A PRACTICAL APPROACH TO GASTROINTESTINAL PATHOLOGY

Course Directors: JOHN R. GOLDBLUM, M.D. Staff, Department of Anatomic Pathology The Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44195 Phone: (216) 444-8238 Fax: (216) 445-6967 ROBERT E. PETRAS, M.D. Director of Gastrointestinal Pathologic Services AmeriPath Incorporated 7730 First Place, Suite A Oakwood Village, Ohio 44146 Phone: (440) 703-2100 Fax: (440) 703-2155 Clinical histories are printed below. Click on the case numbers for text and references of each case. Click on the slide images for a larger view of each slide. Interpretation of Colonic Biopsy Specimens in Patients Suspected of Having Inflammatory Bowel Disease, Collagenous Colitis and Lymphocytic ("Microscopic") Colitis, Mucosal Prolapse Syndromes Case 1 - Diffuse Active Colitis Consistent with Ulcerative Colitis 35-year-old woman with bloody diarrhea. Endoscopically, the mucosa from the rectum to the transverse colon appeared erythematous and granular. This biopsy specimen is from the splenic flexure. Case 1 - Diffuse Active Colitis Consistent with Ulcerative Colitis Case 1 - Diffuse Active Colitis Consistent with Ulcerative Colitis Case 2 - Focal Active Colitis Suggestive of Infectious-type Colitis 22-year-old man with crampy abdominal pain and rectal bleeding. Endoscopically, the mucosa showed focal erythema, but was otherwise unremarkable. These specimens come from the descending colon. Case 2 - Focal Active Colitis Suggestive of Infectious-type Colitis Case 2 - Focal Active Colitis Suggestive of Infectious-type Colitis Case 3 - Collagenous Colitis 56-year-old woman who presented with watery diarrhea of six months' duration. Endoscopic examination was unremarkable. These biopsy specimens are from the ascending colon. Case 3 - Collagenous Colitis Case 3 - Collagenous Colitis Case 3 - Collagenous Colitis Case 4 - Solitary Rectal Ulcer Syndrome 35-year-old woman with abdominal pain, constipation and rectal bleeding. Endoscopically, a polypoid, erythematous lesion was seen on the anterior rectal wall. This biopsy specimen was obtained from this polypoid lesion. Case 4 - Solitary Rectal Ulcer Syndrome Case 4 - Solitary Rectal Ulcer Syndrome Ulcerative Colitis, Dysplasia and Carcinoma Case 5 - Chronic Ulcerative Colitis. High Grade Epithelial Dysplasia 55-year-old man with a 9-year history of ulcerative colitis. Prior biopsies have shown this patient's colitis to extend to the mid-transverse colon. Due to the duration and extent of this patient's colitis, he was placed into a colonoscopic surveillance program. These specimens were obtained from the rectum. Case 5 - Chronic Ulcerative Colitis - High Grade Epithelial Dysplasia Case 5 - Chronic Ulcerative Colitis - High Grade Epithelial Dysplasia Case 5 - Chronic Ulcerative Colitis - High Grade Epithelial Dysplasia Barrett's Esophagus Case 6 - Intestinal Metaplasia of the Gastric Cardia, Probably Secondary to H. Pylori-related Multifocal Atrophic Gastritis 46-year-old woman with epigastric discomfort. An esophagogastroduodenoscopy was performed and biopsies were obtained from the gastric antrum and esophagogastric junction. This biopsy specimen comes from the esophagogastric junction. Case 6 - Intestinal Metaplasia of the Gastric Cardia, Probably Secondary to H. Pylori-related Multifocal Atrophic Gastritis Case 6 - Intestinal Metaplasia of the Gastric Cardia, Probably Secondary to H. Pylori-related Multifocal Atrophic Gastritis. Stain is alcian blue at pH 2.5. Case 7 - Specialized Columnar Epithelium Consistent with Barrett's Esophagus and High Grade Epithelial Dysplasia 60-year-old male with pyrosis. The patient had been treating himself with antacids for over 10 years. Endoscopically, a hiatal hernia was identified. The esophagogastric junction was estimated to be at 39 cm, and these biopsy specimens come from the esophagus, 37 cm from the incisions. Case 7 - Specialized Columnar Epithelium Consistent with Barrett's Esophagus and High Grade Epithelial Dysplasia Case 7 - Specialized Columnar Epithelium Consistent with Barrett's Esophagus and High Grade Epithelial Dysplasia Case 7 - Specialized Columnar Epithelium Consistent with Barrett's Esophagus and High Grade Epithelial Dysplasia Small Bowel Biopsy: Interpretation and Specimen Handling Case 8 - Lymphocytic Enterocolitis 40-year-old woman with chronic watery diarrhea, weight loss and an endoscopically normal-appearing colon. Colonoscopic biopsies revealed a marked epithelial lymphocytosis and the absence of thickening of the subepithelial collagen plate. This specimen, a small bowel biopsy, was performed at the same time as the colonic biopsies. The patient's symptoms did not improve with dietary Gluten withdrawal. Case 8 - Lymphocytic Enterocolitis Case 8 - Lymphocytic Enterocolitis Case 9 - Nodular Lymphoid Hyperplasia with Changes Consistent with Common Variable Immune Deficiency Syndrome - Giardiasis 47-year-old woman with diarrhea. Small bowel biopsy specimen. Case 9 - Nodular Lymphoid Hyperplasia with Changes Consistent with Common Variable Immune Deficiency Syndrome - Giardiasis Case 9 - Nodular Lymphoid Hyperplasia with Changes Consistent with Common Variable Immune Deficiency Syndrome - Giardiasis Case 9 - Nodular Lymphoid Hyperplasia with Changes Consistent with Common Variable Immune Deficiency Syndrome - Giardiasis Adenomas and Malignant Colorectal Polyps Case 10 - Invasive Moderately Differentiated Adenocarcinoma Arising in Association with a Tubular Adenoma 57-year-old man with a semi-pedunculated polyp of sigmoid colon. A. What should appear in your pathology report~ B. What is your recommendation regarding further therapy~ Case 10 - Invasive Moderately Differentiated Adenocarcinoma Arising in Association with a Tubular Adenoma Case 10 - Invasive Moderately Differentiated Adenocarcinoma Arising in Association with a Tubular Adenoma Case 10 - Invasive Moderately Differentiated Adenocarcinoma Arising in Association with a Tubular Adenoma A. Invasive Moderately Differentiated Adenocarcinoma Arising in Association with a Tubular Adenoma Comment: The margin of resection is visualized and is free of neoplasm (>2 mm from margin). B. Since this malignant polyp falls into our Favorable Histology Group, we would recommend no further Therapy. Gastrointestinal Stromal Tumors of the Stomach and Small Bowel Case 11 - Benign Spindle - Cell GIST (Cellular Leiomyoma) 65-year-old man with a 4.5 cm well-circumscribed mass of the gastric antrum. The overlying mucosa was intact. This is a representative section from the resection specimen. Case 11 - Benign Spindle - Cell GIST (Cellular Leiomyoma) Case 11 - Benign Spindle - Cell GIST (Cellular Leiomyoma) Case 11 - Benign Spindle - Cell GIST (Cellular Leiomyoma) Case 12 - Malignant Spindle - Cell GIST (Leiomyosarcoma) 50-year-old man with vague abdominal pain and lower gastrointestinal bleeding. The patient was subsequently found to have a 6 cm mass of the jejunum with focal ulceration of the overlying mucosa. This is a representative section from the resection specimen. Case 12 - Malignant Spindle - Cell GIST (Leiomyosarcoma) Case 12 - Malignant Spindle - Cell GIST (Leiomyosarcoma) Opinions stated and/or conclusions reached in this syllabus are the responsibility of the authors and are not necessarily endorsed by the Academy.