GASTROINTESTINAL GASTROINTESTINAL PATHOLOGYPATHOLOGY

EsophagusEsophagus

Normal esophagusNormal esophagus

This is a normal esophagus with the usual white to tan This is a normal esophagus with the usual white to tan smooth mucosa seen at the left. The smooth mucosa seen at the left. The

gastroesophageal junctiongastroesophageal junction (not an anatomic (not an anatomic sphincter) is at the center, and the stomach is at the sphincter) is at the center, and the stomach is at the

right. right.

Normal esophagusNormal esophagus

This is normal esophageal squamous mucosa at the left, This is normal esophageal squamous mucosa at the left, with underlying submucosa containing mucus glands with underlying submucosa containing mucus glands

and a duct surrounded by lymphoid tissue. The and a duct surrounded by lymphoid tissue. The muscularis is at the right.muscularis is at the right.

Candida esophagitisCandida esophagitis

Tan-yellow plaques are seen in the lower esophagus, Tan-yellow plaques are seen in the lower esophagus, along with mucosal hyperemia. The same lesions are along with mucosal hyperemia. The same lesions are

also seen at the upper right in the stomach.also seen at the upper right in the stomach.

Acute esophagitisAcute esophagitis

Acute esophagitis is manifested here by increased Acute esophagitis is manifested here by increased neutrophils in the submucosa as well as neutrophils neutrophils in the submucosa as well as neutrophils infiltrating into the squamous mucosa at the right.infiltrating into the squamous mucosa at the right.

Herpes simplex esophagitisHerpes simplex esophagitis

GROSSGROSS: The lower esophagus here shows sharply : The lower esophagus here shows sharply demarcated ulcerations that have a brown-red base, demarcated ulcerations that have a brown-red base, contrasted with the normal pale white esophageal contrasted with the normal pale white esophageal mucosa at the far left. Such "punched out" ulcers are mucosa at the far left. Such "punched out" ulcers are suggestive of herpes simplex infection.suggestive of herpes simplex infection.

LPOLPO: A herpetic ulcer is seen microscopically to have a : A herpetic ulcer is seen microscopically to have a sharp margin. The ulcer base at the left shows sharp margin. The ulcer base at the left shows

loss of loss of overlying squamous epithelium with only necrotic overlying squamous epithelium with only necrotic debris remaining. debris remaining.

HPOHPO: the squamous mucosa at the margin of the herpetic : the squamous mucosa at the margin of the herpetic ulcer shows pale pink "ground glass" inclusions ulcer shows pale pink "ground glass" inclusions

within within squamous epithelial cells. Some of the inclusions squamous epithelial cells. Some of the inclusions are are clustered together-- multinucleation is another clustered together-- multinucleation is another

common viral cytopathic effect. common viral cytopathic effect. ENDOSCOPIC FINDINGENDOSCOPIC FINDING: there are rounded, erythematous : there are rounded, erythematous

ulcerations of the lower esophagus ulcerations of the lower esophagus

LPO

HPO

Barrett's esophagusBarrett's esophagus

LPOLPO: Another cause for inflammation is a so-called : Another cause for inflammation is a so-called "Barrett's esophagus" in which there is gastric-type "Barrett's esophagus" in which there is gastric-type mucosa above the gastroesophageal junction. Note the mucosa above the gastroesophageal junction. Note the

columnar epithelium to the left and the squamous columnar epithelium to the left and the squamous epithelium at the right. This is "typical" Barrett's epithelium at the right. This is "typical" Barrett's mucosa, because there is intestinal metaplasia as mucosa, because there is intestinal metaplasia as

well well (note the goblet cells in the columnar mucosa).(note the goblet cells in the columnar mucosa). Endoscopic viewEndoscopic view: In Pic 1, these two endoscopic views : In Pic 1, these two endoscopic views

demonstrate Barrett esophagus demonstrate Barrett esophagus areas of mucosal areas of mucosal erythemaerythema (white arrow) of the lower esophagus, (white arrow) of the lower esophagus,

with with islands of normalislands of normal (black arrow) pale esophageal (black arrow) pale esophageal squamous mucosa. If the area of Barrett mucosa squamous mucosa. If the area of Barrett mucosa extends less than 2 cm above the normal extends less than 2 cm above the normal

squamocolumnar junction, then the condition is called squamocolumnar junction, then the condition is called "short "short segment" Barrett esophagus, as shown in Pic 2.segment" Barrett esophagus, as shown in Pic 2.

LPO

Pic 1

Pic 2

Esophageal varicesEsophageal varices(a)(a) At the lower end of the esophagus At the lower end of the esophagus

(which has been turned inside out at (which has been turned inside out at autopsy) are linear dark blue autopsy) are linear dark blue submucosal dilated veins known as submucosal dilated veins known as varices. In patients with portal varices. In patients with portal hypertension (usually micronodular hypertension (usually micronodular cirrhosis from chronic alcoholism), cirrhosis from chronic alcoholism), the submucosal esophageal veins the submucosal esophageal veins become dilated (form varices). become dilated (form varices). These varices are prone to bleed.These varices are prone to bleed.

(b)(b) Here is another varix near the Here is another varix near the gastroesophageal junction that is gastroesophageal junction that is dark red black because it has been dark red black because it has been bleeding. (The esophagus has been bleeding. (The esophagus has been turned inside out.) The plexus of turned inside out.) The plexus of veins also involves some of the veins also involves some of the upper stomach, but it is generically upper stomach, but it is generically called the esophageal plexus of called the esophageal plexus of veins and, hence, bleeding here is veins and, hence, bleeding here is termed esophageal variceal termed esophageal variceal bleeding.bleeding.

(c)(c) Below the squamous mucosa is an Below the squamous mucosa is an elongated, inflamed varix. elongated, inflamed varix.

(d)(d) Inflammation and hemorrhage is Inflammation and hemorrhage is seen here in the region of a ruptured seen here in the region of a ruptured varix of the esophagus.varix of the esophagus.

(e) & (f) Endoscopic views of esophageal (e) & (f) Endoscopic views of esophageal varices are shown, with dilated veins varices are shown, with dilated veins bulging into the lower esophageal bulging into the lower esophageal lumen. lumen.

(a) (b)

(c) (d)

(e) (f)

Stomach, scleroderma Stomach, scleroderma with fibrosiswith fibrosis

(a)(a) Esophageal motility problems can occur in patients with progressive Esophageal motility problems can occur in patients with progressive systemic sclerosis (scleroderma) because the submucosa becomes systemic sclerosis (scleroderma) because the submucosa becomes fibrotic. This occurs most often in the esophagus, but may also be seen fibrotic. This occurs most often in the esophagus, but may also be seen elsewhere in the GI tract. Here in the stomach, a trichrome stain elsewhere in the GI tract. Here in the stomach, a trichrome stain demonstrates a blue submucosa because of the extensive fibrosis. demonstrates a blue submucosa because of the extensive fibrosis.

(b)(b) This radiograph taken following barium swallow demontrates a This radiograph taken following barium swallow demontrates a stricturestricture (arrow) in the lower esophagus, with pooling of the contrast (arrow) in the lower esophagus, with pooling of the contrast above the point of stricture. Such stricture may complicate conditions above the point of stricture. Such stricture may complicate conditions such as scleroderma, gastroesophageal reflux disease, or carcinoma.such as scleroderma, gastroesophageal reflux disease, or carcinoma.

(a) (b)

Esophageal carcinomaEsophageal carcinoma

An ill-defined mass at the gastroesophageal junction An ill-defined mass at the gastroesophageal junction produces mucosal ulceration and irregularity, which led produces mucosal ulceration and irregularity, which led

to the clinical symptoms of pain and difficulty to the clinical symptoms of pain and difficulty swallowing.swallowing.

Esophageal squamous Esophageal squamous cell carcinomacell carcinoma

(a)(a) This irregular reddish, ulcerated This irregular reddish, ulcerated exophytic exophytic mid-esophageal mid-esophageal massmass (arrow) as seen on the (arrow) as seen on the mucosal surface is a squamous mucosal surface is a squamous cell carcinoma. cell carcinoma.

(b)(b) At the upper left is a remnant of At the upper left is a remnant of squamous esophageal mucosa squamous esophageal mucosa that has been undermined by that has been undermined by an infiltrating squamous cell an infiltrating squamous cell carcinoma of the mid-carcinoma of the mid-esophagus. Solid nests of esophagus. Solid nests of neoplastic cells are infiltrating neoplastic cells are infiltrating down through the submucosa down through the submucosa at the right. at the right.

(c)(c) Infiltrating nests of neoplastic Infiltrating nests of neoplastic cells have abundant pink cells have abundant pink cytoplasm and distinct cell cytoplasm and distinct cell borders typical for squamous borders typical for squamous cell carcinoma. cell carcinoma.

(d)(d) Endoscopic views of an Endoscopic views of an ulcerated mid-esophageal ulcerated mid-esophageal squamous cell carcinoma squamous cell carcinoma causing lumenal stenosis are causing lumenal stenosis are seen seen

(a)

(b) (c)

(d)

StomachStomach

Stomach, normalStomach, normal

This is the normal appearance of the stomach, which has This is the normal appearance of the stomach, which has been opened along the been opened along the greater curvature greater curvature (GC)(GC). The . The esophagusesophagus (E) (E) is at the left. In the fundus can be seen the is at the left. In the fundus can be seen the lesser curvature lesser curvature (LC).(LC). Just beyond the Just beyond the antrumantrum (A)(A) is the is the pylorus pylorus (P) (P) emptying into the first portion of emptying into the first portion of duodenumduodenum (D)(D) is is at the lower right. at the lower right.

GC

E

LC

A

P

D

Stomach, pylorus, normalStomach, pylorus, normal

(a)(a) This is the normal appearance of the gastric antrum (A) extending to the This is the normal appearance of the gastric antrum (A) extending to the pylorus (P) at the right of center. The first portion of the duodenum pylorus (P) at the right of center. The first portion of the duodenum (duodenal bulb) is at the far right. (duodenal bulb) is at the far right.

(b)(b) In the endoscopic views, the normal appearance of the pylorus is seen at In the endoscopic views, the normal appearance of the pylorus is seen at the left, with the first portion of the duodenum at the right.the left, with the first portion of the duodenum at the right.

A P D

(a) (b)

Stomach, fundus, normalStomach, fundus, normal

This is the normal appearance of the gastric fundal mucosa, This is the normal appearance of the gastric fundal mucosa, with short pits lined by pale columnar mucus cells leading with short pits lined by pale columnar mucus cells leading

into long glands which contain bright pink parietal cells that into long glands which contain bright pink parietal cells that secrete hydrochloric acid.secrete hydrochloric acid.

Acute gastritisAcute gastritis

(a)(a) This is a more typical acute gastritis with a diffusely This is a more typical acute gastritis with a diffusely hyperemic gastric mucosa. There are many causes for acute hyperemic gastric mucosa. There are many causes for acute gastritis: alcoholism, drugs, infections, etc.gastritis: alcoholism, drugs, infections, etc.

(b)(b) At high power, gastric mucosa demonstrates infiltration by At high power, gastric mucosa demonstrates infiltration by neutrophils.neutrophils.

(a) (b)

Gastropathy with gastric Gastropathy with gastric erosionserosions

Here are some larger areas of gastric hemorrhage that could best be Here are some larger areas of gastric hemorrhage that could best be termed "erosions" because the superficial mucosa is eroded away. termed "erosions" because the superficial mucosa is eroded away.

Such erosions are typical for the pathologic process termed Such erosions are typical for the pathologic process termed gastropathy, which describes gastric mucosal injury without gastropathy, which describes gastric mucosal injury without

significant inflammation. significant inflammation.

Acute gastric ulcer, Acute gastric ulcer, benignbenign

A 1 cm acute gastric ulcer A 1 cm acute gastric ulcer is shown in the upper is shown in the upper fundus. The ulcer is fundus. The ulcer is shallow and sharply shallow and sharply demarcated, with demarcated, with surrounding hyperemia. It surrounding hyperemia. It is probably benign. is probably benign. However, all gastric ulcers However, all gastric ulcers should be biopsied to rule should be biopsied to rule out a malignancy. out a malignancy.

The endoscopic The endoscopic appearance of a similar appearance of a similar acute peptic ulcer in the acute peptic ulcer in the prepyloric region is prepyloric region is shown.shown.

Gastric ulcers, endoscopy Gastric ulcers, endoscopy

Seen above are gastric ulcers of Seen above are gastric ulcers of smallsmall, , mediummedium, and , and largelarge size on upper endoscopy. All gastric ulcers are biopsied, size on upper endoscopy. All gastric ulcers are biopsied, since gross inspection alone cannot determine whether a since gross inspection alone cannot determine whether a malignancy is present. Smaller, more sharply demarcated malignancy is present. Smaller, more sharply demarcated

ulcers are more likely to be benign.ulcers are more likely to be benign.

Gastric ulcer, malignantGastric ulcer, malignant

Here is a much larger 3 x 4 cm gastric ulcer that led to the resection of the Here is a much larger 3 x 4 cm gastric ulcer that led to the resection of the stomach shown here. This ulcer is much deeper with more irregular stomach shown here. This ulcer is much deeper with more irregular margins. Complications of gastric ulcers (either benign or malignant) margins. Complications of gastric ulcers (either benign or malignant)

include pain, bleeding, perforation, and obstruction.include pain, bleeding, perforation, and obstruction.

Acute gastric ulcerAcute gastric ulcer

(a)(a) Microscopically, the ulcer here is sharply demarcated, with normal Microscopically, the ulcer here is sharply demarcated, with normal gastric mucosa on the left falling away into a deep ulcer whose base gastric mucosa on the left falling away into a deep ulcer whose base contains infamed, necrotic debris. An arterial branch at the ulcer base contains infamed, necrotic debris. An arterial branch at the ulcer base is eroded and bleeding.is eroded and bleeding.

(b)(b) The mucosa at the upper right merges into the ulcer at the left which The mucosa at the upper right merges into the ulcer at the left which is eroding through the mucosa. Ulcers will penetrate over time if they is eroding through the mucosa. Ulcers will penetrate over time if they do not heal. Penetration leads to pain. If the ulcer penetrates through do not heal. Penetration leads to pain. If the ulcer penetrates through the muscularis and through adventitia, then the ulcer is said to the muscularis and through adventitia, then the ulcer is said to "perforate" and leads to an acute abdomen. An abdominal radiograph "perforate" and leads to an acute abdomen. An abdominal radiograph may demonstrate free air with a perforation. may demonstrate free air with a perforation.

(a) (b)

Acute gastric ulcer Acute gastric ulcer penetrating to arterypenetrating to artery

The ulcer at the right is penetrating through the muscularis and The ulcer at the right is penetrating through the muscularis and approaching an artery. Erosion of the ulcer into the artery will lead to approaching an artery. Erosion of the ulcer into the artery will lead to another major complication of ulcers--hemorrhage. This hemorrhage another major complication of ulcers--hemorrhage. This hemorrhage

can be life threatening. Chronic blood loss may lead to an iron can be life threatening. Chronic blood loss may lead to an iron deficiency anemia.deficiency anemia.

Helicobacter pylori in Helicobacter pylori in stomachstomach

Gastritis is often accompanied by infection with Helicobacter Gastritis is often accompanied by infection with Helicobacter pylori. This small curved to spiral rod-shaped bacterium is pylori. This small curved to spiral rod-shaped bacterium is found in the surface epithelial mucus of most patients with found in the surface epithelial mucus of most patients with active gastritis. The rods are seen here with a methylene active gastritis. The rods are seen here with a methylene

blue stain.blue stain.

Acute duodenal ulcerAcute duodenal ulcer

The strongest association with Helicobacter pylori is with The strongest association with Helicobacter pylori is with duodenal peptic ulceration--over 85% of duodenal ulcers. duodenal peptic ulceration--over 85% of duodenal ulcers.

Seen here is a penetrating Seen here is a penetrating acute ulcerationacute ulceration (arrow) in the (arrow) in the duodenum just beyond the pylorus. duodenum just beyond the pylorus.

Anti-parietal cell Anti-parietal cell autoantibodyautoantibody

Another association with gastritis is pernicious anemia. Chronic Another association with gastritis is pernicious anemia. Chronic atrophic gastritis is associated with autoantibodies that block atrophic gastritis is associated with autoantibodies that block

or bind intrinsic factor. Another type of autoantibody or bind intrinsic factor. Another type of autoantibody demonstrated here is anti-parietal cell antibody. The bright demonstrated here is anti-parietal cell antibody. The bright

green immunofluorescence is seen in the paritetal cells of the green immunofluorescence is seen in the paritetal cells of the gastric mucosa.gastric mucosa.

Gastric adenocarcinomaGastric adenocarcinoma

Gastric adenocarcinoma Gastric adenocarcinoma with ulcerationwith ulceration

Here is a gastric ulcer in the center of the picture. It is shallow and is Here is a gastric ulcer in the center of the picture. It is shallow and is about 2 to 4 cm in size. about 2 to 4 cm in size.

Gastric adenocarcinoma, Gastric adenocarcinoma, linitis plastica typelinitis plastica type

(a)(a) This is an example of This is an example of linitis plastica, a diffuse linitis plastica, a diffuse infiltrative gastric infiltrative gastric adenocarcinoma which adenocarcinoma which gives the stomach a gives the stomach a shrunken "leather bottle" shrunken "leather bottle" appearance with appearance with extensive mucosal extensive mucosal erosionerosion (white arrow) (white arrow) and a and a markedly markedly thickenedthickened (black arrow) (black arrow) gastric wall. This type of gastric wall. This type of carcinoma has a very carcinoma has a very poor prognosis. poor prognosis.

(b)(b) The endoscopic view of The endoscopic view of this lesion is shown, with this lesion is shown, with extensive mucosal extensive mucosal erosion.erosion.

Gastric adenocarcinoma Gastric adenocarcinoma with metastaseswith metastases

At autopsy, the thoracic cavity and abdominal cavity are both opened to At autopsy, the thoracic cavity and abdominal cavity are both opened to reveal the stomach just to the right and below the edge of liver in this reveal the stomach just to the right and below the edge of liver in this photograph. Gastric adenocarcinoma has infiltrated through the wall photograph. Gastric adenocarcinoma has infiltrated through the wall and appears on the surface as irregular tan masses. The extensive and appears on the surface as irregular tan masses. The extensive

tumor in this case caused gastric outlet obstruction.tumor in this case caused gastric outlet obstruction.

Gastric adenocarcinomaGastric adenocarcinoma

(a)(a) A moderately differentiated gastric adenocarcinoma is infiltrating up and into the submucosa below the A moderately differentiated gastric adenocarcinoma is infiltrating up and into the submucosa below the squamous mucosa of the esophagus. The neoplastic glands are variably sized.squamous mucosa of the esophagus. The neoplastic glands are variably sized.

(b)(b) The neoplastic glands of gastric adenocarcinoma demonstrate mitoses, increased nuclear/cytoplasmic The neoplastic glands of gastric adenocarcinoma demonstrate mitoses, increased nuclear/cytoplasmic ratios, and hyperchromatism. There is a desmoplastic stromal reaction to the infiltrating glands.ratios, and hyperchromatism. There is a desmoplastic stromal reaction to the infiltrating glands.

(c)(c) This gastric adenocarcinoma is so poorly differentiated that glands are not visible. Instead, rows of This gastric adenocarcinoma is so poorly differentiated that glands are not visible. Instead, rows of infiltrating neoplastic cells with marked pleomorphism are seen. Many of the neoplastic cells have clear infiltrating neoplastic cells with marked pleomorphism are seen. Many of the neoplastic cells have clear vacuoles of mucin.vacuoles of mucin.

(d)(d) This is a signet ring cell pattern of adenocarcinoma in which the cells are filled with mucin vacuoles that This is a signet ring cell pattern of adenocarcinoma in which the cells are filled with mucin vacuoles that push the nucleus to one side, as shown at the arrow.push the nucleus to one side, as shown at the arrow.

(a) (b)

(c) (d)

LPO Medium power

HPO HPO, signet ring pattern

Cytokeratin positive Cytokeratin positive gastric adenocarcinomagastric adenocarcinoma

This is an immunoperoxidase stain with antibody to cytokeratin, which is This is an immunoperoxidase stain with antibody to cytokeratin, which is positive in the poorly differentiated neoplastic cells seen here infiltrating positive in the poorly differentiated neoplastic cells seen here infiltrating through the gastric wall. Cytokeratin staining is typical for neoplasms of through the gastric wall. Cytokeratin staining is typical for neoplasms of

epithelial origin (carcinomas).epithelial origin (carcinomas).

Small IntestineSmall Intestine

Normal mesentery

Seen here is a loop of bowel attached via the mesentery. Note the extent of the veins. Arteries run in the same location. Thus, there is an extensive anastomosing arterial blood supply to the bowel, making it more difficult to infarct. Also, the extensive venous drainage is incorporated into the portal venous system heading to the liver.

Normal terminal ileum

This is the normal appearance of terminal ileum. In the upper frame, note the ileocecal valve (arrow), and several darker oval Peyer's patches (P) are

present on the mucosa. In the lower frame, a Peyer's patch, which is a concentration of

submucosal lymphoid tissue, is present. Note the folds are not as prominent here as in the jejunum, as

evidenced by the colonoscopic view.

P

P

Normal small intestinal Normal small intestinal mucosamucosa

This is the normal appearance of small intestinal mucosa with This is the normal appearance of small intestinal mucosa with long villi that have occasional goblet cells. The villi provide a long villi that have occasional goblet cells. The villi provide a

large area for digestion and absorption.large area for digestion and absorption.

Adhesions, peritoneum, Adhesions, peritoneum, small intestinesmall intestine

This is an adhesion between loops of small intestine. Such adhesions are This is an adhesion between loops of small intestine. Such adhesions are typical following abdominal surgery. More diffuse adhesions may also typical following abdominal surgery. More diffuse adhesions may also

form following peritonitis.form following peritonitis.

Small intestinal infarctionSmall intestinal infarction

The dark red infarcted small intestine contrasts with the light pink viable The dark red infarcted small intestine contrasts with the light pink viable bowel. The forceps extend through an internal hernia in which a loop of bowel. The forceps extend through an internal hernia in which a loop of

bowel and mesentery has been caught. This is one complication of bowel and mesentery has been caught. This is one complication of adhesions from previous surgery. The trapped bowel has lost its blood adhesions from previous surgery. The trapped bowel has lost its blood

supply.supply.

Cecum, volvulusCecum, volvulus

Volvulus is a twisting of the bowel. Volvulus is most common in adults, Volvulus is a twisting of the bowel. Volvulus is most common in adults, where it occurs with equal frequency in small intestine (around a where it occurs with equal frequency in small intestine (around a

twisted mesentery) and colon (in either sigmoid or cecum which are twisted mesentery) and colon (in either sigmoid or cecum which are more mobile). In very young children, volvulus almost always happens more mobile). In very young children, volvulus almost always happens

in the small intestine.in the small intestine.

Ischemic enteritisIschemic enteritis(a)(a) The small intestinal mucosa demonstrates The small intestinal mucosa demonstrates

marked hyperemia as a result of ischemic marked hyperemia as a result of ischemic enteritis. Such ischemia most often results enteritis. Such ischemia most often results from hypotension (shock) from cardiac from hypotension (shock) from cardiac failure, from marked blood loss, or from loss failure, from marked blood loss, or from loss of blood supply from mechanical obstruction of blood supply from mechanical obstruction (as with the bowel incarcerated in a hernia (as with the bowel incarcerated in a hernia or with volvulus or intussusception). If the or with volvulus or intussusception). If the blood supply is not quickly restored, the blood supply is not quickly restored, the bowel will infarct.bowel will infarct.

(b)(b) In LPO, the mucosal surface of the bowel In LPO, the mucosal surface of the bowel seen here shows early necrosis with seen here shows early necrosis with hyperemia extending all the way from hyperemia extending all the way from mucosa to submucosal and muscular wall mucosa to submucosal and muscular wall vessels. The submucosa and muscularis, vessels. The submucosa and muscularis, however, are still intact.however, are still intact.

(c)(c) At higher magnification with more advanced At higher magnification with more advanced necrosis, the small intestinal mucosa shows necrosis, the small intestinal mucosa shows hemorrhage with acute inflammation in this hemorrhage with acute inflammation in this case of ischemic enteritis.case of ischemic enteritis.

(a)

(b)

(c)

Peritonitis from bowel Peritonitis from bowel perforationperforation

Perforation of GI tract (from lower esophagus to colon) can result in a Perforation of GI tract (from lower esophagus to colon) can result in a peritonitis as seen here at autopsy. A thick yellow purulent exudate peritonitis as seen here at autopsy. A thick yellow purulent exudate covers peritoneal surfaces. An ovarian carcinoma caused sigmoid covers peritoneal surfaces. An ovarian carcinoma caused sigmoid colonic obstruction (the sigmoid is the markedly dilated grey-black colonic obstruction (the sigmoid is the markedly dilated grey-black

bowel in the pelvis seen here) with perforation. bowel in the pelvis seen here) with perforation.

Carcinoid tumor of small Carcinoid tumor of small intestineintestine

(a)(a) Seen here at the ileocecal valve is a Seen here at the ileocecal valve is a tumor that has a faint yellowish tumor that has a faint yellowish color. This is a carcinoid tumor. color. This is a carcinoid tumor. Most benign tumors are incidental Most benign tumors are incidental submucosal lesions, though rarely submucosal lesions, though rarely they can be large enough to they can be large enough to obstruct the lumen.obstruct the lumen.

(b)(b) In LPO, the carcinoid tumor is seen In LPO, the carcinoid tumor is seen here to be a discreet, though not here to be a discreet, though not encapsulated, mass of multiple encapsulated, mass of multiple nests of small blue cells in the nests of small blue cells in the submucosa.submucosa.

(c)(c) At high magnification, the nests of At high magnification, the nests of carcinoid tumor have a typical carcinoid tumor have a typical endocrine appearance with small endocrine appearance with small round cells having small round round cells having small round nuclei and pink to pale blue nuclei and pink to pale blue cytoplasm. Rarely, a malignant cytoplasm. Rarely, a malignant carcinoid tumor can occur as a carcinoid tumor can occur as a large bulky mass. Metastatic large bulky mass. Metastatic carcinoid to the liver can rarely carcinoid to the liver can rarely result in the carcinoid syndrome.result in the carcinoid syndrome.

(a)

(b)

(c)

LPO

HPO

Metastasis to small Metastasis to small intestineintestine

The most common neoplasm in small bowel is a metastasis as seen here. The most common neoplasm in small bowel is a metastasis as seen here. This mass caused local obstruction. Primary sites are often from This mass caused local obstruction. Primary sites are often from

nearby colon, ovary, pancreas, and stomach.nearby colon, ovary, pancreas, and stomach.

Primary adenocarcinoma, Primary adenocarcinoma, ampullaampulla

This adenocarcinoma arose in the ampulla of Vater. Primary small This adenocarcinoma arose in the ampulla of Vater. Primary small intestinal carcinomas are very rare, but the majority of those that do intestinal carcinomas are very rare, but the majority of those that do

occur arise in the region of the ampulla, where they may become occur arise in the region of the ampulla, where they may become symptomatic through biliary or pancreatic duct obstruction. The symptomatic through biliary or pancreatic duct obstruction. The

appearance of such a appearance of such a massmass on esophagogastroduodenoscopy is on esophagogastroduodenoscopy is seen, and following placement of a stent for drainage.seen, and following placement of a stent for drainage.

Leiomyosarcoma of small Leiomyosarcoma of small intestineintestine

This is a leiomyosarcoma of the small bowel. As with sarcomas in This is a leiomyosarcoma of the small bowel. As with sarcomas in general, this one is big and bad. Sarcomas are uncommon at this site, general, this one is big and bad. Sarcomas are uncommon at this site,

but must be distinguished from other types of neoplasms.but must be distinguished from other types of neoplasms.

Non-Hodgkin's lymphoma Non-Hodgkin's lymphoma of small intestineof small intestine

In LPO, the large blue non-Hodgkin's lymphoma cells can be seen In LPO, the large blue non-Hodgkin's lymphoma cells can be seen infiltrating through the mucosa.infiltrating through the mucosa.

At high magnification, the non-Hodgkin's lymphoma cells have prominent At high magnification, the non-Hodgkin's lymphoma cells have prominent clumped chromatin and nucleoli with occasional mitotic figures. clumped chromatin and nucleoli with occasional mitotic figures.

LPO HPO

Meckel's diverticulumMeckel's diverticulum

Congenital anomalies of bowel consist mainly of diverticulae or atresias Congenital anomalies of bowel consist mainly of diverticulae or atresias which are often in association with other congenital anomalies. Seen which are often in association with other congenital anomalies. Seen

here is the most common congenital anomaly of the GI tract--a here is the most common congenital anomaly of the GI tract--a Meckel's diverticulum. Remember the number 2: about 2% of people Meckel's diverticulum. Remember the number 2: about 2% of people have them; they are usually located 2 feet from the ileocecal valve.have them; they are usually located 2 feet from the ileocecal valve.

Celiac sprue compared to Celiac sprue compared to normal small intestinenormal small intestine

Normal small intestinal mucosa is seen at the left, and mucosa Normal small intestinal mucosa is seen at the left, and mucosa involved by celiac sprue at the right. There is blunting and involved by celiac sprue at the right. There is blunting and

flattening of villi with celiac disease, and in severe cases a loss of flattening of villi with celiac disease, and in severe cases a loss of villi with flattening of the mucosa as seen here. villi with flattening of the mucosa as seen here.

Celiac sprue, Celiac sprue, small intestinesmall intestine

The small intestinal mucosa at high magnification shows marked chronic inflammation The small intestinal mucosa at high magnification shows marked chronic inflammation in celiac sprue. There is sensitivity to gluten, which contains the protein gliaden, in celiac sprue. There is sensitivity to gluten, which contains the protein gliaden, found in cereal grains wheat, oats, barley, and rye. Removing foods containing found in cereal grains wheat, oats, barley, and rye. Removing foods containing

these grains from the diet will cause this gluten-sensitive enteropathy to subside. these grains from the diet will cause this gluten-sensitive enteropathy to subside. The enteropathy shown here has loss of crypts, increased mitotic activity, loss of The enteropathy shown here has loss of crypts, increased mitotic activity, loss of

brush border, and infiltration with lymphocytes and plasma cells (B-cells sensitized brush border, and infiltration with lymphocytes and plasma cells (B-cells sensitized to gliaden).to gliaden).

Giardia lamblia, Giardia lamblia, small intestinesmall intestine

This is an example of infectious diarrhea due to Giardia lamblia infection This is an example of infectious diarrhea due to Giardia lamblia infection of the small intestine. The small pear-shaped trophozoites live in the of the small intestine. The small pear-shaped trophozoites live in the

duodenum and become infective cysts that are excreted. They duodenum and become infective cysts that are excreted. They produce a watery diarrhea. A useful test for diagnosis of infectious produce a watery diarrhea. A useful test for diagnosis of infectious

diarrheas is stool examination for ova and parasites.diarrheas is stool examination for ova and parasites.

Cryptosporidiosis, Cryptosporidiosis, small intestinesmall intestine

This is another infectious agent that is becoming more frequent in This is another infectious agent that is becoming more frequent in immunocompromised patients, particularly those with AIDS. The immunocompromised patients, particularly those with AIDS. The

small round blue organisms at the lumenal border are cryptosporidia. small round blue organisms at the lumenal border are cryptosporidia. Cryptosporidiosis produces a copious watery diarrhea.Cryptosporidiosis produces a copious watery diarrhea.

Colon and Colon and AppendixAppendix

Normal colonic views with colonoscopyNormal colonic views with colonoscopyCecum and Cecum and appendiceal orificeappendiceal orifice

Splenic flexureSplenic flexure

CecumCecum Sigmoid colonSigmoid colon

Ascending colonAscending colon RectumRectum

Transverse colonTransverse colon

Normal colonic mucosaNormal colonic mucosa

Note the crypts that are lined by numerous goblet cells. In the submucosa Note the crypts that are lined by numerous goblet cells. In the submucosa is a lymphoid nodule. The gut-associated lymphoid tissue as a unit is a lymphoid nodule. The gut-associated lymphoid tissue as a unit

represents the largest lymphoid organ of the body.represents the largest lymphoid organ of the body.

Pseudomembranous Pseudomembranous colitiscolitis

(a)(a) The mucosal surface of the colon seen here is hyperemic and is partially covered The mucosal surface of the colon seen here is hyperemic and is partially covered by a yellow-green exudate. The mucosa itself is not eroded. by a yellow-green exudate. The mucosa itself is not eroded.

(b)(b) In LPO, the pseudomembrane is seen to be composed of inflammatory cells, In LPO, the pseudomembrane is seen to be composed of inflammatory cells, necrotic epithelium, and mucus in which the overgrowth of microorganisms takes necrotic epithelium, and mucus in which the overgrowth of microorganisms takes place. The underlying mucosa shows congested vessels, but is still intact.place. The underlying mucosa shows congested vessels, but is still intact.

(c)(c) At higher magnification, the overlying pseudomembrane at the left has numerous At higher magnification, the overlying pseudomembrane at the left has numerous inflammatory cells, mainly neutrophils.inflammatory cells, mainly neutrophils.

(a)

(b)

(c)

LPO

HPO

Appendix, normalAppendix, normal

This is the normal appearance of the This is the normal appearance of the appendixappendix against the against the background of the cecum. The colonoscopic view of the background of the cecum. The colonoscopic view of the

appendiceal orificeappendiceal orifice between the fork of two haustral folds between the fork of two haustral folds in the cecum is seen below.in the cecum is seen below.

Acute appendicitisAcute appendicitis

(a)(a) Seen here is acute appendicitis with yellow to tan exudate and hyperemia, including the Seen here is acute appendicitis with yellow to tan exudate and hyperemia, including the periappendiceal fat superiorly, rather than a smooth, glistening pale tan serosal surface.periappendiceal fat superiorly, rather than a smooth, glistening pale tan serosal surface.

(b)(b) In LPO, acute appendicitis is marked by mucosal inflammation and necrosis.In LPO, acute appendicitis is marked by mucosal inflammation and necrosis.(c)(c) The mucosa shows ulceration and undermining by an extensive neutrophilic exudate.The mucosa shows ulceration and undermining by an extensive neutrophilic exudate.(d)(d) Neutrophils extend into and through the wall of the appendix in a case of acute Neutrophils extend into and through the wall of the appendix in a case of acute

appendicitis. appendicitis.

(a) (b)

(c) (d)

LPO

Medium power HPO

Colon, adenomatous Colon, adenomatous polyp (tubular adenoma)polyp (tubular adenoma)

(a)(a) This lesion is called a "tubular This lesion is called a "tubular adenoma" because of the rounded adenoma" because of the rounded nature of the neoplastic glands that nature of the neoplastic glands that form it. It has smooth surfaces and form it. It has smooth surfaces and is discreet. is discreet.

(b)(b) This small adenomatous polyp This small adenomatous polyp (tubular adenoma) on a small stalk (tubular adenoma) on a small stalk is seen microscopically to have is seen microscopically to have more crowded, disorganized glands more crowded, disorganized glands than the normal underlying colonic than the normal underlying colonic mucosa. Goblet cells are less mucosa. Goblet cells are less numerous and the cells lining the numerous and the cells lining the glands of the polyp have glands of the polyp have hyperchromatic nuclei. However, it hyperchromatic nuclei. However, it is still well-differentiated and is still well-differentiated and circumscribed, without invasion of circumscribed, without invasion of the stalk, and is benign. the stalk, and is benign.

(c)(c) This adenomatous polyp has a This adenomatous polyp has a hemorrhagic surface (which is why hemorrhagic surface (which is why they may first be detected with stool they may first be detected with stool occult blood screening) and a long occult blood screening) and a long narrow stalk. The size of this polyp--narrow stalk. The size of this polyp--above 2 cm--makes the possibility above 2 cm--makes the possibility of malignancy more likely, but this of malignancy more likely, but this polyp proved to be benign.polyp proved to be benign.

(d)(d) The colonoscopic appearance of The colonoscopic appearance of rectal polyps that proved to be rectal polyps that proved to be tubular adenomas tubular adenomas

(a)

(b) (c)

(d)

Colon, multiple Colon, multiple adenomatous polypsadenomatous polyps

Here are multiple adenomatous polyps of the cecum. A small Here are multiple adenomatous polyps of the cecum. A small portion of terminal ileum appears at the right. portion of terminal ileum appears at the right.

Colon, familial Colon, familial adenomatous polyposisadenomatous polyposis

This is familial polyposis in which the mucosal surface of the This is familial polyposis in which the mucosal surface of the colon is essentially a carpet of small adenomatous polyps. colon is essentially a carpet of small adenomatous polyps.

Colon, familial adenomatous Colon, familial adenomatous polyposis (Gardner's polyposis (Gardner's syndrome)syndrome)

Here is another example of polyposis with numerous small polyps Here is another example of polyposis with numerous small polyps covering the colonic mucosa. In this particular case, there were covering the colonic mucosa. In this particular case, there were

osteomas of the skull, a periampullary adenocarcinoma, and osteomas of the skull, a periampullary adenocarcinoma, and epidermal inclusion cysts. Thus, this is a case of Gardner's epidermal inclusion cysts. Thus, this is a case of Gardner's

syndrome. As with familial adenomatous polyposis, the syndrome. As with familial adenomatous polyposis, the inheritance pattern is autosomal dominant.inheritance pattern is autosomal dominant.

Colon, adenomatous polyp Colon, adenomatous polyp (tubular adenoma) compared (tubular adenoma) compared to normal mucosa to normal mucosa

A microscopic comparison of normal colonic mucosa on the left and A microscopic comparison of normal colonic mucosa on the left and that of an adenomatous polyp (tubular adenoma) on the right is that of an adenomatous polyp (tubular adenoma) on the right is seen here. The neoplastic glands are more irregular with darker seen here. The neoplastic glands are more irregular with darker (hyperchromatic) and more crowded nuclei. This neoplasm is (hyperchromatic) and more crowded nuclei. This neoplasm is benign and well-differentiated, as it still closely resembles the benign and well-differentiated, as it still closely resembles the

normal colonic structure.normal colonic structure.

Colon, villous adenoma, Colon, villous adenoma, composite composite

Note that this type of adenoma is sessile, rather than pedunculated, Note that this type of adenoma is sessile, rather than pedunculated, and larger than a tubular adenoma (adenomatous polyp). A villous and larger than a tubular adenoma (adenomatous polyp). A villous adenoma averages several centimeters in diameter, and may be up adenoma averages several centimeters in diameter, and may be up to 10 cm. to 10 cm.

Microscopically, a villous adenoma is shown at its edge on the left, Microscopically, a villous adenoma is shown at its edge on the left, and projecting above the basement membrane at the right. The and projecting above the basement membrane at the right. The cauliflower-like appearance is due to the elongated glandular cauliflower-like appearance is due to the elongated glandular structures covered by dysplastic epithelium. Though villous structures covered by dysplastic epithelium. Though villous adenomas are less common than adenomatous polyps, they are adenomas are less common than adenomatous polyps, they are much more likely to have invasive carcinoma in them (about 40% of much more likely to have invasive carcinoma in them (about 40% of villous adenomas).villous adenomas).

On colonoscopy, a sessile polyp is seen On colonoscopy, a sessile polyp is seen

Colon, adenocarcinoma Colon, adenocarcinoma

An encircling An encircling adenocarcinomaadenocarcinoma (arrow) of the rectosigmoid (arrow) of the rectosigmoid region is seen here. There is a heaped up margin of tumor at region is seen here. There is a heaped up margin of tumor at each side with a central area of ulceration. This produces the each side with a central area of ulceration. This produces the bleeding that allows detection through a stool guaiac test. bleeding that allows detection through a stool guaiac test. Normal mucosa appears at the right. The tumor encircles the Normal mucosa appears at the right. The tumor encircles the colon and infiltrates into the wall. Staging is based upon the colon and infiltrates into the wall. Staging is based upon the degree of invasion into and through the wall. degree of invasion into and through the wall.

The colonoscopic views of a smaller rectal adenocarcinoma, The colonoscopic views of a smaller rectal adenocarcinoma, but still with an ulcerated surface, are shown above.but still with an ulcerated surface, are shown above.

The barium enema technique instills the radiopaque barium The barium enema technique instills the radiopaque barium sulfate into the colon, producing a contrast with the wall of the sulfate into the colon, producing a contrast with the wall of the colon that highlights any masses present . In this case, the colon that highlights any masses present . In this case, the classic "apple core" lesion is present (arrow), representing an classic "apple core" lesion is present (arrow), representing an encircling adenocarcinoma that constricts the lumen.encircling adenocarcinoma that constricts the lumen.

Colon, adenocarcinoma Colon, adenocarcinoma

adenocarcinoma arising in villous adenoma

Colon, adenocarcinoma Colon, adenocarcinoma

The neoplastic glands are long and frond-like, similar to those seen in a villous adenoma. The growth is primarily exophytic (outward

into the lumen) and invasion is not seen at this point.

LPO

Microscopically, a moderately differentiated adenocarcinoma of colon is seen here. There is still a glandular configuration, but the glands are irregular and very crowded. Many of them have lumens

containing bluish mucin.

Medium power

Here is an adenocarcinoma in which the glands are much larger and filled with necrotic debris.

At high magnification, the neoplastic glands of adenocarcinoma have crowded nuclei with hyperchromatism and pleomorphism. No

normal goblet cells are seen.

Medium power HPO

Colon, descending, Colon, descending, adenocarcinoma ** check adenocarcinoma ** check MRIMRI

The encircling mass of firm adenocarcinoma in this colon at the left is The encircling mass of firm adenocarcinoma in this colon at the left is typical for adenocarcinomas arising in the descending colon. A change typical for adenocarcinomas arising in the descending colon. A change in stool or bowel habits can be created by the mass effect. in stool or bowel habits can be created by the mass effect.

By colonoscopy, a fungating, ulcerating mass is seen.By colonoscopy, a fungating, ulcerating mass is seen. This CT image of the abdomen demonstrates an encircling mass This CT image of the abdomen demonstrates an encircling mass

involving the colon (arrow) ****involving the colon (arrow) ****

Sigmoid colon, Sigmoid colon, diverticulosis diverticulosis

The sigmoid colon at the right The sigmoid colon at the right appears lighter in color than the appears lighter in color than the

adjacent small intestine and has a adjacent small intestine and has a band of band of taenia colitaenia coli (T) muscle (T) muscle

running longitudinally. Protruding running longitudinally. Protruding from the sigmoid colon are multiple from the sigmoid colon are multiple

rounded bluish-gray rounded bluish-gray diverticula diverticula (arrow). Diverticula are much more (arrow). Diverticula are much more common in the colon than in small common in the colon than in small

intestine, and they are more intestine, and they are more common in the left colon, and they common in the left colon, and they are more common in persons living are more common in persons living in developed nations in which the in developed nations in which the

usual diet has less fiber.usual diet has less fiber.

T

Colon, diverticulosis Colon, diverticulosis (a)(a) Several diverticula are seen Several diverticula are seen

along the length of the along the length of the descending colon. Focal descending colon. Focal weaknesses in the bowel wall weaknesses in the bowel wall and increased lumenal pressure and increased lumenal pressure contribute to the formation of contribute to the formation of diverticula.diverticula.

(b)(b) The colon has been opened to The colon has been opened to reveal the presence of non-reveal the presence of non-inflamed diverticula. Each has an inflamed diverticula. Each has an openingopening (arrow) to the colonic (arrow) to the colonic lumen through a narrow neck. lumen through a narrow neck.

(c)(c) The surface of the colon is The surface of the colon is hyperemic because of hyperemic because of inflammation as a result of inflammation as a result of diverticulitis. The erosion of the diverticulitis. The erosion of the mucosa by the stool in the mucosa by the stool in the diverticula can produce diverticula can produce inflammation and hemorrhage.inflammation and hemorrhage.

(d)(d) This diverticulum has become This diverticulum has become inflamed and has ruptured inflamed and has ruptured outward, seen as the dark brown outward, seen as the dark brown irregular tract extending down irregular tract extending down from the mucosal surface here.from the mucosal surface here.

(a) (b)

(c) (d)

At low magnification, a colonic At low magnification, a colonic diverticulum has a central lumen diverticulum has a central lumen

with surrounding mucosa, while the with surrounding mucosa, while the wall (lacking a muscularis) is wall (lacking a muscularis) is

attenuated. The narrow neck of the attenuated. The narrow neck of the diverticulum may become eroded.diverticulum may become eroded.

Colon, diverticulosis Colon, diverticulosis

Colonoscopic views of diverticula

Prolapsed true Prolapsed true hemorrhoids hemorrhoids

Seen here is the anus and perianal region with prominent prolapsed true (internal) Seen here is the anus and perianal region with prominent prolapsed true (internal) hemorrhoids. Hemorrhoids consist of dilated submucosal veins which may thrombose and hemorrhoids. Hemorrhoids consist of dilated submucosal veins which may thrombose and rupture with hematoma formation. External hemorrhoids form beyond the intersphincteric rupture with hematoma formation. External hemorrhoids form beyond the intersphincteric

groove to produce an "acute pile" at the anal verge. Chronic constipation, chronic groove to produce an "acute pile" at the anal verge. Chronic constipation, chronic diarrhea, pregnancy, and portal hypertension enhance hemorrhoid formation. diarrhea, pregnancy, and portal hypertension enhance hemorrhoid formation.

Hemorrhoids can itch and bleed (usually bright red blood, during defacation). Seen on the Hemorrhoids can itch and bleed (usually bright red blood, during defacation). Seen on the right is on colonoscopy are views of hemorrhoids at the anorectal junction. right is on colonoscopy are views of hemorrhoids at the anorectal junction.

Inflammatory Inflammatory Bowel DiseaseBowel Disease

Crohn's diseaseCrohn's disease

Though any portion of the gastrointestinal tract may be involved with Crohn's disease, the small intestine--Though any portion of the gastrointestinal tract may be involved with Crohn's disease, the small intestine--and the terminal ileum in particular--is most likely to be involved. The middle portion of bowel seen here and the terminal ileum in particular--is most likely to be involved. The middle portion of bowel seen here

has a thickened wall and the mucosa has lost the regular folds. The serosal surface demonstrates has a thickened wall and the mucosa has lost the regular folds. The serosal surface demonstrates reddish indurated adipose tissue that creeps over the surface. Serosal inflammation leads to adhesions. reddish indurated adipose tissue that creeps over the surface. Serosal inflammation leads to adhesions. The areas of inflammation tend to be discontinuous throughout the bowel. The endoscopic appearance The areas of inflammation tend to be discontinuous throughout the bowel. The endoscopic appearance

with colonoscopy, demonstrating mucosal erythema and erosion, is seen with colonoscopy, demonstrating mucosal erythema and erosion, is seen

This is another example of Crohn's disease involving the small intestine. Here, the mucosal surface

demonstrates an irregular nodular appearance with hyperemia and focal superficial ulceration.

TERMINAL ILEUM

Crohn's disease Crohn's disease

Microscopically, Crohn's disease is characterized by transmural Microscopically, Crohn's disease is characterized by transmural inflammation. Here, inflammatory cells (the bluish infiltrates) inflammation. Here, inflammatory cells (the bluish infiltrates)

extend from mucosa through submucosa and muscularis extend from mucosa through submucosa and muscularis and appear as nodular infiltrates on the serosal surface with and appear as nodular infiltrates on the serosal surface with

pale granulomatous centers.pale granulomatous centers.

COLON

At high magnification the granulomatous nature of the At high magnification the granulomatous nature of the inflammation of Crohn's disease is demonstrated here with inflammation of Crohn's disease is demonstrated here with

epithelioid cells, giant cells, and many lymphocytes. epithelioid cells, giant cells, and many lymphocytes.

SMALL INTESTINE

One complication of Crohn's disease is fistula formation. Seen One complication of Crohn's disease is fistula formation. Seen here is a fissure extending through mucosa at the left into here is a fissure extending through mucosa at the left into the submucosa toward the muscular wall, which eventually the submucosa toward the muscular wall, which eventually

will form a fistula. Fistulae can form between loops of bowel, will form a fistula. Fistulae can form between loops of bowel, bladder, and skin. With colonic involvement, perirectal bladder, and skin. With colonic involvement, perirectal

fistulae are common.fistulae are common.

Chronic ulcerative colitisChronic ulcerative colitis

LEFT: LEFT: This gross appearance is characteristic for ulcerative colitis. The most intense This gross appearance is characteristic for ulcerative colitis. The most intense inflammation begins at the lower right in the sigmoid colon and extends upward and inflammation begins at the lower right in the sigmoid colon and extends upward and around to the ascending colon. At the lower left is the ileocecal valve with a portion around to the ascending colon. At the lower left is the ileocecal valve with a portion of terminal ileum that is not involved. Inflammation with ulcerative colitis tends to be of terminal ileum that is not involved. Inflammation with ulcerative colitis tends to be continuous along the mucosal surface and tends to begin in the rectum. The mucosa continuous along the mucosal surface and tends to begin in the rectum. The mucosa becomes eroded, as in this photograph, which shows only remaining islands of becomes eroded, as in this photograph, which shows only remaining islands of mucosa called "pseudopolyps".mucosa called "pseudopolyps".

RIGHT: RIGHT: At higher magnification, the pseudopolyps can be seen clearly as raised red At higher magnification, the pseudopolyps can be seen clearly as raised red islands of inflamed mucosa. Between the pseudopolyps is only remaining islands of inflamed mucosa. Between the pseudopolyps is only remaining muscularis.muscularis.

Chronic ulcerative colitisChronic ulcerative colitis

LEFT: LEFT: Here is another example of extensive ulcerative colitis (UC). The Here is another example of extensive ulcerative colitis (UC). The ileocecal valve is seen at the lower left. Just above this valve in the cecum is ileocecal valve is seen at the lower left. Just above this valve in the cecum is the beginning of the mucosal inflammation with erythema and granularity. As the beginning of the mucosal inflammation with erythema and granularity. As the disease progresses, the mucosal erosions coalesce to linear ulcers that the disease progresses, the mucosal erosions coalesce to linear ulcers that undermine remaining mucosa. undermine remaining mucosa.

RIGHT: RIGHT: Colonoscopic views of less severe UC are seen, with friable, Colonoscopic views of less severe UC are seen, with friable, erythematous mucosa with reduced haustral folds.erythematous mucosa with reduced haustral folds.

Chronic ulcerative colitisChronic ulcerative colitis

PseudopolypsPseudopolyps (arrow) are seen here in a case of severe ulcerative colitis. (arrow) are seen here in a case of severe ulcerative colitis. The remaining mucosa has been ulcerated away and is hyperemic. A The remaining mucosa has been ulcerated away and is hyperemic. A colonoscopic view of active ulcerative colitis, but not so eroded as to colonoscopic view of active ulcerative colitis, but not so eroded as to

produce pseudopolyps, is seen on the right image.produce pseudopolyps, is seen on the right image.

Chronic ulcerative colitisChronic ulcerative colitis

LPO:LPO: Microscopically, the inflammation of ulcerative colitis is confined Microscopically, the inflammation of ulcerative colitis is confined primarily to the mucosa. Here, the mucosa is eroded by an ulcer that primarily to the mucosa. Here, the mucosa is eroded by an ulcer that undermines surrounding mucosa.undermines surrounding mucosa.

HPO:HPO: At higher magnification, the intense inflammation of the mucosa is At higher magnification, the intense inflammation of the mucosa is seen. The colonic mucosal epithelium demonstrates loss of goblet seen. The colonic mucosal epithelium demonstrates loss of goblet cells. An exudate is present over the surface. Both acute and chronic cells. An exudate is present over the surface. Both acute and chronic inflammatory cells are present.inflammatory cells are present.

LPO HPO

Chronic ulcerative colitis Chronic ulcerative colitis with crypt abscesses with crypt abscesses

LEFT: LEFT: The colonic mucosa of active ulcerative colitis shows "crypt abscesses" The colonic mucosa of active ulcerative colitis shows "crypt abscesses" in which a neutrophilic exudate is found in glandular lumens. The in which a neutrophilic exudate is found in glandular lumens. The submucosa shows intense inflammation. The glands demonstrate submucosa shows intense inflammation. The glands demonstrate

loss of loss of goblet cells and hyperchromatic nuclei with inflammatory atypia.goblet cells and hyperchromatic nuclei with inflammatory atypia. RIGHT: RIGHT: Crypt abscesses are a histologic finding more typical with ulcerative Crypt abscesses are a histologic finding more typical with ulcerative

colitis. Unfortunately, not all cases of inflammatory bowel disease can colitis. Unfortunately, not all cases of inflammatory bowel disease can be be classified completely in all patients.classified completely in all patients.

Medium power HPO

Chronic ulcerative colitis Chronic ulcerative colitis with dysplasia with dysplasia

Over time, there is a risk for adenocarcinoma with ulcerative colitis. Over time, there is a risk for adenocarcinoma with ulcerative colitis. Here, more normal glands are seen at the left, but the glands at Here, more normal glands are seen at the left, but the glands at the right demonstrate dysplasia, the first indication that there is a the right demonstrate dysplasia, the first indication that there is a

move towards neoplasia.move towards neoplasia.

Gigi - sec D – ustmed2007