflammation

• Pick of incidece at 15-40
years, second pick at 60s

• Granuloma are often
found in histology

• Perianal disease and/or
fistulizing disease

key pa

GENETIC
PRE-DISPOSITION

IBD:
athogenic signatures

key pa

GENETIC
PRE-DISPOSITION

SPECIFIC ADAPTIVE-
IMMUNITY
PATHWAYS
INVOLVED

(Th1-Th2-Th17)

SPECIFIC INNATE-IMMUNITY
PATHWAYS INVOLVED

(NLRS, INFLAMMASOME…)

IBD:
athogenic signatures

DELAY IN INJURY-
REPAIR

PROCESSESS

DYSBIOSIS

NEO-
ANGIOGENESIS
Y AND NON IMMUNE

CELL
INVOLVEMENT

U
key

• lifelong disea

• characterised
course. Relap
frequent (≥ 2

• Severe acute
represent ma

• Negative pro
of sistemic st
positivity…

• Possibility of

Axel Dignass et al, ECCO guidelines. Journal of C

Ulcerative Colitis:
clinical signatures

ase

d by a relapsing and remitting
pse may be infrequent (≤ 1/year),
2 relapses/ year), or continuous

e colitis and toxic megacolon
ajor clinical challanges

ognostic factors are considered use
teroids at first episode, ANCA

f extra-intestinal manifestations

Crohn's and Colitis (2012)

C
key

• lifelong disea

• characterised
course. Relap
frequent (≥ 2

• Perianal disea
disease repre

• Negative pro
young age at
disease, ASCA

• Possibility of

Gert Van Assche et al. Ecco guidelines. Journal o

Crohn’s Disease:
clinical signatures

ase

d by a relapsing and remitting
pse may be infrequent (≤ 1/year),
2 relapses/ year), or continuous

ase, stricturing and fistulizing
esent major complications

ognostic factors are considered
t diagnosis, ileal disease, perianal
A positivity, etc…

extra-intestinal manifestations

of Crohn's and Colitis (2009)

Inflamm Bo

owel Dis ● Volume 13, Number 6, June 2007

Inflamm Bo

owel Dis ● Volume 13, Number 6, June 2007

SCAD an
are they “sa

nd IBD:
ame entity”?

DIS
sa

 Pathogenesis
 Diagnosis
 Natural history
 therapy

Still low number of studie

SEASE DEFINITION:
ame or different?

es assessing SCAD!!

DIS
sa

 Pathogenesis

 Diagnosis

 Natural history

 therapy

SEASE DEFINITION:
ame or different?









ENROLLMENT OF CONSECUTIVE patie
mRNA per TNF-a expression in:

• acute uncomplicated diverticulitis (

• symptomatic uncomplicated divert

• asymptomatic diverticulosis (AD)

• segmental colitis associated with d

• ulcerative colitis (UC)

• healthy individuals (HC)

Colorectal Disease 2012 The Association of Coloproctology of Great Brita

ents (12 per group) for PCR assessing
(AUD) (12 patients)
ticular disease (SUDD)
diverticulosis (SCAD)

ain and Ireland. 14, e258–e263

Colorectal Disease 2012 The Association of Coloproctology of Great Brit

acute SCAD UC
uncomplicated
diverticulitis

symptomatic CONTROLS
uncomplicated
divert disease

Asymptomatic
divert disease

tain and Ireland. 14, e258–e263

J Gastrointestin Liver Dis, December 2011 Vol. 20 No 4, 365-370



Path

• No genetic information
• No evidence of specific

disregulation (Th1-Th2
• No evidence of dysbios

hogenesis of SCAD:
limits

n on predisposing genes

c adaptive immunity
or Th17)

sis

Chr

ronic inflammation
and TNF-a

The vi
inf

Foods PGE2 ROM NO
LTB4 Proteases
Epithelial cells

Blood vessels: Activated Growt
endothelium PMN Trefoi

Selectins Activa
M
PMN

Integrins ICAM-1 IL
Monocyte
MAdCAM-1

Lymphocyte

Modifyied from Mesenchymal cells:
Claudio Fiocchi
Intestinal fibroblasts

itious circle of chronic
flammation in IBD

Bacteria Intestinal
lumen
O
PAF

Thromboxane

Epithelial cells

Resting Naive
T cell
th factors Mo
IL-2 B cell
il proteins CD4+ Lamina
T cell CD40L Propria
ated CD40
Mo TNF-a
IL-4
IL-12
L-8 IL-1 T cells

IFN- Th1 Th2 IL-10 Immune

cells

The vi
inf

Foods PGE2 ROM NO
LTB4
Epithelial cells Proteases

Injur
and
repa

Blood vessels: Activated Growt
endothelium PMN Trefoi

Non immune Selectins Activa
cells M
PMN
activation
Integrins ICAM-1 IL
Monocyte
MAdCAM-1

Lymphocyte

Mesenchymal cells:

Modifyied from Intestinal fibroblasts
Claudio Fiocchi

itious circle of chronic
flammation in IBD

Bacteria Intestinal
lumen
O
PAF

Thromboxane

ry

d Epithelial cells

air Naive
Resting T cell
th factors Mo
IL-2 B cell
il proteins CD4+ Lamina
T cell CD40L Propria
ated CD40
Mo TNF-a
IL-4
IL-12
L-8 IL-1 T cells

IFN- Th1 Th2 IL-10 Immune
cells
Immune cells

activation