Difference between revisions of "Stomach"

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→‎Gastric dysplasia: split out to Stomach adenoma
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[[Image:Gray1051.png|thumb|300px|A drawing of the stomach.]]
'''Stomach''' is an important organ for pathologists.  It is often inflamed and may be a site that cancer arises from.  Gastroenterologists often biopsy the organ.  Surgeons take-out the organ.  It connects the [[esophagus]] to the [[duodenum]].  An introduction to gastrointestinal pathology is in the ''[[gastrointestinal pathology]]'' article.
'''Stomach''' is an important organ for pathologists.  It is often inflamed and may be a site that cancer arises from.  Gastroenterologists often biopsy the organ.  Surgeons take-out the organ.  It connects the [[esophagus]] to the [[duodenum]].  An introduction to gastrointestinal pathology is in the ''[[gastrointestinal pathology]]'' article.


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Notes:
Notes:
*Intraepithelial lymphocytes in the gastric mucosa have a clear halo around 'em.<ref>Sternberg H4P 2nd Ed., P.484</ref>
*Intraepithelial lymphocytes in the gastric mucosa have a clear halo around 'em.<ref>Sternberg H4P 2nd Ed., P.484</ref>
*Memory device: '''F'''olveolar cells have '''f'''riends, i.e. they are close to other foveolar cells.
*Memory device: '''F'''oveolar cells have '''f'''riends, i.e. they are close to other foveolar cells.


===Gastric antrum versus gastric body===
===Gastric antrum versus gastric body===
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===Sign out===
===Sign out===
====Short version====
====Short version====
<pre>
Stomach, Biopsy:
- Antral-type gastric mucosa within normal limits.
</pre>
<pre>
Stomach, Biopsy:
- Body and antral-type gastric mucosa within normal limits.
</pre>
<pre>
Stomach, Biopsy:
- Antral-type gastric mucosa within normal limits.
- NEGATIVE for Helicobacter-like organisms.
</pre>
=====Block letters=====
<pre>
<pre>
STOMACH, BIOPSY:
STOMACH, BIOPSY:
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====Sleeve gastrectomy====
====Sleeve gastrectomy====
*Indication: morbid [[obesity]].
{{Main|Sleeve gastrectomy}}
<pre>
STOMACH, GREATER CURVE, SLEEVE GASTRECTOMY:
- STOMACH WALL WITHIN NORMAL LIMITS.
</pre>


=Introduction=
=Introduction=
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==Portal hypertensive gastropathy==
==Portal hypertensive gastropathy==
*Abbreviated ''PHG''.
*Abbreviated ''PHG''.
===General===
{{Main|Portal hypertensive gastropathy}}
*Due to [[portal hypertension]].
**Usually secondary to [[liver cirrhosis]] which is typically due to [[alcoholism]].
***Reported in approximately 65% of cirrhotics with portal hypertension in one paper.<ref name=pmid15648238>{{Cite journal  | last1 = Mesihovic | first1 = R. | last2 = Prohic | first2 = D. | last3 = Gribajcevic | first3 = M. | last4 = Vanis | first4 = N. | last5 = Gornjakovic | first5 = S. | last6 = Sarac | first6 = A. | title = Portal hypertensive gastropathy (PHG). | journal = Med Arh | volume = 58 | issue = 6 | pages = 377-9 | month =  | year = 2004 | doi =  | PMID = 15648238 }}
</ref>
 
===Gross===
Features:<ref name=pmid12492178>{{Cite journal  | last1 = Thuluvath | first1 = PJ. | last2 = Yoo | first2 = HY. | title = Portal Hypertensive gastropathy. | journal = Am J Gastroenterol | volume = 97 | issue = 12 | pages = 2973-8 | month = Dec | year = 2002 | doi = 10.1111/j.1572-0241.2002.07094.x | PMID = 12492178 }}</ref>
*Mosaic-like pattern.
**May be referred to as [[Gastric snakeskin appearance|snakeskin-like pattern]].<ref name=pmid22211417/>
**Usu. body of stomach.
*+/-Red spots.
 
Note:
*May mimic [[eosinophilic gastritis]].<ref name=pmid22211417>{{Cite journal  | last1 = Sikanderkhel | first1 = S. | last2 = Luthra | first2 = M. | last3 = Chavalitdhamrong | first3 = D. | title = Snakeskin-like pattern mimicking portal hypertensive gastropathy in patient with eosinophilic gastritis. | journal = Dig Endosc | volume = 24 | issue = 1 | pages = 53 | month = Jan | year = 2012 | doi = 10.1111/j.1443-1661.2011.01155.x | PMID = 22211417 }}</ref>
 
====Images====
<gallery>
Image:PHGastro.jpg | PHG. (WC/Samir)
</gallery>
 
===Microscopic===
Features:<ref name=Ref_GLP120-1>{{Ref GLP|120-1}}</ref>
*Dilated capillaries in the submucosa (prominent) and to a lesser extent in the lamina propria - '''key feature'''.
 
Notes:
*May be associated with [[hyperplastic polyp of the stomach|hyperplastic]]-like polyps.<ref name=pmid22002002>{{Cite journal  | last1 = Lam | first1 = MC. | last2 = Tha | first2 = S. | last3 = Owen | first3 = D. | last4 = Haque | first4 = M. | last5 = Chatur | first5 = N. | last6 = Gray | first6 = JR. | last7 = Yoshida | first7 = EM. | title = Gastric polyps in patients with portal hypertension. | journal = Eur J Gastroenterol Hepatol | volume = 23 | issue = 12 | pages = 1245-9 | month = Nov | year = 2011 | doi = 10.1097/MEG.0b013e32834c15cf | PMID = 22002002 }}</ref>
**Subepithelial [[granulation tissue]] and vascular proliferation.
*Findings in mucosal biopsies are often [[specificity|nonspecific]], i.e. not diagnostic.<ref name=Ref_GLP120-1>{{Ref GLP|120-1}}</ref>
 
DDx:
*[[Gastric antral vascular ectasia]] - have thrombi in the dilated blood vessels.
 
===Sign out===
<pre>
STOMACH, BIOPSY:
- ANTRAL-TYPE AND BODY-TYPE GASTRIC MUCOSA WITH PROMINENT CAPILLARIES
AND MODERATE CHRONIC INACTIVE INFLAMMATION.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
 
COMMENT:
No fibrin thrombi are seen.  The findings are compatible with portal hypertension.
Clinical correlation is required.
</pre>


==Amyloidosis of the stomach==
==Amyloidosis of the stomach==
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==Gastric dysplasia==
==Gastric dysplasia==
:''Gastric adenoma'' directs here.
{{Main|Stomach adenoma}}
*[[AKA]] ''gastric columnar dysplasia''.
===General===
*Lesions that protrude into the lumen ''and'' are macroscopically apparent are known as: ''adenomas''.<ref name=pmid10680883>{{Cite journal  | last1 = Rugge | first1 = M. | last2 = Correa | first2 = P. | last3 = Dixon | first3 = MF. | last4 = Hattori | first4 = T. | last5 = Leandro | first5 = G. | last6 = Lewin | first6 = K. | last7 = Riddell | first7 = RH. | last8 = Sipponen | first8 = P. | last9 = Watanabe | first9 = H. | title = Gastric dysplasia: the Padova international classification. | journal = Am J Surg Pathol | volume = 24 | issue = 2 | pages = 167-76 | month = Feb | year = 2000 | doi =  | PMID = 10680883 }}</ref>
*Polypoid forms are grouped various ways.<ref name=pmid18384215>{{Cite journal  | last1 = Park | first1 = do Y. | last2 = Lauwers | first2 = GY. | title = Gastric polyps: classification and management. | journal = Arch Pathol Lab Med | volume = 132 | issue = 4 | pages = 633-40 | month = Apr | year = 2008 | doi = 10.1043/1543-2165(2008)132[633:GPCAM]2.0.CO;2 | PMID = 18384215 | url=http://www.archivesofpathology.org/doi/full/10.1043/1543-2165(2008)132%5B633:GPCAM%5D2.0.CO;2 }}</ref>
 
====Grading====
Like in the colon - they are divided into:
*Low grade.
*High grade.
 
====Subclassification====
One subclassification:<ref>URL: [http://surgpathcriteria.stanford.edu/gitumors/gastric-adenoma/printable.html http://surgpathcriteria.stanford.edu/gitumors/gastric-adenoma/printable.html]. Accessed on: 18 December 2012.</ref>
*Intestinal: goblet cells or [[Paneth cell]]s.
**Not associated with FAP.
*Gastric: foveolar epithelium.
**Associated with [[familial adenomatous polyposis]] (FAP).
 
===Microscopic===
*Histologic criteria similar to columnar dysplasia in the [[esophagus]].
**The threshold is much lower than in the colon and rectum.
 
====Foveolar type====
Features:
*Hyperchromasia at the surface - '''key feature'''.
*Cytoplasm with (shortened) champagne flute-like luminal aspect (apical mucin caps).
*Nuclear changes:
**Hyperchromasia.
**Enlargement.
*No intestinal metaplasia.
 
DDx:
*[[Gastric carcinoma]].
*[[Reactive changes]].
 
====Intestinal type====
Features - intestinal:
*[[Intestinal metaplasia of the stomach|Intestinal metaplasia]].
*Hyperchromasia of cytoplasm.
*Nuclear changes:
**Loss of nuclear polarity.
**Increased [[NC ratio]].
**Elongation of nucleus and pseudostratification.
 
DDx:
*[[Gastric carcinoma]].
*[[Reactive changes]].
*[[Intestinal metaplasia of the stomach|Intestinal metaplasia]].
 
=====Images=====
<gallery>
Image:Gastric_adenoma_(1).jpg | Gastric adenoma. (WC/KGH)
Image:Gastric_adenoma_(2).jpg | Gastric adenoma. (WC/KGH)
</gallery>
www:
*[http://www.sciencedirect.com/science/article/pii/S1756231710001878 Gastric polyps - several images (sciencedirect.com)].
*[http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165%282008%29132%5B633%3AGPCAM%5D2.0.CO%3B2 Gastric polyps - several images (achivesofpathology.org)].
 
====Grading====
=====Low-grade gastric dysplasia=====
Features:
*Nuclear changes:
**Nuclear crowding/pseudostratification with hyperchromasia.
**Elongation of nuclei (cigar-shaped nuclei).
**Nuclear stratification intact; nuclei close to the basement membrane.
*Architecture:
**Focal irregularities in the glandular contours.
 
Negatives:
*No desmoplasia.
*No necrosis.
*No surface maturation.
 
DDx:
*Indefinite for dysplasia.
*High-grade gastric columnar dysplasia - see below.
**The threshold is much lower than in the colon and rectum!
 
Images:
*[http://path.upmc.edu/cases/case431.html Low-grade gastric columnar dysplasia - several images (upmc.edu)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3204467/figure/F4/ Gastric low-grade dysplasia (nih.gov)].<ref name=pmid22076218>{{Cite journal  | last1 = Kushima | first1 = R. | last2 = Kim | first2 = KM. | title = Interobserver Variation in the Diagnosis of Gastric Epithelial Dysplasia and Carcinoma between Two Pathologists in Japan and Korea. | journal = J Gastric Cancer | volume = 11 | issue = 3 | pages = 141-5 | month = Sep | year = 2011 | doi = 10.5230/jgc.2011.11.3.141 | PMID = 22076218 }}</ref>
=====High-grade gastric dysplasia=====
Features:
*Nuclear changes:
**Round hyperchromatic nuclei.
**Loss of normal nuclear stratification.
*Architecture:
**Irregularities in the glandular contours.
**Back-to-back glands.
**+/-Cribriforming of the glands.
**+/-Necrosis.
 
Negatives:
*No [[desmoplasia]].
 
DDx:
*Low-grade gastric columnar dysplasia.
*[[Gastric adenocarcinoma]].
 
=====Images=====
<gallery>
Image:High_grade_gastric_dysplasia_-_low_mag.jpg | High grade gastric dysplasia - low mag. (WC/Nephron)
Image:High_grade_gastric_dysplasia_-_very_high_mag.jpg | High grade gastric dysplasia - very high mag. (WC/Nephron)
</gallery>
www:
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3404600/figure/F8/ Gastric high-grade dysplasia - probably (nih.gov)].<ref name=pmid22188910>{{Cite journal  | last1 = Correa | first1 = P. | last2 = Piazuelo | first2 = MB. | title = The gastric precancerous cascade. | journal = J Dig Dis | volume = 13 | issue = 1 | pages = 2-9 | month = Jan | year = 2012 | doi = 10.1111/j.1751-2980.2011.00550.x | PMID = 22188910 }}</ref>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3204467/figure/F7/ Gastric high-grade dysplasia - probably (nih.gov)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3204467/figure/F6/ Gastric high-grade dysplasia (nih.gov)].<ref name=pmid22076218/>
 
===Sign out===
====Indefinite for dypslasia====
<pre>
STOMACH, ANTRUM, BIOPSIES:
- ANTRAL-TYPE MUCOSA INDEFINITE FOR DYSPLASIA WITH MODERATE CHRONIC INFLAMMATION.
- EXTENSIVE INTESTINAL METAPLASIA.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANSIMS.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
====Intestinal type====
<pre>
STOMACH, ANTRUM, BIOPSIES:
- ANTRAL-TYPE MUCOSA WITH FOCUS OF LOW-GRADE DYSPLASIA (INTESTINAL TYPE).
- EXTENSIVE INTESTINAL METAPLASIA.
- MODERATE CHRONIC INFLAMMATION.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANSIMS.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
====Foveolar type====
<pre>
STOMACH POLYP, EXCISION:
- ADENOMATOUS POLYP, FOVEOLAR TYPE.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
</pre>
 
====Foveolar type with high-grade dysplasia====
<pre>
STOMACH POLYP, EXCISION:
- LARGE ADENOMATOUS POLYP (FOVEOLAR TYPE) WITH HIGH-GRADE DYSPLASIA.
- NEGATIVE FOR MALIGNANCY.
</pre>


==Gastric neuroendocrine tumour==
==Gastric neuroendocrine tumour==
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Others:
Others:
*CD3 (T cells) - scatter positivity.
*CD3 (T cells) - scatter positivity.
*CD20 (B cells) +ve.
*[[CD20]] (B cells) +ve.
*CD138 (plasma cells).
*CD138 (plasma cells).
*kappa, lambda -- often one is predominant, suggesting clonality.
*kappa, lambda -- often one is predominant, suggesting clonality.
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! Other
! Other
|-
|-
| Hereditary diffuse gastric cancer (HDGC) syndrome  
| [[Hereditary diffuse gastric cancer syndrome|Hereditary diffuse gastric cancer (HDGC) syndrome]]
| CDH1 (E-cadherin)<ref>{{OMIM|192090}}</ref>
| CDH1 (E-cadherin)<ref>{{OMIM|192090}}</ref>
| diffuse - more specifically [[signet ring cell carcinoma]]
| diffuse - more specifically [[signet ring cell carcinoma]]
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|-
|-
| Familial breast and ovarian cancer 2<ref name=omim600185>{{OMIM|600185}}</ref>
| Familial breast and ovarian cancer 2<ref name=omim600185>{{OMIM|600185}}</ref>
| BRCA2
| [[BRCA2]]
| ?
| ?
| ?
| ?
Michael
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