ORIGINAL ARTICLEALIMENTARY TRACT

Evaluation of diagnostic criteria for Crohns disease in Japan

Takashi Hisabe Fumihito Hirai Toshiyuki Matsui

Mamoru Watanabe

Received: 17 January 2013 / Accepted: 14 March 2013 / Published online: 3 April 2013

Springer Japan 2013

Abstract

Background In Japan, Crohns disease (CD) is diagnosed

according to a single, well-established set of diagnostic

criteria. However, no nationwide attempt has been made to

determine which specific criteria within these diagnostic

criteria are used to make diagnoses.

Methods A questionnaire-based survey was conducted of

patients given a definitive or suspected diagnosis of CD before

January 2011 according to the Japanese Diagnostic Criteria

for Crohns Disease. The survey included 579 patients with a

definitive diagnosis of CD and 59 patients with a suspected

diagnosis of CD at 34 Japanese medical institutions.

Results A total of 87.4 % of definitive diagnoses of CD were

based on the criterion in the definite category: major finding A

longitudinal ulcer (LU) or B cobblestone-like appearance

(CSA). A total of 30.4 % of definitive diagnoses were based

on the criterion: major finding C non-caseating epithelioid

cell granuloma (NCEG) with minor finding a irregular-

shaped and/or quasi-circular ulcers or aphthous ulcerations

found extensively in the gastrointestinal tract or b charac-

teristic perianal lesions. Finally, 7.1 % of definitive diag-

noses were made according to the criterion: all minor findings

a, b and c characteristic gastric and/or duodenal lesions.

Among suspected diagnoses of CD, 74.6 % were based on the

criterion in the suspected category: one or two minor findings.

Conclusions The Japanese diagnostic criteria for Crohns

disease consist of combinations of specific morphological

findings. Many of the diagnoses were based on the findings

of LU or CSA.

Keywords Crohns disease Inflammatory boweldisease Diagnostic criteria

Introduction

Crohn et al. [1] were the first to report subacute or chronic

ileitis invading the terminal ileum as regional ileitis. This

condition, Crohns disease (CD), was subsequently estab-

lished as a distinct pathological entity comprising lesions

throughout the gastrointestinal tract, from the mouth to the

anus. CD is a well-known type of refractory inflammatory

bowel disease of unknown etiology, and the number of

affected patients is growing in Japan [2]. CD causes both

symptoms attributable to gastrointestinal lesions and

complications throughout the body, appearing with many

clinical manifestations, so accurate diagnosis of CD in the

early stages is very important. No single gold standard for

the diagnosis of CD is currently available. The diagnosis is

therefore confirmed by clinical evaluation and a combi-

nation of endoscopic, histological, radiological, and/or

biochemical investigations [3].

In 1976, the Japanese Society of Gastroenterology

(Nippon Shokakibyo Gakkai Zasshi 1976;73:146778)

became the first Japanese organization to propose diag-

nostic criteria for CD. The criteria have been repeatedly

revised to reflect the continually advancing understanding

T. Hisabe (&) F. Hirai T. MatsuiDepartment of Gastroenterology,

Fukuoka University Chikushi Hospital,

1-1-1 Zokumyoin, Chikushino,

Fukuoka 818-8502, Japan

e-mail: hisabe@cis.fukuoka-u.ac.jp

M. Watanabe

Department of Gastroenterology and Hepatology,

Graduate School of Medicine, Tokyo Medical and Dental

University, Tokyo, Japan

123

J Gastroenterol (2014) 49:9399

DOI 10.1007/s00535-013-0798-x

of CD. The Research Group of Intractable Inflammatory

Bowel Disease granted by the Ministry of Health, Labour,

and Welfare of Japan authored the latest version of the

criteria [4] in 2011. As proposed, the current version of the

CD diagnostic criteria contains five main sections: (1)

disease concept; (2) primary features (including clinical

symptoms, surgical findings, histopathological findings);

(3) diagnostic criteria; (4) disease classification; and (5)

severity classification. However, the diagnostic criteria for

definitively diagnosing CD consist of morphological find-

ings (i.e., radiographic, endoscopic, and pathological

findings) only, and do not include symptomatology [5].

Differentiating those findings from morphological findings

present in other disease is therefore very important.

We recently conducted a questionnaire-based nation-

wide survey to determine how diagnoses are made with the

Japanese diagnostic criteria and to evaluate the suitability

of these criteria.

Methods

A questionnaire on the diagnosis of CD was sent to each

participating medical institution of the Research Group of

Intractable Inflammatory Bowel Disease. These institutions

were asked to base their responses on the 20 most recent

consecutive cases of CD, as of January 2011, diagnosed

according to the CD diagnostic criteria [4, 6] (Table 1).

The survey also asked about suspected cases of CD iden-

tified during the period over which the 20 most recent cases

were diagnosed. The respondents were asked to identify the

sex, age, and symptoms of the patients as well as the

particular criterion on which the diagnosis was based, the

test methods used, and the time required to reach the

diagnosis.

Results

The survey included 579 patients given a definitive diag-

nosis of CD and 59 patients given a suspected diagnosis of

CD at the 34 responding medical institutions (Table 2).

Definite cases of CD

Mean age at the time of diagnosis for patients given a

definitive diagnosis of CD was 27.8 13.7 years. A mean

interval of 3.1 10.0 months passed between initial

examination and definitive diagnosis. Abdominal pain was

the most common clinical manifestation (414 patients,

71.5 %), followed by diarrhea (366 patients, 63.2 %) and

weight loss (201 patients, 34.7 %). Ileocolonic type was

the most common disease location (305 patients, 52.7 %),

followed by ileal type (153 patients, 26.4 %) and colonic

type (121 patients, 20.9 %) (Table 3).

The particular criteria used to make the diagnoses are

listed in Table 4. A total of 87.4 % of the definitive

diagnoses of CD were based on Definite 1 (D1): major

finding A longitudinal ulcer (LU) or B cobblestone-

like appearance (CSA). Moreover, 81.7 % of these

diagnoses were based on major finding A LU. A total of

30.4 % of the definitive diagnoses were based on Definite

2 (D2): major finding C noncaseating epithelioid cell

granuloma (NCEG) with minor finding a irregular-

shaped and/or quasi-circular ulcers or aphthous ulcerations

found extensively in the gastrointestinal tract or b

characteristic perianal lesions. Finally, 7.1 % of the

definitive diagnoses were made according to Definite 3

(D3): All minor findings a irregular-shaped and/or quasi-

circular ulcers or aphthous ulcerations found extensively

in the gastrointestinal tract, b characteristic perianal

lesions, and c characteristic gastric and/or duodenal

lesions.

Endoscopy was the most common procedure used to

make the finding on which the definitive diagnosis was

based (512 patients). Many of the colon lesions leading to

the diagnosis were identified with endoscopy, while many

of the small bowel lesions were identified with radiogra-

phy. The percentage of patients given a definitive diagnosis

through biopsy, i.e., the detection rate of NCEG was

26.3 % (152 of 579 patients) (Table 5).

Suspected cases of CD

Mean age at the time of diagnosis of patients given a

suspected diagnosis of CD was 36.3 18.6 years.

Abdominal pain was the most common clinical manifes-

tation (41 patients, 69.5 %), followed by diarrhea (35

patients, 59.3 %). The most common disease location was

colonic type (25 patients, 42.4 %) followed by ileal type

(20 patients, 33.9 %) and ileocolonic type (13 patients,

22.0 %) (Table 6).

The particular criteria used to make suspected diagnoses

are listed in Table 7. Of the suspected diagnoses of CD,

74.6 % were based on Suspected 4 (S4): One or two minor

findings. Moreover, 16.9 % of suspected diagnoses were

based on Suspected 2 (S2): major finding A LU or B

CSA, but cannot be differentiated from ischemic colitis

or ulcerative colitis. Among patients given a suspected

diagnosis of CD, the pathology could not be differentiated

from ulcerative colitis (11 patients), Behcets disease/

simple ulcer (9 patients), intestinal tuberculosis (5

patients), ischemic colitis (2 patients), infectious entero-

colitis (2 patients), sarcoidosis (1 patient), and collagenous

colitis (1 patient).

94 J Gastroenterol (2014) 49:9399

123

Discussion

The present survey represents the first nationwide attempt

to determine which specific criteria in the Japanese diag-

nostic criteria for CD were used to make diagnoses.

Physical examination, laboratory tests, and gastrointestinal

investigations should be conducted when CD is suspected

from the medical interview, and the definitive diagnosis of

CD is made based on the Japanese diagnostic criteria of CD

[4]. The Japanese diagnostic criteria of CD consist mainly

of morphological findings from the gastrointestinal tract

[6]. The criteria provide some supplemental information

about these findings. LU and CSA, two of the criterias

three major findings, have long been considered charac-

teristic of CD [3, 710]. The criteria define a LU as an

ulcer C5 cm that runs longitudinally along the gastroin-

testinal tract and further state that LU encountered in

ischemic and infectious enterocolitis rarely display a CSA.

In CD, CSA is described as involving dense protrusions

of mucous membrane of uneven sizes, large or small,

surrounded by LU and smaller ulcers. The criteria further

state, This appearance may be seen in ischemic colitis, but

in ischemic colitis the protrusions are smaller and redness

is more intense. NCEG [1114] is an important histopa-

thological finding, but also associated with intestinal

tuberculosis. The criteria recommend creating serial sec-

tions and assigning assessment to a pathologist familiar

with the gastrointestinal tract to improve diagnostic accu-

racy. Irregular-shaped and/or quasi-circular ulcers or aph-

thous ulcerations found extensively in the gastrointestinal

Table 1 Proposed diagnostic criteria for Crohns disease in Japan

(1) Major findings A. Longitudinal ulcer a

B. Cobblestone-like appearance C. Noncaseating epithelioid cell granuloma b

(2) Minor findings a. Irregular-shaped and/or quasi-circular ulcers or aphthous ulcerations found extensively in the gastrointestinal tract c

b. Characteristic perianal lesions d

c. Characteristic gastric and/or duodenal lesions e

Definite 1. Major finding A or B f 2. Major finding C, with minor finding a or b

3. All minor findings a, b, and c Suspected

1. Major finding C, with minor finding c 2. Major finding A or B, but cannot be differentiated from ischemic colitis or ulcerative colitis

3. Major finding C only g 4. One or two minor findings

a In the small intestine, the ulcer occurs more commonly on the mesentery sideb The rate of detection of this granuloma is improved by creating serial sections. It is advisable that a pathologist familiar with the gastroin-

testinal tract examine a specimen of itc In typical cases, the ulcers are arranged longitudinally, but this does not occur in some cases. It is necessary that they persist for at least

3 months. With regard to this condition, it is necessary to exclude enteric tuberculosis, intestinal Behcets disease, simple ulcers, nonsteroidal

anti-inflammatory drug (NSAID)-induced ulcers, and infectious enterocolitisd These lesions consist of anal fissures, cavitating ulcers, anal fistulas, perianal abscesses, and edema-like anal skin tags. Preferably, colorectal

surgeons familiar with Crohns disease are consulted to examine such lesions, referring to the Atlas of findings by visual observation of lesions in

anus Crohns diseasee These lesions have a bamboo joint-like appearance, with notch-like depressions. Preferably, specialists familiar with Crohns disease are

consulted to examine such lesionsf In cases with only longitudinal ulcers, it is necessary to exclude ischemic intestinal lesions and ulcerative colitis. In cases with only a

cobblestone-like appearance, it is necessary to exclude ischemic intestinal lesionsg It is necessary to exclude inflammatory diseases with granulomas such as intestinal tuberculosis

J Gastroenterol (2014) 49:9399 95

123

tract, one minor finding of the criteria, must persist for

C3 months to be relevant. The listed characteristic perianal

lesions are anal fissures, cavitating ulcers, anal fistulas,

perianal abscesses, and edema-like anal skin tags. Perianal

lesions in CD are an important feature that sometimes leads

to the diagnosis, because of their high frequency and

occasional appearance before abdominal features [1518].

CD also commonly features upper gastrointestinal lesions

[1922]. Characteristic gastroduodenal lesions include a

bamboo joint-like appearance and a notch-shaped appear-

ance. Detailed testing is required to identify the findings of

the diagnostic criteria. The diagnostic imaging and histo-

pathological findings of this testing must be fully consid-

ered to properly differentiate CD from other diseases.

It should be noted that the present survey does not

exhaustively represent CD diagnosis throughout Japan,

because primarily IBD specialist institutions were sur-

veyed. In the survey, 87.4 % of definitive diagnoses of CD

were made based on D1. The vast majority of these

definitive diagnoses were made based on the presence of

LU and CSA are the first findings listed in the definite

category of the criteria. As these findings are characteristic

of CD, it follows that they would serve as the basis for

many diagnoses. A total of 30.4 % of definitive diagnoses

were based on D2. Finally, 7.1 % of definitive diagnoses

were made according to D3. We can think of several rea-

sons why D2 and D3 in the definite category did not

contribute as substantially to the diagnoses. Even non-IBD

specialists are capable of diagnosing CD based on full-

blown, typical lesions such as LU and CSA. The expertise

of an IBD specialist, however, is required to identify the

three minor findings in the criteria list, and differentiating

Table 2 Participated facilities in this study (n = 34)

Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka;

Akita Health Care Center, Japanese Red Cross Akita Hospital, Akita;

Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori;

Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Shimane;

Center for Gastroenterology and Hepatology, Ofune Chuo Hospital, Kanagawa;

Department of Gastroenterology, Osaka City Sumiyoshi Hospitsal, Osaka;

Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and PharmaceuticalSciences, Okayama;

Department of Gastroenterology, Tohoku University School of Medicine, Miyagi;

Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical College, Hokkaido;

Department of Gastroenterology, Kitasato University East Hospital, Kanagawa;

Department of Gastroenterology, Nagoya University Graduate School of Medicine, Aichi;

Department of Gastroenterology, Aichi Medical University School of Medicine, Aichi;

Department of Gastroenterology and Hepatology, Jikei University School of Medicine, Tokyo;

Department of Gastroenterology, Osaka General Hospital of West Japan Railway Company, Osaka;

Department of Gastroenterology, Nagoya City University Hospital, Aichi;

Department of Inflammatory Bowel Disease, Yokohama Municipal Citizens Hostipal, Kanagawa;

Department of Internal Medicine, Social insurance Central General Hospital, Tokyo;

Department of Endoscopy Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima;

Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto;

Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Science, Kagoshima;

Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma;

Center for Gastroenterology and Inflammatory Bowel Disease Research, Hamamatsu South Hospital, Shizuoka;

Third Department of Internal Medicine, Nara Medical University, Nara;

Department of Medicine, Shiga University of Medical Scinence, Shiga;

Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka;

Division of Lower Gastroenterology, Hyogo College of Medicine, Hyogo;

Department of Internal Medicine, National Defense Medical College, Saitama;

Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka;

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo;

IBD Center, Sapporo Kosei General Hospital, Hokkaido;

Department of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka;

Department of Pediatrics, Osaka Medical College, Osaka;

Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka;

Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo

96 J Gastroenterol (2014) 49:9399

123

CD from other diseases can be difficult in patients pre-

senting with these findings. General practitioners would

sometimes be unable to diagnose CD based on perianal

lesions, which should be examined by a proctologist

familiar with CD. The somewhat low biopsy-based detec-

tion rate of NCEG (26.3 %) identified in the survey is

likely another reason.

Several facilities and guidelines in the United States and

Europe have proposed diagnostic criteria, many of which

are composed of clinical symptoms and image-based,

surgical, and histopathological findings [3, 2330]. The

European Crohns and Colitis Organisation (ECCO) [3]

Table 3 Clinical characteristics of a definitive diagnosis of CD(n = 579)

Male/female 459/120

Age (mean SD, years) 27.8 13.7

Period from initial visit to diagnosis (mean SD,

months)

3.1 10.0

Clinical manifestations

Abdominal pain 414

Diarrhea 366

Weight loss 201

Fever 189

Perianal disease 167

Intestinal obstruction 32

Intestinal perforation 14

Bleeding 19

Arthritis 19

Asymptomatic 14

Fistulas 10

Extent of lesions

Ileal type 153

Colonic type 121

Ileocolonic type 305

Isolated upper disease 115

SD standard deviation

Table 6 Clinical characteristics of a suspected diagnosis of CD(n = 59)

Male/female 37/22

Age (mean SD, years) 36.3 18.6

Duration of suspected diagnosis of CD

(mean SD, months)

22.2 17.7

Clinical manifestations

Abdominal pain 41

Diarrhea 35

Intestinal obstruction 8

Fever 7

Weight loss 5

Bleeding 5

Perianal disease 2

Fistulas 1

Asymptomatic 1

Extent of lesions

Ileal type 20

Colonic type 25

Ileocolonic type 13

Isolated upper disease 1

SD standard deviation

Table 5 Morphological and pathological examinations to make adefinitive diagnosis of CD

Endoscopy

(n = 512)

Radiography

(n = 346)

Biopsy

(n = 152)

Resected

specimen

(n = 46)

Upper

gastrointestinal

tract

115 5 10 0

Small intestine 161 311 46 38

Colon 416 67 116 18

Table 4 Particular criteria used to make a definite diagnosis(n = 579)

Definite 1

Major finding A or B 506/579 (87.4 %)

A 473/579 (81.7 %)

B 238/579 (41.1 %)

Definite 2

Major finding C with minor finding a or b 176/579 (30.4 %)

C ? a 148/579 (25.6 %)

C ? b 71/579 (12.3 %)

Definite 3

All minor findings a, b and c 41/579 (7.1 %)

Table 7 Particular criteria used to make a suspected diagnosis(n = 59)

Suspected 1 Major finding C

with minor finding c

0/59 (0 %)

Suspected 2 Major finding A or B,

but cannot be differentiated

from ischemic colitis

or ulcerative colitis

10/59 (16.9 %)

A 9/59 (15.3 %)

B 1/59 (1.7 %)

Suspected 3 Major finding C only 8/59 (13.6 %)

Suspected 4 One or two minor findings 44/59 (74.6 %)

a 40/59 (67.8 %)

b 2/59 (3.4 %)

c 6/59 (10.2 %)

J Gastroenterol (2014) 49:9399 97

123

offers guidelines for managing CD. These guidelines state,

a single gold standard for the diagnosis of CD is not

available. The diagnosis is confirmed by clinical evaluation

and a combination of endoscopic, histological, radiologi-

cal, and/or biochemical investigations.

As has been described, the Japanese diagnostic criteria

for CD consist of several combinations of specifically

defined morphological findings. The Japanese diagnostic

criteria differ from the criteria used in the United States

and Europe in that a definitive diagnosis of CD is made

based on findings of LU and CSA, which are defined in

detail, and in that aphthous lesions are defined for defini-

tive diagnosis of CD. Patients benefit enormously when the

disease can be diagnosed soon after onset based on aph-

thous lesions. CD is relatively easily diagnosed when

classical morphological findings are present. CD, however,

is difficult to differentiate from other diseases when only

early findings or non-classical findings are present [3133],

and a substantial number of CD cases do not satisfy the

diagnostic criteria. The suspected category in the Japanese

diagnostic criteria was included for just such cases, which

are definitively diagnosed only after repeated observations.

CD with aphthous lesions alone is particularly difficult to

identify. An early indicator of CD, aphthous lesions

develop into LU and other classical findings in some

patients [3436]. However, no diagnosis can be made

based on aphthous lesions alone, because these nonspecific

findings also appear in infectious enterocolitis, intestinal

Behcets disease, and other related conditions. CD can be

definitively diagnosed under the Japanese criteria by

demonstrating NCEG with aphtha or by identifying all

three minor findings. The fact that 67.8 % of suspected

cases in the survey could not be differentiated from other

diseases because of the presence of only irregular-shaped

and/or quasi-circular ulcers or aphthous ulcerations found

extensively in the gastrointestinal tract indicates just how

difficult reaching a diagnosis can be.

In conclusion, in addition to short-term care, Crohns

disease requires a well-formulated, long-term treatment

plan to be properly managed. Early, accurate identification

of the disease and proper characterization of its manifes-

tations are critical parts of such plans. Our survey indicates

that the majority of CD diagnoses made in Japan are based

on the classical finding of LU or CSA, representing an

appropriate rationale. CD, however, remains underdiag-

nosed based on aphthous lesions and NCEG found in

biopsy.

Acknowledgments This work was supported by Health and LabourSciences Research Grants for Research on Intractable Disease from

the Ministry of Health, Labour and Welfare of Japan.

Conflict of interest Toshiyuki Matsui received research grants fromEisai Co., Ltd., Mitsubishi Tanabe Pharma Co., Ajinomoto Pharma-

ceuticals Co., Ltd., Zeria Pharmaceutical Co., Ltd., Kyorin Pharma-

ceutical Co., Ltd., JIMRO Co., Ltd., Astellas Pharma Inc.; received

lecture fees from Eisai Co., Ltd. Mamoru Watanabe received research

grants from abbvie.co.jp., Astellas Pharma Inc., Asahi Kasei Kuraray

Medical Co., Ltd, Ajinomoto Pharma Co., Ltd, Chugai Pharmaceu-

tical Co., Ltd, DAIICHI SANKYO CO., LTD, Eisai Co., Ltd, Kyowa

Hakko Kirin Co., Ltd, Kyorin Pharmaceutical Co. Ltd, JIMRO

Co.Ltd, Mitsubishi Tanabe Pharma Corporation, MSD K.K., Otsuka

Pharma Co., Ltd, Takeda Pharmaceutical Co., Ltd, UCB Japan Co.,

Ltd, and Zeria Pharmaceutical Co., Ltd. Takashi Hisabe and Fumihito

Hirai have no conflict of interest.

Appendix: Contributors in the development

of the diagnostic criteria for Crohns disease in Japan

(the Research Group of Intractable Inflammatory

Bowel Disease granted by the Ministry of Health,

Labour and Welfare of Japan)

Toshiyuki Matsui (Chair); Department of Gastroenterol-

ogy, Fukuoka University Chikushi Hospital, Chikushino,

Japan

Takayuki Matsumoto; Department of Medicine and

Clinical Science, Graduate School of Medical Science,

Kyushu University, Fukuoka, Japan

Yasuo Suzuki; Department of Gastroenterology, Toho

University Sakura Medical Center, Sakura, Japan

Shinji Tanaka; Department of Endoscopy, Hiroshima

University Hospital, Hiroshima, Japan

Hiroyuki Hanai; Center for Gastroenterology and

Inflammatory Bowel Disease Research, Hamamatsu South

Hospital, Hamamatsu, Japan

Nobuo Hiwatashi; Department of Gastroenterology,

Iwaki Kyoritsu Hospital, Iwaki, Japan

Nagamu Inoue; Division of Gastorenterology and

Hepatology, Department of Internal Medicine, Keio Uni-

versity School of Medicine, Tokyo, Japan

Ichiro Hirata; Department of Gastroenterology, Fujita

Health University, Toyoake, Japan

Fumihito Hirai; Department of Gastroenterology, Fu-

kuoka University Chikushi Hospital, Chikushino, Japan

Kiyonori Kobayashi; Department of Gastroenterology,

Kitasato University East Hospital, Sagamihara, Japan

Nobuhide Oshitani; Department of Gastroenterology,

Osaka City University Graduate School of Medicine,

Osaka, Japan

Toshifumi Ashida; Center for Inflammatory Bowel

Disease, Sapporo Higashi Tokushukai Hospital, Sapporo,

Japan

Toshiaki Watanabe; Department of Surgical Oncology

and Vascular Surgery, University of Tokyo, Tokyo, Japan

Hisao Fujii; Department of Surgery, Nara Medical

University, Kashihara, Japan

Akira Sugita; Department of Inflammatory bowel disease,

Yokohama Municipal Citizens Hostipal, Yokohama, Japan

98 J Gastroenterol (2014) 49:9399

123

Akinori Iwashita; Department of Pathology, Fukuoka

University Chikushi Hospital, Chikushino, Japan

Yoichi Ajioka; Division of Molecular and Diagnostic

Pathology, Niigata University Graduate School of Medical

and Dental Sciences, Niigata, Japan

Masanori Tanaka; Department of Pathology and Labo-

ratory Medicine, Hirosaki Municipal Hospital, Hirosaki,

Japan

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Evaluation of diagnostic criteria for Crohns disease in JapanAbstractBackgroundMethodsResultsConclusions

IntroductionMethodsResultsDefinite cases of CDSuspected cases of CD

DiscussionAcknowledgmentsAppendix: Contributors in the development of the diagnostic criteria for Crohns disease in Japan (the Research Group of Intractable Inflammatory Bowel Disease granted by the Ministry of Health, Labour and Welfare of Japan)References