Ostomy associated cutaneous colonic metaplasia
Authors: Kseniya Golubets, Oana M Radu, Jonhan Ho, Lisa M Grandinetti
Journal: Journal of the American Academy of Dermatology (2013)

To the Editor: More than 70% of people with surgically induced intestinal stomas experience peristomal skin complications, including contact reactions, malignant neoplasms, preexisting skin diseases, infections, pyoderma gangrenosum, and other ulcerations.1Lyon C.C. Smith A.J. Griffiths C.E. Beck M.H. The spectrum of skin disorders in abdominal stoma patients.Br J Dermatol. 2000; 143: 1248-1260Crossref PubMed Scopus (127) Google Scholar However, to our knowledge, there has been only 1 reported case in the literature describing a peristomal skin ulcer with scattered intestinal tubular glands consistent with cutaneous intestinal metaplasia,2Ono R. Oka M. Sakaguchi M. Kawakami F. Nagano T. Kunisada M. et al.Peristomal skin ulcer with intestinal metaplasia.Br J Dermatol. 2012; 167: 204-206Crossref PubMed Scopus (7) Google Scholar which is distinct from lesions of overgranulation with intestinal metaplasia.1Lyon C.C. Smith A.J. Griffiths C.E. Beck M.H. The spectrum of skin disorders in abdominal stoma patients.Br J Dermatol. 2000; 143: 1248-1260Crossref PubMed Scopus (127) Google Scholar, 2Ono R. Oka M. Sakaguchi M. Kawakami F. Nagano T. Kunisada M. et al.Peristomal skin ulcer with intestinal metaplasia.Br J Dermatol. 2012; 167: 204-206Crossref PubMed Scopus (7) Google Scholar, 3Johnson C.D. White H. Colonic metaplasia with colonic-type polyps on an ileostomy stoma in polyposis coli. Report of a case.Dis Colon Rectum. 1988; 31: 405-407Crossref PubMed Scopus (14) Google Scholar We describe the second case of cutaneous peristomal intestinal metaplasia.A 76-year-old Caucasian female with history of ulcerative colitis, who had undergone a colectomy at age 17 resulting in a right lower abdominal ileostomy, presented to the dermatology department with a 2-year history of persistent stinging and irritation at the ileostomy site. She denied any changes in her stoma care. Her ulcerative colitis had been well controlled since the surgery.On physical exam there was a red, superficially erosive plaque extending along the cutaneous border of the stoma, initially suggestive of irritant dermatitis. Topical triamcinolone 0.1% ointment every other day for 1 month was recommended at that time, without improvement of the erosion or symptoms on follow-up. Zinc oxide ointment mixed with triamcinolone ointment was recommended for an additional 3 months, but lack of significant improvement on follow-up prompted a punch biopsy of the plaque.Histologic examination showed alternating epidermis with granular layer and colonic-type glandular mucosa, numerous goblet cells, and no discernible Paneth cells (Fig 1). The glandular elements expressed epithelial mucin, and by immunohistochemistry showed strong, diffuse expression of EMA, CAM5.2 and CK20. Ki-67 proliferative index was not increased. Overall, these findings suggested a metaplastic phenomenon.Our patient returned to clinic for suture removal (Fig 2, left) and at that time was treated with electrocoagulation on a focal 1-cm region of the erosion. On follow-up visit, the treated erosion had evidence of reepithelialization and additional areas of the erosion were treated, with a total of 4 sessions of electrocoagulation scheduled 4 weeks apart (Fig 2, right). Repeat punch biopsy performed at the conclusion of therapy was consistent with cicatrix, without evidence of intestinal metaplasia.Fig 2Ileostomy with cutaneous intestinal metaplasia. Before treatment (punch biopsy site at 4 o'clock; left). After treatment (right).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Peristomal intestinal metaplasia has been rarely described.1Lyon C.C. Smith A.J. Griffiths C.E. Beck M.H. The spectrum of skin disorders in abdominal stoma patients.Br J Dermatol. 2000; 143: 1248-1260Crossref PubMed Scopus (127) Google Scholar, 2Ono R. Oka M. Sakaguchi M. Kawakami F. Nagano T. Kunisada M. et al.Peristomal skin ulcer with intestinal metaplasia.Br J Dermatol. 2012; 167: 204-206Crossref PubMed Scopus (7) Google Scholar, 3Johnson C.D. White H. Colonic metaplasia with colonic-type polyps on an ileostomy stoma in polyposis coli. Report of a case.Dis Colon Rectum. 1988; 31: 405-407Crossref PubMed Scopus (14) Google Scholar, 4Berman J.J. Ullah A. Colonic metaplasia of ileostomies. Biological significance for ulcerative colitis patients following total colectomy.Am J Surg Pathol. 1989; 13: 955-960Crossref PubMed Scopus (29) Google Scholar We report a second case of intestinal metaplasia in a flat peristomal ulcer without overgranulation, with an emphasis on management of this condition. The pathogenesis is hypothesized to be related to dissemination of intestinal mucosal cells into the peristomal skin during surgery, or the promotion of colonic mucosa migration and growth by bile salts in intestinal contents.5Strauch E.D. Yamaguchi J. Bass B.L. Wang J.Y. Bile salts regulate intestinal epithelial cell migration by nuclear factor-kappa B-induced expression of transforming growth factor-beta.J Am Coll Surg. 2003; 197: 974-984Abstract Full Text Full Text PDF PubMed Scopus (40) Google ScholarIn 1 previous case report of peristomal intestinal metaplasia, the authors induced effective reepithelialization of the erosion after 11 electrocoagulation treatments,2Ono R. Oka M. Sakaguchi M. Kawakami F. Nagano T. Kunisada M. et al.Peristomal skin ulcer with intestinal metaplasia.Br J Dermatol. 2012; 167: 204-206Crossref PubMed Scopus (7) Google Scholar based on the hypothesis that destruction of intestinal tubular glands eliminates the secreted factors that may promote the erosion. Given reports of primary adenocarcinoma at sites of intestinal metaplasia,4Berman J.J. Ullah A. Colonic metaplasia of ileostomies. Biological significance for ulcerative colitis patients following total colectomy.Am J Surg Pathol. 1989; 13: 955-960Crossref PubMed Scopus (29) Google Scholar when evaluating a patient with a peristomal erosion recalcitrant to therapy, it is recommended that a biopsy be performed to establish the nature of the peristomal skin changes and to guide proper treatment and management. To the Editor: More than 70% of people with surgically induced intestinal stomas experience peristomal skin complications, including contact reactions, malignant neoplasms, preexisting skin diseases, infections, pyoderma gangrenosum, and other ulcerations.1Lyon C.C. Smith A.J. Griffiths C.E. Beck M.H. The spectrum of skin disorders in abdominal stoma patients.Br J Dermatol. 2000; 143: 1248-1260Crossref PubMed Scopus (127) Google Scholar However, to our knowledge, there has been only 1 reported case in the literature describing a peristomal skin ulcer with scattered intestinal tubular glands consistent with cutaneous intestinal metaplasia,2Ono R. Oka M. Sakaguchi M. Kawakami F. Nagano T. Kunisada M. et al.Peristomal skin ulcer with intestinal metaplasia.Br J Dermatol. 2012; 167: 204-206Crossref PubMed Scopus (7) Google Scholar which is distinct from lesions of overgranulation with intestinal metaplasia.1Lyon C.C. Smith A.J. Griffiths C.E. Beck M.H. The spectrum of skin disorders in abdominal stoma patients.Br J Dermatol. 2000; 143: 1248-1260Crossref PubMed Scopus (127) Google Scholar, 2Ono R. Oka M. Sakaguchi M. Kawakami F. Nagano T. Kunisada M. et al.Peristomal skin ulcer with intestinal metaplasia.Br J Dermatol. 2012; 167: 204-206Crossref PubMed Scopus (7) Google Scholar, 3Johnson C.D. White H. Colonic metaplasia with colonic-type polyps on an ileostomy stoma in polyposis coli. Report of a case.Dis Colon Rectum. 1988; 31: 405-407Crossref PubMed Scopus (14) Google Scholar We describe the second case of cutaneous peristomal intestinal metaplasia. A 76-year-old Caucasian female with history of ulcerative colitis, who had undergone a colectomy at age 17 resulting in a right lower abdominal ileostomy, presented to the dermatology department with a 2-year history of persistent stinging and irritation at the ileostomy site. She denied any changes in her stoma care. Her ulcerative colitis had been well controlled since the surgery. On physical exam there was a red, superficially erosive plaque extending along the cutaneous border of the stoma, initially suggestive of irritant dermatitis. Topical triamcinolone 0.1% ointment every other day for 1 month was recommended at that time, without improvement of the erosion or symptoms on follow-up. Zinc oxide ointment mixed with triamcinolone ointment was recommended for an additional 3 months, but lack of significant improvement on follow-up prompted a punch biopsy of the plaque. Histologic examination showed alternating epidermis with granular layer and colonic-type glandular mucosa, numerous goblet cells, and no discernible Paneth cells (Fig 1). The glandular elements expressed epithelial mucin, and by immunohistochemistry showed strong, diffuse expression of EMA, CAM5.2 and CK20. Ki-67 proliferative index was not increased. Overall, these findings suggested a metaplastic phenomenon. Our patient returned to clinic for suture removal (Fig 2, left) and at that time was treated with electrocoagulation on a focal 1-cm region of the erosion. On follow-up visit, the treated erosion had evidence of reepithelialization and additional areas of the erosion were treated, with a total of 4 sessions of electrocoagulation scheduled 4 weeks apart (Fig 2, right). Repeat punch biopsy performed at the conclusion of therapy was consistent with cicatrix, without evidence of intestinal metaplasia. Peristomal intestinal metaplasia has been rarely described.1Lyon C.C. Smith A.J. Griffiths C.E. Beck M.H. The spectrum of skin disorders in abdominal stoma patients.Br J Dermatol. 2000; 143: 1248-1260Crossref PubMed Scopus (127) Google Scholar, 2Ono R. Oka M. Sakaguchi M. Kawakami F. Nagano T. Kunisada M. et al.Peristomal skin ulcer with intestinal metaplasia.Br J Dermatol. 2012; 167: 204-206Crossref PubMed Scopus (7) Google Scholar, 3Johnson C.D. White H. Colonic metaplasia with colonic-type polyps on an ileostomy stoma in polyposis coli. Report of a case.Dis Colon Rectum. 1988; 31: 405-407Crossref PubMed Scopus (14) Google Scholar, 4Berman J.J. Ullah A. Colonic metaplasia of ileostomies. Biological significance for ulcerative colitis patients following total colectomy.Am J Surg Pathol. 1989; 13: 955-960Crossref PubMed Scopus (29) Google Scholar We report a second case of intestinal metaplasia in a flat peristomal ulcer without overgranulation, with an emphasis on management of this condition. The pathogenesis is hypothesized to be related to dissemination of intestinal mucosal cells into the peristomal skin during surgery, or the promotion of colonic mucosa migration and growth by bile salts in intestinal contents.5Strauch E.D. Yamaguchi J. Bass B.L. Wang J.Y. Bile salts regulate intestinal epithelial cell migration by nuclear factor-kappa B-induced expression of transforming growth factor-beta.J Am Coll Surg. 2003; 197: 974-984Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar In 1 previous case report of peristomal intestinal metaplasia, the authors induced effective reepithelialization of the erosion after 11 electrocoagulation treatments,2Ono R. Oka M. Sakaguchi M. Kawakami F. Nagano T. Kunisada M. et al.Peristomal skin ulcer with intestinal metaplasia.Br J Dermatol. 2012; 167: 204-206Crossref PubMed Scopus (7) Google Scholar based on the hypothesis that destruction of intestinal tubular glands eliminates the secreted factors that may promote the erosion. Given reports of primary adenocarcinoma at sites of intestinal metaplasia,4Berman J.J. Ullah A. Colonic metaplasia of ileostomies. Biological significance for ulcerative colitis patients following total colectomy.Am J Surg Pathol. 1989; 13: 955-960Crossref PubMed Scopus (29) Google Scholar when evaluating a patient with a peristomal erosion recalcitrant to therapy, it is recommended that a biopsy be performed to establish the nature of the peristomal skin changes and to guide proper treatment and management.