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| The '''colon''' smells like [[poo]]... 'cause that's where poo comes from. This article also covers the '''rectum''' and '''cecum''' as both have a similar mucosa. | | [[Image:Blausen_0603_LargeIntestine_Anatomy.png|thumb|right|Anatomy of the colon and rectum. (WC)]] |
| | The '''colon''' is section of the large bowel. This article also covers the '''rectum''' and '''cecum''' as both have a similar mucosa. |
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| It commonly comes to pathologists because there is a suspicion of [[colorectal cancer]] or a known history of [[inflammatory bowel disease]] (IBD). | | It commonly comes to pathologists because there is a suspicion of [[colorectal cancer]] or a known history of [[inflammatory bowel disease]] (IBD). |
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| An introduction to gastrointestinal pathology is found in the ''[[gastrointestinal pathology]]'' article. The ''[[anus]]'' and ''[[ileocecal valve]]'' are dealt with in separate articles. | | An introduction to gastrointestinal pathology is found in the ''[[gastrointestinal pathology]]'' article. The ''[[anus]]'' and ''[[ileocecal valve]]'' are dealt with in separate articles. |
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| Technically, the rectum and cecum are ''not'' part of the colon. Thus, inflammation of the rectum should be ''proctitis'' and inflammation of the cecum should be ''cecitis''. | | Technically, the rectum and cecum are ''not'' part of the colon. Thus, inflammation of the rectum should be ''proctitis'' and inflammation of the cecum should be ''cecitis''. |
| | |
| | =Anatomy= |
| | *The [[rectum]] has several definition. These are discussed in the ''[[rectum]]'' article. |
| | *The large bowel may be submitted with segment names or with the distance to the anal verge. |
| | |
| | A conversion between named segments and distance - as per NCI of the United States:<ref>URL: [https://training.seer.cancer.gov/colorectal/anatomy/figure/figure1.html]https://training.seer.cancer.gov/colorectal/anatomy/figure/figure1.html]. Accessed on: 8 February 2018.</ref> |
| | {| class="wikitable sortable" |
| | !Named segment |
| | !Distance to anal verge (cm) |
| | |- |
| | |Anus |
| | |0-4 |
| | |- |
| | |[[Rectum]] |
| | |4-16 |
| | |- |
| | |Rectosigmoid |
| | |15-17 |
| | |- |
| | |Sigmoid |
| | |17-57 |
| | |- |
| | |Descending |
| | |57-82 |
| | |- |
| | |Transverse |
| | |82-132 |
| | |- |
| | |Ascending |
| | |132-147 |
| | |- |
| | |Cecum |
| | |150 |
| | |} |
|
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| =Common clinical problems= | | =Common clinical problems= |
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| # Subtotal colectomy - part of colon removed --or-- some of the rectum remains. | | # Subtotal colectomy - part of colon removed --or-- some of the rectum remains. |
| # Right hemicolectomy - right colon + distal ileum. | | # Right hemicolectomy - right colon + distal ileum. |
| # Lower anterior resection (LAR) - proximal rectum +/- sigmoid (for proximal rectal malignancies). | | # [[Lower anterior resection]] (LAR) - proximal rectum +/- sigmoid (for proximal rectal malignancies). |
| #* Specimens have should have intact mesorectum - ''total mesorectal excision'' (TME) - reduces local recurrence.<ref name=pmid8665198>{{Cite journal | last1 = Arbman | first1 = G. | last2 = Nilsson | first2 = E. | last3 = Hallböök | first3 = O. | last4 = Sjödahl | first4 = R. | title = Local recurrence following total mesorectal excision for rectal cancer. | journal = Br J Surg | volume = 83 | issue = 3 | pages = 375-9 | month = Mar | year = 1996 | doi = | PMID = 8665198 }}</ref> | | #* Specimens have should have intact mesorectum - ''[[total mesorectal excision]]'' (TME) - reduces local recurrence.<ref name=pmid8665198>{{Cite journal | last1 = Arbman | first1 = G. | last2 = Nilsson | first2 = E. | last3 = Hallböök | first3 = O. | last4 = Sjödahl | first4 = R. | title = Local recurrence following total mesorectal excision for rectal cancer. | journal = Br J Surg | volume = 83 | issue = 3 | pages = 375-9 | month = Mar | year = 1996 | doi = | PMID = 8665198 }}</ref> |
| # Abdominoperineal resection (APR) - anus + rectum - results in a permanent [[stoma]] (for distal rectal malignancies). | | # [[Abdominoperineal resection]] (APR) - anus + rectum - results in a permanent [[stoma]] (for distal rectal malignancies). |
| # [[Stoma]] - these are often done emergently and then get cut-out after the patient's condition has settled. | | # [[Stoma]] - these are often done emergently and then get cut-out after the patient's condition has settled. |
| | #[[Doughnuts]] (also ''donuts'') from an end-to-end anastomosis stapler. |
| | #*Often accompany lower anterior resections. |
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| ===Images=== | | ===Images=== |
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| **Rectum starts/sigmoid ends @ place where serosa ends on the posterior aspect of the bowel. | | **Rectum starts/sigmoid ends @ place where serosa ends on the posterior aspect of the bowel. |
| ***The proximal, anterior aspect of the rectum has serosa, i.e. it is not painted. | | ***The proximal, anterior aspect of the rectum has serosa, i.e. it is not painted. |
| | |
| | Note: |
| | *There are several definitions for the rectum.<ref name=pmid24130630>{{Cite journal | last1 = Kenig | first1 = J. | last2 = Richter | first2 = P. | title = Definition of the rectum and level of the peritoneal reflection - still a matter of debate? | journal = Wideochir Inne Tech Maloinwazyjne | volume = 8 | issue = 3 | pages = 183-6 | month = Sep | year = 2013 | doi = 10.5114/wiitm.2011.34205 | PMID = 24130630 }}</ref> |
| | **In a survey of surgeons: |
| | **67% defined it by an anatomical landmark |
| | ***35% of all respondants considered the peritoneal reflection the proximal boundary of the rectum. |
| | **30% defined the proximal boundary as a distance from the anal verge. |
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| =Common non-neoplastic disease= | | =Common non-neoplastic disease= |
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| ==Volvulus== | | ==Volvulus== |
| ===General===
| | {{Main|Volvulus}} |
| *Uncommonly comes to pathology.
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| *It is essentially a radiologic diagnosis.
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| *In the context of [[autopsy]], it is a gross diagnosis.
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| | |
| ===Gross===
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| *Intestine folded over itself - typically leads to ischemia.
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| Images:
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| *[http://library.med.utah.edu/WebPath/GIHTML/GI032.html Cecal volvulus (utah.edu)].
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| *[http://pathsrvr.rockford.uic.edu/inet/GI/Photo%202%20-%20Volvulus%20of%20small%20intestine_%20gross.gif Volvulus (uic.edu)].<ref>URL: [http://pathsrvr.rockford.uic.edu/inet/GI/GI%20Station%201.htm http://pathsrvr.rockford.uic.edu/inet/GI/GI%20Station%201.htm]. Accessed on: 9 April 2012.</ref>
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| ===Microscopic===
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| Features:
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| *+/-Ischemic changes and/or [[necrosis]].
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| DDx - essentially anything that causes ischemia:
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| *Embolus.
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| *Thrombosis.
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| *[[Vasculitis]].
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| | |
| ===Sign out===
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| <pre>
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| RECTOSIGMOID, RESECTION:
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| - MURAL ISCHEMIA WITH PERFORATION, SEROSITIS, MICROABSCESS FORMATION AND POORLY FORMED PSEUDOMEMBRANES.
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| - SUBMUCOSAL FIBROSIS.
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| - NEGATIVE FOR MALIGNANCY.
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| COMMENT:
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| The findings are consistent with volvulus and the submucosal fibrosis suggests this may have been recurrent.
| |
| </pre>
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| =Inflammatory diseases= | | =Inflammatory diseases= |
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| *Basal, i.e. crypt base, plasmacytosis with severe chronic inflammation, | | *Basal, i.e. crypt base, plasmacytosis with severe chronic inflammation, |
| *Crypt architectural abnormalities, and | | *Crypt architectural abnormalities, and |
| *Distal Paneth cell metaplasia. | | *Distal [[Paneth cell]] metaplasia. |
| **Paneth cells should ''not'' be in the left colon<ref name=pmid11851832>{{cite journal |author=Tanaka M, Saito H, Kusumi T, ''et al'' |title=Spatial distribution and histogenesis of colorectal Paneth cell metaplasia in idiopathic inflammatory bowel disease |journal=J. Gastroenterol. Hepatol. |volume=16 |issue=12 |pages=1353–9 |year=2001 |month=December |pmid=11851832 |doi= |url=http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0815-9319&date=2001&volume=16&issue=12&spage=1353}}</ref> - if you see 'em think of IBD and other long-standing injurious processes. | | **Paneth cells should ''not'' be in the left colon<ref name=pmid11851832>{{cite journal |author=Tanaka M, Saito H, Kusumi T, ''et al'' |title=Spatial distribution and histogenesis of colorectal Paneth cell metaplasia in idiopathic inflammatory bowel disease |journal=J. Gastroenterol. Hepatol. |volume=16 |issue=12 |pages=1353–9 |year=2001 |month=December |pmid=11851832 |doi= |url=http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0815-9319&date=2001&volume=16&issue=12&spage=1353}}</ref> - if you see 'em think of IBD and other long-standing injurious processes. |
| **Some claim that (friendly right colonic) paneth cells and paneth cell metaplasia look quite different and can be distinguished.<ref name=pmid12655793>{{cite journal |author=Rubio CA, Nesi G |title=A simple method to demonstrate normal and metaplastic Paneth cells in tissue sections |journal=In Vivo |volume=17 |issue=1 |pages=67–71 |year=2003 |pmid=12655793 |doi= |url=}}</ref> | | **Some claim that (friendly right colonic) paneth cells and paneth cell metaplasia look quite different and can be distinguished.<ref name=pmid12655793>{{cite journal |author=Rubio CA, Nesi G |title=A simple method to demonstrate normal and metaplastic Paneth cells in tissue sections |journal=In Vivo |volume=17 |issue=1 |pages=67–71 |year=2003 |pmid=12655793 |doi= |url=}}</ref> |
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| ==Eosinophilic colitis== | | ==Eosinophilic colitis== |
| ===General===
| | *Abbreviated ''EC''. |
| *Rare.
| | {{Main|Eosinophilic colitis}} |
| *May be a component of ''[[eosinophilic gastroenteritis]]''.<ref name=pmid22012125/> | |
| | |
| Clinical features:<ref name=pmid22012125/>
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| *Abdominal pain
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| *Diarrhea +/-blood.
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| *+/-Weight loss.
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| ===Gross===
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| Features - endoscopic:<ref name=pmid22012125>{{Cite journal | last1 = Alfadda | first1 = AA. | last2 = Storr | first2 = MA. | last3 = Shaffer | first3 = EA. | title = Eosinophilic colitis: an update on pathophysiology and treatment. | journal = Br Med Bull | volume = 100 | issue = | pages = 59-72 | month = | year = 2011 | doi = 10.1093/bmb/ldr045 | PMID = 22012125 | PMC = 3165205 }}</ref>
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| *Edema.
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| *Granular appearance.
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| ===Microscopic===
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| Features:<ref name=pmid22012125/>
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| *Abundant eosinophils - no agreed upon number.
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| **"Most use 20/[[HPF]]" <ref name=pmid19554649>{{Cite journal | last1 = Okpara | first1 = N. | last2 = Aswad | first2 = B. | last3 = Baffy | first3 = G. | title = Eosinophilic colitis. | journal = World J Gastroenterol | volume = 15 | issue = 24 | pages = 2975-9 | month = Jun | year = 2009 | doi = | PMID = 19554649 | PMC = 2702104 }}</ref> - a definition that suffers from [[HPFitis]].
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| ***There is variation along the large bowel - normal in rectum <10/HPF, normal in cecum <30/HPF (???).<ref name=pmid19554649/>
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| DDx:<ref name=pmid22012125/>
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| *[[Inflammatory bowel disease]]:
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| **[[Crohn's disease]].
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| **[[Ulcerative colitis]].
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| *Infection:
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| **[[Pinworm]].
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| **[[Strongyloidiasis]].
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| *Autoimmune disease:
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| **[[Scleroderma]].
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| **[[Churg-Strauss syndrome]].
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| **[[Celiac disease]].
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| *[[Drug reaction]]s.
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| Image:
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| *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2702104/figure/F1/ EC (nih.gov)].<ref name=pmid19554649>{{Cite journal | last1 = Okpara | first1 = N. | last2 = Aswad | first2 = B. | last3 = Baffy | first3 = G. | title = Eosinophilic colitis. | journal = World J Gastroenterol | volume = 15 | issue = 24 | pages = 2975-9 | month = Jun | year = 2009 | doi = | PMID = 19554649 | PMC = 2702104 }}</ref>
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| ===Sign out===
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| <pre>
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| DESCENDING COLON, BIOPSY:
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| - COLONIC MUCOSA WITH MILD EOSINOPHILIA, SEE COMMENT.
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| - NEGATIVE FOR DYSPLASIA.
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| COMMENT:
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| Focally, there are up to 40 eosinophils / 0.2376 mm*mm (approx. field area at 400X). This
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| is a non-specific finding. No eosinophilic crypt abscesses are seen. No (neutrophilic)
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| cryptitis is present. Clinical correlation is suggested.
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| </pre>
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| | |
| <pre>
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| DESCENDING COLON, BIOPSY:
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| - COLONIC MUCOSA WITH MILD EOSINOPHILIA, SEE COMMENT.
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| - NEGATIVE FOR ACTIVE COLITIS.
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| - NEGATIVE FOR DYSPLASIA.
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| COMMENT:
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| There are up to 40 eosinophils / 0.2376 mm*mm (field area at 400X). This is a
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| non-specific finding. The differential diagnosis includes inflammatory bowel
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| disease, infection (especially helminths), a drug reaction, and autoimmune
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| disorders (e.g. Churg-Strauss syndrome, celiac disease, scleroderma). Clinical
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| correlation is required.
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| </pre>
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| =Infectious= | | =Infectious= |
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| {{Main|CMV}} | | {{Main|CMV}} |
| *Abbreviated ''CMV colitis''. | | *Abbreviated ''CMV colitis''. |
| ===General===
| | {{Main|Cytomegalovirus colitis}} |
| *Uncommon.
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| *Immunosuppressed population at risk, e.g. transplant recipients, individuals with [[HIV]].
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| ===Microscopic===
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| Features:
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| *Enlarged nucleus - classically in endothelial cells.
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| DDx:
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| *[[Infectious colitis]] without a distinctive morphology.
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| *CMV colitis superimposed on [[inflammatory bowel disease]].
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| ====Images====
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| <gallery>
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| Image:CMV_colitis_-_intermed_mag.jpg | CMV colitis - intermed. mag. (WC/Nephron)
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| Image:CMV_colitis_-_high_mag_-_cropped.jpg | CMV colitis - high mag. (WC/Nephron)
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| </gallery>
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| www:
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| *[http://www.flickr.com/photos/lunarcaustic/4615988256/ CMV colitis (flickr.com/lunar caustic)].
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| *[http://www.flickr.com/photos/lunarcaustic/4615988164/ CMV colitis (flickr.com/lunar caustic)]
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| ===IHC===
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| *CMV +ve.
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| Others:
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| *HSV-1.
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| *HSV-2.
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| *VZV.
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| *[[EBV]].
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| ==Intestinal spirochetosis== | | ==Intestinal spirochetosis== |
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| ==Amebiasis== | | ==Amebiasis== |
| *May also be spelled ''amoebiasis''. | | *May also be spelled ''amoebiasis''. |
| ===General===
| | {{Main|Amebiasis}} |
| *Infection with ''Entamoeba histolytica''.<ref>URL: [http://www.health.state.ny.us/diseases/communicable/amebiasis/fact_sheet.htm http://www.health.state.ny.us/diseases/communicable/amebiasis/fact_sheet.htm]. Accessed on: 17 June 2010.</ref>
| |
| *May mimic [[colon cancer]].<ref name=pmid19332922>{{Cite journal | last1 = Fernandes | first1 = H. | last2 = D'Souza | first2 = CR. | last3 = Swethadri | first3 = GK. | last4 = Naik | first4 = CN. | title = Ameboma of the colon with amebic liver abscess mimicking metastatic colon cancer. | journal = Indian J Pathol Microbiol | volume = 52 | issue = 2 | pages = 228-30 | month = | year = | doi = | PMID = 19332922 | url=http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2009;volume=52;issue=2;spage=228;epage=230;aulast=Fernandes }}</ref>
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| | |
| May cause:<ref name=pmid20303955>{{Cite journal | last1 = Mortimer | first1 = L. | last2 = Chadee | first2 = K. | title = The immunopathogenesis of Entamoeba histolytica. | journal = Exp Parasitol | volume = | issue = | pages = | month = Mar | year = 2010 | doi = 10.1016/j.exppara.2010.03.005 | PMID = 20303955 }}</ref>
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| *Dysentery (diarrhea containing mucus and/or blood in the feces).
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| *Colitis.
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| *Liver abscess.
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| ===Microscopic===
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| Features:
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| *Entamoeba histolytica are round/ovoid eosinophilic bodies ~ 40-60 micrometers in maximal dimension.
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| **Found in bowel lumen.
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| **Ingest [[RBC]]s.
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| ====Image====
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| <gallery>
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| Image:Amebiasis_-_very_high_mag.jpg | Amebiasis - very high mag. (WC/Nephron)
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| Image:Amoebic_dysentery_in_colon_biopsy_%281%29.jpg | Amebiasis (WC)
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| </gallery>
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|
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| ==Cryptosporidiosis== | | ==Cryptosporidiosis== |
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| *[[AKA]] ''solitary rectal ulcer syndrome''. | | *[[AKA]] ''solitary rectal ulcer syndrome''. |
| *''[[Mucosal prolapse syndrome]]'' may be used as a synonym; however, it encompasses other entities.<ref name=pmid22697798>{{Cite journal | last1 = Abid | first1 = S. | last2 = Khawaja | first2 = A. | last3 = Bhimani | first3 = SA. | last4 = Ahmad | first4 = Z. | last5 = Hamid | first5 = S. | last6 = Jafri | first6 = W. | title = The clinical, endoscopic and histological spectrum of the solitary rectal ulcer syndrome: a single-center experience of 116 cases. | journal = BMC Gastroenterol | volume = 12 | issue = | pages = 72 | month = | year = 2012 | doi = 10.1186/1471-230X-12-72 | PMID = 22697798 }}</ref> | | *''[[Mucosal prolapse syndrome]]'' may be used as a synonym; however, it encompasses other entities.<ref name=pmid22697798>{{Cite journal | last1 = Abid | first1 = S. | last2 = Khawaja | first2 = A. | last3 = Bhimani | first3 = SA. | last4 = Ahmad | first4 = Z. | last5 = Hamid | first5 = S. | last6 = Jafri | first6 = W. | title = The clinical, endoscopic and histological spectrum of the solitary rectal ulcer syndrome: a single-center experience of 116 cases. | journal = BMC Gastroenterol | volume = 12 | issue = | pages = 72 | month = | year = 2012 | doi = 10.1186/1471-230X-12-72 | PMID = 22697798 }}</ref> |
| ===General===
| | {{Main|Solitary rectal ulcer}} |
| *Clinically may be suspected to a malignancy - biopsied routinely.
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| *Mucosal ulceration.
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| *"Three-lies disease":<ref name=pmid18271667>{{cite journal |author=Crespo Pérez L, Moreira Vicente V, Redondo Verge C, López San Román A, Milicua Salamero JM |title=["The three-lies disease": solitary rectal ulcer syndrome] |language=Spanish; Castilian |journal=Rev Esp Enferm Dig |volume=99 |issue=11 |pages=663–6 |year=2007 |month=November |pmid=18271667 |doi= |url=http://www.grupoaran.com/mrmUpdate/lecturaPDFfromXML.asp?IdArt=459864&TO=RVN&Eng=1}}</ref>
| |
| # May not be solitary.
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| # May not be rectal -- can be in left colon.
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| # May not be ulcerating -- non-ulcerated lesions: polypoid and/or erythematous.
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| Note: Each of the words in ''solitary rectal ulcer'' is a lie.
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| ====Epidemiology====
| |
| *Typically younger patients - average age of presentation ~30 years in one study.<ref name=pmid17139403>{{cite journal |author=Chong VH, Jalihal A |title=Solitary rectal ulcer syndrome: characteristics, outcomes and predictive profiles for persistent bleeding per rectum |journal=Singapore Med J |volume=47 |issue=12 |pages=1063–8 |year=2006 |month=December |pmid=17139403 |doi= |url=http://www.sma.org.sg/smj/4712/4712a7.pdf}}</ref>
| |
| *Rare.
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| | |
| ====Clinical presentation====
| |
| *Usually presents as BRBPR ~ 85% of cases.<ref name=pmid17139403/>
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| *Abdominal pain present in approx. 1/3.<ref name=pmid17139403/>
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| **May be very painful.
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| Treatment:
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| *Usually conservative, i.e. non-surgical.
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| *Resection - may be done for fear of malignancy.
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| ===Gross===
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| *Classically, anterior or anterolateral wall of the rectum.<ref name=pmid18271667/>
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| ===Microscopic===
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| Features:<ref name=pmid18271667/><ref name=pmid2091997>{{Cite journal | last1 = Malik | first1 = AK. | last2 = Bhaskar | first2 = KV. | last3 = Kochhar | first3 = R. | last4 = Bhasin | first4 = DK. | last5 = Singh | first5 = K. | last6 = Mehta | first6 = SK. | last7 = Datta | first7 = BN. | title = Solitary ulcer syndrome of the rectum--a histopathologic characterisation of 33 biopsies. | journal = Indian J Pathol Microbiol | volume = 33 | issue = 3 | pages = 216-20 | month = Jul | year = 1990 | doi = | PMID = 2091997 }}</ref>
| |
| *Fibrosis of the lamina propria.
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| *Thickened muscularis mucosa with abnormal extension to the lumen.
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| *+/-Mucosa ulceration.
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| *+/-Submucosal fibrosis.
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| DDx:
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| *[[Inflammatory pseudopolyp]] (inflammatory polyp).
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| **Associated with [[inflammatory bowel disease]].
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| *[[Rectal prolapse]].
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| *Well-differentiated [[colonic adenocarcinoma|adenocarcinoma]].
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| ===IHC===
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| *p53 -ve.
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| **May be used to help exclude adenocarcinoma.
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|
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| ==Rectal prolapse== | | ==Rectal prolapse== |
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| ==Angiodysplasia== | | ==Angiodysplasia== |
| ===General===
| | {{Main|Angiodysplasia}} |
| *Causes (lower) GI haemorrhage.
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| *Generally, not a problem pathologists see.
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| *May be associated with [[aortic stenosis]]; known as ''Heyde syndrome''.<ref name=pmid19652242>{{cite journal |author=Hui YT, Lam WM, Fong NM, Yuen PK, Lam JT |title=Heyde's syndrome: diagnosis and management by the novel single-balloon enteroscopy |journal=Hong Kong Med J |volume=15 |issue=4 |pages=301–3 |year=2009 |month=August |pmid=19652242 |doi= |url=http://www.hkmj.org/abstracts/v15n4/301.htm}}</ref>
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| Epidemiology:
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| *Older people.
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| Etiology:
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| *Thought to be caused by the higher wall tension of cecum (due to larger diameter) and result from (intermittent) venous occlusion/focal dilation of vessels.<ref name=Ref_PBoD854>{{Ref PBoD|854}}</ref>
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| ===Gross===
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| *Cecum - classic location.
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| Note:
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| *[[Crohn's disease]] - may mimic angiodysplasia radiographically.<ref name=pmid3054852/>
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| ===Microscopic===
| |
| Features:<ref name=pmid3054852>{{Cite journal | last1 = Hemingway | first1 = AP. | title = Angiodysplasia: current concepts. | journal = Postgrad Med J | volume = 64 | issue = 750 | pages = 259-63 | month = Apr | year = 1988 | doi = | PMID = 3054852 }}</ref>
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| *Dilated vessels in mucosa and submucosa.
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|
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| ==Drugs== | | ==Drugs== |
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| *[[Intestinal polyps]]. | | *[[Intestinal polyps]]. |
| *[[Small bowel]]. | | *[[Small bowel]]. |
| | *[[Doughnuts]]. |
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| =References= | | =References= |