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Click on each Case number below to display the text and references for that section
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Introduction
Classically, we have divided the inflammatory bowel diseases into chronic and acute forms, with
ulcerative colitis and Crohn's disease predominantly comprising the chronic category. However,
pathobiology rarely conforms to our attempts at neat categorization. Numerous other forms of chronic
colitis have been described, such as collagenous colitis and lymphocytic colitis; in addition, we now
recognize an increasing number of variations of ischemic colitis and drug or chemical-related colitis.
This course will address some the so-called "atypical" colitides, that is, forms of colitis other
than ulcerative colitis or Crohn's, often lacking constitutional symptoms, and often with nonspecific
laboratory data. In addition, some variants of ischemic and drug/chemical-related colitis will be
addressed, as will examples of interesting infectious diseases and changing patterns of distrubution in
ulcerative colitis.
General Approach to Evaluation of Intestinal Mucosal Biopsies for Inflammatory
Disease
The "question-oriented approach" to inflammatory bowel diseases can facilitate both our diagnostic
endeavors and our ability to communicate with our gastroenterology colleagues. Unless the following
questions are answered in the course of the evaluation of a colonic mucosal biopsy, our interpretations
may be limited, if not downright wrong. The responsibility is born equally between the
gastroenterologist and the pathologist to pose and answer these questions:
1. Why was the biopsy done? [diagnosis, response to therapy, dysplasia
surveillance, etc.]
2. What are the duration and nature of the patient's symptoms? [weeks,
months, bloody diarrhea, watery diarrhea]
3. From where EXACTLY in the bowel is the biopsy taken?
4. What were the endoscopic findings?
Following this exercise, our goals should be to:
- Provide a useful, reproducible diagnostic report
- Provide feedback regarding adequacy and artifacts [e.g. cautery, size of biopsy, etc.]
- Be aware of the clinical implications of our diagnosis
- Choose direct communication over "clinical correlation recommended."
These rectal biopsies are from a 38 year old man with Crohn's disease, status post resection of his terminal ileum and right colon. He has an ileostomy and a Hartmann's pouch.
Case 1 - Figure 1 - Low magnification view showing superficial mucosal erosion and prominent mucosal lymphoid aggregates, yet no significant architectural distortion.
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Case 1 - Figure 2 - Higher magnification of the prominent lymphoid aggregates typical of diversion colitis. Although some cases of diversion colitis have cryptitis and crypt abscesses, this case does not.
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These biopsies are from the sigmoid colon of a 67 year old man with abdominal pain and occasional diarrhea.
Case 2 - Figure 1 - Note expansion of the lamina propria by a lymphoplasmacytic infiltrate, and moderate architectural distortion, resembling ulcerative colitis.
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Case 2 - Figure 2 - Note expansion of the lamina propria by a lymphoplasmacytic infiltrate, and moderate architectural distortion, resembling ulcerative colitis.
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Case 2 - Figure 3 - Cryptitis and prominent lymphoid aggregates may be present.
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This 47 year old woman had an eight month history of diarrhea, nausea, vomiting, and peripheral eosinophilia of 11%.
Case 3 - Figure 1 - Low magnification shows thickened subepithelial collagen band as well as a mixed inflammatory infiltrate within the lamina propria and epithelium.
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Case 3 - Figure 2 - Higher magnification highlights the inflammatory infiltrate typical of collagenous colitis, sometimes including increased eosinophils.
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This 54 year old Jewish physician underwent screening colonoscopy for
polyps.
Case 4 - Figure 1 - Low magnification of ileal biopsy shows superficial mucosal ulceration, mild villous blunting, and prominent lymphoid aggregates. Prominent lymphoid aggregates are normally present within ileal mucosa, but may confound the histologic evaluation of inflammatory processes.
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Case 4 - Figure 2 - Higher magnification shows villous edema and mixed inflammatory infiltrate in lamina propria, features that may be seen in the context of NSAID-related injury.
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This 74 year old man was status post right lung lobectomy, with acute decompensation on post-operative day 4.
Case 5 - Figure 1 - Mucosal and submucosal necrosis with the resin crystals typical of kayexelate induced bowel necrosis.
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Case 5 - Figure 2 - Mucosal and submucosal necrosis with the resin crystals typical of kayexelate induced bowel necrosis.
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This 22 year old woman presented with diarrhea, occasionally alternating with constipation, and bleeding per rectum.
Case 6 - Figure 1 - Low magnification view shows prolapse polyp with mushroom-like cap of fibrinopurulent exudates.
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Case 6 - Figure 2 - Architectural distortion, crypt abscesses, and reactive epithelial atypia within a prolapse polyp, accompanied by marked hemosiderin deposition.
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Case 6 - Figure 3 - Higher magnification emphasizes congested capillaries within lamina propria, as well as hypertrophic muscularis mucosa extending into the mucosa in a perpendicular fashion.
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This 38 year old female presented with hematochezia.
Case 7 - Figure 1 - Low magnification shows superficial mucosal erosion and hemorrhage, accompanied by gland withering and marked lamina propria fibrosis.
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Case 7 - Figure 2 - High magnification emphasizes gland withering and lamina propria fibrosis.
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This case is a compilation of features from two patients. In the first case a 24 year old man presented with diarrhea and abdominal pain. The second case is that of a 50 year old man with abdominal pain and fever.
Case 8 - Figure 1 - Note expansion of lamina propria by inflammatory infiltrate and mucosal edema at low magnification, yet preservation of architecture.
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Case 8 - Figure 2 - Higher magnification shows prominent neutrophils within the lamina propria, particularly within the upper half of the mucosa; there is also focal cryptitis. These features are typical of the "acute self-limited colitis" pattern of inflammation.
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Case 8 - Figure 3 - Marked lymphoid hyperplasia and epithelioid granulomas with giant cells are seen in this right colon section.
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Case 8 - Figure 4 - Higher magnification shows cryptitis, crypt abscesses, and mild architectural distortion.
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This case represents a 66 year old woman who had chronic lymphocytic leukemia. She presented with diarrhea and occasional fever.
Case 9 - Figure 1 - Low magnification of this colon biopsy shows a mild lymphohistiocytic infiltrate within the mucosa and submucosa, focally. Note absence of discrete granulomas.
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Case 9 - Figure 2 - GMS stain shows clusters of intracellular yeast forms within the mucosa and superficial submucosa.
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Case 9 - Figure 3 - High magnification of GMS stain shows that the organisms are small and ovoid with a point at one end, consistent with Histoplasma capsulatum.
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A 20 year old female underwent a subtotal colectomy with ileostomy for ulcerative colitis three years ago. Nine months after surgery, the patient became symptomatic again, prompting evaluation.
Case 10 - Figure 1 - Low magnification shows moderate blunting of duodenal villi and expansion of the lamina propria by a lymphoplasmacytic infiltrate.
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Case 10 - Figure 2 - Higher magnification emphasizes architectural distortion of the duodenal glands, and the dense lymphoplasmacytic infiltrate.
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Case 10 - Figure 3 - Focal cryptitis, crypt abscesses, and gland loss are noted.
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