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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
Disclosure: The speakers have indicated they have nothing to disclose.
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for Text and References
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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Case 1 - Figure 1 - Low magnification of this colon lesion. The epicenter of the process is in the submucosa but the overlying mucosa has been affected and displays marked reactive epithelial changes and crypt distortion.
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Case 1 - Figure 2 - Higher magnification of the surface mucosa. On mucosal biopsies, this process was virtually impossible to diagnose.
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Case 1 - Figure 3 - The submucosal lesion is characterized by spindle cells arranged in whorls around vessels.
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for Text and References
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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Case 2 - Figure 1 - Low-magnification view of the small bowel tumor. The tumor is composed of fairly bland-appearing spindled cells arranged into nests and short intersecting fascicles. Some areas of the tumor showed prominent vascular spaces.
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Case 2 - Figure 2 - High-magnification view of bland-appearing spindled cells arranged into a vaguely storiform growth pattern. The cells have abundant eosinophilic fibrillar cytoplasm. Cytologic atypia is not conspicuous.
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Case 2 - Figure 3 - High-magnification view of bland spindled cells with conspicuous collagen globules between the cells. Mitotic figures are not seen.
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Case 2 - Figure 4 - Separate from the main tumor, there was a grossly inconspicuous but histologically apparent spindle cell proliferation that interdigitated with the surrounding more densely eosinophilic muscle fibers of the muscularis propria.
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Case 2 - Figure 5 - Higher magnification view of separate spindle cell proliferation interdigitating among the muscle fibers of the muscularis propria. This spindle cell proliferation is histologically similar to that seen in the other figures from the main tumor.
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for Text and References
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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Case 3 - Figure 1 - The resection specimen contained 50-100 erythematous, sessile polyps that were more numerous in the rectum, but also involved the sigmoid colon. The polyps ranged in size from <0.1 cm to 2.5 cm and, in some areas, formed confluent plaques spanning up to 6 cm.
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Case 3 - Figure 2 - Representative sections of the polypoid lesions demonstrated that the polyps contained numerous cystically dilated crypts that tended to be most prominent in the superficial component of the polyps.
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Case 3 - Figure 3 - All of the polyps showed attenuation of the surface epithelium or frank ulceration associated with a granulation tissue reaction.
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Case 3 - Figure 4 - The crypts contained a mucoid exudate with enmeshed inflammatory cells and denuded epithelial cells, which was also adherent to the surface of the polyp.
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Case 3 - Figure 5 - The superficial crypts were lined by attenuated epithelial cells with mucin depletion.
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Case 3 - Figure 6 - In other areas, the epithelial cells in the crypt region contain either abundant mucin or eosinophilic cytoplasm, as well as enlarged nuclei with small, but conspicuous nucleoli, and evenly dispersed chromatin.
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Case 3 - Figure 7 - The crypts near the polyp base showed mild architectural distortion, crypt dilation, and limited serration. The lamina propria did not contain smooth muscle fibrils emanating from the muscularis mucosae, which was of normal thickness.
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for Text and References
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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Case 4 - Figure 1 - Colonic tissue demonstrating hemorrhage with superficial mucosal necrosis, mild acute inflammation, preservation of deep crypts, reepithelialization of the surface and occasional deep crypt apoptosis. The submucosa demonstrates edema hemorrhage and a mild mixed inflammatory infiltrate (20x, H &E).
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Case 4 - Figure 2 - Colonic tissue demonstrating hemorrhage with superficial mucosal necrosis, mild acute inflammation, preservation of deep crypts, reepithelialization of the surface and occasional deep crypt apoptosis. The submucosa demonstrates edema hemorrhage and a mild mixed inflammatory infiltrate (20x, H &E).
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Case 4 - Figure 3 - Colonic tissue demonstrating hemorrhage with superficial mucosal necrosis, mild acute inflammation, preservation of deep crypts, reepithelialization of the surface and occasional deep crypt apoptosis. The submucosa demonstrates edema hemorrhage and a mild mixed inflammatory infiltrate (20x, H &E).
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Case 4 - Figure 4 - A small fragment of fibrinopurulent exudate with foreign (fecal) material (40x, H&E)
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Case 4 - Figure 5 - Deep mucosal capillaries with fibrin thrombi (40x, H &E).
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Case 4 - Figure 6 - Colonic tissue demonstrating hemorrhage with superficial mucosal necrosis, mild acute inflammation, preservation of deep crypts and reepithelialization of the surface. (40x, H &E).
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for Text and References
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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Case 5 - Figure 1 - Low power of ileal section revealing thickened wall and transmural inflammatory changes typical of Crohn's disease
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Case 5 - Figure 2 - Medium power of above highlighting mucosal architectural distortion and submucosal fibrosis.
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Case 5 - Figure 3 - Medium power of above to demonstrate neuronal hyperplasia, and serosal granulomas and lymphoid follicles.
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Case 5 - Figure 4 - Low power of medium sized mesenteric artery included in the ileocecetomy specimen, reveal occusion due to intimal hyperplasia and fibrosis.
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Case 5 - Figure 5 - Medium power demonstrating active arteritis.
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Case 5 - Figure 6 - High power reveal multinucleated giant cells and disruption of the elastica.
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Case 5 - Figure 7 - Another mesentery artery exhibiting active giant cell arteritis and surrounded by granulomatous inflammation.
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Case 5 - Figure 8 - Another mesenteric artery exhibiting active giant cell arteritis.
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