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Pathology of the
LOWER ALIMENTARY TRACT
I. Diseases of the Stomach
II. Diseases of the Small Intestine
III. Diseases of the Colon
IV. Diseases of the Appendix
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STOMACH
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I. Diseases of the Stomach
A. Congenital Pyloric Stenosis
B. Gastritis
C. Peptic Ulcer of the Stomach
D. Malignant Tumor of the Stomach
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I. Diseases of the Stomach
A. Congenital Pyloric Stenosis
Is caused by hypertrophy of circular muscular layer of the pylorus
often results as papable mass
obstruction of gastric outlet episodes of projectile vomiting
(beginning in the first 2 weeks of life)
Much more common in boys Is corrected by surgical incision of the hypertrophied muscle
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a. Causes
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Cigarette smoking
- heavy alcohol intake
- Burn injury (severe) Curling ulcer- Brain injury Cushing ulcer
- ingestion of strong acid or alkaline
b. Characteristic
- focal damage of mucosa with acute inflammation, necrosis,and hemorrhage
- may be manifest as gastric ulcer often multiple
I. Diseases of the Stomach
B. Gastritis: 1. Acute (erosive) gastritis
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Acute gastritis
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- Helicobacter pylori – associated gastritis
- gram – neg. organism, in the surface
epithelium beneath the mucous barrier
- cells desquamation and lead to polymorph
and chronic inflammatory cells- predominantly affects the anthrum
- most common form of gastritis
- often has increased gastric acid
- young adulthood and early middle age- associated with gastric cancer
I. Diseases of the Stomach
B. Gastritis: 2. Chronic gastritis
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HISTOLOGIC PICTURE OF CHRONIC
GASTRITIS
• Early stage: inflammation affects the superficial parts ofthe mucosal layers superficial chronic gastritis
• Next stage: the inflammation affects all mucosal andsubmucosal layers – with germinal center
1. Inflammatory cells: mononuclear cells; active
netrophil (+)2. Metaplasia: intestinal metaplasia pre-malignant
condition
3. Glandular atrophy: glandular tissue is reduced in
amount and undergoes to intestinal metaplasia4. H. pylori
5. Dysplasia: carcinoma
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ATROPHIC
GASTRITIS
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H.pylori
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H. PYLORY AND CHRONIC GASTRITIS
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OTHER GASTRITIS
• Eosinophyillic gastritis: food allergy ?
• Granulomatous gastritis: tuberculosis,
syphilis, sarcoidosis, fungi, Crohn disease
• Reflux gastritis: duodenal and bile reflux
• Menetrier disease (giant hypertrophic
gastritis)
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Menetrier disease (HYPERTROPHIC GASTROPATHY)
• Severe hyperplasia of mucosal layer
cells + glandular atrophy extremeenlargement of gastric rugae
• Hypertrophic gastropathy + hyper-secretion: mucosal cells, parietal andchief cells hyperplasia.
• Gastrinoma excessive gastrinexcretion gastric glandularhyperplasia (Zollinger-Ellisonsyndrome)
• Sometimes with severe loss of plasmaproteins from the altered mucosa
• Risk of peptic ulcer
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I. Diseases of the Stomach
C. Peptic Ulcer of the Stomach• Most often at or near lesser curvature, in the anthral & pre-pyloric
region
• Is not a precursor lesion of Ca of the stomach
• Is not dependent on increased gastric acid secretion – but rarelyoccur in association with absolute achlorhydria
• Middle-later age group
• Male > female, 1.5 to 2:1
• Often solitary
• >50% Ø 4cm
• Ø 0,6 cm ulcer
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PEPTIC ULCER
Etiopathogenic mechanism:
- H. pylori : 90-100% duodenal ulcer, 70% gastric ulcer; bacterial
urease & protease break down glycoprotein in gastric mucus interfering with epithelial protection
- NSAID
- alcohol, smoke, blood-group, HLA-B5
- Increased permeability of the gastric mucosa to hydrogen ion
back diffusion of H2 ion injury to gastric mucosa- Bile-induced gastritis leading to gastric ulceration
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PEPTIC ULCER
Complications:
1.Bleeding2.Perforation
3.Obstruction: due to Edema or cicatrix
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G STRIC ULCER
• Destruction of mucosa and sub-mucous
• Almost always single, 2-3 cm,
• Type:
– Acute peptic ulcer: both mucous andsub-mucous layer are involved, 1 cm,
single/ multiple
– Chronic peptic ulcer: penetrated anddestroy the muscle coat.
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ACUTE GASTRIC ULCER
• Multiple• Gastric > duodenum
• Erosion – ulceration
• Ø 1 cm, circular, rarely invade to mucosal layer
• Etiology – Shock, burning ulcer, sepsis, severe trauma
– High intracranial pressure Cushing ulcer
– Proximal the duodenum + severe burning
ulcer/trauma Curling ulcer
– NSAID
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TRIGER F CTORS OF PEPTIC ULCER
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PEPTIC ULCER
Cylindric epithelia
Necrotic debris
Granulation tissue with lymphocytic infiltratio
Glands hyperplasia
Edema
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POLYP – Polypoid mass
– >90% non neoplasm (inflammatory/ hyperplasia)
– Sessile / pedunculated
– 20-25% multiple
– Mostly occur in chronic gastritis – No malignant potential
ADENOMA
– neoplasm 5-10% of gastric polyp
– Sessile / pedunculated
– distal – anthrum predominant
– Six decade, Male: female = 2:1
– Some cases origin from chronic gastritis with intestinalmetaplasia
I. Diseases of the stomach
D. Tumors of the stomach (benign)
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I. Diseases of the stomach
D. Tumors of the stomach (malignant)
• Adenocarcinoma is about 90-95% of gastric malignancy
• High incidence: japan, Chili, Costa Rica, China
• Location: - 40-50% pylorus/anthrum; 25% cardia
- 40% minor curvature; 12% c. major
- Etiology:
- Diet
- Chronic atrophic gastritis
- H. pylori infection
- partial gastrectomy- Gastric Adenoma
- Genetic : A blood group, family factor
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GASTRIC CANCER
– Invasion
• Early ( mucosa and sub- mucosa)
• Advanced (invade the sub- mucosa)
– Macroscopic growth
• Exophytic• flat/ depressed
• Excavation
Linitis plastica – tumor cells diffusely infiltrate gastric wall
leather bottle appearance
– Histology
• intestinal gland type
• Diffuse: signet-ring cell
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The Growth of Gastric Cancer
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Other gastric tumors
• MALIGNANT LYMPHOMA
– 40% malignant lymphoma of GIT – 5% of gastric malignancy
– B cell type predominant, MALT origin
• CARCINOID TUMOR Carcinoid syndrome
– Low grade malignancy
– Metastasis to the liver – Multiple lesions
• LEIOMYOMA
• SECONDARY TUMORS (METASTASIS)
– rare
– Mostly from leukemia or general lymphoma
– From breast / lung cancer diffuse linitisplastica
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GASTRIC CARCINOMA
• Prognosis:
– Depend on the depth of tumor invasion
and metastasis process
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Adenocarcinoma, NOS
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ULCUS CARCINOMATOSA
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REDUPLICATION STENOSIS DIVERTICULUM ATRESIA
Diseases of the Intestine
A. CONGENITAL ABNORMALITIES
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HERNIA
Mechanic obstruction-atresia
-stenosis
-stricture
-hernia
-volvulus
-invagination / intususeption
Neurogenic obstruction-paralytic - adinamic-spastic - dinamic
Vascular obstruction-trombosis-embolism
Diseases of the Intestine
B. INTESTINAL OBSTRUCTION
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Invagination/ intususeption Volvulus
Vascular obstruction
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II. Diseases of the Small Intestine
A. Peptic Ulcer
B. Crohn DiseaseC. Meckel Diverticulum
D. Malabsorption syndrome
E. Tumors of the Small Intestine
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II. Diseases of the Small Intestine
A. Peptic Ulcer of the Intestine
• Most frequently in the first portion of duodenum
• Is not a precursor of malignancy
• Is always associated with hypersecretion of gastric acid
and pepsin
• increased frequency in persons of blood group O
genetic factors?
• Often complicated by hemorrhage with melena,
perforation, obstruction
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II. Diseases of the Small Intestine
A. Peptic Ulcer of the Intestine
Sometimes associated with:
• Aspirin or other NSAID
• Smoker: the incidence is two-fold greater
• Zollinger-Ellison syndrome gastric acid hypersecretiondue togastrin secreting islet cell tumor of the pancreas
• Primary hyperparathyroidisme
• Multiple Endocrine Neoplasia (MEN Wermer syndrome), an
autosomal dominant syndrome characterized by pituitary, thyroid,
parathyroid, adrenal cortical, and pancreatic islet cell adenoma, orhyperplasias associated with hypergastrinemia and peptic ulcer
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II. Diseases of the Small Intestine
B. Crohn’s Disease
• Chronic inflammatory condition of unknown etiology
• Tends to affect young people in 2nd and 3rd decades of life
• Occurs most frequently in Jewish descent
• Cinical manifestations:
– Abdominal pain and diarrhea
– Malabsorption
– Fever
– Intestinal obstruction resulting from fibrous tissue
– Fistulas: inter-intestine, between intestine – bladder, vagina, skin
II Diseases of the Small Intestine
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II. Diseases of the Small Intestine
B. Crohn’s Disease
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Crohn Disease Ulcerative Colitis
May involve any portion of the gastrointestinal
tract, usually the ileocecal region, small intestine,or colon.
Chronic inflammatory reaction extends through
the entire thickness of the intestinal wall.
Fistulous tracts between loops of intestines, or
between the intestine and other site; skip lesionswith mucosal cobblestone appearance.
Non-caseating granulomatous inflammation with
lymphocytic infiltration, fibrosis, and thickening of
intestinal wall.
Incidence of secondary malignancy is much lowerthan in ulcerative colitis
Affects only colon.
Inflammation and ulceration
limited to mucosa and submucosa
Crypt abscess, pseudopolyp
Greatly increased incidence ofcolon cancer in longstanding
cases
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Comparison of the lesions
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II. Diseases of the Small Intestine
C. Meckel Diverticulum
• Most common congenital anomaly of the small intestine
• Remnant of embryonic vitelline duct distal small bowel
• May contain ectopic gastric, duodenal, colon, pancreatic
tissue• Usually asymptomatic, ectopic tissue product com-
plication (peptic ulceration bleeding perforation)
• Occasionally associated with: intussusception and
volvulus
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II. Diseases of the Small Intestine
D. Malabsorption syndrome
Celiac Disease• Sensitivity to gluten in cereal product
• Clinically: weight loss, weakness, diarrhea with pale,
bulky, frothy, foul smelling stools• Growth retardation and general failure to thrive
• Most often become symptomatic in infancy when cerealsare first added to the diet
• Diagnosis biopsy blunting of small intestinal villi
• 10-15% small intestinal malignancy: most oftenenteropathy-type T cell lymphoma
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Disorders Morphologic Features CommentsCeliac disease Flat mucosal surface with marked
villous atrophy
Gluten sensitivity
Tropical sprue Micros: no change abnormalities
similar to those of celiac disease
Probable infectious origin;
often respond to antibiotics
Whipple disease PAS+ macrophages in mucosal
Tropheryma whippelii EM
Most common: small intestine;
arthralgia, cardiac & neuro. S
Disaccharidase
deficiency
No characteristic histologic change Sited in brush border of
mucosal cell of small intestine;
Lactase def.milk intolerance
Abetalipoproteinemia No characteristic features in the in-
testine; circulating acanthocytes
Hereditary deficiency of apo-
protein-B
Intestinal
lymphangiectasiaGeneralized dilatation of the small
intestinal lymphatics
Marked gastrointestinal pro-tein loss hypoproteinemia
II. Diseases of the Small Intestine
D. Malabsorption syndrome
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II. Diseases of the Small Intestine
E. Tumors of the small intestine
• Make up a small percentage of the gastrointestinal tumor
• Carcinoid tumor:
- most frequently in appendix (in small intestine: 30%)
- slow growing, low-grade malignancy (of appendix almost never
metastasizes
- carcinoid syndrome: caused by elaboration of vasoactive peptidesand amines, especially serotonin, manifest clinically by:
(1) cutaneous flushing
(2) watery diarrhea and abdominal cramp
(3) bronchospasm
(4) valvular lesions of the right side of the heart
• Other tumors: lymphoma, adenocarcinoma (rare)
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The Spread of Tumor
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III. Diseases of the Colon
A. Hirschprung disease
B. Diverticula
C. Vascular diseases of the colonD. Inflammatory disorders of the colon
E. Tumors
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III. Diseases of the Colon
A. Hirschprung disease
• Dilatation of colon due to the absence of ganglion cellsof the submucosal and myenteric neural plexuses
• Dilatation is proximal to aganglionic segment
III Di f th C l
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III. Diseases of the Colon
B. Diverticula
• Most common in old person, and almost always multiple• Most frequently involve the sigmoid colon
• It’s a pulsion/false diverticula (pockets of mucosa and submucosa
herniated through the muscular layer)
• Diverticulosis: multiple diverticula without inflammation
• Diverticulitis:
- inflammation of diverticula, mostly in older person
- may be complicated by perforation peritonitis, abscess, bowel
stenosis (can be with lower abdominal bleeding & tenderness,
fever, leukocytosis, others)- bright red rectal bleeding
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Diverticulosis of the Sygmoid
III Diseases of the Colon
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III. Diseases of the Colon
C. Vascular diseases of the colon
-results in mucosal, mural, and trans mural infarction involving the wall of the intestine
-is almost always caused by arteriosclerotic occlusion (at least 2 of the major mesen-teric vessels)
-most often affects the splenic flexures and rectosigmoid junction (watershed areas)
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Ischemic bowel disease
Almost always caused by atheroscle-
rotic occlusion
Most often affects the splenic flexure
and rectosigmoid junction (watershed
Area = relatively poor vascularized
region, between areas supplied by the
superior and inferior mesenteric artery
and internal iliac arteries
III Diseases of the Colon
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III. Diseases of the Colon
C. Vascular diseases of the colon
-Are dilated internal and external
venous plexusses in the anal
canal-Predisposed by low-fiber diet
III Di f th C l
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III. Diseases of the Colon
D. Inflammatory disorders of the colon
Ulcerative Colitis
• Often grouped with Crohn disease as inflammatory bowel disease; unknown
etiology; similar geographic & racial distribution family history; similar
extraintestinal manifestation: polyarthritis, uveitis & episcleritis, sclerosing
cholangitis, sacroiliitis, skin: erythema nodosum and pyoderma gangrenosum
•
Characteristics- mucosal inflammation & ulceration limited to the large intestine
- confined to the mucosa & submucosa crypt abscess
- red, granular appearance of the mucosa
- pseudopolyp
- chronic diarrhea with passage of blood & mucus (bleeding is the most frequent
clinical manifestation)
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Ulcerative Colitis
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ENTERITIS TUBERCULOSA
Primer: milk + mycobacterium tuberculosa
Secunder: sputum + mycobacterium tuberculosa
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Others:
Bacillary dysentery
Cholera
Salmonella
Viral
Parasitic (Amebic, giardia, balantidia, schistosoma, etc.)
III. Diseases of the Colon
C. Vascular diseases of the colon
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Type Comments
Non-neoplastic polyps•Hyperplastic polyp
•Inflammatory polyp
- Lymphoid polyp
- Inflammatory pseudopolyp
•Hamartomatous polyp
- Juvenile polyp
- Peutz-Jeghers polyp
No clinical significance
Rectal mucosa; may be reactive
@ ulcerative colitis and others, granulation tissue
Most frequently in children
@ Peutz-Jeghers syndrome
Neoplastic polyps
•Tubular adenoma
•Tubulovillous adenoma
•Villous adenoma
Often multiple (hereditary multiple polyposis
syndrome) increased risk of malignancy
Greater malignant potential
High potential for malignant change
III. Diseases of the Colon: E. Tumors: Polyps
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Familial Adenomatous Polyposis
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Adenomatous polyp
d i
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• One of the most common neoplasm of the intestine
• Peak age incidence: 6th
– 7th
decades• Associated with increased CEA (carcinoembryonic antigen) to
follow the course of the disease
• Develops through model of: adenoma – carcinoma sequence
• Predisposing factors:
1. Adenomatous polyp
2. Inherited multiple polyposis syndrome
3. Long-standing ulcerative colitis
4. Genetic factors: 4X increase of incidence among relatives of the cancer patients
5. A low fiber, high animal fat diet• Characteristics:
- left colon napkin-ring (annular) often producing early obstruction
- right colon polypoid chronic blood loss anemia
III. Diseases of the Colon: E. Tumors: adenocarcinoma
’ S
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Dukes’ Stage
ASTLER COLLER
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ASTLER - COLLER
Five-year survival rate• A – tumor is limited in the mucosa - 100%
•B1 – reach the muscularis propria,
no lymphonode involvement 67%
•B2 – passing the muscularis propria,no lymphonode involvement 54%
•C1 – reach the muscularis propria,
with lymphonode involvement 43%
•
C2 –
passing the muscularis propria,with lymphonode involvement 22%
•D – metastasis very low FSR
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IV. Diseases of the Appendix
A.Inflammatory diseases
1. Acute appendicitis
2. Chronic appendicitis
B.Tumors of the appendix
The most common : carcinoidtumor
APPENDICITIS
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APPENDICITIS
SIMPLE ACUTE SUPPURATIVE GANGREN
CHRONIC APENDICITIS