Difference between revisions of "An introduction to gastrointestinal pathology"

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'''Gastrointestinal pathology''' is a large part of pathology as [[radiologist]]s can often describe the extent of disease... but don't get the diagnosis right all the time.
[[Image:Tubular adenoma 4 low mag.jpg|thumb|right|250px|[[Micrograph]] of a [[Traditional adenoma|tubular adenoma]], a very common diagnosis in gastrointestinal pathology. [[H&E stain]].]]
'''Gastrointestinal pathology''', also '''gastrointestinal tract pathology''', is a large part of pathology as [[radiologist]]s can often describe the extent of disease... but don't get the [[diagnosis]] right all the time.
 
[[Cytopathology]] of the gastrointestinal tract is dealt with in the ''[[gastrointestinal cytopathology]]'' article.


=Normal=
=Normal=
===Layers===
===Layers===
[[Image:Illu stomach2.jpg|thumb|right|Layers of the stomach. (WC)]]
Layers of the alimentary canal:<ref>URL: [http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/Oral.htm http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/Oral.htm].</ref><ref>URL: [http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/Images/gitplan.gif http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/Images/gitplan.gif].</ref>
Layers of the alimentary canal:<ref>URL: [http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/Oral.htm http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/Oral.htm].</ref><ref>URL: [http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/Images/gitplan.gif http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/Images/gitplan.gif].</ref>
*Mucosa (epithelium, lamina propria, muscularis mucosa).
*Mucosa (epithelium, lamina propria, muscularis mucosa).
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**Subnuclear eosinophilic granules.
**Subnuclear eosinophilic granules.
***Serotonin.
***Serotonin.
*Paneth cells.
*[[Paneth cell]]s.
**Supranuclear eosinophilic granules.
**Supranuclear eosinophilic granules.


Memory device:
Memory device:
*Su'''p'''ranuclear granules = '''p'''aneth cell.
*Su'''p'''ranuclear granules = '''p'''aneth cell.
====Images====
www:
*[http://classconnection.s3.amazonaws.com/474/flashcards/538474/png/ne1307547591546.png Paneth cell versus neuroendocrine cell (amazonaws.com)].
*[http://www.pathology.washington.edu/about/education/barretts/Pseudogoblet.php Goblet cells versus pseudogoblet cells (washington.edu)].


===Bowel===
===Bowel===
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*Submucosal glands (Brunner's glands).
*Submucosal glands (Brunner's glands).


====Large bowel vs. small bowel====
====Large bowel versus small bowel====
*Small intestine.
*Small intestine.
**Villi (key feature).
**Villi (key feature).
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**More goblet cells.
**More goblet cells.
**More lymphocytes usually.
**More lymphocytes usually.
====Cecum versus rectum====
*[[Cecum]].
**Less goblet cells - more absorptive cells.<ref name=Ref_H4P3_633>{{Ref H4P3|633}}</ref>
**More inflammation ([[plasma cell]]s, eosinophils, lymphoid aggregates).<ref name=Ref_H4P3_633>{{Ref H4P3|633}}</ref>
**Paneth cells.
*Rectum.
**More goblet cells.
**No Paneth cells normally.


===DDx by location===
===DDx by location===
A short DDx for location of abnormality:
*Lumen:  
*Lumen:  
**[[Giardiasis]], [[amebiasis]], [[enterobius]].
**[[Giardiasis]], [[amebiasis]], [[enterobius]].
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**[[Cryptosporidiosis]], [[intestinal spirochetes]].
**[[Cryptosporidiosis]], [[intestinal spirochetes]].
*Infiltration of epithelium:
*Infiltration of epithelium:
**Intraepithelial lymphocytes - [[lymphocystic colitis]] & [[collagenous colitis]].
**Intraepithelial lymphocytes - [[lymphocytic colitis]] & [[collagenous colitis]].
**Intraepithelial neutrophils - infection, IBD, ischemia.
**Intraepithelial neutrophils - infection, IBD, ischemia.
*Epithelial architeture:
*Epithelial architeture:
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{{main|Duodenum}}
{{main|Duodenum}}
Commonly biopsied. Celiac... cancer... giardia?
Commonly biopsied. Celiac... cancer... giardia?
===Cecum===
{{Main|Cecum}}
The first part of the large intestine. Technically, it is not part of the colon.
===Appendix===
{{main|Appendix}}
It hangs off the [[cecum]].  Commonly, it comes to the pathologist because of [[acute appendicitis]].


===Colon===
===Colon===
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Colorectal tumours are dealt with in ''[[colorectal tumours]]''.  Crohn's disease and ulcerative colitis are dealt with in the ''[[inflammatory bowel disease]]'' article.
Colorectal tumours are dealt with in ''[[colorectal tumours]]''.  Crohn's disease and ulcerative colitis are dealt with in the ''[[inflammatory bowel disease]]'' article.
Includes discussion of the [[rectum]]. The [[anus]] is a separate article.
Includes discussion of the [[rectum]]. The [[anus]] is a separate article.
===Appendix===
{{main|Appendix}}
[[Acute appendicitis]] and more...


=Accessory organs of the gastrointestinal tract=
=Accessory organs of the gastrointestinal tract=
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==Eosinophilic enterocolitis==
==Eosinophilic enterocolitis==
:For the esophageal disease see: ''[[Eosinophilic esophagitis]]''.
{{Main|Eosinophilic enterocolitis}}
===General===
*Uncommon.
*Associated with food allergies, esp. in children.<ref>{{cite journal |author=Lucendo AJ |title=Eosinophilic diseases of the gastrointestinal tract |journal=Scand. J. Gastroenterol. |volume=45 |issue=9 |pages=1013–21 |year=2010 |month=September |pmid=20509820 |doi=10.3109/00365521003690251 |url=}}</ref>
 
===Microscopic===
Features:
*Eosinophilia.
*Eosinophilic abscesses.
 
DDx:
*[[IBD]].
*Infection.
*Drug reaction.


==Pneumatosis intestinalis==
==Pneumatosis intestinalis==
===General===
{{Main|Pneumatosis intestinalis}}
*Bad prognosis - esp. if diffuse.
 
===Gross===
*Small bubbles in the intestinal wall.
 
===Microscope===
Features:
*Large submucosal pseudocysts.
 
Image:
*[http://www.wjes.org/content/6/1/15/figure/F4?highres=y Pneumatosis cystoides intestinalis (wjes.org)].<ref name=pmid21548980>{{Cite journal  | last1 = Takami | first1 = Y. | last2 = Koh | first2 = T. | last3 = Nishio | first3 = M. | last4 = Nakagawa | first4 = N. | title = Pneumatosis intestinalis leading to perioperative hypovolemic shock: Case report. | journal = World J Emerg Surg | volume = 6 | issue =  | pages = 15 | month =  | year = 2011 | doi = 10.1186/1749-7922-6-15 | PMID = 21548980 |PMC = PMC3108289}}</ref>


==Pneumatosis cystoides intestinalis==
==Pneumatosis cystoides intestinalis==
===General===
{{Main|Pneumatosis cystoides intestinalis}}
*Benign, generally asymptomatic subset of [[pneumatosis intestinalis]].<ref>URL: [http://emedicine.medscape.com/article/371955-overview http://emedicine.medscape.com/article/371955-overview]. Accessed on: 24 January 2012.</ref>
*Small or large bowel.<ref>{{Cite journal  | last1 = Micklefield | first1 = GH. | last2 = Kuntz | first2 = HD. | last3 = May | first3 = B. | title = Pneumatosis cystoides intestinalis: case reports and review of the literature. | journal = Mater Med Pol | volume = 22 | issue = 2 | pages = 70-2 | month =  | year =  | doi =  | PMID = 2102980 }}</ref>
Etiology - many, e.g. [[IBD]], infection.
===Gross===
*Polypoid lesions.
 
Image:
[http://biblioteca.colmed5.org.ar/consultas/pneumatosis.htm Pneumatosis cystoides intestinalis (colmed5.org.ar)].
 
===Microscopic===
Features:
*Large submucosal pseudocysts lined by macrophages and multi-nucleated giant cells.
 
Image:
*[http://www.wjes.org/content/6/1/15/figure/F4?highres=y Pneumatosis cystoides intestinalis (wjes.org)].<ref name=pmid21548980>{{Cite journal  | last1 = Takami | first1 = Y. | last2 = Koh | first2 = T. | last3 = Nishio | first3 = M. | last4 = Nakagawa | first4 = N. | title = Pneumatosis intestinalis leading to perioperative hypovolemic shock: Case report. | journal = World J Emerg Surg | volume = 6 | issue =  | pages = 15 | month =  | year = 2011 | doi = 10.1186/1749-7922-6-15 | PMID = 21548980 |PMC = PMC3108289}}</ref>


=See also=
=See also=
*[[Introduction]].
*[[Introduction]].
*[[Pediatric gastrointestinal pathology]].
*[[Pediatric gastrointestinal pathology]].
*[[Gastrointestinal cytopathology]].


=References=
=References=

Latest revision as of 05:55, 3 February 2016

Micrograph of a tubular adenoma, a very common diagnosis in gastrointestinal pathology. H&E stain.

Gastrointestinal pathology, also gastrointestinal tract pathology, is a large part of pathology as radiologists can often describe the extent of disease... but don't get the diagnosis right all the time.

Cytopathology of the gastrointestinal tract is dealt with in the gastrointestinal cytopathology article.

Normal

Layers

Layers of the stomach. (WC)

Layers of the alimentary canal:[1][2]

  • Mucosa (epithelium, lamina propria, muscularis mucosa).
  • Submuscosa and submucosal plexus (or Meissner's plexus).
  • Muscularis externa (inner longitudinal, myenteric plexus (or Auerbach's plexus) outer circumferential).
  • Adventitia (if retroperitoneal), serosa (if intraperitoneal).

Cell types

  • Goblet cells.
    • Secrete mucin.
  • Enterochromaffin cells, AKA Kulchitsky cells.
    • Subnuclear eosinophilic granules.
      • Serotonin.
  • Paneth cells.
    • Supranuclear eosinophilic granules.

Memory device:

  • Supranuclear granules = paneth cell.

Images

www:

Bowel

Small bowel

  • Villi - should see three good ones in a normal biopsy.
  • Crypts.
  • Paneth cells.
  • Goblet cells.
    • Few in proximal small bowel (duodenum).
    • Abundant in distal small bowel (ileum).

Duodenum

  • Small bowel (as above).
  • Submucosal glands (Brunner's glands).

Large bowel versus small bowel

  • Small intestine.
    • Villi (key feature).
    • Brunner's glands - duodenum only (key feature).
    • Paneth cells more common.
      • Paneth cells are in the base of the crypts and have eosinophilic granules. They are found (normally) in the small bowel and right colon. They may appear on the left side (i.e. descending colon) in pathologic states, e.g. IBD.
  • Large intestine
    • More goblet cells.
    • More lymphocytes usually.

Cecum versus rectum

  • Cecum.
    • Less goblet cells - more absorptive cells.[3]
    • More inflammation (plasma cells, eosinophils, lymphoid aggregates).[3]
    • Paneth cells.
  • Rectum.
    • More goblet cells.
    • No Paneth cells normally.

DDx by location

A short DDx for location of abnormality:

  • Lumen:
  • Surface of epithelium:
  • Infiltration of epithelium:
  • Epithelial architeture:
    • Serration - SSA, hyperplastic polyp.
    • Increased lamina propria/loss of crypts - IBD, juvenile polyp).
    • Distortion - IBD, infection, ischemia.
    • Crypt branching - IBD, ischemia, chronic infection, SSA.
    • Back-to-back glands - malignancy, dysplasia.
  • Single cell infiltrates - lamina propria:
    • Epithelial - signet ring cell carcinoma.
    • Macrophages - MAI, TB, Whipple disease, Yersinia.
  • Nuclear abnormalities:
    • Pseudostratification - repair, dysplasia, malignancy.
    • Nuclear enlargement - malignancy, viral cytopathic effect.
  • Submucosal:
    • Brunner's gland - duodenum.
    • Fibrosis - IBD, prolapse.
    • Nests - neuroendocrine tumours.

Luminal gastroenterology

Non-regional

Intestinal polyps

Main article: Intestinal polyps

The bread and butter of gastrointestinal pathology.

Regional

Esophagus

Main article: Esophagus

Largely forgotten organ at SB... but no shortage of these at SMH.

Stomach

Main article: Stomach

H. pylori, cancer and more...

Small bowel

Main article: Small bowel

The part of the GI tract that pathology has mostly forgot. Crohn's disease is dealt with in a separate article.

Duodenum

Main article: Duodenum

Commonly biopsied. Celiac... cancer... giardia?

Cecum

Main article: Cecum

The first part of the large intestine. Technically, it is not part of the colon.

Appendix

Main article: Appendix

It hangs off the cecum. Commonly, it comes to the pathologist because of acute appendicitis.

Colon

Main article: Colon

Colorectal tumours are dealt with in colorectal tumours. Crohn's disease and ulcerative colitis are dealt with in the inflammatory bowel disease article. Includes discussion of the rectum. The anus is a separate article.

Accessory organs of the gastrointestinal tract

Gallbladder

Main article: Gallbladder

A growth industry... with the expanding waist lines in the (Western) world.

Liver

Main article: Liver

An organ that pathologists now sometimes forget. There are separate articles for the medical liver diseases, liver neoplasms and liver transplantation pathology.

Pancreas

Main article: Pancreas

An organ that is occasionally afflicted by cancer. It is primarily seen in large centers where they do ERCPs and Whipples.

Pathology (detail articles)

Inflammatory bowel disease

Main article: Inflammatory bowel disease

The bread and butter of gastroenterology and GI pathology.

Gastrointestinal stromal tumour

Main article: Gastrointestinal stromal tumour

The most common GI stromal tumour.

Graft-versus-host disease

Main article: Graft-versus-host disease

An uncommon thing that complicates bone marrow transplants.

Eosinophilic enterocolitis

Main article: Eosinophilic enterocolitis

Pneumatosis intestinalis

Main article: Pneumatosis intestinalis

Pneumatosis cystoides intestinalis

Main article: Pneumatosis cystoides intestinalis

See also

References

  1. ↑ URL: http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/Oral.htm.
  2. ↑ URL: http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/Images/gitplan.gif.
  3. ↑ 3.0 3.1 Mills, Stacey E. (2006). Histology for Pathologists (3rd ed.). Lippincott Williams & Wilkins. pp. 633. ISBN 9780781762410.

External links

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