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Gastrointestinal Pathology
Thursday, March 6, 2008, 7:30 PM
Convention Center 205/207
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Moderator:
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LAURA LAMPS
University of Arkansas for Medical Sciences
Little Rock, AR
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Disclosure:
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The speakers have indicated they have nothing to disclose.
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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.
for Text and References
Submitted by: Joseph Misdraji - Massachusetts General Hospital, Boston, MA
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
Low power view of several colonic biopsies shows patchy involvement of an infiltrative process. The biopsy on the left is largely uninvolved, whereas the one on the right shows separation of the crypts by an infiltrative process.
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Case 1 - Figure 2
A medium power view of a colonic biopsy shows widely spaced crypts with an infiltrate that appears confined to the lamina propria.
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Case 1 - Figure 3
Medium and high power views show lamina propria infiltration by eosinophils and histiocytic appearing cells.
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Case 1 - Figure 4
Medium and high power views show lamina propria infiltration by eosinophils and histiocytic appearing cells.
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Case 1 - Figure 5
Medium and high power views show lamina propria infiltration by eosinophils and histiocytic appearing cells.
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Case 1 - Figure 6
The infiltrate consists of a mixture of eosinophils, oval or spindle cells, and the occasional lymphocyte and plasma cell.
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Case 1 - Figure 7
The infiltrate consists of a mixture of eosinophils, oval or spindle cells, and the occasional lymphocyte and plasma cell.
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Case 1 - Figure 8
Very close evaluation shows that the infiltrating oval cells have bland nuclei with some nuclear folding, pale eosinophilic cytoplasm and no mitoses.
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Case 1 - Figure 9
Very close evaluation shows that the infiltrating oval cells have bland nuclei with some nuclear folding, pale eosinophilic cytoplasm and no mitoses.
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for Text and References
Submitted by: Lisa Yerian - Cleveland Clinic Lerner College of Medicine, Cleveland, OH
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
Colon Flat Mucosa - Histologic abnormalities are seen in polypoid and nonpolypoid colonic mucosa. Sections from "flat" colonic mucosa demonstrate separation of the crypts by an edematous lamina propria.
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Case 2 - Figure 2
Sigmoid polyp 2 - Focal nuclear enlargement and hyperchromasia is seen at the surface of a polyp.
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Case 2 - Figure 3
Sigmoid polyp 3 - Some of the colonic crypts are cystically dilated.
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Case 2 - Figure 4
Sigmoid polyp 4 - This sigmoid polyp demonstrate marked crypt architectural distortion. The crypts are widely separated by an edematous and inflamed lamina propria.
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Case 2 - Figure 5
Small bowel - Occasional crypts are cystically dilated.
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Case 2 - Figure 6
Small bowel 2 - Crypts are unevenly spaced in an edematous and inflamed lamina propria.
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Case 2 - Figure 7
Small bowel 3 - Small bowel biopsies exhibit lamina propria edema and inflammation.
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Case 2 - Figure 8
Stomach Flat Mucosa - The intervening nonpolypoid mucosa exhibits lamina propria edema and inflammation similar to that seen in the stomach polyps.
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Case 2 - Figure 9
Stomach polyp 1 - The lamina propria exhibits marked edema and inflammation including lymphocytes and eosinophils. There is also foveolar hyperplasia.
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Case 2 - Figure 10
Stomach polyp 2 - A stomach polyp exhibits foveolar hyperplasia with lamina propria edema and inflammation.
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Case 2 - Figure 11
Stomach polyp 3 - Inflammation and marked lamina propria edema in a gastric polyp.
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for Text and References
Submitted by: David N. Lewin - Medical University of South Carolina, Charleston, SC
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
Gross image of terminal ileum and cecum. Polyp seen in subsequent microscopic images is the 2 cm dome lesion in the terminal ileum. A number of small polypoid lesions are present in the terminal ileum and a pedunculated polyp with a green head is present in the cecum.
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Case 3 - Figure 2
Cross section gross image of the polyp in question in the terminal ileum. The bowel is being squeezed and white mucoid material is identified in the bowel wall and the adjacent mesentery.
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Case 3 - Figure 3
Whole mount view of section through the polyp, bowel wall and adjacent mesentery. The polyp has a central core of smooth muscle that shows tree-like branching covered by normal small intestinal mucosa. At the base of the polyp, glands can be identified extending through the muscularis propria and into the adjacent mesentery.
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Case 3 - Figure 4
Medium power of the tip of the polyp. There is again the arborizing architecture with normal enterocytes. There is no evidence of dysplasia.
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Case 3 - Figure 5
Medium power focusing on the muscularis propria of the bowel. There is prominent placement of glands in and through the muscular wall.
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Case 3 - Figure 6
Medium power of the base of the bowel with extension of the glands through the bowel wall into the adjacent mesenteric fat.
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Case 3 - Figure 7
High power of glands present in the muscular wall. The epithelium is normal with no evidence of dysplasia. Presence of lamina propria is identified around the glands.
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Case 3 - Figure 8
High power of glands present in the muscular wall. The epithelium is normal with no evidence of dysplasia. Presence of lamina propria is identified around the glands.
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Case 3 - Figure 9
High power of glands present in the muscular wall. The epithelium is normal with no evidence of dysplasia. Presence of lamina propria is identified around the glands.
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Case 3 - Figure 10
Highest power of deepest gland present in the mesenteric fat. The nuclei are all basally oriented with cytologically normal nuclei.
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for Text and References
Submitted by: Alyssa M. Krasinskas - University of Pittsburgh Medical Center, Pittsburgh, PA
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
Very low power view of the mucosal biopsy.
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Case 4 - Figure 2
Low power magnification of the gastric mucosa showing a chronic gastritis and eosinophilic cells within the lamina propria. An immunostain for H. pylori was positive.
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Case 4 - Figure 3
Medium power view.
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for Text and References
Submitted by: A. Scott Mills - Virginia Commonwealth University
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.
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