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| The '''colon''' and '''rectum''' smell like poo... 'cause that's where poo comes from. It commonly comes to pathologists because there is a suspicion of cancer or a known history of inflammatory bowel disease (IBD). | | [[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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| ==Common clinical problems== | | It commonly comes to pathologists because there is a suspicion of [[colorectal cancer]] or a known history of [[inflammatory bowel disease]] (IBD). |
| | |
| | An introduction to gastrointestinal pathology is found in the ''[[gastrointestinal pathology]]'' article. The ''[[anus]]'' and ''[[ileocecal valve]]'' are dealt with in separate articles. |
| | |
| | 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 |
| | |} |
| | |
| | =Common clinical problems= |
| ===Obstruction=== | | ===Obstruction=== |
| Top three (in adults):<ref>[http://www.emedicine.com/EMERG/topic65.htm http://www.emedicine.com/EMERG/topic65.htm]</ref> | | Top three (in adults):<ref>URL: [http://www.emedicine.com/EMERG/topic65.htm http://www.emedicine.com/EMERG/topic65.htm]. Accessed on: 28 June 2011.</ref> |
| *Neoplasia, | | *Neoplasia. |
| *Volvulus (cecal, sigmoid), | | *[[Volvulus]] (cecal, sigmoid). |
| *Diverticular disease + stricture formation. | | *[[Diverticular disease]] + stricture formation. |
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| |
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| ===Bleeding=== | | ===Bleeding=== |
| Mnemonic ''CHAND'':<ref>TN 2007 G29.</ref> | | Mnemonic ''CHAND'':<ref>TN 2007 G29.</ref> |
| *Colitis (radiation, infectious, ischemic, IBD (UC >CD), iatrogenic (anticoagulants)), | | *Colitis ([[radiation colitis|radiation]], [[infectious colitis|infectious]], [[ischemic colitis|ischemic]], [[IBD]] (UC >CD), iatrogenic (anticoagulants)). |
| *Hemorrhoids, | | *[[Hemorrhoids]]. |
| *Angiodysplasia, | | *[[Angiodysplasia]]. |
| *Neoplastic, | | *Neoplastic. |
| *Diverticular disease. | | *[[Diverticular disease]]. |
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| Infectious colitis with bleeding - causes: | | Infectious colitis with bleeding - causes: |
| *Enterohemorrhagic Escherichia coli (EHEC) -- commonly 0157:H7, | | *Enterohemorrhagic Escherichia coli (EHEC) -- commonly 0157:H7. |
| *Campylobacter jejuni, | | *Campylobacter jejuni. |
| *Clostridium difficile, | | *[[Clostridium difficile]]. |
| *Shigella. | | *Shigella. |
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| Infectious colitis in the immunosuppressed: | | [[Infectious colitis]] in the immunosuppressed: |
| *Cytomegalovirus (CMV).<ref name=pmid7934809>{{cite journal |author=Golden MP, Hammer SM, Wanke CA, Albrecht MA |title=Cytomegalovirus vasculitis. Case reports and review of the literature |journal=Medicine (Baltimore) |volume=73 |issue=5 |pages=246–55 |year=1994 |month=September |pmid=7934809 |doi= |url=}}</ref> | | *[[Cytomegalovirus]] (CMV).<ref name=pmid7934809>{{cite journal |author=Golden MP, Hammer SM, Wanke CA, Albrecht MA |title=Cytomegalovirus vasculitis. Case reports and review of the literature |journal=Medicine (Baltimore) |volume=73 |issue=5 |pages=246–55 |year=1994 |month=September |pmid=7934809 |doi= |url=}}</ref> |
| **May afflict patients with IBD and lead to colectomy... as IBD patients are put on immunosuppression. | | **May afflict patients with IBD and lead to colectomy... as IBD patients are put on immunosuppression.<ref name=pmid17026558>{{cite journal |author=Kandiel A, Lashner B |title=Cytomegalovirus colitis complicating inflammatory bowel disease |journal=Am. J. Gastroenterol. |volume=101 |issue=12 |pages=2857–65 |year=2006 |month=December |pmid=17026558 |doi=10.1111/j.1572-0241.2006.00869.x |url=}}</ref> |
| **Organ transplant recipients. | | **Organ transplant recipients. |
| **HIV/AIDS. | | **[[HIV|HIV/AIDS]]. |
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| ==Inflammatory bowel disease (IBD)==
| | Images: |
| Exists in two main flavours:
| | <gallery> |
| *Crohn's disease (CD).
| | Image:CMV_colitis_-_high_mag_-_cropped.jpg | CMV colitis - high. mag. (WC/Nephron) |
| *Ulcerative colitis (UC).
| | Image:CMV_colitis_-_intermed_mag.jpg | CMV colitis - intermed. mag. (WC/Nephron) |
| | </gallery> |
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| |
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| ===Clinical=== | | =Grossing= |
| *It is important to differentiate UC and CD as the management is different.
| | ==Types of specimens== |
| *UC patients get pouches... CD patients do not. | | Introduction to colorectal surgery: |
| | # Colonic resection - remove a piece of large bowel. |
| | # Total colectomy - leaves rectum and anus.<ref>[http://www.allaboutbowelsurgery.com/shared/stoma_care/stoma_surgery/procedures/surgery_colon/subtotal.htm http://www.allaboutbowelsurgery.com/shared/stoma_care/stoma_surgery/procedures/surgery_colon/subtotal.htm]</ref> |
| | # Subtotal colectomy - part of colon removed --or-- some of the rectum remains. |
| | # Right hemicolectomy - right colon + distal ileum. |
| | # [[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> |
| | # [[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. |
| | #[[Doughnuts]] (also ''donuts'') from an end-to-end anastomosis stapler. |
| | #*Often accompany lower anterior resections. |
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| Epidemiology:
| | ===Images=== |
| *NOD2/CARD15 variants are assoc. with stricturing CD, early need for surgery and recurrence.<ref name=pmid16244543 >{{cite journal |author=Alvarez-Lobos M, Arostegui JI, Sans M, ''et al.'' |title=Crohn's disease patients carrying Nod2/CARD15 gene variants have an increased and early need for first surgery due to stricturing disease and higher rate of surgical recurrence |journal=Ann. Surg. |volume=242 |issue=5 |pages=693–700 |year=2005 |month=November |pmid=16244543 |pmc=1409853 |doi= |url=}}</ref>
| | <gallery> |
| | Image:Rectum - anterior view.jpg | APR specimen - anterior (WC) |
| | Image: Rectum - lateral view.jpg | APR specimen - lateral (WC) |
| | Image: Rectum - anterior and lateral - inked.jpg | APR specimen - inked (WC) |
| | </gallery> |
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| ===Microscopic=== | | ==Identifying the specimen== |
| Features helpful for the diagnosis of IBD - as based on a study:<ref name=pmid10048734>{{cite journal |author=Tanaka M, Riddell RH, Saito H, Soma Y, Hidaka H, Kudo H |title=Morphologic criteria applicable to biopsy specimens for effective distinction of inflammatory bowel disease from other forms of colitis and of Crohn's disease from ulcerative colitis |journal=Scand. J. Gastroenterol. |volume=34 |issue=1 |pages=55–67 |year=1999 |month=January |pmid=10048734 |doi= |url=}}</ref>
| | *Transverse colon - has [[omentum]]. |
| *Basal, i.e. crypt base, plasmacytosis with severe chronic inflammation,
| | *Ascending colon - usu. comes with [[ileocecal valve]] and a bit of ileum. |
| *Crypt architectural abnormalities, and
| | *Descending colon - has a bare area. |
| *Distal Paneth cell metaplasia.
| | *Rectum - has adventitia. |
| **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. | | **Pathologists define it as starting where the adventitia starts/the serosal surface no longer completely surrounds the large intestine.<ref>{{Ref Lester3|339}}</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>
| | **Anatomists define it in relation to the third sacral vertebra.<ref>URL: [http://www.bartleby.com/107/249.html http://www.bartleby.com/107/249.html]. Accessed on: 19 October 2012.</ref> |
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| |
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| Notes:
| | ===Images=== |
| # Microscopic features can be remembered by [[mnemonic]] ''CPP'': Crypts (abnormal), Plasmacytosis, Paneth cells where they don't belong.
| | <gallery> |
| # If you see architectural distortion (e.g. crypt branching) in the left colon, look for Paneth cells.
| | Image: Rectum - lateral view.jpg | Sigmoid and rectum. APR specimen. (WC) |
| # The hepatic flexure is considered the divider for normal paneth cells and abnormal paneth cells, i.e. paneth cells proximal to the hepatic flexure are normal; paneth cells distal to the hepatic flexure are abnormal.<ref>STC. 14 December 2009.</ref>
| | </gallery> |
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| ===Crohn's disease vs. ulcerative colitis=== | | ==Lymph nodes== |
| UC features:<ref>PBoD P.850.</ref>
| | *One should get at least 12 [[lymph nodes]] if it is cancer.<ref name=pmid18780863>{{cite journal |author=Bilimoria KY, Bentrem DJ, Stewart AK, ''et al.'' |title=Lymph node evaluation as a colon cancer quality measure: a national hospital report card |journal=J. Natl. Cancer Inst. |volume=100 |issue=18 |pages=1310–7 |year=2008 |month=September |pmid=18780863 |doi=10.1093/jnci/djn293 |url=http://www.medscape.com/viewarticle/581463}}</ref> |
| *Mucosal involvement --sometimes submucosa.
| |
| *No skip lesions.
| |
| *Colon/rectum only.
| |
| ** UC may have 'ileal backwash' -- mild ileal inflammation due to backwash of inflammatory soup from colon.
| |
| *"No granulomas".
| |
| **Superficial granulomas in the mucosa are non-specific, especially if they are beside an inflammed crypt, i.e. they may be present in UC.<ref name=pmid12147095>{{Cite journal | last1 = Shepherd | first1 = NA. | title = Granulomas in the diagnosis of intestinal Crohn's disease: a myth exploded? | journal = Histopathology | volume = 41 | issue = 2 | pages = 166-8 | month = Aug | year = 2002 | doi = | PMID = 12147095 }}</ref><ref name=pmid12121237>{{Cite journal | last1 = Mahadeva | first1 = U. | last2 = Martin | first2 = JP. | last3 = Patel | first3 = NK. | last4 = Price | first4 = AB. | title = Granulomatous ulcerative colitis: a re-appraisal of the mucosal granuloma in the distinction of Crohn's disease from ulcerative colitis. | journal = Histopathology | volume = 41 | issue = 1 | pages = 50-5 | month = Jul | year = 2002 | doi = | PMID = 12121237 }}</ref> | |
| ***Deep granulomas are specific for Crohn's disease.
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| Example of a superficial granuloma that is non-specific, i.e. this could be UC or CD:
| | ==Quirke method== |
| *[http://commons.wikimedia.org/wiki/File:Colitis_with_granuloma_low_mag.jpg Colitis with a superficial granuloma (wikimedia.org)].
| | *Bowel is not opened - it is fixed... then sliced.<ref name=pmid18667357>{{cite journal |author=West NP, Morris EJ, Rotimi O, Cairns A, Finan PJ, Quirke P |title=Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study |journal=Lancet Oncol. |volume=9 |issue=9 |pages=857–65 |year=2008 |month=September |pmid=18667357 |doi=10.1016/S1470-2045(08)70181-5 |url=}}</ref><ref name=pmid18541901>{{cite journal |author=West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P |title=Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer |journal=J. Clin. Oncol. |volume=26 |issue=21 |pages=3517–22 |year=2008 |month=July |pmid=18541901 |doi=10.1200/JCO.2007.14.5961 |url=}}</ref> |
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| ==Ulcerative colitis== | | ==Standard method== |
| ===General===
| | *Bowel is prep'ed by [[opening]] it along the antimesenteric side. |
| *Often abbreviated as ''UC''. | | *Dimensions - length, circumference at both [[margins]]. |
| | *Radial margin/circumferential margin - should be painted. |
| | **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. |
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| ===Epidemiology===
| | Note: |
| *Associated with ''[[sclerosing cholangitis]]''. | | *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> |
| *Appendicitis is considered protective against UC.<ref name=pmid19685454>{{Cite journal | last1 = Beaugerie | first1 = L. | last2 = Sokol | first2 = H. | title = Appendicitis, not appendectomy, is protective against ulcerative colitis, both in the general population and first-degree relatives of patients with IBD. | journal = Inflamm Bowel Dis | volume = | issue = | pages = | month = Aug | year = 2009 | doi = 10.1002/ibd.21064 | PMID = 19685454 }}</ref><ref name=pmid19273505>{{Cite journal | last1 = Timmer | first1 = A. | last2 = Obermeier | first2 = F. | title = Reduced risk of ulcerative colitis after appendicectomy. | journal = BMJ | volume = 338 | issue = | pages = b225 | month = | year = 2009 | doi = | PMID = 19273505 }}</ref>
| | **In a survey of surgeons: |
| *Smoking is protective; the opposite is true for Crohn's disease.<ref name=pmid19273505/> | | **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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| ===Gross=== | | =Common non-neoplastic disease= |
| *Conventionally considered to be contiguous, i.e. no "skip lesions", with rectal involvement being most severe.
| | ==Colorectal polyps== |
| *Dependent on the study one reads... rectal sparing may be seen in 15% of UC patients.<ref>{{cite journal |author=Bernstein CN, Shanahan F, Anton PA, Weinstein WM |title=Patchiness of mucosal inflammation in treated ulcerative colitis: a prospective study |journal=Gastrointest. Endosc. |volume=42 |issue=3 |pages=232-7 |year=1995 |month=September |pmid=7498688 |doi= |url=}}</ref>
| | {{main|Intestinal polyps}} |
| | Polyps are the bread & butter of [[GI pathology]]. They are very common. |
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| ===Microscopic===
| | Main types: |
| *Lack of granulomas. | | *Hyperplastic - most common, benign. |
| *No full wall-thickness inflammation. | | *Adenomatous - quite common, pre-malignant. |
| | *[[Hamartomatous polyps|Hamartomatous]] - rare, weird & wonderful. |
| | *Inflammatory, [[AKA]] inflammatory pseudopolyps - associated with [[IBD]]. |
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| ==Crohn's disease==
| | Most common (images): |
| ===General=== | | <gallery> |
| *Often abbreviated as ''CD''. | | Image:Hyperplastic_polyp1.jpg | Hyperplastic polyp image - intermed. mag. (WC/Nephron) |
| | | Image:Hyperplastic_polyp2.jpg | Hyperplastic polyp image - low mag. (WC/Nephron) |
| ===Gross===
| | </gallery> |
| *Transmural inflammation, i.e. full thickness of bowel wall.
| | ==Ischemic colitis== |
| *Creeping fat. | | *[[AKA]] ''colonic ischemia''. |
| *Cobblestone appearance -- may be described as such on endoscopy.
| | *[[AKA]] ''ischemia of the colon''. |
| *Serpiginous ulcers.
| | {{Main|Ischemic colitis}} |
| ** Image: [http://en.wikipedia.org/wiki/File:CD_serpiginous_ulcer.jpg Serpiginous ulcer (endoscopy) - wikipedia.org].
| |
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| ===Microscopic=== | | ==Diverticular disease== |
| Features:<ref name=pmid10048734/>
| | {{Main|Diverticular disease}} |
| *Segmental crypt architectural abnormalities,
| |
| *Mucin depletion,
| |
| *Mucin preservation at the active sites, and
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| *Focal chronic inflammation without crypt atrophy.
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| ==Bowel ischemia== | | ==Pseudomembranous colitis== |
| ===Radiologic correlate===
| | {{Main|Pseudomembranous colitis}} |
| *Bowel wall thickening.
| |
|
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| ===Gross=== | | ==Volvulus== |
| Features:<ref>PBoD P.852.</ref>
| | {{Main|Volvulus}} |
| *Luminal part (mucosa & submucosa) affected.
| |
| *Splenic flexture of colon commonly affected (vascular watershed).
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| Note:
| | =Inflammatory diseases= |
| *May have pseudomembranes (classically assoc. with ''C. difficle'' colitis), i.e. mimics an infectious process.
| | ==Inflammatory bowel disease== |
| *DDx for pseudomembranes:<ref>PBoD P.837-8.</ref>
| | {{main|Inflammatory bowel disease}} |
| **C. difficle induced pseudomembranous colitis,
| |
| **Ischemic colitis,
| |
| **Volvulus,
| |
| **Necrotizing infections,
| |
| **... anything that causes severe mucosal injury.
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|
| Histology of pseudomembranes:<ref>PBoD P.837-8.</ref>
| | The bread 'n butter of gastroenterology. A detailed discussion of '''IBD''' is in the ''[[inflammatory bowel disease]]'' article. It comes in two main flavours (Crohn's disease, ulcerative colitis). |
| *Loss of surf. epithelium,
| |
| *PMNs in lamina propria,
| |
| *+/- capillary fibrin thrombi.
| |
| NB: Pseudomembranes arise from the crypts.
| |
|
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|
| Image:
| | ===Microscopic=== |
| *[http://commons.wikimedia.org/wiki/File:Colonic_pseudomembranes_low_mag.jpg Micrograph of pseudomembranes - low mag. (wikimedia.org)].
| | Features helpful for the diagnosis of IBD - as based on a study:<ref name=pmid10048734>{{cite journal |author=Tanaka M, Riddell RH, Saito H, Soma Y, Hidaka H, Kudo H |title=Morphologic criteria applicable to biopsy specimens for effective distinction of inflammatory bowel disease from other forms of colitis and of Crohn's disease from ulcerative colitis |journal=Scand. J. Gastroenterol. |volume=34 |issue=1 |pages=55–67 |year=1999 |month=January |pmid=10048734 |doi= |url=}}</ref> |
| *[http://commons.wikimedia.org/wiki/File:Colonic_pseudomembranes_intermed_mag.jpg Micrograph of pseudomembranes - intermed. mag. (wikimedia.org)]. | | *Basal, i.e. crypt base, plasmacytosis with severe chronic inflammation, |
| | *Crypt architectural abnormalities, and |
| | *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. |
| | **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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| ==Angiodysplasia== | | ==Microscopic colitis== |
| ===General===
| | :''Microscopic colitis'' may refer to a microscopic manifestation of an unspecified disease process that can be apparent macroscopically. This section links to a pair of diseases (''lymphocytic colitis'' and ''collagenous colitis'') that are considered to only have microscopic manifestations and characteristic clinical presentation. |
| *Causes (lower) GI haemorrhage.
| | {{Main|Lymphocytic colitis}} |
| *Generally, not a problem pathologists see.
| | {{Main|Collagenous colitis}} |
|
| |
|
| ===Location=== | | ==Diversion colitis== |
| *Cecum.
| | {{Main|Diversion colitis}} |
|
| |
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| ===Epidemiology=== | | ==Eosinophilic colitis== |
| *Older people. | | *Abbreviated ''EC''. |
| | {{Main|Eosinophilic colitis}} |
|
| |
|
| ===Etiology=== | | =Infectious= |
| *Thought to be caused by the higher wall tension of cecum (due to larger diameter) and result from (intermittent) venous occulsion/focal dilation of vessels.<ref>PBoD P.854</ref>
| | ==Infectious colitis== |
| | | :This section covers non-specific colitides that appear to have an infective etiology. |
| ==Melanosis coli== | |
| *AKA ''Pseudomelanosis coli''.<ref>[http://www.medicinenet.com/melanosis_coli/article.htm http://www.medicinenet.com/melanosis_coli/article.htm]</ref>
| |
| *''Not melanin'' as the name suggests; it is actually lipofuscin (in macrophages).<ref name=pmid18666316>{{cite journal |author=Freeman HJ |title="Melanosis" in the small and large intestine |journal=World J. Gastroenterol. |volume=14 |issue=27 |pages=4296-9 |year=2008 |month=July |pmid=18666316 |doi= |url=http://www.wjgnet.com/1007-9327/14/4296.asp}}</ref>
| |
| *Endoscopist may see brown pigmentation of mucosa and suspect the diagnosis.
| |
| | |
| ===Epidemiology===
| |
| *Classically associated with anthracene containing laxative (e.g. Senokot) use and herbal remedies.<ref name=pmid18666316/>
| |
| | |
| ===Features===
| |
| *Brown pigmentation of the mucosa.
| |
| *Typically more prominent in the cecum and proximal colon.<ref name=pmid18666316/>
| |
| | |
| DDx of brown pigment:
| |
| *Lipofuscin - comes with age (can be demonstrated with a ''Kluver-Barrera stain''<ref>URL: [http://education.vetmed.vt.edu/curriculum/VM8054/labs/Lab2/Examples/exkluvbarr.htm http://education.vetmed.vt.edu/curriculum/VM8054/labs/Lab2/Examples/exkluvbarr.htm]. Accessed on: 5 May 2010.</ref>).
| |
| **Melanosis coli.
| |
| *Old haemorrhage, i.e. hemosiderin-laden macrophages (may be demonstrated with ''Prussian blue stain''<ref>URL: [http://education.vetmed.vt.edu/curriculum/VM8054/labs/Lab2/Examples/exprussb.htm http://education.vetmed.vt.edu/curriculum/VM8054/labs/Lab2/Examples/exprussb.htm]. Accessed on: 5 May 2010.</ref>).
| |
| *Melanin (from melanocytes) - rare in colon (may be demonstrated with a ''Fontana-Masson stain''<ref>URL: [http://education.vetmed.vt.edu/curriculum/VM8054/labs/Lab2/Examples/exfontana.htm http://education.vetmed.vt.edu/curriculum/VM8054/labs/Lab2/Examples/exfontana.htm]. Accessed on: 5 May 2010.</ref> -- though not so useful in the GI tract).
| |
| *Foriegn material (e.g. tattoo pigment) - not seen in GI tract.
| |
| | |
| Images:
| |
| *[http://commons.wikimedia.org/wiki/File:Melanosis_coli_high_mag.jpg Melanosis coli - high mag. (WC)].
| |
| *[http://commons.wikimedia.org/wiki/File:Melanosis_coli_low_mag.jpg Melanosis coli - low mag. (WC)].
| |
| | |
| ==Microscopic colitis==
| |
| ===General=== | | ===General=== |
| Definition:
| | *Common. |
| *As the name suggests, they are microscopic, i.e. endoscopic examination is normal. | | *Diarrhea - typical symptom. |
|
| |
|
| Presentation:
| | ===Gross=== |
| *Chronic diarrhea, non-bloody.<ref name=medscape180664>URL: [http://emedicine.medscape.com/article/180664-overview http://emedicine.medscape.com/article/180664-overview]. Accessed on: 31 May 2010.</ref> | | *+/-Erythema on endoscopy. |
|
| |
|
| ===Microscopic colitis - types=== | | ===Microscopic=== |
| *Lymphocytic colitis (LC).
| | Features: |
| *Collagenous colitis (CC). | | *Neutrophils predominant - '''key feature'''.<ref name=Ref_GLP324>{{Ref GLP|324}}</ref> |
| | | **The neutrophils are often superficial - they go to were the bad guys are. |
| Some believe that LC and CC are different time points in the same process-- but this is unproven.<ref name=medscape180664/>
| | *No architectural distortion - if acute. |
|
| |
|
| ===Epidemiology===
| | DDx: |
| *Age: a disease of adults - usually 50s. | | *[[Inflammatory bowel disease]] - lymphoplasmacytic infiltrate predominant,<ref name=Ref_GLP324>{{Ref GLP|324}}</ref> usually has chronic changes. |
| *Sex:
| | *[[Ischemic colitis]]. |
| **LC males ~= females,<ref name=medscape180664/>
| | *Medications - focal neutrophils. |
| **CC females:males = 20:1.<ref name=medscape180664/> | | *[[Lymphocytic colitis]] - lymphocytes with a squiggly nucleus, may be confused with neutrophils. |
| *Drugs are associated with LC and CC. | | *Specific causes of infective colitis - with a distinctive morphology. |
| **NSAIDs - posulated association/weak association, | | **[[CMV colitis]] - esp. in the immunodeficient. |
| **SSRIs (used primarily for depression) - moderate association, dependent on specific drug. | | **[[Pseudomembranous colitis]] - usu. due to ''C. difficle'', has characteristic gross & microscopic appearance. |
| *Associated with autoimmune disorders - celiac disease, diabetes mellitus, thyroid disorders and arthritis.<ref name=pmid19109861>{{cite journal |author=Tysk C, Bohr J, Nyhlin N, Wickbom A, Eriksson S |title=Diagnosis and management of microscopic colitis |journal=World J. Gastroenterol. |volume=14 |issue=48 |pages=7280-8 |year=2008 |month=December |pmid=19109861 |doi= |url=http://www.wjgnet.com/1007-9327/14/7280.asp}}</ref> | | **[[Intestinal spirochetes]]. |
| *No increased risk of colorectal carcinoma.<ref name=pmid19109861/> | | **[[Amebiasis]]. |
| | **[[Strongyloidiasis]]. |
| | **[[Cryptosporidiosis]]. |
|
| |
|
| ===Treatment=== | | ===IHC=== |
| *Sometimes just follow-up. | | Done if the patient is immunosuppressed, or there is clinical or morphological suspicion: |
| *Steroids - budesonide -- short-term treatment.<ref name=pmid19109861/> | | *[[CMV]]. |
| | *HSV-1. |
| | *HSV-2. |
| | *[[EBV]] - may mimic IBD.<ref name=pmid21119609>{{Cite journal | last1 = Karlitz | first1 = JJ. | last2 = Li | first2 = ST. | last3 = Holman | first3 = RP. | last4 = Rice | first4 = MC. | title = EBV-associated colitis mimicking IBD in an immunocompetent individual. | journal = Nat Rev Gastroenterol Hepatol | volume = 8 | issue = 1 | pages = 50-4 | month = Jan | year = 2011 | doi = 10.1038/nrgastro.2010.192 | PMID = 21119609 }}</ref> |
|
| |
|
| ===Characteristics=== | | ===Sign out=== |
| ====Lymphocytic colitis====
| | <pre> |
| *Lots of intraepithelial lymphocytes (>=20/100 lymphocytes/surface epithelial cells<ref name=pmid19109861>{{cite journal |author=Tysk C, Bohr J, Nyhlin N, Wickbom A, Eriksson S |title=Diagnosis and management of microscopic colitis |journal=World J. Gastroenterol. |volume=14 |issue=48 |pages=7280-8 |year=2008 |month=December |pmid=19109861 |doi= |url=http://www.wjgnet.com/1007-9327/14/7280.asp}}</ref>) and
| | ASCENDING COLON, BIOPSY: |
| *lymphocytes in the lamina propria.
| | - MILD ACTIVE COLITIS, SEE COMMENT. |
| *NEGATIVES:<ref name=hopkins_cc_lc>[http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm?pg=disease1&disease=29&organ=6&lang_id=1 http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm?pg=disease1&disease=29&organ=6&lang_id=1]</ref>
| |
| **No PMNs.
| |
| **No crypt distortion.
| |
|
| |
|
| ====Collagenous colitis====
| | COMMENT: |
| *Intraepithelial lymphocytes, and
| | There is are no granulomas. The crypt architecture is normal. A benign lymphoid nodule is |
| *lymphocytes in the lamina propria.
| | present. |
| *Collagenous material in the lamina propria (pink on H&E) -- '''key feature'''.
| |
| **Can be demonstrated with a trichrome stain -- collagen = green on trichrome.
| |
| **Subepithelial collagen needs to be >= 10 micrometres thick for Dx.<ref name=pmid19109861/>
| |
| ***8 micrometres is the diameter of a RBC.
| |
| ***The normal thickness of the subepithelial collagen is 3 micrometres.<ref name=pmid19109861/>
| |
| **Thickening "follows the crypts from the surface" - useful for differentiating from tangential sections of the basement membrane.<ref>BEC 4 Mar 2009</ref>
| |
| **Collagen may envelope capillaries - useful to discern from basement membrane.<ref>BEC 4 Mar 2009</ref>
| |
| *NEGATIVES<ref name=hopkins_cc_lc/>
| |
| **No [[PMN]]s.
| |
| **No crypt distortion.
| |
|
| |
|
| Notes: CC is typically more prominent in the proximal colon - may reflect concentration gradient of offending causitive agents.<ref name=pmid19109861/>
| | The differential diagnosis includes infective etiologies, early inflammatory |
| | bowel disease and ischemia. The histomorphology is more in keeping with an infective |
| | etiology as neutrophils are a predominant feature; however, clinical correlation is |
| | required. |
| | </pre> |
|
| |
|
| ==Spirochetes== | | ==Cytomegalovirus colitis== |
| ===General===
| | {{Main|CMV}} |
| *Very rare cause of diarrhea.
| | *Abbreviated ''CMV colitis''. |
| *Caused by ''Serpulina pilosicoli'' and ''Brachyspira aalborgi''.<ref name=pmid14718105>{{cite journal |author=Amat Villegas I, Borobio Aguilar E, Beloqui Perez R, de Llano Varela P, Oquiñena Legaz S, Martínez-Peñuela Virseda JM |title=[Colonic spirochetes: an infrequent cause of adult diarrhea] |language=Spanish; Castilian |journal=Gastroenterol Hepatol |volume=27 |issue=1 |pages=21–3 |year=2004 |month=January |pmid=14718105 |doi= |url=}}</ref>
| | {{Main|Cytomegalovirus colitis}} |
| *Tx: metronidazole.<ref name=pmid17914949>{{cite journal |author=Calderaro A, Bommezzadri S, Gorrini C, ''et al.'' |title=Infective colitis associated with human intestinal spirochetosis |journal=J. Gastroenterol. Hepatol. |volume=22 |issue=11 |pages=1772–9 |year=2007 |month=November |pmid=17914949 |doi=10.1111/j.1440-1746.2006.04606.x |url=}}</ref> | |
|
| |
|
| ===Histology=== | | ==Intestinal spirochetosis== |
| *Hyperchromatic fuzz on luminal aspect of epithelial cells; at brush border. | | *[[AKA]] ''intestinal spirochetes''; more specifically ''colonic spirochetes'', ''colonic spirochetosis''. |
| | {{Main|Intestinal spirochetosis}} |
|
| |
|
| Special stain:
| | ==Amebiasis== |
| *Silver stains highlight 'em (e.g. Warthin-Starry stain). | | *May also be spelled ''amoebiasis''. |
| | {{Main|Amebiasis}} |
|
| |
|
| ==Amebiasis== | | ==Cryptosporidiosis== |
| | {{Main|Cryptosporidiosis}} |
| ===General=== | | ===General=== |
| *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> | | *Usually in immune incompetent individuals, e.g. [[HIV|HIV/AIDS]]. |
|
| |
|
| 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>
| | ===Microscopic=== |
| *Dysentery (diarrhea containing mucus and/or blood in the feces).
| |
| *Colitis.
| |
| *Liver abscess.
| |
| | |
| 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>
| |
| | |
| ===Microscopy===
| |
| Features: | | Features: |
| *Round/Ovoid eosinophilic bodies ~ 40-60 micrometers in maximal dimension. | | *Uniform spherical nodules 2-4 micrometres in diameter, typical location - GI tract brush border. |
| *Found in bowel lumen. | | **Bluish staining of brush border '''key feature''' - low power. |
| *Ingest RBCs. | |
|
| |
|
| Image:
| | =Rectal pathology= |
| *[http://commons.wikimedia.org/wiki/File:Amoebic_dysentery_in_colon_biopsy_%281%29.jpg Amebiasis (WC)]. | | ==Solitary rectal ulcer== |
| | *[[AKA]] ''solitary ulcer syndrome of the rectum'', abbreviated ''SUS''. |
| | *[[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> |
| | {{Main|Solitary rectal ulcer}} |
|
| |
|
| ==Polyps== | | ==Rectal prolapse== |
| {{main|Intestinal polyps}} | | {{Main|Rectal prolapse}} |
| Polyps are the bread & butter of GI pathology. They are very common.
| |
| | |
| Main types:
| |
| *Hyperplastic (most common)
| |
| *Adenomatous (quite common, pre-malignant)
| |
| *Hamartomatous (rare, weird & wonderful)
| |
| *Inflammatory (associated with IBD)
| |
| | |
| Most common (images):
| |
| *[http://en.wikipedia.org/wiki/File:Hyperplastic_polyp1.jpg Hyperplastic polyp image - intermed. mag. (wikipedia.org)].
| |
| *[http://commons.wikimedia.org/wiki/File:Hyperplastic_polyp2.jpg Hyperplastic polyp image - low mag. (wikipedia.org)].
| |
|
| |
|
| | =Neoplastic disease= |
| ==Colorectal Tumours== | | ==Colorectal Tumours== |
| ===Epidemiology===
| | {{main|Colorectal tumours}} |
| Very common type of cancer.
| | These are very common. The are covered in a separate article entitled ''[[colorectal tumours]]''. |
|
| |
|
| ===Classification=== | | ==Neuroendocrine tumour== |
| *Colon & rectum, most common --by far-- is [[adenocarcinoma]].<ref>PBoD P.864.</ref> | | {{Main|Neuroendocrine neoplasms#GI tract}} |
| | *[[AKA]] ''carcinoid''. |
|
| |
|
| Other tumours - many (incomplete list):<ref>WMSP P.198.</ref>
| | ==Goblet cell carcinoid== |
| *Mucinous carcinoma.
| | :Described in detail in the ''[[appendix]]'' article. |
| *Adenosquamous carcinoma.
| | *AKA ''crypt cell carcinoma''. |
| *Signet-ring carcinoma.
| | *Biphasic tumour; features of ''carcinoid tumour'' and ''adenocarcinoma''. |
| *Squamous carcinoma.
| |
| *Neuroendocrine neoplasms (carcinoid tumours).
| |
| *Lipoma.
| |
| *Leiomyoma.
| |
| *[[GIST]].
| |
| *Angiosarcoma. | |
| *Lymphoma (Non-Hodgkin's lymphoma). | |
|
| |
|
| ===Grading=== | | =Other= |
| *"adenocarcinoma in situ" and "high-grade dysplasia" is used interchangeably by many in the colon and rectum.
| | ==Colonic pseudo-obstruction== |
| **splitting hairs - ''adenocarcinoma in situ'' is ''invasion into the lamina propria'', high-grade dysplasia does not have lamina propria invasion. Ergo, the difference (in my opinion) amounts to seeing a [[desmoplastic stroma]] (adenocarcinoma) or not seeing one (dysplasia).
| | {{Main|Colonic pseudo-obstruction}} |
|
| |
|
| Grading of tumours:
| | ==Pseudomelanosis coli== |
| *Tis - in situ (intramucosal), | | *[[AKA]] ''melanosis coli''. |
| *T1 - into submucosa (through mucularis mucosae),
| | {{Main|Pseudomelanosis coli}} |
| **this is different than elsewhere,
| |
| *T2 - into muscularis propria,
| |
| *T3 - into fat beyond musclaris propria,
| |
| *T4 - into something else.
| |
|
| |
|
| Nodes:
| | ==Angiodysplasia== |
| *N0 - no positive nodes,
| | {{Main|Angiodysplasia}} |
| *N1 - 1-3 positive nodes,
| |
| *N2 - 4+ positive nodes.
| |
|
| |
|
| ===Staging of colorectal cancer=== | | ==Drugs== |
| ====Simple version==== | | {{Main|Drug toxicity}} |
| Tumour/node grade for stage:<ref>TN 2006 GS27</ref>
| | ===Sodium polystyrene sulfonate=== |
| *Stage I - '''T1 or T2''' N0 M0. | | *AKA ''Kayexalate''. |
| *Stage II - '''T3 or T4''' N0 M0.
| | ====General==== |
| *Stage III - Tx '''N1 or N2''' M0. | | *Used to treat hyperkalemia - as may be seen in renal failure. |
| *Stage IV - Tx Nx '''M1'''.
| |
|
| |
|
| ====Complex version==== | | ====Microscopic==== |
| Detailed tumour/node grade for stage:<ref>[http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_is_colon_and_rectum_cancer_staged.asp http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_is_colon_and_rectum_cancer_staged.asp]</ref>
| | Features:<ref name=pmid11342776>{{cite journal |author=Abraham SC, Bhagavan BS, Lee LA, Rashid A, Wu TT |title=Upper gastrointestinal tract injury in patients receiving kayexalate (sodium polystyrene sulfonate) in sorbitol: clinical, endoscopic, and histopathologic findings |journal=Am. J. Surg. Pathol. |volume=25 |issue=5 |pages=637-44 |year=2001 |month=May |pmid=11342776 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0147-5185&volume=25&issue=5&spage=637}}</ref> |
| *Stage I - T1 or T2. | | *Purple blobs on H&E stain - look somewhat like [[calcium phosphate]]. |
| *Stage IIA - T3. | | *Can cause focal [[necrosis]]. |
| *Stage IIB - T4.
| |
| *Stage IIIA - T1 N1 or T2 N1.
| |
| *Stage IIIB - T3 N1 or T4 N1.
| |
| *Stage IIIC - Tx N2.
| |
| *Stage IV - Tx Nx M1.
| |
|
| |
|
| ===Surgery=== | | =====Image===== |
| Introduction to colorectal surgery:
| | <gallery> |
| # Colonic resection - remove a piece of large bowel.
| | Image:Cecal_adenocarcinoma.jpg | Adenocarcinoma and sodium polystyrene crystals (WC/Nephron) |
| # Total colectomy - leaves rectum and anus.<ref>[http://www.allaboutbowelsurgery.com/shared/stoma_care/stoma_surgery/procedures/surgery_colon/subtotal.htm http://www.allaboutbowelsurgery.com/shared/stoma_care/stoma_surgery/procedures/surgery_colon/subtotal.htm]</ref>
| | </gallery> |
| # Subtotal colectomy - part of colon removed --or-- some of the rectum remains.
| | ==Graft-versus host disease== |
| # right hemicolectomy - right colon + distal ileum.
| | {{Main|Graft-versus-host disease}} |
| # lower anterior resection (LAR) - proximal rectum +/- sigmoid (for proximal rectal malignancies).
| | *Abbreviated as ''GVHD''. |
| # abdominoperineal resection (APR) - anus + rectum - results in a permanent stoma (for distal rectal malignancies).
| | *Seen in the context of bone marrow transplants. |
|
| |
|
| ==Grossing== | | ==Bowel transplant== |
| *Lymph nodes - should get at least 12.<ref name=pmid18780863>{{cite journal |author=Bilimoria KY, Bentrem DJ, Stewart AK, ''et al.'' |title=Lymph node evaluation as a colon cancer quality measure: a national hospital report card |journal=J. Natl. Cancer Inst. |volume=100 |issue=18 |pages=1310–7 |year=2008 |month=September |pmid=18780863 |doi=10.1093/jnci/djn293 |url=http://www.medscape.com/viewarticle/581463}}</ref>
| | The histology of bowel transplant rejection is identical to GVHD - see ''[[GVHD]]''. |
|
| |
|
| ''Quirke method''
| | ==Chronic constipation== |
| *Bowel is not opened.
| | :This section deals with ''chronic constipation'' that has no apparent cause. |
| **References: <ref name=pmid18667357>{{cite journal |author=West NP, Morris EJ, Rotimi O, Cairns A, Finan PJ, Quirke P |title=Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study |journal=Lancet Oncol. |volume=9 |issue=9 |pages=857–65 |year=2008 |month=September |pmid=18667357 |doi=10.1016/S1470-2045(08)70181-5 |url=}}</ref>, <ref name=pmid18541901>{{cite journal |author=West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P |title=Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer |journal=J. Clin. Oncol. |volume=26 |issue=21 |pages=3517–22 |year=2008 |month=July |pmid=18541901 |doi=10.1200/JCO.2007.14.5961 |url=}}</ref>.
| |
| | |
| ''Standard method'' | |
| *Bowel is prep'ed by opening it along the antimesenteric side.
| |
| *Dimensions - length, circumference at both margins.
| |
| *Radial margin/circumferential margin - should be painted.
| |
| **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.
| |
| | |
| ==Solitary rectal ulcer==
| |
| ===General=== | | ===General=== |
| *Clinically may be suspected to a malignancy - biopsied routinuely. | | *This is occasionally an indication for [[colectomy]].<ref name=pmid21382578>{{Cite journal | last1 = Knowles | first1 = CH. | last2 = Farrugia | first2 = G. | title = Gastrointestinal neuromuscular pathology in chronic constipation. | journal = Best Pract Res Clin Gastroenterol | volume = 25 | issue = 1 | pages = 43-57 | month = Feb | year = 2011 | doi = 10.1016/j.bpg.2010.12.001 | PMID = 21382578 }} |
| *Mucosal ulceration.
| | </ref> |
| *"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,
| |
| # May not be rectal -- can be in left colon,
| |
| # May not be ulcerating -- non-ulcerated lesions: polypoid and/or erythematous.
| |
|
| |
|
| Note: Each of the words in ''solitary rectal ulcer'' is a lie.
| | General differential diagnosis for constipation: |
| | *Tumour. |
| | *Adhesions - due to previous surgery. |
| | *Neuropathy.<ref name=pmid21382578/> |
| | **[[Parkinson disease]]. |
| | *Congenital defect ([[Hirschsprung's disease]]). |
| | *Myopathy.<ref name=pmid21382578/> |
| | *Medications/substance use. |
| | *Idiopathic. |
|
| |
|
| ===Epidemiology=== | | ===Gross=== |
| *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> | | *No changes. |
| *Rare.
| |
|
| |
|
| ===Clinical=== | | ===Microscopic=== |
| *Usually presents as BRBPR ~ 85% of cases.<ref name=pmid17139403/> | | Features: |
| *Abdominal pain present in approx. 1/3.<ref name=pmid17139403/>
| | *Colon within normal limits. |
| **May be very painful.
| | **Look for the Ganglion cells (submucosal plexus, myenteric plexus). |
| | **Look for interstitial cells of Cajal (with CD117) - typically most common around the myenteric plexus.<ref name=pmid17222246>{{Cite journal | last1 = Streutker | first1 = CJ. | last2 = Huizinga | first2 = JD. | last3 = Driman | first3 = DK. | last4 = Riddell | first4 = RH. | title = Interstitial cells of Cajal in health and disease. Part I: normal ICC structure and function with associated motility disorders. | journal = Histopathology | volume = 50 | issue = 2 | pages = 176-89 | month = Jan | year = 2007 | doi = 10.1111/j.1365-2559.2006.02493.x | PMID = 17222246 | url = http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2559.2006.02493.x/pdf }}</ref> |
|
| |
|
| ===Histology===
| | Negatives: |
| Features:<ref name=pmid18271667/>
| | *No significant vascular disease. |
| *Fibrosis of the lamina propria - should be obliterated. | | *No fibrosis. |
| *Thickened muscularis mucosa - abnormally extends to the lumen. | | *No loss of muscle. |
|
| |
|
| ===Histologic DDx=== | | ===Stains & IHC=== |
| *Rectal prolapse. (?) | | Work-up if no tumour is identified:<ref>IAV. 15 December 2009.</ref><ref name=pmid19360428/> |
| | | *Routine H&E. |
| ===Treatment=== | | *Smooth muscle actin - confirm myocyte loss. |
| *Usually conservative, i.e. non-surgical.
| | *Gomori trichrome - examine connective tissue. |
| *Resection - may be done for fear of malignancy.
| | *CD117 - to look for the ''interstitial cells of Cajal''. |
| | **<50% the expected = abnormal.<ref name=pmid19360428/> |
| | ***Normal numbers not defined. |
| | *HU - neuronal marker.<ref name=pmid8586967>{{cite journal |author=Barami K, Iversen K, Furneaux H, Goldman SA |title=Hu protein as an early marker of neuronal phenotypic differentiation by subependymal zone cells of the adult songbird forebrain |journal=J. Neurobiol. |volume=28 |issue=1 |pages=82–101 |year=1995 |month=September |pmid=8586967 |doi=10.1002/neu.480280108 |url=}}</ref> |
|
| |
|
| ==Rectal prolapse== | | ===Sign out=== |
| ===Histopathology=== | | *A long list of things to report is contained the recommendation of a working group.<ref name=pmid19360428>{{Cite journal | last1 = Knowles | first1 = CH. | last2 = De Giorgio | first2 = R. | last3 = Kapur | first3 = RP. | last4 = Bruder | first4 = E. | last5 = Farrugia | first5 = G. | last6 = Geboes | first6 = K. | last7 = Gershon | first7 = MD. | last8 = Hutson | first8 = J. | last9 = Lindberg | first9 = G. | title = Gastrointestinal neuromuscular pathology: guidelines for histological techniques and reporting on behalf of the Gastro 2009 International Working Group. | journal = Acta Neuropathol | volume = 118 | issue = 2 | pages = 271-301 | month = Aug | year = 2009 | doi = 10.1007/s00401-009-0527-y | PMID = 19360428 }}</ref> |
| Features:<ref>NEED REF.</ref>
| | **Most pathology practises do not report much. |
| *"Fibromuscular hyperplasia":
| |
| **Fibrosis,
| |
| **Muscularis mucosae is "too superficial".
| |
| *Surface ulceration + inflammation (neutrophils).
| |
| *+/-Serration of epithelium at the surface.
| |
| *NEGATIVES:
| |
| **No nuclear atypia. | |
|
| |
|
| ==Mucosal prolapse syndrome==
| | <pre> |
| *Similar to rectal prolapse???
| | TERMINAL ILEUM, CECUM, COLON (ASCENDING, TRANSVERSE AND SIGMOID), COLECTOMY: |
| | - SMALL BOWEL, CECUM, AND COLON WITHIN NORMAL LIMITS. |
| | - FOUR LYMPH NODES NEGATIVE FOR MALIGNANCY ( 0 POSITIVE / 4 ). |
| | - NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY. |
|
| |
|
| ==Weird stuff==
| | COMMENT: |
| Kayexalate (sodium polystyrene sulfonate):<ref name=pmid11342776>{{cite journal |author=Abraham SC, Bhagavan BS, Lee LA, Rashid A, Wu TT |title=Upper gastrointestinal tract injury in patients receiving kayexalate (sodium polystyrene sulfonate) in sorbitol: clinical, endoscopic, and histopathologic findings |journal=Am. J. Surg. Pathol. |volume=25 |issue=5 |pages=637-44 |year=2001 |month=May |pmid=11342776 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0147-5185&volume=25&issue=5&spage=637}}</ref>
| | Several stains were done: |
| *Used to treat hyperkalemia.
| | CD117: interstitial cells of Cajal present, no apparent decrease. |
| *Purple blobs on H&E stain - look somewhat like [[calcium phosphate]].
| | SMA: no significant myocyte loss. |
| *Can cause focal necrosis.
| | Gomori trichrome: no abnormal fibrosis apparent. |
| | | Tau: no abnormalities apparent. |
| Image: [http://commons.wikimedia.org/wiki/File:Cecal_adenocarcinoma.jpg Sodium polystyrene crystals - commons.wikimedia.org].
| | </pre> |
| | |
| ==Chronic constipation==
| |
| This is occasionally an indication for colectomy.
| |
| | |
| Causes:
| |
| *Tumour.
| |
| *Adhesions - due to previous surgery.
| |
| *Neuropathy.
| |
| *Congenital defect (Hirschsprung's disease).
| |
| *Medications/substance use.
| |
| *Idiopathic.
| |
| | |
| Work-up if no tumour is identified:<ref>IAV. 15 December 2009.</ref>
| |
| *Routine H&E.
| |
| *Pan-actin.
| |
| *Gomori trichrome.
| |
| *CD117 - to look for the ''interstitial cell of Cajal''.
| |
| *HU - neuronal marker.<ref name=pmid8586967>PMID 8586967.</ref>
| |
| | |
| ==Goblet cell carcinoid==
| |
| :Described in detail in the ''[[appendix]]'' article.
| |
| *AKA ''crypt cell carcinoma''.
| |
| *Biphasic tumour; features of ''carcinoid tumour'' and ''adenocarcinoma''.
| |
|
| |
|
| ==See also==
| | =See also= |
| *[[GIST]]. | | *[[GIST]]. |
| *[[Gastrointestinal pathology]]. | | *[[Gastrointestinal pathology]]. |
| *[[Intestinal polyps]]. | | *[[Intestinal polyps]]. |
| *[[Small bowel]]. | | *[[Small bowel]]. |
| | *[[Doughnuts]]. |
|
| |
|
| ==References==
| | =References= |
| {{reflist|2}} | | {{reflist|2}} |
|
| |
|
| [[Category:Gastrointestinal pathology]] | | [[Category:Gastrointestinal pathology]] |
| | [[Category:Colon|Colon]] |