Case 1

submitted by:
Shari Taylor
GI Pathology Partners, PC
Memphis, Tennessee

Clinical Summary:

A 20-year-old man presented to his gastroenterologist with progressive dysphagia. At endoscopy, a short distal esophageal stricture was noted, which was dilated. In addition, the endoscopist noted an "atypical" esophagitis in the proximal esophagus, with an endoscopic appearance concerning for candidal esophagitis. Biopsies were obtained from both proximal and distal esophagus.

Case 1 - Figure 1 - Low power view of eosinophilic esophagitis. The squamous mucosa is hyperplastic and there is an adherent inflammatory "pseudomembrane".

Case 1 - Figure 2 - Eosinophilic esophagitis. The squamous mucosa is infiltrated by numerous eosinophils with a predilection for the superficial half of the mucosa. The "pseudomembrane" is composed of numerous eosinophils within parakeratotic debris.

Case 2

submitted by:
Barbara McKenna
University of Michigan
Ann Arbor, Michigan

Clinical Summary:

A 40-year-old woman presented with epigastric pain. CT scan of abdomen showed a small distal gastric mural nodule, suspicious for neoplasm. The patient underwent a partial gastrectomy. A 1.5 cm tan, well-circumscribed subserosal nodule was present on the distal gastric wall.

Case 2 - Figure 1 - A large pancreatic-type duct is surrounded by fibrous tissue in the muscular wall of the stomach.

Case 2 - Figure 2 - Lobular arrangements of mucous glands are also present between muscle bundles of the muscularis propria.

Case 2 - Figure 3 - Muscle tends to wrap around the glandular structures.

Case 2 - Figure 4 - Round nests of endocrine cells identical to normal pancreatic islets are scattered in the interstitium of the muscularis propria.

Case 3

submitted by:
Susan Abraham
Mayo Clinic
Rochester, Minnesota

Clinical Summary:

A 54-year-old Caucasian woman was referred for upper endoscopic examination because of early satiety and midepigastric pain. Endoscopic examination revealed thickened gastric folds and multiple polypoid lesions in the gastric body and fundus, which were biopsied. Serologic workup showed markedly elevated serum levels of chromogranin A (1500 pg/mL; normal <14 pg/mL) and gastrin (1400 pg/mL; normal <75 pg/mL). Based on this endoscopic appearance, laboratory work-up, and the biopsy results, she underwent subtotal gastrectomy with antrectomy. Slides from the thickened folds and nodules in the gastric body are shown.

Case 3 - Figure 1 - Gross image of the subtotal gastrectomy specimen demonstrating thickened rugal folds and several polypoid nodules in the gastric body, ranging up to 1.3 cm in diameter.

Case 3 - Figure 2 - Low power photomicrograph of one of the polyps in the body mucosa, showing a carcinoid tumor, with invasion into the superficial submucosa.

Case 3 - Figure 3 - High power photomicrograph of the carcinoid tumor, here showing a pseudoacinar architecture and the uniform neoplastic cells characteristic of carcinoid tumors.

Case 3 - Figure 4 - Low power photomicrograph of the thickened body mucosa, which demonstrates marked hyperplasia and dilatation of the specialized oxyntic (fundic) glands. The overlying foveolar neck regions and surface epithelium are of normal thickness.

Case 3 - Figure 5 - In many areas of body mucosa, the parietal cells were cytologically abnormal, with vacuolated cytoplasm and cytoplasmic protrusions into dilated oxyntic glands.

Case 3 - Figure 6 - The carcinoid tumors arose in a background of nodular neuroendocrine (ECL cell) hyperplasia, which is evident here at the base of the gastric body mucosa.

Case 4

submitted by:
Laura Lamps
University of Arkansas for Medical Sciences
Little Rock, Arkansas

Clinical Summary:

A 53-year-old man presented with a several month history of fatigue and vague abdominal pain. Laboratory evaluation revealed mild anemia but no other abnormalities in his complete blood count or electrolyte studies. The patient subsequently presented with massive upper gastrointestinal bleeding. Endoscopy revealed bleeding from multiple ulcerated sites in the gastric mucosa. No masses were seen. An emergent subtotal gastrectomy was performed to control the bleeding. Images submitted are from the subtotal gastrectomy specimen.

Case 4 - Figure 1 - Low power view of section from gastric resection shows diffuse, extensive infiltration of the submucosa by amyloid.

Case 4 - Figure 2 - Higher power view shows extensive perivascular amyloid deposition with associated hemorrhage.

Case 4 - Figure 3 - Amyloid appears as an amorphous, waxy, eosinophilic material on H&E staining (3A)...

Case 4 - Figure 4 - ...and upon Congo red staining has a red/green birefringent appearance under polarized light (3B).

Case 5

submitted by:
Henry Appelman
University of Michigan
Ann Arbor, Michigan

Clinical Summary:

4 years ago, this teenager had a terminal ileal and right colonic resection with an ileostomy for a traumatic perforation. Except for the acute perforation, the resected colon and ileum were normal. The rest of the colon from the hepatic flexure through the rectum was left in place as a diverted segment. About 3 ½ years later, occasional stool drainage from the rectum began, and this lasted for about 6 months up to the present. Recently, there has been some blood spotting superimposed on the drainage. A colonoscopic exam was performed, but the endoscopist did not see any abnormalities. The whole colon and rectum were resected about 6 weeks after the colonoscopy. The reason for this resection is not important for this presentation. In the resected specimen, there were numerous small mucosal nodules scattered throughout. In addition, there were several small partial strictures due to mural thickening and some of these had small ulcers which tended to be situated over the points where the vessels penetrate the wall. In this slide, there are 2 sections of the colon. Figure 1 contains several of the small gross mucosal nodules. The other three figures are from one of the strictures.

Case 5 - Figure 1 - Most of the colon looked like this. There was prominent lymphoid hyperplasia at the mucosal-submucosal junction. Some follicles contained small granulomas, and some had small foci of mucosal inflammation including tiny ulcers, in other words, aphthous lesions.

Case 5 - Figure 2 - Superimposed on the features in the first slide, there were segments of transmural inflammation with ulcers, some of which were fissure ulcers. The inflammation obliterated the submucosa, extended through the muscularis propria, involved the pericolic adipose tissue and produced strictures. Loose granulomas were present from the submucosa through the pericolic adipose tissue.

Case 5 - Figure 3 - In the submucosa of these strictures, there were numerous lymphocytic aggregates.

Case 5 - Figure 4 - In some places, numerous large loose granulomas almost filled the submucosa.