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Gastrointestinal Pathology
Sunday, March 25, 2007, 7:30 PM
Elizabeth A - E
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Moderator:
JOEL GREENSON
University of Michigan Medical School
Ann Arbor, MI
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Submitted by: Elizabeth Montgomery - Johns Hopkins Hospital - Baltimore, MD
Transverse colon mass in a 66 year old man. Initially, a small biopsy was received on which several observers were unable to make a diagnosis. In the interim, the patient became obstructed and a resection was performed.
Case 1 - Slide 1
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Submitted by: John R. Goldblum - Cleveland Clinic - Cleveland, OH
58-year-old male with multiple neurofibromas, including several plexiform neurofibromas, who presented with a 4 cm small intestinal mass. He also appeared to have two small, less than 1 cm masses in the wall of the small bowel several cms away from the main mass. This is a representative section of the 4 cm mass.
Case 2 - Slide 1
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Submitted by: Rhonda Yantiss - Weill Medical College of Cornell University - New York, NY
A 62 year-old white male presented with a several month history of changing bowel habits and mucoid diarrhea. He underwent a lower colonoscopic examination and was found to have numerous (>10) small sessile polyps in the rectosigmoid region, some of which were biopsied and interpreted to be hyperplastic polyps. His symptoms worsened over the next several months and he re-presented with copious mucoid secretions as well as incontinence of mucoid stool. A second colonoscopic examination revealed an increase in the number of polyps present up to 20 cm from the anal verge. The polyps were sessile, erythematous, and friable, and many were eroded or covered with a fibrinous exudate. Several polyps were sampled and again interpreted to be hyperplastic. A representative biopsy of the intervening colonic mucosa showed "hyperplastic changes".
His medical history included coronary artery disease, status post coronary artery bypass graft, aortic and mitral valve replacements, cardiac pacemaker placement, atrial fibrillation, transient ischemic attacks, and hypothyroidism. Medications included aspirin, Synthroid, lisinopril, coumadin, Lipitor, and amiodarone.
Two months after the second colonoscopy, the patient was admitted to the hospital with complaints of severe rectal straining, constant bloody/mucoid secretions per rectum, 7-10 bowel movements per day, as well as anal leakage and the use of 15-20 pads/day. He also reported a 20-pound weight loss over the course of six months and an inability to ambulate due to intense anal pressure. He underwent a flexible sigmoidoscopy, which revealed innumerable large, friable sessile polyps from 5-6 cm above the anal verge to the proximal extent of the examination. He underwent a hand-assisted laparoscopic resection of the sigmoid colon and proximal rectum for symptomatic relief. Representative sections were obtained from the lesional areas.
Case 3 - Slide 1
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Submitted by: Charles R. Lassman - David Geffin School of Medicine at UCLA - Los Angeles, CA
A 31 year old woman, presented to the emergency room with severe cramps and bloody diarrhea. She had been in good health until two days prior to presentation when she suffered from acute onset of watery diarrhea and abdominal cramping. After two days, the diarrhea turned bloody and she sought medical attention.
Examination in emergency room was notable for a tender abdomen, which was not felt to require surgical intervention. The patient was afebrile. Routine laboratory work was unremarkable. The patient was placed on levafloxacin and sent home; stool cultures were not performed. The patient continued to pass moderate amounts of blood in her stool and returned to the ER the following day with worsening cramps. A CT suggested "inflammation and ischemia" of the hepatic flexure and right transverse colon; the patient was admitted for further evaluation and observation.
On admission stool was sent for culture and analysis and the patient was continued on levafloxacin with a presumptive diagnosis of acute infectious colitis. Stool cultures were negative for pathogenic organisms. Severe cramping and bloody diarrhea continued unabated for two more days. Five days after the onset of symptoms and 4 days after antibiotic treatment was started, colonoscopy was performed and biopsies were taken.
Colonoscopy demonstrated normal appearing mucosa from the cecum to the proximal transverse colon. The proximal transverse colon appeared inflamed and markedly edematous with areas of extensive superficial ulceration. The distal transverse colon appeared less edematous, with less severe ulceration. The rectum was minimally involved. Biopsies were obtained from the rectum as well as the transverse colon.
Endoscopic impression: Acute inflammatory process of the transverse colon, probable severe acute infectious colitis, ischemic colitis can not be excluded, less likely, though still possible is inflammatory bowel disease, specifically Crohn's.
Case 4 - Slide 1
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Submitted by: John Hart - University of Chicago Hospitals - Chicago, IL
The patient is a 15-year-old male with a several year history of Crohn's disease. The patient has been treated in the past with steroids and infliximab. Recently obstructive symptoms led to a small bowel follow through, which revealed a tight stricture in the terminal ileum. An ileocecectomy was performed. Gross examination of the specimen documented a 3 cm stricture of the distal terminal ileum with linear ulcers and effacement of the usual mucosal fold pattern. The cecum and appendix were grossly unremarkable. A representative section from the ileal stricture is provided for review.
Case 5 - Slide 1
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During the meeting the slides and protocols will be available for study in the microscope
room in the Manchester Grand Hyatt (Betsy A-C) for participants who wish to review them prior to the
evening session.
Handouts for all Specialty Conferences will be accessible via the
"Educational Materials" section on the homepage the morning after each respective conference. Printed
copies of the handout will not be available at the meeting. However, we will provide a booklet at the
meeting which will have a page for each Specialty Conference, listing the names of speakers and space for the important "take home messages".
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