—  SPECIALTY CONFERENCE  — Gastrointestinal Pathology Thursday, March 6, 2008, 7:30 PM Convention Center 205/207 Click the button above to add this event to your Itinerary Planner... Moderator: LAURA LAMPS University of Arkansas for Medical Sciences Little Rock, AR Clinical Histories and Still Images are displayed below. Click on slide thumbnail images for an enlarged view. If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137. Case 1 Submitted by: Joseph Misdraji - Massachusetts General Hospital, Boston, MA Clinical Summary: An 80 year old woman presented with a history of explosive diarrhea dating back a few months. Several months ago, she began experiencing liquid stool about once per day, but now it is up to 3 times per day, with occasional cramping pain and she is sometimes awakened by symptoms. Lately, it has become difficult for her to always reach the bathroom in time, with several incontinent episodes. She has eliminated dairy foods and most vegetables without effect. There had been a gradual weight loss over several years (from 60 kg a few years ago to 50 kg now) but now weight is stable. Pepto-Bismol has had some effect, although too much caused her constipation. No jaundice, fever, nausea, vomiting, rash or other significant skin findings. No peripheral eosinophilia; slightly elevated absolute neutrophil count but otherwise unremarkable blood counts. An exam for occult blood in stool was negative. Her medical history is significant only for hypertension, for which she takes atenolol. Evaluation for diarrhea included stool culture and O&P, both negative. She was put on Metamucil for presumed irritable bowel syndrome with slight improvement. She was referred to a gastroenterologist who performed a colonoscopy. The colon appeared normal and random biopsies were obtained. Case 1 - Figure 1 Case 1 - Figure 2 Case 1 - Figure 3 Case 1 - Figure 4 Case 1 - Figure 5 Case 1 - Figure 6 Case 1 - Figure 7 Case 1 - Figure 8 Case 1 - Figure 9 Case 2 Submitted by: Lisa Yerian - Cleveland Clinic Lerner College of Medicine, Cleveland, OH Clinical Summary: The patient is a 71 year old woman with six month history of a severe gastrointestinal illness which presented clinically with diarrhea and a protein-losing enteropathy. The symptoms began after travel to the east coast of the United States. Endoscopy at that time showed marked polypoid abnormalities throughout the stomach, small bowel, and colon. The esophagus appeared normal. The patient was also recently found to have positive IgM titers for Lyme disease, for which she received treatment. The patient received oral steroids for her gastrointestinal illness with some resolution in symptoms, but the endoscopic abnormalities persisted with minimal interval improvement. Serologic markers for gluten sensitive enteropathy were pending at the time of biopsy review. Biopsies were taken from polyps and intervening mucosa (stomach polyp, figs 1-3; flat stomach mucosa, fig 4; small bowel polyp figs 5-6; small bowel mucosa fig 7; colon polyps figs 8-10; flat colon mucosa fig 11). Case 2 - Figure 1 Case 2 - Figure 2 Case 2 - Figure 3 Case 2 - Figure 4 Case 2 - Figure 5 Case 2 - Figure 6 Case 2 - Figure 7 Case 2 - Figure 8 Case 2 - Figure 9 Case 2 - Figure 10 Case 2 - Figure 11 Case 3 Submitted by: David N. Lewin - Medical University of South Carolina, Charleston, SC Clinical Summary: A 26-year-old-male with a two year history of epigastric pain, nausea, vomiting, and rectal bleeding recently underwent upper GI endoscopy and colonoscopy. The colonoscopy showed a greater than 100 polyps throughout the colon with biopsies at an outside facility called adenomas polyps. The upper endoscopy revealed a duodenum carpeted with polypoid lesions. The patient stated he has a ten pound weight loss over two months and noted pain in the epigastrium and nausea and vomiting after eating. He has a known history of iron deficiency anemia and a history of a gastric ulcer in 1985. His mother has a history of lupus and his father's family history is unknown. He uses neither tobacco nor spirits. He is an active duty sailor (a nuclear technician). Physical examination was unremarkable. The patient was recommended to undergo pancreaticoduodenectomy and colectomy with restorative proctocolectomy either as a staged or simultaneous procedure. The patient was taken to the operating room. There were multiple intraabdominal adhesions of small and large bowel. A right hemicolectomy was performed and sent to pathology for evaluation. Multiple polyps were identified within both the cecum and terminal ileum. The largest polyp in the ileum was fixed to the underlying muscularis. On cut sectioning, mucus was identified in the muscularis mucosa. A gross photograph of the specimen, cut section and representative histologic images are presented. Case 3 - Figure 1 Case 3 - Figure 2 Case 3 - Figure 3 Case 3 - Figure 4 Case 3 - Figure 5 Case 3 - Figure 6 Case 3 - Figure 7 Case 3 - Figure 8 Case 3 - Figure 9 Case 3 - Figure 10 Case 4 Submitted by: Alyssa M. Krasinskas - University of Pittsburgh Medical Center, Pittsburgh, PA Clinical Summary: A 59 year-old female presented to our gastroenterologist from an outside institution with the history of a "gastric deformity/subepithelial tumor." The in-house endoscopy showed a single 8 mm nodule in the gastric fundus. It "had a yellow hue, central depression, and was firm when probed." By EUS, this lesion appeared to originate from within the muscularis propria. The lesion was biopsied and essentially removed with cold jumbo forceps. H&E photomicrographs are provided, as well as a cytokeratin AE1/3 stain (Figure 7) and an S-100 stain (Figure 8). Case 4 - Figure 1 Case 4 - Figure 2 Case 4 - Figure 3 Case 4 - Figure 4 Case 4 - Figure 5 Case 4 - Figure 6 Case 4 - Figure 7 - Cytokeratin AE1/3 Case 4 - Figure 8 - S100 Case 5 Submitted by: A. Scott Mills - Virginia Commonwealth University Clinical Summary: This patient is a middle-aged male who was referred to our institution for evaluation of abnormalities noted at upper GI endoscopy. Repeat EGD at VCUHS showed multiple mucosal plaques in the hypopharynx and esophagus that had the appearance of those illustrated in Figure 1. The plaques in the esophagus were most numerous in the upper and middle thirds and failed to stain with Lugol's solution. The initial biopsies of these plaques showed the histologic features noted in Figures 2A & 2B. Immunohistochemistry for human papilloma virus (HPV) was non-reactive. During the first year after referral, multiple lesions in the esophagus were ablated by photodynamic therapy (PDT) and/or excised by endoscopic mucosal resection (EMR). Varying degrees of squamous hyperplasia and dysplasia were noted in biopsy material (Figures 3-5). Thirteen months after referral, a lesion involving the right aryepiglottic fold was biopsied by the ENT service (Figures 6A & 6B). This lesion was irradiated. After completion of radiation therapy to the larynx / hypopharynx, multiple sessions of photodynamic therapy were resumed to ablate lesions in the esophagus. These resulted in strictures that were relieved by multiple dilatations. About 42 months after referral, an ulcerated 1.4 cm nodule was detected in the middle third of the esophagus (Figure 7). Biopsy findings of this lesion are shown in Figures 8A & 8B. This malignant neoplasm was staged T3, N1 by endoscopic ultrasound (EUS) and was subsequently treated with radiation therapy. Case 5 - Figure 1 Case 5 - Figure 2A Case 5 - Figure 2B Case 5 - Figure 3 Case 5 - Figure 4 Case 5 - Figure 5 Case 5 - Figure 6A Case 5 - Figure 6B Case 5 - Figure 7 Case 5 - Figure 8A Case 5 - Figure 8B If there are glass slides for a conference, they will be available for study in the microscope room in the Convention Center Room 101 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".