Use of Confocal endomicroscopy to Assess for DALM in Crohn’s Colitis: Case Aline Charabaty MD, Gina Gessner RN, Iram Khan MD, Amrita Patel MD BACKGROUND: The risk of developing neoplasia leading to colorectal cancer is signifcantly increased in longstanding ulcerative or Crohn’s colitis. The main purpose of CRC surveillance in IBD is to detect early dysplastic alterations. These dysplastic changes of the intestinal mucosa may occur in fat or raised mucosal lesions, known as dysplasia- associated lesion or mass (DALM) and adenoma-like mass (ALM). Optical colonoscopy with random biopsies, chromoendoscopy, virtual chromoendoscopy and confocal endomicroscopy are different techniques used to identify dysplastic changes. We present a case of DALM in Crohn’s colitis that found was subsequently to be non-dysplastic with the use of confocal endomicroscopy. CASE REPORT: 37 year old female with history of Crohn’s disease (UGI, small bowel and colon) diagnosed approximately 3 yrs ago, although had symptoms for about 5 years. GI work-up revealed Crohns with granulomas in the stomach, duodenitis, and ileocolitis. She was treated with Mesalamine alone for a length of time due to receiving IVF therapy which resulted in pregnancy. She developed abdominal pain, nausea, and persistent diarrhea after she stopped breastfeeding. Colonoscopy showed ileocolitis with granulomas and two polypoid areas - one at the ICV and the other overlying two folds in the transverse colon. She was therefore started on Adalimumab. Biopsies from the transverse colon polypoid area revealed low grade dysplasia, which was confrmed at a tertiary care center. She was referred to our facility for second opinion about the LGD noted on recent colon biopsies. We repeated the colonoscopy and examined the above mentioned areas with I-scan as well Cell-Vizio. Crypts were distorted with dark cells with decrease in space between the crypts in the polypoid areas of transverse colon. Biopsy showed infammatory changes in the polypoid area with no dysplasia. Entocort was added later on as patient was complaining of symptom recurrence, while continuing with Adalimumab and Mesalamine. Repeat colonoscopy with I-scan and Cell-vizio in three months showed decrease in the size of the polypoid area. Cell-vizio also confrmed normal crypt architecture. Biopsies showed colonic mucosa with no infammation. DISCUSSION: The standard of care for DALM in IBD is colectomy. Infammatory changes can be incorrectly labeled as DALM. This is a unique case where colectomy was spared using confocal endomicroscopy. In one randomized controlled trial by Neurath et al, endomicroscopy predicted the presence of neoplastic changes with high sensitivity, specifcity, and accuracy (94.7%, 98.3%, and 97.8%, respectively) in patients with UC. In another study by Hurlstone et al, the accuracy of endomicroscopy was 97%, and there was an excellent agreement between endomicroscopy and histopathological diagnosis (κ = 0.91) for DALM and ALM. Most of this data comes from Europe, with little literature from US. We conclude that confocal endomicroscopy is a useful technique that can help differentiate between DALM and infammatory changes in patients with IBD related colitis and hence unnecessary colectomy can be avoided. 1. In-vivo characterization of DALM in ulcerative colitis with high-resolution probe-based confocal laser endomicroscopy. De Palma GD, Staibano S, Siciliano S, Maione F, Siano M, Esposito D, Persico G. World J Gastroenterol. 2011 Feb 7;17(5):677-80. 2. Confocal endomicroscopy in ulcerative colitis: differentiating dysplasia-associated lesional mass and adenoma-like mass. Hurlstone DP, Thomson M, Brown S, Tiffin N, Cross SS, Hunter MD. Clin Gastroenterol Hepatol. 2007 Oct;5(10):1235-41. Epub 2007 Aug 8. Correspondence: Aline Charabaty MD, Director of IBD, Assistant Professor of Medicine, Division of GI, For more information visit : http://www.cellvizio.net/iccu

Source: http://www.cellvizio.net/sites/default/files/u1157/Charabaty.pdf

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