Session 79 GI Pathology (TURBO-PATH) Review

1 hour

Purpose and Method

A pathologist-led rapid review of gross and microscopic pathology of selected important
disorders of the gastrointestinal tract, hepatobiliary system, and pancreas.

Learning Objective:
Review prior knowledge of gastrointestinal, hepatobiliary, and pancreatic pathology.

Pre-Work:
None

Materials Needed:
Student and Instructor: PowerPoint file

Post-Work:
None

Detailed Session Instructions

Activity Method Duration (minutes)
Lecture-Discussion Mixed Lecture/Discussion 50
Wrap Up Mixed Lecture/Discussion 10
Session 79 GI Pathology (TURBO-PATH) Review
Instructor Guide

Note to Instructor:
Ideally, this session is designed to be a rapid review of visual images- gross and
microscopic of GI/Hepatobiliary/Pancreatic disease that students should be able to
recognize, describe, and relate to clinical findings.

A brief description for each image is included in this guide. Presenters can ask students
to identify the entity or describe it, or ask a question related to the entity.
Given the time constraints, not all images may involve discussion.
1-2) TITLE SLIDES

3) Esophageal atresia with tracheo-esophageal fistula

upper photo: left image: fistula of trachea and distal esophagus (L), atretic proximal
esophagus (R)
lower: schematic of forms of malformation (type C is lower left- most common)

4) Achalasia- gross and barium study

- primary: loss of myenteric neurons = loss of LES relaxation in esophagus
- secondary: Chaga’s, malignancies
- x-ray “bird beak” appearance of distal esophagus on barium swallow
- increased risk of squamous cell carcinoma

5) Mallory Weiss tears

- longitudinal tears in mucosa, GE junction
- violent vomiting/retching

6) Esophageal varices

7) Eosinophilic esophagitis
- micrograph and endoscopy/radiograph
- trachealization and linear furrow shown in endoscopy photos

8) Herpes esophagitis
- HSV- I most common (but can be HSV-2)
- extensive ulcers in esophagus (upper right)
- classic multinucleated cells, eosinophilic inclusions

9) Candida esophagitis
- white exudate “curd-like”
- yeast and pseudohyphae on micro

10) Kissing ulcers of pill esophagitis

- antibiotics are most common cause
- lack of adequate water with pill, also achalasia can predispose

11) Changes of reflux esophagitis

- epithelial hyperplasia (thickened basal layer, increased height of lamina propria
papillae, eosinophils.
- erythema, exudate on endoscopy

12) Barrett’s esophagus- endoscopy, gross, and micro

- tongues, patches of glandular mucosa
- goblet cells
- increased risk for adenocarcinoma

13) Adenocarcinoma of esophagus

- majority associated with Barrett’s
- distal esophagus (similar to distribution of Barretts)
-may see Barrett’s adjacent to CA
- most common type of esophageal CA in US

14) Squamous cell carcinoma of the esophagus- gross and micro

- hi risk- African American, smokers, alcohol, caustic injury, achalasia
- mid, upper esophagus

15) TITLE SLIDE

16) Salivary gland pathology- Sjogren Syndrome

- middle age woman – bilateral parotid enlargement
- microscopic- sheets of lymphocytes, loss of acini- residual ductal epithelium

17) Benign salivary gland tumors

- Upper: Pleomorphic adenoma- most common, 10% may develop carcinoma over
lifetime if not removed
- Lower: Warthin tumor: common in smokers, oncocytic epithelium and lymphoid tissue

18) Malignant salivary gland tumor

- mucoepidermoid carcinoma (most common)
- tumors in smaller (sublingual, minor salivary glands) have higher likelihood of being
malignant

19) TITLE SLIDE

20) Acute “stress” ulcers, stomach

- Curling ulcer: trauma, burns
- Cushing ulcer: CNS process
- superficial, not associated with chronic gastritis or H pylori

21) Chronic gastritis with H pylori

- H pylori most common cause of chronic gastritis
- upper photo shows intestinal metaplasia (increased risk for dysplasia, gastric
adenocarcinoma)

22) Peptic ulcers gross and micro

Gastric ulcer (left) duodenal ulcer (right)
- well demarcated, no heaping up of borders
- insert diagram and photo of microscopic stratification of chronic peptic ulcer

23) Benign (left) vs Malignant (right) ulcers

- note irregular contours and heaped up borders of the malignant ulcer compared with
the peptic ulcer

24) Hypertrophic gastropathy

- rare- this is Menetrier’s disease- foveolar (mucus cell hyperplasia)
- TGF-alpha increased, loss of protein, diarrhea, increased CA risk
25) Gastric CA- intestinal type
- polypoid (upper left) and ulcerated (lower left) gastric adenocarcinomas
- micro (right)- intestinal type adenocarcinoma- cribriform glands, luminal necrosis

26) Gastric CA- diffuse type

- Gross: thickened wall, no discrete mass “linitis plastic”
- Micro: signet ring cells typical of diffuse gastric CA

27) Metastatic GI adenocarcinoma (most commonly stomach) to ovary: Kruckenburg

tumor-
- micro shows signet ring cells (arrows)

28) TITLE SLIDE

29) “Congenital megacolon”- Hirschprung disease

- dilated proximal colon shown in x ray and operative photo
- normal caliber segment is aganglionic segment
- lack of migration of neural crest cells results in lack of ganglion cells/normal
innervation of distal colorectum

30) Celiac Disease

- normal (left) versus abnormal (upper right)- small bowel. Loss of villi, hyperplastic
crypts, lymphocytic infiltrate with increased intra-epithelial lymphocytes
- rash of dermatitis herpetiformis, which may be initial presenting feature- typical on
extensor surfaces.

31) Upper- Whipple’s disease: macrophages in LP, PAS stain (+)

Lower: abetalipoproteinemia- lipid vacuoles in enterocytes (dysfunctional microsomal
transport protein- failed chylomicron synthesis)- fat malabsorption, acanthocytosis

32) Pseudomembranous colitis due to C. diff gross and micro

- yellow pseudomembranes (left), eruptive acute inflammation (right)

33) Ischemic colitis- small bowel infarct – operative photo and microscopic
- most likely acute occlusion of a mesenteric artery
- other common form of ischemic injury- watershed infarcts (not shown)

34) IBD- Crohn’s disease gross photos

- segmental involvement with adjacent normal tissue (lower right)
- cobblestoning of mucosa due to linear ulceration and intervening preserved mucosa
- lower right also shows creeping fat- evidence of transmural inflammation

35) Ulcerative colitis- gross

left- pan colitis , upper right- distal ulceration, with transition to uninvolved proximal
colon
lower right- ulcerations and Pseudopolyps, mucosal bridging
36) IBD microscopic- crypt abscess (upper left), granuloma (lower right)

37) IBD Summary Slide from Robbins

38) Microscopic colitis

- left: lymphocytic colitis, right: collagenous colitis
- watery diarrhea, middle age/older women

39) Congenital conditions

Left- Meckel’s diverticulum
Right upper- gastroschisis, Right lower- omphalocele

40) Double bubble sign- x ray of duodenal atresia

41) Intestinal obstruction-

upper left- ischemic bowel from incarcerated hernia
lower left- intussusception- tumor illustrated as lead point of intussusception (tumors
more commonly associated with intussusception in adults)
lower right- ileocolic intussusception (most common location in children)

42) Diverticular disease- sigmoid diverticular disease (upper)

Para-diverticular abscess- lower

43) Colon polyps

- upper: hyperplastic polyps
- lower: Peutz-Jegher polyp and mucosal lentigines in syndrome (autosomal dominant)

44) Adenomas- tubular/pedunculated (left) villous/sessile (right)

45) Familial Adenomatous Polyposis (autosomal dominant)

46) Sessile serrated adenoma- endoscopy, micro

- precursor lesion for MSI-associated colon cancers

47) Colonic adenocarcinoma- cecal (polypoid)- upper left, left colon (constricting/napkin
ring)-lower right

48) Colon adenocarcinoma- micro

Benign mucosa on right side
Infiltrating malignant glands- left half or photo- extend into muscle

49) High mag of colon adenocarcinoma- cribriform pattern with luminal necrosis

50) Liver with multiple metastases. Liver most common site of colon CA metastasis.
Metastatic tumor is the most common malignant tumor in the liver.

51) Carcinoid, ileum, gross, micro, and EM

- ileal carcinoids more aggressive
- desmoplasia leads to obstruction
- carcinoid syndrome can occur when liver mets are present
52) Small intestinal lymphoma- gross and microscopic
- bowel is most common site of extranodal non-Hodgkin lymphoma
- most are B-cell
- T cell lymphoma associated with celiac disease

53) TITLE SLIDE

54) Hepatocyte cytoplasmic material: left- Mallory Denk bodies, right- alpha-1-
antitrypsin deficiency

55) Centrilobular necrosis- global ischemia (hypotension), acetaminophen toxicity

56) Nutmeg liver – severe centrilobular congestion

57) Acidophil (Councilman) body (left)- associated with (particularly) viral hepatitis
Upper right- portal inflammation, lower right- interface hepatitis- patterns seen in
chronic hepatitis (viral, autoimmune)

58) Interface hepatitis

59) Ground glass hepatocyte (arrow) seen in Hepatitis B

60) Cholestasis: upper right – intracellular (hepatocytes), lower right – canalicular

(“plugs”), lower left- extravasated bile “lakes” with adjacent feathery degeneration of
hepatocytes

61) Biliary ductular reaction

- proliferating ductules at limiting plate seen in response to liver necrosis, obstructive
cholestasis, primary biliary cholangitis
represents regenerative attempts (cells from the Canals of Hering)

62) Cirrhosis- upper photos- micronodular (common pattern seen in alcoholic liver
disease)
Lower photo- macronodular cirrhosis, follows episode of severe hepatic injury, necrosis
“post-necrotic cirrhosis”

63) Micronodular cirrhosis- photomicrograph

64) Primary biliary cholangitis- lymphocytic infiltrate w/ destruction of interlobular bile

duct (upper left)
Portal area lacking bile duct, with lymphocytic infiltrate (lower right)
-not shown: may get granulomatous inflammation in PBC

65) Hepatocellular carcinoma- gross and micro

gross photos shows background of cirrhosis
66) Adenoma, liver- gross photo, micrograph shows pseudo capsule with sheets of
benign hepatocytes lacking normal lobular architecture (lower right photo)

67) Focal nodular hyperplasia (non-neoplastic nodule) diff dx with liver adenoma
often with central scar as shown here

68) Gallbladder with cholesterolosis (“strawberry gallbladder”)

69) Primary sclerosing cholangitis (PSC)

Classic ERCP photo showing multiple constrictions of biliary tree, typical microscopic
appearance of sparse chronic inflammation, but prominent fibrosis (sclerosis) creating
onionskin pattern around interlobular bile duct

70) Cholangiocarcinoma- irregular, ill-defined mass (gross photo- upper right)

Invasive adenocarcinoma- malignant glands may resemble bile ducts- associated with
IBD and liver flukes

71) TITLE SLIDE

72) Acute pancreatitis- upper left: hemorrhagic necrotizing pancreatitis, lower right-
pancreas with fat necrosis

73) Cullen’s sign- periumbilical hemorrhage (left)

Grey-Turner’s sign- posterior flank hematomas
Signs of acute hemorrhagic pancreatitis

74) Chronic pancreatitis- micro: fibrosis, chronic inflammation, residual acini, islets,
ducts

75) Chronic pancreatitis- higher power- islets are prominent due to loss of acini

76) Adenocarcinoma of the pancreas (ductal type)- gross

77) Adenocarcinoma of the pancreas (ductal type)- microscopic

78) Well differentiated neuroendocrine tumor (pancreatic neuroendocrine tumor or

PNET) Gross and Micro- EM shows dense core granules typical of a neuroendocrine
neoplasm.