Colon

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The colon smell like poo... 'cause that's where poo comes from. This article also covers the rectum and cecum as both have a similar mucosa.

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 is dealt with in a separate article.

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.

Common clinical problems

Obstruction

Top three (in adults):[1]

Bleeding

Mnemonic CHAND:[2]

Infectious colitis with bleeding - causes:

  • Enterohemorrhagic Escherichia coli (EHEC) -- commonly 0157:H7.
  • Campylobacter jejuni.
  • Clostridium difficile.
  • Shigella.

Infectious colitis in the immunosuppressed:

Grossing

Types of specimens

Introduction to colorectal surgery:

  1. Colonic resection - remove a piece of large bowel.
  2. Total colectomy - leaves rectum and anus.[5]
  3. Subtotal colectomy - part of colon removed --or-- some of the rectum remains.
  4. Right hemicolectomy - right colon + distal ileum.
  5. Lower anterior resection (LAR) - proximal rectum +/- sigmoid (for proximal rectal malignancies).
    • Specimens have should have intact mesorectum - total mesorectal excision (TME) - reduces local recurrence.[6]
  6. Abdominoperineal resection (APR) - anus + rectum - results in a permanent stoma (for distal rectal malignancies).
  7. Stoma - these are often done emergently and then get cut-out after the patient's condition has settled.

Images:

Identifying the specimen

  • Transverse colon - has omentum.
  • Ascending colon - usu. comes with ileocecal valve and a bit of ileum.
  • Descending colon - has a bare area.
  • Rectum - has adventitia.
    • Pathologists define it as starting where the adventitia starts/the serosal surface no longer completely surrounds the large intestine.[8]
    • Anatomists define it in relation to the third sacral vertebra.[9]

Image:

Lymph nodes

Quirke method

  • Bowel is not opened - it is fixed... then sliced.[11][12]

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.

Common non-neoplastic disease

Colorectal polyps

Polyps are the bread & butter of GI pathology. They are very common.

Main types:

  • Hyperplastic - most common, benign.
  • Adenomatous - quite common, pre-malignant.
  • Hamartomatous - rare, weird & wonderful.
  • Inflammatory, AKA inflammatory pseudopolyps - associated with IBD.

Most common (images):

Ischemic colitis

  • AKA colonic ischemia.
  • AKA ischemia of the colon.

General

  • May occur together with ischemic enteritis, in which case it is known as ischemic enterocolitis.

Etiology - anything that leads to vascular occlusion:

Possible associated pathology:

Closely related:

  • Radiation colitis.
  • Infective colitis.

Note:

  • Ischemia = compromised blood supply.

Gross

Features - location:[13]

  • Luminal part (mucosa & submucosa) affected - edema.
  • Splenic flexture of colon commonly affected (vascular watershed).

Note:

  • May have pseudomembranes (classically assoc. with C. difficile colitis), i.e. mimics an infectious process.
  • DDx for pseudomembranes:[14]
    • C. difficile induced pseudomembranous colitis.
    • Ischemic colitis.
    • Volvulus.
    • Necrotizing infections.
    • ... anything that causes severe mucosal injury.
  • Radiologic correlate = bowel wall thickening.

Microscopic

Features:

  • Crypt loss/drop-out.
    • Less intestinal crypts present.
  • Withering crypts.
    • Colonic epithelium has decreased cytoplasm - NC ratio increased.
  • Lamina propria hyalinization.
    • Dense pink material replaces loose connective tissue.
  • Submucosa hyalinization.
  • +/-Pseudomembranes (microscopic):[14]
    • Loss of surface epithelium.
    • PMNs in lamina propria.
    • +/-Capillary fibrin thrombi.

Note:

  • Pseudomembranes arise from the crypts - considered acute.

DDx:

Images:

Sign out

LEFT COLON AND SIGMOID COLON, RESECTION:
- PSEUDOMEMBRANOUS COLITIS, SEE COMMENT.
- ONE LYMPH NODE NEGATIVE FOR MALIGNANCY ( 0 POSITIVE / 1 ).
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

COMMENT:
Pseudomembrane formation is a non-specific finding.  It is consistent with ischemia;
however, it may be seen in other contexts, including infection. Clinical correlation is
required.

Micro

Negative

The sections show colorectal mucosa with preservation of the crypt density and epithelium with a normal nuclear-to-cytoplasm ratio. There is no apparent lamina propria hyalinization. The muscularis mucosa is prominent. Focally, lymphoid aggregates are present.

No cryptitis is present. Neutrophils are not apparent in the lamina propria. No erosions are identified.

The epithelium matures appropriately from the crypt base to the surface.

Diverticular disease

Diverticulitis redirect here.
  • AKA diverticulosis.

General

  • Very common.

Complications:

  • Diverticulitis.
  • Diverticular-associated colitis[15] - rare.

Gross

  • Corrugated - like cardboard.
  • Wall thickening (reactive).[16]

Endoscopic image: DD (WC).

Microscopic

Features:

  • Mucosa/submucosa invagination into the musuclaris propria (MP).
    • At the site the blood vessels supplying the mucosa and submucosa penetrate the MP.[17]

Image:

Sign out

RECTO-SIGMOID, LARGE BOWEL RESECTION:
- PERFORATED DIVERTICULITIS WITH SEROSITIS AND ABSCESS FORMATION.
- SUBMUCOSAL FIBROSIS.
- ONE LYMPH NODE NEGATIVE FOR MALIGNANCY ( 0 POSITIVE / 1 ).
- NEGATIVE FOR MALIGNANCY.
SIGMOID COLON, SIGMOIDECTOMY:
- DIVERTICULAR DISEASE WITHOUT DIVERTICULITIS.
- NEGATIVE FOR MALIGNANCY.

Pseudomembranous colitis

General

  • Pseudomembranous colitis is a histomorphologic description which has a DDx. In other words, it can be caused by a number of things.

DDx of pseudomembranous colitis:[14]

Etiology:

  • Anything that causes a severe mucosal injury.

Gross

Features:[19]

  • Pseudomembranes:
    • Pale yellow (or white) irregular, raised mucosal lesions.
    • Early lesions: typical <10 mm.
  • Interlesional mucosa often near normal grossly.

Images:

Microscopic

Features:[14]

  • Heaped necrotic surface epithelium.
    • Described as "volanco lesions" - this is what is seen endoscopically.
  • PMNs in lamina propria.
  • +/-Capillary fibrin thrombi.

Note:

  • Pseudomembranes arise from the crypts.

Images:

Volvulus

General

  • Uncommonly comes to pathology.
  • It is essentially a radiologic diagnosis.
  • In the context of autopsy, it is a gross diagnosis.

Gross

  • Intestine folded over itself - typically leads to ischemia.

Images:

Microscopic

Features:

DDx - essentially anything that causes ischemia:

Inflammatory diseases

Inflammatory bowel disease

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).

Microscopic

Features helpful for the diagnosis of IBD - as based on a study:[21]

  • 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[22] - 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.[23]

Microscopic colitis

Microscopic colitis may refer to a microscopic manifestation of an unspecified disease process that can be apparent macroscopically. This section deals with a pair of diseases (lymphocytic colitis and collagenous colitis) that are considered to only have microscopic manifestations and characteristic clinical presentation.

General

Presentation:

  • Chronic diarrhea, non-bloody.[24]

Notes:

Gross

  • As the name suggests, they are microscopic, i.e. endoscopic examination is normal.

Microscopic colitis - types

  • Lymphocytic colitis (LC).
  • Collagenous colitis (CC).

Some believe that LC and CC are different time points in the same process-- but this is unproven.[24]

Epidemiology

  • Age: a disease of adults - usually 50s.
  • Sex:
    • LC males ~= females,[24]
    • CC females:males = 20:1.[24]
  • Drugs are associated with LC and CC.
    • NSAIDs - posulated association/weak association,
    • SSRIs (used primarily for depression) - moderate association, dependent on specific drug.
  • Associated with autoimmune disorders - celiac disease, diabetes mellitus, thyroid disorders and arthritis.[25]
  • No increased risk of colorectal carcinoma.[25]

Treatment

  • Sometimes just follow-up.
  • Steroids - budesonide -- short-term treatment.[25]

Microscopic

Lymphocytic colitis

Features:

  • Lots of intraepithelial lymphocytes (>=20/100 lymphocytes/surface epithelial cells[25]) and
  • Lymphocytes in the lamina propria.
  • NEGATIVES:[26]
    • No PMNs.
    • No crypt distortion.

Image:

Collagenous colitis

Features:

  • Intraepithelial lymphocytes, and
  • lymphocytes in the lamina propria.
  • 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.[25]
      • 8 micrometres is the diameter of a RBC.
      • The normal thickness of the subepithelial collagen is 3 micrometres.[25]
    • Thickening "follows the crypts from the surface" - useful for differentiating from tangential sections of the basement membrane.[27]
    • Collagen may envelope capillaries - useful to discern from basement membrane.[28]

Images:

Notes:

  • CC is typically more prominent in the proximal colon - may reflect concentration gradient of offending causitive agents.[25]
  • Significant negative findings:[26]
    • No PMNs.
    • No crypt distortion.
  • Should not be diagnosed in the cecum - as it (normally) has a thickened subepithelial collagen band. (???)

Diversion colitis

General

  • Segment of de-functioned bowel due to surgical diversion, i.e. stoma (ileostomy or colostomy).
  • Diagnosis dependent on history - key point.

Microscopic

Features:[29]

Notes:

  • May show IBD-like changes.[30]
    • IBD should not be diagnosed on a diverted segment of bowel.

Eosinophilic colitis

General

Clinical features:[31]

  • Abdominal pain
  • Diarrhea +/-blood.
  • +/-Weight loss.

Gross

Features - endoscopic:[31]

  • Edema.
  • Granular appearance.

Microscopic

Features:[31]

  • Abundant eosinophils - no agreed upon number.
    • "Most use 20/HPF" [32] - a definition that suffers from HPFitis.
      • There is variation along the large bowel - normal in rectum <10/HPF, normal in cecum <30/HPF (???).[32]

DDx:[31]

Image:

Sign out

DESCENDING COLON, BIOPSY:
- COLONIC MUCOSA WITH MILD EOSINOPHILIA, SEE COMMENT.
- NEGATIVE FOR DYSPLASIA.

COMMENT:
Focally, there are up to 40 eosinophils / 0.2376 mm*mm (approx. field area at 400X). This
is a non-specific finding. No eosinophilic crypt abscesses are seen. No (neutrophilic)
cryptitis is present. Clinical correlation is suggested.
DESCENDING COLON, BIOPSY:
- COLONIC MUCOSA WITH MILD EOSINOPHILIA, SEE COMMENT.
- NEGATIVE FOR ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA.

COMMENT:
There are up to 40 eosinophils / 0.2376 mm*mm (field area at 400X). This is a 
non-specific finding.  The differential diagnosis includes inflammatory bowel 
disease, infection (especially helminths), a drug reaction, and autoimmune 
disorders (e.g. Churg-Strauss syndrome, celiac disease, scleroderma). Clinical 
correlation is required.

Infectious

Cytomegalovirus colitis

  • Abbreviated CMV colitis.

General

  • Uncommon.
  • Immunosuppressed population at risk, e.g. transplant recipients, individuals with HIV.

Microscopic

Features:

  • Enlarged nucleus - classically in endothelial cells.

Images:

IHC

  • CMV +ve.

Others:

  • HSV-1.
  • HSV-2.
  • VZV.
  • EBV.

Intestinal spirochetosis

  • AKA intestinal spirochetes; more specifically colonic spirochetes, colonic spirochetosis.

General

  • Caused by spirochetes[33][34] - specifically Brachyspira piloicoli[35] (previously Serpulina pilosicoli[36]) and Brachyspira aalborgi.
  • Very rare cause of diarrhea, associated with male homosexual behaviour.

Symptoms:[34]

  • Watery diarrhea, abdominal pain, +/-blood per rectum.

Treatment:[37]

  • Metronidazole.

Microscopic

Features:

  • Hyperchromatic fuzz on luminal aspect of epithelial cells; at brush border.

Images:

Special stains

  • Silver stains highlight 'em (e.g. Warthin-Starry stain).

Amebiasis

  • May also be spelling amoebiasis.

General

May cause:[40]

  • Dysentery (diarrhea containing mucus and/or blood in the feces).
  • Colitis.
  • Liver abscess.

Microscopic

Features:

  • Entamoeba histolytica are round/ovoid eosinophilic bodies ~ 40-60 micrometers in maximal dimension.
    • Found in bowel lumen.
    • Ingest RBCs.

Image:

Cryptosporidiosis

General

  • Usually in immune incompetent individuals, e.g. HIV/AIDS.

Microscopic

Features:

  • Uniform spherical nodules 2-4 micrometres in diameter, typical location - GI tract brush border.
    • Bluish staining of brush border key feature - low power.

Rectal pathology

Solitary rectal ulcer

  • AKA solitary ulcer syndrome of the rectum, abbreviated SUS.

General

  • Clinically may be suspected to a malignancy - biopsied routinuely.
  • Mucosal ulceration.
  • "Three-lies disease":[41]
  1. May not be solitary.
  2. May not be rectal -- can be in left colon.
  3. May not be ulcerating -- non-ulcerated lesions: polypoid and/or erythematous.

Note: Each of the words in solitary rectal ulcer is a lie.

Epidemiology

  • Typically younger patients - average age of presentation ~30 years in one study.[42]
  • Rare.

Clinical presentation

  • Usually presents as BRBPR ~ 85% of cases.[42]
  • Abdominal pain present in approx. 1/3.[42]
    • May be very painful.

Treatment:

  • Usually conservative, i.e. non-surgical.
  • Resection - may be done for fear of malignancy.

Gross

  • Classically, anterior or anterolateral wall of the rectum.[41]

Microscopic

Features:[41][43]

  • Fibrosis of the lamina propria.
  • Thickened muscularis mucosa with abnormal extension to the lumen.
  • +/-Mucosa ulceration.
  • +/-Submucosal fibrosis.

DDx:

Rectal prolapse

General

  • Usually close to the anal verge.
  • Rare forms can occasionally be confused with cancer.[44]

Microscopic

Features:[45]

  • "Fibromuscular hyperplasia" - key feature:
    • Fibrosis (submucosa, lamina propria).
    • Muscularis mucosae is "too superficial" (muscle in the lamina propria).
  • Surface ulceration + inflammation (neutrophils).
  • +/-Serration of epithelium at the surface.

Notes:

  • Important negative: no nuclear atypia.

Images:

Neoplastic disease

Colorectal Tumours

These are very common. The are covered in a separate article entitled colorectal tumours.

Neuroendocrine tumour

Goblet cell carcinoid

Described in detail in the appendix article.
  • AKA crypt cell carcinoma.
  • Biphasic tumour; features of carcinoid tumour and adenocarcinoma.

Other

Pseudomelanosis coli

  • AKA melanosis coli.[46]

General

  • Not melanin as the name melanosis coli suggests; it is actually lipofuscin (in macrophages).[47]
  • Endoscopist may see brown pigmentation of mucosa and suspect the diagnosis.
  • Presence may lead to endoscopic misinterpretation of colitis severity.[48]

Epidemiology

Gross

  • Brown pigmentation of the mucosa, esp. cecum and proximal colon.

Image:

Microscopic

Features:

  • Brown granular pigment - in the lamina propria.
    • Typically more prominent in the cecum and proximal colon.[47]

Images:

Notes:

  • DDx of brown pigment:
    • Lipofuscin - comes with age (can be demonstrated with a PAS stain[50] or Kluver-Barrera stain[51]).
      • Melanosis coli.
    • Old haemorrhage, i.e. hemosiderin-laden macrophages (may be demonstrated with Prussian blue stain[52]).
    • Melanin (from melanocytes) - rare in colon (may be demonstrated with a Fontana-Masson stain[53] -- though not so useful in the GI tract).
    • Foreign material (e.g. tattoo pigment) - not seen in GI tract.

Stains

Angiodysplasia

General

  • Causes (lower) GI haemorrhage.
  • Generally, not a problem pathologists see.
  • May be associated with aortic stenosis; known as Heyde syndrome.[55]

Epidemiology:

  • Older people.

Etiology:

  • 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.[56]

Gross

  • Cecum - classic location.

Note:

Microscopic

Features:[57]

  • Dilated vessels in mucosa and submucosa.

Drugs

Sodium polystyrene sulfonate

  • AKA Kayexalate.

General

  • Used to treat hyperkalemia - as may be seen in renal failure.

Microscopic

Features:[58]

Image:

Graft-versus host disease

  • Abbreviated as GVHD.
  • Seen in the context of bone marrow transplants.

Bowel transplant

The histology of bowel transplant rejection is identical to GVHD - see GVHD.

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:[59]

  • Routine H&E.
  • Pan-actin.
  • Gomori trichrome.
  • CD117 - to look for the interstitial cells of Cajal.
  • HU - neuronal marker.[60]

See also

References

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