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Gastrointestinal Pathology
Tuesday, February 14, 2006 - 7:30 PM
Centennial Ballroom II - IV
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Moderator:
Joel K. Greenson
University of Michigan Medical School
Ann Arbor, MI
Disclosure: The speakers have indicated they have nothing to disclose.
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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:
John R. Goldblum
Cleveland Clinic
Cleveland, OH
63-year-old male with a long history of "heartburn." Eventually, the patient underwent an EGD and was found to have a 4-cm length of columnar-lined esophagus. Four-quadrant biopsy specimens were obtained for every cm of columnar-lined esophagus.
Case 1 - Figure 1 - Low-magnification view of this esophageal biopsy. There is a vaguely villiform architecture, and rare goblet cells can be seen. At low magnification, there is a complex glandular pattern associated with overt cytologic atypia, which is identifiable even from this magnification. The cytologic atypia clearly extends onto the surface epithelium.
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Case 1 - Figure 2 - Different area of this same biopsy specimen. Again, cytologic atypia is identifiable at low magnification, including on the surface. There is a complex glandular architecture with "back-to-back" glands.
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Case 1 - Figure 3 - Higher-magnification view of a focus of crowded atypical glands. There is little, if any, lamina propria between the glands.
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Case 1 - Figure 4 - In addition to the larger rounded glands, there are smaller "abortive" glands, including glands with intraluminal necrotic debris.
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Case 1 - Figure 5 - At the base of the biopsy specimen, there is an enlarged dilated atypical gland that infiltrates into the superficial aspect of the muscularis mucosae.
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Case 1 - Figure 6 - Scattered dilated atypical glands with intraluminal necrotic debris were identified.
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Submitted by:
Elizabeth Montgomery
Johns Hopkins Hospital
Baltimore, MD
This specimen was from a 51 year old man with a history of Crohn's disease diagnosed in 1991. The patient lived in Richmond, Virginia. He had had erythema nodosum in 1997 and a history of ileal strictures (1997). The patient developed steroid-induced diabetes when treatment with steroids was used. He subsequently failed therapy with Cipro, Flagyl, Imuran, and 6-Mercapto Purine. In 12/01, he began methotrexate 25 mg IM qwk and Remicade (infliximab, anti-tumor necrosis factor-α) 5mg/kg (12/01). Remicade was increased to 10mg/kg q16 wks (6/02), to 10mg/kg q8 wks (8/04), and to 10mg/kg q6 wks (2/05). The patient developed progressive low-grade fevers, chills, anorexia, and dry cough (5/05) and was admitted to The Johns Hopkins Hospital (JHH) Gastroenterology service with jejunoileitis. An abdominal abdominal CT showed marked bowel thickening and focal narrowing consistent with Crohn's disease with a possible fistula (5/05). The patient was discharged to home (06/05). Remicade was effective for symptomatic control for 4 wks when the patient developed abdominal pain and cramps. Despite increasing Remicade, the patient was readmitted to the JHH for continued fevers and chills. Despite aggressive treatment and bowel rest with total parenteral nutrition, he underwent an emergency resection of a segment of jejunum containing a fistula.
Case 2 - Figure 1 - Low magnification of the resected segment of small bowel showing transmural inflammation
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Case 2 - Figure 2 - A focus of pyloric metaplasia seen in the small intestinal mucosa.
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Case 2 - Figure 3 - Note the presence of granulomatous inflammation.
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Case 2 - Figure 4 - Higher magnification of one of the necrotizing granulomas from this small bowel resection.
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Case 2 - Figure 5 - High magnification of one of the granulomas. Macrophages are laden with organisms; the diagnosis can be suggested on the routine H&E preparation.
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Case 2 - Figure 6 - Vascular spaces are plugged with macrophages containing organisms (H&E).
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Case 2 - Figure 7 - Gomori methenamine silver displaying numerous organisms compatible with Histoplasma capsulatum.
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Case 2 - Figure 8 - This view shows budding forms of Histoplasma capsulatum.
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Submitted by:
John Hart
University of Chicago Hospitals
Chicago, IL
This 52 year-old male initially presented in 2003 with complaints of episodic crampy abdominal pain and fatigue but no diarrhea. In September 2004 he developed rectal bleeding. Stool cultures at that time were negative, but he was started on antibiotics for possible infectious colitis. Colonoscopy revealed ulcers in the right colon and biopsies documented acute colitis without crypt architectural distortion. Biopsies of the ileum were normal. A small bowel follow-through and upper endoscopy with biopsies of the stomach and duodenum revealed no abnormalities. The patient denied NSAID use. Serologic testing revealed negative ASCA and ANCA antibody titers, but a positive anti-OMPC antibody titer. He was treated with I.V. prednisolone for possible Crohn's colitis and improved. Over the next year he had a couple more episodes of abdominal pain. A repeat colonoscopy with biopsies in September 2004 revealed no abnormalities.
The patient was seen at the University of Chicago in December 2004 with continued complaints of crampy abdominal pain without diarrhea. He reported a 10-pound weight loss over the last six months. A Doppler ultrasound of the mesenteric vessels revealed no abnormalities. He then developed rectal bleeding. The patient admitted to taking small doses of a NSAID to alleviate pain from a traumatic rib fracture. A colonoscopy documented a single large ulcerated lesion in the cecum. The terminal ileum and the rest of the colon appeared normal. Biopsies from the lesion revealed acute colitis, while biopsies of the remainder of the colon were normal. The bleeding continued and a right hemicolectomy was performed. Gross examination revealed a single 10.4 x 5.8 cm cecal ulcer. The surrounding colonic mucosa was unremarkable, as was the terminal ileum. A section of the ulcer is submitted for your review.
The patient was instructed to discontinue all NSAID use. Subsequently it was learned that the patient suffered from numerous bouts of aphthous ulceration of the mouth and throat over the past 5 years, which had not responded to anti-viral therapy, but did seem to improve with steroids. Over the next 10 months the patient reported several episodes of crampy abdominal pain without diarrhea, identical to those he suffered prior to the hemicolectomy. He then developed recurrent rectal bleeding and underwent colonoscopy on 10/11/05. It revealed a single large colonic ulcer just distal to the anastomosis. The ileum and the rest of the colonic mucosa appeared unremarkable. Biopsies revealed ulceration with surrounding normal colonic mucosa. The patient denied any NSAID use and a urine screen for NSAIDs was negative.
Submitted by:
Christine Hobbs
Centennial Medical Center
Nashville, TN
This 17 year-old female from a small rural town presented to a general surgeon complaining of a self-limited period of intermittent rectal bleeding. At the surgeon's office she was also found to have Hemoccult positive stools and mild anemia. Her endoscopy was limited to colonoscopy. The only finding on colonoscopy was a pedunculated polyp approximately 1.5 cm in size at 25 cm. The polyp was completely excised and its base cauterized. After removing the polyp, but before reviewing the pathology report, the surgeon's impression and plans were: A single, pedunculated polyp, probably accounting for her rectal bleeding and Hemoccult positive stools. She is a little bit anemic with a hemoglobin of 11.5. When I see her back, I will probably put her on iron and check another series of Hemoccult tests as well as repeat her H&H. I'll check the pathology on the polyp and schedule her next colonoscopy accordingly, it will probably be somewhere around three years.
The next doctor's office note, one month following the polypectomy, starts out by giving the pathologic diagnosis of the polyp. No discussion of that diagnosis follows. The note goes on to say the patient has not seen any further blood, but she sometimes has a little more trouble "getting her bowel movement out than normal." The surgeon states that her hemoglobin at initial presentation was 11.5 and it is now 11.8. He goes on to say "I think at this point I would like to treat her with iron as her MCV is 75. I would like to check another 3 stool Hemoccults because her bleeding should have resolved with the removal of the polyp."
The patient's records note that those three Hemoccult tests were negative.
The next doctor's office note, four months post polypectomy, states that the patient has had no further GI bleeding. It also notes that the patient found out that an uncle had polyps removed and so did his daughter. It says the patient is feeling okay but still has the same symptoms mentioned in the previous note. The note concludes by saying the patient should be scheduled for a repeat scope 1 year since her first scope.
That was the last note on this patient by her surgeon. The only other doctor this patient has seen is her family practitioner. Just recently, after many attempts, I reached the surgeon and discussed the significance of the patient's polyp and work-up options. The details of that conversation will be revealed when this case is presented.
Case 4 - Figure 4 - Periphery of polyp at still higher magnification [with obvious low grade dysyplasia].
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Case 4 - Figure 5 - Polyp immunostained with smooth muscle actin.
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Submitted by:
Henry D. Appelman
University of Michigan Medical School
Ann Arbor, MI
For the past 2 years, this 25 year old man has had painless bright red rectal bleeding with every bowel movement. He has about 2 to 4 soft bowel movements per day, and he has no other symptoms such as tenesmus or abdominal pain. During defecation, he does not have to strain or bare down. He sometime feels tissue prolapsing through his anus, and occasionally he has to self-reduce it. He spent three years lifting heavy weights, but he has not worked out in the last eight months. Three colonoscopies were performed over this 2 year period, and during all of them, 3 large, multilobulated polyps, from 1 to 2.5 cm across, were found in the rectum, just above the anorectal junction, but there were no ulcers. These polyps were partly removed at each endoscopy, but were too large to remove completely, so eventually, because of continuing bleeding, surgical excision was required. The images are from the polyps.
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