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Gastrointestinal Pathology
Wednesday, March 2, 2005 - 7:30 PM
Convention Center Ballroom B
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Moderator:
Joel K. Greenson
University of Michigan Medical School
Ann Arbor, MI
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Clinical histories are printed below.
Click on the case numbers for text and references of each case.
Click on each slide thumbnail image for an enlarged view
Submitted by:
Susan C. Abraham
Mayo Clinic
Rochester, MN
This 36-year-old man was in excellent health until 5 ½ months before the small bowel biopsy was taken.
He initially presented with boring epigastric pain and was found to have biochemical evidence of
pancreatitis, which required prolonged hospitalization. At the same time he began to pass massive
amounts of stool – up to 12 L/day. The diarrhea continued with fasting and ultimately led to a 45-pound
weight loss, necessitating TPN.
At the time of his presentation to Mayo Clinic, he had already undergone several small bowel biopsies
with negative evaluations for lymphoma including negative molecular studies for clonal T-cell receptor
gene rearrangements.
24-hour stool collection resulted in more than 8 kg stool and 97 g fat (normal, 2-7 g/24 hrs). Stool
studies for cryptosporidium and other parasites were negative. Laboratory workup was notable for a
mildly elevated ANA titer of 2.1 U (normal, <1.0 U). Celiac serology including IgA tissue
transglutaminase level was negative, and HLA typing was inconsistent with celiac disease. Moreover, the
patient had attempted a gluten-free diet over a 2-month period without relief of his symptoms. Workup
for immunodeficiency was negative, including negative HIV serologies and normal immunoglobulin levels for
IgG (including normal IgG subclasses), IgA, and IgM.
Upper endoscopy was repeated at Mayo Clinic and the endoscopic appearance of the duodenum and stomach
was normal. Abdominal CT scan was notable only for mild mesenteric lymphadenopathy. Because of the
concern for small bowel lymphoma and because of the unrevealing workup for the etiology of the patient's
severe diarrhea, a decision was made to pursue full-thickness small bowel biopsy. The section shown is
taken from the full-thickness jejunal biopsy, which was obtained laparoscopically.
Case 1 - Figure 1 - Jejunal biopsy shows marked villous blunting and intense mucosal inflammation.
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Case 1 - Figure 2 - Scattered crypt abscesses are present.
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Case 1 - Figure 3 - Crypt bases are lifted from the muscularis mucosa by a dense band of chronic inflammation including lymphocytes, plasma cells, and eosinophils. Crypts lack goblet cells and Paneth cells and are replaced in many foci by areas of pseudopyloric metaplasia.
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Case 1 - Figure 4 - Some crypts (e.g., at center) show features resembling graft-vs.-host disease, with increased numbers of apoptotic bodies and infiltration of crypt epithelium by lymphocytes.
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Case 1 - Figure 5 - The surface epithelium is severely injured, with a disorganized appearance. The degree of surface intra-epithelial lymphocytosis (in contrast to celiac disease) is quite mild.
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Case 1 - Figure 6 - Low power view of the full-thickness small bowel biopsy highlights a complete lack of transmural inflammation.
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Submitted by:
John A. Hart
University of Chicago Hospitals
Chicago, IL
This 43-year-old male presented with an acute abdomen and underwent an exploratory laparotomy,
revealing a colonic perforation. An ileocecectomy was performed. [Case courtesy of Dr. Hong Chen, St.
Mary's Hospital, Centralia, IL]
Case 2 - Figure 1 - Low power view demonstrating mucosa ischemia and submucosa edema.
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Case 2 - Figure 2 - Medium power view reveal mucosal ischemia and active vasculitis involving small submucosal vessels
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Case 2 - Figure 3 - Small artery with active vasculitis, partially occluded by thrombus.
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Case 2 - Figure 4 - Higher power view of small vessel as in Figure 3, highlighting the inflammatory cell infiltration of the wall.
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Case 2 - Figure 5 - Adjacent small arteries demonstrating the patchy nature of involvement by the vasculitic process.
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Case 2 - Figure 6 - High power view showing the extravascular inflammatory cell infiltrates.
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Submitted by:
Laura W. Lamps
University of Arkansas for Medical Sciences
Little Rock, AR
A 39 year old man presented to the Emergency Department with a two day history of severe, crampy
abdominal pain accompanied by nausea and vomiting. The patient was reportedly writhing, moaning, and
yelling due to the pain. There was no significant past medical history except for mild asthma, and there
was no past history of intra-abdominal surgery. Review of systems indicated intermittent abdominal pain
and diarrhea in the past, but no fever, chills, weight loss, or vomiting. Social history was significant
for extensive methamphetamine use. Physical examination revealed a soft, distended, diffusely tender
abdomen with decreased bowel sounds; there were no masses, rebound effect, or point tenderness.
Laboratory evaluation was significant for an elevated white blood cell count of 12,000 with increased
eosinophils. All other labs were unremarkable. Abdominal xrays showed multiple air-fluid levels, and CT
scan showed a small bowel obstruction. The patient was taken to surgery for exploratory laparotomy,
which revealed a segment of dilated and thickened jejunum associated with a small amount of ascitic fluid
and adhesions to adjacent loops of bowel. The abnormal segment of small intestine was resected.
Case 3 - Figure 1 - Low power view of a section of jejunum shows a dense eosinophilic infiltrate involving all layers of the bowel wall.
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Case 3 - Figure 2 - The lamina propria contains a predominantly eosinophilic infiltrate, with focal infiltration of small bowel epithelium.
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Case 3 - Figure 3 - The eosinophilic infiltrate percolates between muscle bundles in the muscularis propria.
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Case 3 - Figure 4 - The serosa of the small bowel is involved by a striking eosinophilic infiltrate, and there was associated eosinophilic ascites.
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Submitted by:
Christine M. Hobbs
Centennial Medical Center
Nashville, TN
A 77-year-old man presented to his primary care physician (PCP) with a recent increase in chest pain.
The patient had a several year history of gastroesophageal reflux disease and was currently being treated
with a proton pump inhibitor. The patient's last esophagogastroduodenoscopy, performed three years
previously, showed "histologic changes consistent with reflux esophagitis; negative for intestinal
metaplasia." After the patient underwent testing essentially excluding a cardiac etiology, his PCP
referred him to a gastroenterologist for repeat upper endoscopy. At endoscopy, 12 polyps were found
along the greater curvature and anterior wall of the gastric body. These polyps ranged in size from 3 mm
to 10 mm. The gastric mucosa otherwise appeared unremarkable as did the esophagus and gastroesophageal
junction. The images show one of the gastric polyps and the glass slide shows a few of the polyps.
Submitted by:
Henry D. Appelman
University of Michigan Medical School
Ann Arbor, MI
This is a middle aged adult of either sex, who has suffered from chronic dyspepsia for several years,
and the symptoms have gradually worsened. So, he/she went to his/her family doctor who prescribed a PPI.
When this failed to control the symptoms, he/she was referred to a gastroenterologist who performed an
upper endoscopy, during which an erythematous GE junction was noticed, an enticement for biopsies. What
about these biopsies must be mentioned in the diagnosis that has unequivocal clinical significance?
Case 5 - Figure 1 - The biopsy at 10x: columnar mucosa with pits, expanded lamina propria and different gland types
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Case 5 - Figure 2 - Higher power of the cellular lamina propria
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