Small and Large Intestine Pathology – December 5, 2006

Developmental Anomalies
Small Intestine:
~ 1) atresia (Stenosis) – either complete failure of development of the intestinal
lumen or narrowing. Only involved one segment of the bowel
~ 2) duplication – well formed structures, may or may not communicate with lumen
of SI
~ 3) Meckel diverticulum – failed involution of omphalomesenteric duct, get blind-
ended tubular protrusion
~ 4) Omphalocele – intestines herniated into this congenital defect membranous sac
Large Intestine
~ 1) malrotation of developing bowel – predisposed to volvulus
~ 2) Hirschsprung disease – congenital megacolon

Hirschsprung Disease: Congenital Megacolon

~ distention of colon
~ happens when caudal neural crest cells stops before it reaches the anus in embryo
development
~ functional obstruction and progressive distention of parts of colon

Acquired Megacolon
~ can result from:
~ 1) chagas diseases – from protozoans
~ 2) organic bowel obstruction
~ 3) toxic megacolon
~ 4) functional psychosomatic disorder

Vascular Disorders

Ischemic Bowel Disease

~ ischemic from obstruction of 1 of 3 major trunks of descending aorta after T12
~ leads to hypoxia  infarction  necrosis  fibrosis

Ischemic Bowel Disease

~ transmural  major mesenteric
~ mucosal/mural  usually local anatomical problem or hypoperfusion
~ predisposing conditions for all 3 ischemic forms
~ 1) arterial thrombosis
~ 2) arterial embolism
~ 3) venous thrombosis
~ 4) nonocclusive ischemia
~ 5) miscellaneous

Hemorrhoids
~ variceal dilation in anal/perianal submucosal venous plexus
~ internal hemorrhoid – covered by rectal mucosa above anorectal line in superior and
middle hemorrhoidal veins
~ external hemorrhoid – below anorectal line, cover by anal mucosa dilation of inferior
hemorrhoidal plexus
~ internal and external bleed easily
~ internal can prolapse and get strangled by anal sphincter

Diarrheal Diseases
~ biggest problem = dehydration

Diarrhea and Dysentery

~ diarrhea: increase stool mass, stool frequency, and fluidity
~ see pain, urgency, perianal discomfort, and incontinence
~ dysentery: low-volume, bloody diarrhea
~ diarrheal disorders are categorized as follows:
~ 1) secretory diarrhea: same osmolarity as plasma, lasts even though fasting
~ 2) osmotic diarrhea: xs fluid that your body doesn’t really like
~ 3) exudative diseases: infection
~ 4) malabsorption: xs fat (steatorrhea) and not absorbing nutrients
~ 5) deranged motility: not pushing bolus properly, some move/some don’t

Infectious Enterocolitis
~ microbial origin
~ rotavirus, calciviruses, and enterotoxigenic E. coli
~ major cause of chronic or recurrent infectious enterocolitis

Viral Gastroenteritis
~ virus destroys microvilli and decreases absorption
~ osmotic diarrhea
~ villi repopulated with immature enterocytes and preservation of crypt secretory cells
~ have net water and electrolyte secretion

Bacterial Enterocolitis
~ mechanisms underlying bacterial diarrheal illnesses
~ 1) take preformed toxin
~ 2) take toxigenic organism
~ 3) enteroinvasive  destroy mucosal cells
~ all 3 need: adherence, elaborate enterotoxin, need to invade

Protozoal Infection
~ Entamoeba histolytica
~ causes dysentery
~ invade crypts of colonic glands  go into submucosa and therefore can move
elsewhere
~ fecal oral spread
~ Giardia lamblia
 ~ in SI mucosa, no invasion
~ mucousy diarrhea
~ get through feces-contaminated water
~ Cryptosporidiosis
~ emergent cause
~ fatal complication of AIDS
~ waterborne contamination

Malabsorption Syndromes
~ suboptimal absorption – fat, vitamine, protein, electrolytes, carbs, mineral, water
~ results in at disturbing at least one of:
~ 1) intraluminal digestion of proteins, cars, fats
~ 2) terminal digestion: hydrolysis of carbs, peptides at SI brush border
~ 3) transepithelial transport: nutrients, fluid, electrolytes across intestinal
~ M/C: pancreatic insufficiency, celiac disease, Crohn’s disease
~ osmotic diarrhea and steatorrhea
~ lactose intolerance – class example of defective mucosal cell absorption
~ abetalipoproteinemia – unable to export lipid b/c of autosomal recessive disorder
~ Gluten-sensitive enteropathy – reduction in SI absorptive surface area
~ celiac disease: gluten sensitivity
~ strong genetic susceptibility
~ early exposure of immature immune system to high gliadin levels
~ total flattening of mucosal villi
~ Tropical sprue: resemble celiac disease but occurs exclusively in tropics
~ Whipple disease: rare, systemic infection
~ mainly affects intestine, CNS, joints
~ cause: gram +ve Tropheryma whippelii
~ consequences:
~ 1) hematopoietic system
~ 2) MSK system
~ 3) endocrine system
~ 4) skin
~ 5) nervous system

IBD
~ Crohn ds (CD) and ulcerative colitis (UC)
~ called idiopathic IBD b/c they share many symptoms
~ CD – affects any part of GI tract but mainly SI and colon
~ show noncaseating granulomatous inflammation
~ UC – nongranulomatous disease only in colon
~ pathogenesis:
~ 1) genetic predisposition?
~ 2) immunologic factors – T cells
~ 3) microbial factors – may provide antigenic trigger
~ IBD – heterogeneous group of diseases with exaggerated and destructive mucosal
immune response
~ inflammation is final common pathway
~ see neutophils initially and mononuclear cells later
~ inflammation causes:
~ 1) impaired integrity of mucosal epithelial barrier
~ 2) loss of surface epithelial cell absorptive function
~ 3) activation of crypt epithelial cell secretion
~ bloody diarrhea

Crohn Disease
~ any level of alimentary tract
~ extraintestinal complications of immune origin
~ systemic inflammatory disease with predominant GI involvement
~ worldwide distribution

Ulcerative Colitis
~ ulceroinflammatory disease affecting colon
~ limited to mucosa and submucosa except in most severe cases
~ begin in rectum and goes proximally
~ systemic disorder

Colonic Diverticulosis
~ diverticulum is a blind pouch leading off alimentary tract
~ it is lined by mucosa and communicates with lumen of gut
~ prototype: Meckel diverticulum
~ acquired diverticula – anywhere in alimentary tract (but m/c colon)  diverticular
disease (Aka diverticulosis)
~ potential sites for herniations – where nerves and arterial vasa recta enter the inner
circular muscle coat of the colon
~ 2 factors in genesis:
~ 1) exaggerated peristaltic contractions with increased intraluminal pressure
~ 2) focal defects to normal muscual colonic wall

Bowel Obstruction
~ 1) Hernias
~ weakness or defect in peritoneal cavity wall
~ protrusion causes hernial sac
~ inguinal, femoral canals, umbilicus, surgical scars
~ if viscera that protrude and get trapped it can lead to permanent trapping
(incarceration) and strangulation (infarction of trapped)
~ 2) Adhesions
~ surgery, infection, and endometriosis localized/general peritoneal inflammation
(peritonitis)
~ adhesions might develop b/w bowel segments during healing process
~ fibrous bridges can create closed loops where intestines may slide and become
trapped (internal herniation)
~ 3) Intussusception
 ~ telescoping proximal segment of bowel into distal segment
~ can be a tumour that becomes trapped by peristaltic wave and pulls its attachment
into distal segment
~ 4) Volvulus
~ twisting of a loop of bowel or other structure
~ constricts venous outflow
~ affects small bowel