Gastrointestinal Pathology Case Studies Part 1

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Gastrointestinal Pathology Case Studies Part 1
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CASE 1

• Clinical History
• A 62 year old male had a 2 month history of
  increasing difficulty swallowing. He also had a
  history of chronic alcoholism and smoking. The
  lesion was seen on upper GI endoscopy in slide
  1.1. The mass is shown in slide 1.2. It was 3 cm
  in diamter and appeared to extend through the
  muscular wall. On the surface it was ulcerated.
  The low and high power microscopic appearances
  are shown in Slides 1.3 and 1.4.

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Slide 1.1The endoscopic appearances of a
mid-esophageal mass with lumenal stenosis are
seen here.
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Slide 1.2The gross appearance of the
mid-esophageal mass lesion is seen here.
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Slide 1.3The low power microscopic appearance of
the mid-esophageal mass lesion is seen here.
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Slide 1.4The high power microscopic appearance
of the mid-esophageal mass lesion is seen here.
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Case 1

• Questions
• What is the diagnosis?
• What are typical presenting symptoms?
• What are contributing factors for development of
  this lesion?
• What is the prognosis?

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CASE 1 Esophageal squamous cell carcinoma

1. What is the diagnosis? This is squamous cell
   carcinoma of the esophagus.
2. What are typical presenting symptoms? Typical
   symptoms include dysphagia, pain, and weight
   loss. Less commonly, patients may have hemorrhage
   or may have aspiration.
3. What are contributing factors for development of
   this lesion? Smoking and alcoholism are
   predisposing factors in the U.S. Overall, males
   are more frequently affected than females and
   Blacks more than whites. Food contaminated with
   Aspergillus or foods rich in nitrites or
   nitrosamines, molybdenum and zinc deficiencies,
   esophageal stricture, and esophageal web are also
   implicated (anything leading to chronic
   esophagitis).
4. What is the prognosis? The prognosis is very poor
   (lt10 5 year survival).

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CASE 2Know this case, he said he always asks it
on the lab

• Clinical History
• This 55 year old white male had suffered from
  chronic reflux esophagitis for several decades
  (Slide 2.1). He then presented with dysphagia. On
  endoscopy a mass lesion was found in the lower
  esophagus and was biopsied (Slide 2.2). Based
  upon the biopsy findings, a partial esophagectomy
  was performed. The mass lesion extended into the
  muscular wall and ulcerated the surface mucosa
  (Slide 2.3). The predisposing lesion which
  developed from reflux is shown in Slide 2.4 and
  2.5. The precursor lesion is seen in Slide 2.6,
  and the mass lesion in 2.7.

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Slide 2.1Endoscopic views of the lower esophagus
are seen here, revealing areas of erythematous
mucosa and islands of intervening normal pale
squamous mucosa.
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Slide 2.2An endoscopic view of the lower
esophagus reveals a mass lesion projecting into
the lumen.
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Slide 2.3The gross appearance of the lower
esophageal mass lesion is seen here. The
abdominal CT scan views below demonstrate a lower
esophageal mass near the gastroesophageal
junction and extending to the upper stomach.
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Slide 2.4The predisposing lesion for the
esophageal mass is seen here. What symptoms do
you think this patient had for years?
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Slide 2.5The predisposing lesion for the
esophageal mass is seen here. What type of mucosa
is this?
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Slide 2.6Dysplasia is seen here. Note the
stratification of the nuclei along with
hyperchromatism.
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Slide 2.7Adenocarcinoma is seen here
microscopically. Note the irregular glandular
structures infiltrating the muscularis.
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Questions

1. What is the diagnosis?
2. Where is this lesion arising?
3. What is the major predisposing condition for
   lesions such as this that are known to arise
   within the esophagus?

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CASE 2 Esophageal adenocarcinoma arising in
Barrett mucosa

1. What is the diagnosis? This is adenocarcinoma.
2. Where is this lesion arising? About 5 to 10 of
   esophageal carcinomas are adenocarcinomas, but
   adenocarcinoma of the stomach that invades into
   the lower esophagus is probably more frequent.
3. What is the major predisposing condition for
   lesions such as this that are known to arise
   within the esophagus? Of adenocarcinomas that
   arise in the esophagus, Barrett's mucosa is
   present in the majority. These patients often
   give a history of "heartburn" or burning
   substernal chest pain, especially after eating.
   The columnar metaplasia is seen in Slides 2.4 and
   2.5 (it is gastric in Slide 2.4 but more
   intestinal with goblet cells in Slide 2.5--either
   can occur but intestinal type mucosa is the most
   typical for Barrett). After many years, a
   dysplasia can arise in Barrett's mucosa, as shown
   in Slide 2.6, and from this can arise an
   adenocarcinoma, as shown in Slide 2.7. There is
   about a 10 lifetime risk for adenocarcinoma in
   patients with Barrett esophagus.

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CASE 3

• Clinical History
• A 55 year old woman, with a history of epigastric
  pain relieved by food, complained of hematemesis.
  Endoscopy with biopsy was performed (Slide 3.1).
  This section is from the subsequent partial
  gastrectomy (Slide 3.2). The section shows a
  cup-shaped ulcer filled with blood clot. The
  ulcer, which extends almost through the gastric
  wall, is lined by necrotic debris and acute
  inflammatory cells overlying a base of
  granulation tissue and fibrosis (Slides 3.3 and
  3.4) with a large vessel at the base (Slide 3.5).

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Slide 3.1Here is a large gastric ulceration with
a necrotic base penetrating well into the gastric
wall, as seen on upper endoscopy.
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Slide 3.2The gross appearance of the ulcer in
this partial gastrectomy is seen here. The
radiographic view below from an upper GI series
in another patient with ulcer disease reveals an
ulcer with an edematous mounded border.
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Slide 3.3The microscopic appearance of the ulcer
in this partial gastrectomy is seen here at low
power. Note the loss of the epithelium and
extension of the ulcer downward to the muscularis
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Slide 3.4The microscopic appearance of the ulcer
in this partial gastrectomy is seen here at
higher power.
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Slide 3.5The microscopic appearance of the ulcer
base with a large vessel is seen here.
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Questions

1. What is the diagnosis?
2. What is the cause of the hematemesis?
3. Why should biopsy of such lesions be performed?
4. What does the adjacent gastric mucosa show?

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CASE 3 Peptic ulcer

1. What is the diagnosis? This proved to be a benign
   chronic peptic ulcer of stomach, despite the
   large size.
2. What is the cause of the hematemesis? There is
   erosion of the ulcer into the wall and into a
   large artery, which explains the hematemesis in
   this patient.
3. Why should biopsy of such lesions be performed?
   Biopsy should be done because it is not possible
   to tell a benign from a malignant ulcer by
   appearance alone.
4. What does the adjacent gastric mucosa show? The
   adjacent mucosa shows chronic gastritis, which is
   usually present in about 75 of gastric ulcers.

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CASE 4

• Clinical History
• A 60 year old male complained of anorexia,
  vomiting, and vague abdominal pain accompanied by
  weight loss of 15 kg over the past two months.
  Physical examination revealed supraclavicular
  lymphadenopathy. An abdominal CT scan revealed
  that the stomach wall was diffusely thickened
  (Slide 4.1). He became progressively cachectic
  and died. At autopsy, the stomach was diffusely
  thickened and leather-like (Slide 4.2).
  Microscopic sections of the gastric wall are in
  Slides 4.3 and 4.4. Describe the cells.

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Slide 4.1These abdominal CT scan views
demonstrate a thickened gastric wall surrounding
a small lumen partly filled with contrast. This
thickened wall has resulted from diffuse
infiltration by gastric carcinoma.
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Slide 4.2The gross appearance of the diffusely
thickened, leather-like stomach at autopsy is
seen here.
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Slide 4.3The low power microscopic appearance of
the diffusely thickened, leather-like stomach at
autopsy is seen here.
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Slide 4.4The high power microscopic appearance
of the diffusely thickened, leather-like stomach
at autopsy is seen here.
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Questions

1. What is the diagnosis?
2. What are some predisposing factors for this
   lesion?
3. What is the typical prognosis?

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CASE 4 Gastric adenocarcinoma

1. What is the diagnosis? This is poorly
   differentiated gastric adenocarcinoma, diffuse
   type (linitis plastica). The neoplasm is not even
   forming glands, and some of the cells have a
   "signet ring" appearance.
2. What are some predisposing factors for this
   lesion? Predisposing factors include chronic
   atrophic gastritis, a diet high in salt or
   nitrates, and decreased green leafy vegetables
   and fruits. Persons living in Japan have a much
   higher incidence of gastric cancer than persons
   in the U.S., where the incidence has been falling
   for decades.
3. What is the typical prognosis? The prognosis in
   this case is poor. Overall, the 5-year survival
   for gastric cancer in the U.S. is only about 10
   to 15. In Japan, the prognosis is better because
   more of these lesions are detected as early
   gastric carcinomas.

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CASE 5

• Clinical History
• A 20 year old woman presented to the emergency
  room with only a one day history of lower
  abdominal pain, nausea, and fever. On physical
  examination, there was right lower quadrant
  tenderness and her temperature was 38.50 C. The
  WBC count was 11,500 with 79 polys and 6 bands.
  The radiographic finding on abdominal CT scan is
  seen in Slide 5.1. A laparotomy was performed and
  the gross appearance of the lesion is shown in
  Slide 5.2. The microscopic appearance is seen in
  Slides 5.3 and 5.4.

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Slide 5.1These abdominal CT scan views reveal a
thickened appendix with faint linear stranding
into the surrounding fat, typical for
inflammation.
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Slide 5.2The gross appearance of the appendix
removed at surgery is seen here. The abdominal CT
scan views below reveal a thickened appendix with
faint linear stranding into the surrounding fat,
typical for inflammation.
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Slide 5.3The low power microscopic appearance of
the appendix removed at surgery is seen here.
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Slide 5.4The high power microscopic appearance
of the appendix removed at surgery is seen here.
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Questions

1. What diagnosis do you suspect?
2. What should be done next?
3. What is seen prominently in the tissue section?
4. What could happen if this is not promptly treated?

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CASE 5 Acute appendicitis

1. What diagnosis do you suspect? Acute
   appendicitis.
2. What should be done next? The patient should be
   taken to surgery and an appendectomy performed.
   There is no medical therapy for acute
   appendicitis.
3. What is seen prominently in the tissue section?
   There is acute inflammation with many
   neutrophils. The mucosa is focally eroded. The
   inflammation extends through the wall and appears
   on the serosa.
4. What could happen if this is not promptly
   treated? The wall of the appendix could rupture,
   producing an acute peritonitis nd/or abscess. The
   patient could become septic and die. Since there
   is about a 2 mortality associated with
   appendiceal perforation, surgeons err on the side
   of fase positive diagnosis with acute
   appendicitis (about 1 in 5 or 1 in 10 removed
   will be normal).

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CASE 6

• Clinical History
• A 43 year old man came in to the emergency room
  because of intense abdominal pain associated with
  abdominal swelling. A plain film of the abdomen
  showed numerous dilated loops of small intestine.
  A laparotomy was performed. The lower ileum was
  found to have a palpable mass lesion in the wall
  that obstructed the lumen (Slide 6.1). A
  segmental resection of ileum was performed. The
  section shows a segment of buckled small bowel.
  At the apex of the buckle, the mucosa is
  ulcerated. Beneath this are small invasive nests
  of a neoplasm composed of monotonous, bland cells
  (Slides 6.2 to 6.3).

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Slide 6.1The lower ileum was found to have a
palpable mass lesion in the wall that obstructed
the lumen.
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Slide 6.2The low power microscopic appearance of
the nests of cells forming this submucosal mass
is seen here.
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Slide 6.3The high power microscopic appearance
of the small nests of cells forming the mass is
seen here.
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Questions

1. What is the diagnosis?
2. What are common sites for this lesion?
3. What are more typical etiologies for intestinal
   obstruction in adults?
4. What syndrome may be associated with this
   neoplasm?

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CASE 6 Carcinoid tumor of small intestine

1. What is the diagnosis? This is a carcinoid tumor.
   All of these are potentially malignant, but most
   are not and are incidental findings at autopsy.
   Those in the small intestine, particularly when
   they are larger than 2 cm or when they invade,
   are more likley to metastasize.
2. What are common sites for this lesion? Common
   locations are the small intestine and appendix,
   but they can occur from stomach to rectum.
3. What are more typical etiologies for intestinal
   obstruction in adults? Hernias, adhesions, and
   malignancies are more common causes for
   obstruction.
4. What syndrome may be associated with this
   neoplasm? The "carcinoid syndrome" may accompany
   carcinoids that are metastatic to liver and
   elaborate a large quantity of serotonin to
   produce flushing, diarrhea, right heart
   endocardial fibrosis, and symptoms of
   bronchoconstriction (cough, dyspnea, and
   wheezing).

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CASE 7

• Clinical History
• This 48 year old male was taken by his wife to
  the emergency room late one evening after he
  began vomiting large quantities of bright red
  blood. She related that he had a long history of
  drinking. Endoscopy localized the source of the
  bleeding to the lower esophagus near the
  gastroesophageal junction (Slide 7.1). He could
  not be stabilized and he died a day later. The
  lesion at autopsy is shown (Slide 7.2). Sections
  reveal the microscopic appearance (Slides 7.3 and
  7.4).

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Slide 7.1The endoscopic view of the lower
esophagus is seen here, with several round red
lesions bulging into the lumen.
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Slide 7.2The lesion is seen in the lower
esophagus near the gastroesophageal junction.
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Slide 7.3The low power microscopic appearance of
the esophageal lesion in the submucosa is seen
here.
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Slide 7.4The high power microscopic appearance
of the esophageal lesion is seen here.
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Questions

1. What is the diagnosis?
2. What causes this to happen?

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CASE 7 Esophageal varices

1. What is the diagnosis? Large, dilated submucosal
   esophageal veins are present. These are varices.
2. What causes this to happen? The veins dilate as
   portal venous hypertension from cirrhosis of the
   liver in alcoholism leads to shunting of venous
   blood to collateral veins. These veins dilate.
   Those just under the esophagus can be eroded very
   easily, leading to extensive hemorrhage.

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CASE 8

• Clinical History
• A 48 year old male has had vague abdominal
  discomfort for a number of years. There is no
  history of hematemesis, but he has occasional
  nausea and vomiting. An upper endoscopy is
  performed. There is no evidence for ulceration or
  a mass, and gastric biopsies are taken. Slides
  8.1 and 8.2 demonstrate the gastric mucosa at low
  and high magnification. The surface of the
  gastric mucosa at high magnification is seen in
  slides 8.3 and 8.4.

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Slide 8.1The low power microscopic appearance of
the gastric mucosa is seen here. Note the chronic
inflammatory cell infiltrates.
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Slide 8.2The high power microscopic appearance
of the gastric mucosa is seen here. The
inflammatory cell infiltrates are composed of
lymphocytes and plasma cells (occasionally, some
neutrophils could be present as well).
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Slide 8.3There are small thin rod-like organisms
present in the gastric mucus above the columnar
cells seen here with HE staining at high
magnification.
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Slide 8.4The organisms appear as small thin rods
just above the columnar cells with Giemsa
staining at high magnification.
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Questions

1. What is the diagnosis?
2. What are the organisms seen above the mucosa?
3. What is the prognosis?

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CASE 8 Chronic gastritis

1. What is the diagnosis? This is chronic
   non-specific gastritis. There is no ulceration.
2. What are the organisms seen above the mucosa?
   These are Helicobacter pylori organisms. They are
   short curved to S-shaped rods that can be barely
   seen with HE stains, and better seen with Giemsa
   or silver stains. H. pylori organisms are
   non-invasive, living in the gastric mucus above
   the mucosa. Somehow, they create an environment
   in which chronic gastritis, as well as peptic
   ulcer disease, are more likely. The incidence of
   H. pylori infection increases with age and is
   higher in developing nations.
3. What is the prognosis? The gastritis itself is
   not life-threatening and can be treated with
   pharmacologic agents that are aimed at
   eliminating the H. pylori. The long-term benefit
   for this therapy is a reduction in the risk for
   gastric carcinomas and lymphomas. In fact, the
   mucosa-associated lymphoid tissue (MALT)
   lymphomas arise in the setting of H. pylori
   infection and will regress when these organisms
   are eliminated.