How should I interpret histopathology results when managing patients with suspected inflammatory bowel disease?

When interpreting histopathology results in patients with suspected inflammatory bowel disease (IBD), it is essential to integrate clinical, endoscopic, and histological findings to differentiate between ulcerative colitis (UC) and Crohn's disease (CD), as well as to exclude other mimics such as infections or celiac disease. Histopathology should be assessed for architectural distortion, chronic inflammatory infiltrate, crypt abscesses, granulomas, and mucosal ulceration, which are key features supporting IBD diagnosis ¹ (Feakins, 2014).

In UC, histology typically shows continuous mucosal inflammation with crypt architectural distortion, basal plasmacytosis, and crypt abscesses, whereas CD often demonstrates patchy transmural inflammation, granulomas, and fissuring ulcers, although granulomas are not always present ¹ (Feakins, 2014). The presence of granulomas strongly supports CD but their absence does not exclude it.

Histopathological interpretation must also consider differential diagnoses such as celiac disease, which can mimic IBD histologically; thus, features like villous atrophy and increased intraepithelial lymphocytes should prompt consideration of celiac disease and appropriate serological testing (Villanacci et al., 2020).

It is important to recognize that histological features can overlap and may be influenced by treatment or disease stage, so correlation with clinical presentation and endoscopic findings is critical ¹ (M'Koma, 2022). Additionally, repeated biopsies may be necessary for diagnostic clarity.

In summary, histopathology in suspected IBD should be interpreted as part of a multidisciplinary assessment, focusing on characteristic features of UC and CD, while excluding mimics, and always integrating clinical and endoscopic data to guide diagnosis and management ¹ (Feakins, 2014; M'Koma, 2022; Villanacci et al., 2020).