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Pathology Laboratory Medical Faculty Jember

University
Reading requirements
Robbins Basic Pathology 8th edition
Pgs 588-591 eosophagus
Pgs 591-593 stomach
Pgs 597-600 stomach
Pgs 611-629 small and large bowel
Pgs 663-672 liver
Pgs 681-685 pancreas
Barrett Esophagus
Complication in 10 % of symptomatic GERD
patients over time.
Pathogenesis not clear.
Think alteration in the differentiation program
of stem cells of Eosph. Mucosa.
Clinical: age 40 to 60 years
Highest among white males.
Barrett Eosophagus
It is the single most important risk factor for
esophageal adenocarcinoma. 30-40 times
increased rate in long segment disease.
Criteria for diagnosis of BE are:
A) Endoscopic evidence of columnar epithelial
lining above the GE Junction (normally
squamous cells)
B) Histological evidence of intestinal
metaplasia in the specimen from the
columnar epithelium
BE
In addition: A) long segment extending
cephalad 3 cm from the manometric
gastroeosophegeal junction.
B) short segment less than 3cm
cephalad extension.
First a normal esophagus and then the
disease.
In this low-power image of the upper esophagus, the lumen is visible in two places at the
top above the basophilic mucosa. Subjacent to the mucosa is the submucosa and
underlying muscularis propria.
A high-power view of the mucosa shows the non-keratinized stratified squamous epithelium
and subjacent a small amount of lamina propria and muscularis mucosae with its smooth
muscle fibers cut in cross-section.
A high-power view of the muscularis propria (inset in the survey image) show the interface
between skeletal muscles cut in cross- and longitudinal section. In cross-section, note the
peripheral location of myofiber nuclei. Cross-striations of the myofibers in longitudinal
section are difficult to see in this image.
Reflux eosophagitis
Reflux esophagitis. Low-power view of the
superficial portion of the mucosa. Numerous
eosinophils within the squamous epithelium,
elongation of the lamina propria papillae, and
basal zone hyperplasia are present.
Barrett esophagus. A, B, Gross view of distal
esophagus (top) and proximal stomach
(bottom), showing A, the normal
gastroesophageal junction (arrow) and B, the
granular zone of Barrett esophagus (arrow). C,
Endoscopic view of Barrett esophagus showing
red velvety gastrointestinal mucosa extending
from the gastroesophageal orifice. Note the
paler squamous esophageal mucosa.
BE
BE
Benign tumors
Leiomyomas
Lipomas; pedunculated or fibrovascular
polyps
Squamous papillomas.
Inflammatory pseudo- tumors.
Malignant Tumors
Squamous Cell Carcinoma
Adult males predominant in Blacks in the US
and worldwide.
Most common type of carcinoma of
Eosophagus.
First a few slides normal of the EG junction.
A low-magnification image of the gastro-esophageal junction shows the abrupt transition
between epithelia in the mucosa of these two regions of the digestive tract. At right is the
stratified squamous epithelium of the esophagus and at left is the simple columnar
epithelium of the stomach.
In this higher-power view, esophageal and gastric epithelia are seen, although the exact
transition is not evident because of the poor quality of this section.
In this view of the gastric mucosa, surface mucous cells are seen lining the invaginations of
the gastric pits and subjacent circular profiles representing cross-sections of the tubular
gastric glands.
Large ulcerated squamous cell carcinoma of the esophagus.
Squamous cell carcinoma of the esophagus: low-power microscopic
view showing invasion into the submucosa.
Malignant tumors of
Eosph.
Adenocarcinoma malignant epithelial tumor
with glandular differentiation.
Barrett predisposes to this type of carcinoma.
Prognosis poor.
ADENOCARCINOMA
Adenocarcinoma of the
esophagus.
Gross view of an ulcerated, exophytic mass at the
gastroesophageal junction, arising from the granular mucosa of
Barrett esophagus. The gray-white esophageal mucosa is on the

top, and the folds of gastric mucosa are below .


Microscopic view of malignant intestinal-type glands in
adenocarcinoma arising from Barrett esophagus.
Stomach
Acute gastritis and chronic gastritis.
Heliobacter pylori
Microscopic view of antral
mucosa.
Microscopic view of fundic
mucosa.
Low-power microscopic view of focal mucosal disruption with
hemorrhage; the adjacent mucosa is normal.
Acute gastritis. A, Gross view showing punctate erosions in an
otherwise unremarkable mucosa; adherent blood is dark due to
exposure to gastric acid
Chronic gastritis, showing partial replacement of the gastric mucosal
epithelium by intestinal metaplasia (upper left) and inflammation of
the lamina propria (right) containing lymphocytes and plasma cells.
Peptic ulcer of the duodenum. Note that the ulcer is small (2 cm) with a
sharply punched-out appearance. Unlike cancerous ulcers, the margins
are not elevated. The ulcer base is clean.
Multiple stress ulcers of the stomach, highlighted by dark digested
blood on their surfaces.
Note Just for your interest
and
Pyloricmine too!!
stenosis occurs in newborns after a
few days to weeks of being born symptoms
become more obvious.
There are usually no other symptoms and
child is usually very well otherwise.
More common in males than females.
Tumors of stomach
Benign: Definition of polyp: any nodule or
mass that projects above the level of the
surrounding mucosa.
Polyps not common in stomach.
Inflammatory fibroid polyp or Peutz Jegher
polys can be seen even here sometimes.
Gastric hyperplastic polyp.
Low-power microscopic view of the polyp showing hyperplastic foveolar

epithelium and inflammation .


Gastric adenoma. Gross photograph showing a large polyp in the
stomach.
Carcinoma of the
stomach
2 most common tumor in the world.
nd

6 fold less in the US than certain other parts


of the world.
Though Heliobacter infections (chronic)
generally increases the incidence of gastric
carcinoma about 6 fold the vast number of
infected individuals do not develop ca and not
all H pylori infections increase the risk of ca.
Location of Ca in
stomach
Pyloris and antrum 50 to 60 %.
25% in cardia.
Lesser curvature about 40%; greater about
12%.
Favored loction lesser curvature of the
antropyloric region.
Ca of stomach
For unknown reasons gastric carcinomas
frequently metastasize to the supraclavicular
sentinal node (Virchov).
Sometimes they metastasize to periumbilical
area and then these are called Sister Mary
Joseph nodule.
If to the ovaries this is called Krukenberg
tumor.
Cancer of stomach
The prognosis with early gastric carcinoma
(EGC) is good, compared with other gastric
cancers.
Early gastric carcinoma (EGC) usually does
not metastasize. This is defined as mucosa
and submucosa invasion even if distal lymph
node involvement.
A signet ring cell pattern is more typical for a
poorly differentiated, diffuse type of gastric
carcinoma, not an early gastric carcinoma
(EGC). Advanced gastric ca is defined as
extending below submucosa into muscular
region.
Linitis plastica characterizes a diffuse cancer
with a poor prognosis, not an early gastric
carcinoma (EGC).
Inflammatory fibroid polyp; microscopic photograph showing
submucosal growth of inflamed vascularized fibromuscular tissue with
prominent eosinophilic infiltrate.
Gastric carcinoma. Gross photograph showing an ill-defined, excavated
central ulcer surrounded by irregular, heaped-up borders.
Intestinal type demonstrating gland formation by malignant cells,
which are invading the muscular wall of the stomach.
Diffuse type demonstrating signet-ring carcinoma cells.
Less common tumors
Gastric lymphoma
Gastrointestinal stromal tumor
Carcinoid tumor
Metastatic cancer (Unusual to stomach)
Gastric MALT lymphoma. Note the lymphoepithelial lesions (arrows) .
(mucosa-associated lymphoid tissue MALT lymphomas)
Gastrointestinal stromal tumor. A, Gross photograph of the tumor
arising from the muscularis propria of the gastric wall. B, Microscopic
view of the tumor showing spindle cell feature.
Small and large
intestines
IBD are UC and CD
Both relapsing disease of unknown etiology.
CD is an autoimmune disease that may affect
any portion of the GI tract but most frequently
affects distal ileum and colon.
UC is a chronic inflammatory disease limited
to colon and rectum.
Both exhibit extraintestinal inflammatory
manifestations.
SB and LB
CD features:
1) sharply delimited and typically transmural
involvement of the bowel by an inflammatory
process with mucosal damage
2) presence of noncaseating granulomas
3) fissuring with formation of fistulas.
CD
Intestinal wall rubbery thick edematous
inflammation, fibrosis and hypertrophy of the
muscularis propria.
Fibrosing strictures; marked loss of albumin
(protein loosing enteropathy), specific
malabsorption of vitamin B12 causing
pernicious anemia; malabsorption of bile salts
and steatorrhea.
UC
Limited to colon and rectum
Affecting only the mucosa and submucosa
except in severe cases.
Extends in continuous process.
Like CD UC is a systemic disorder and thus
migratory polyarthritis ankylosis spondylitis,
pericolangitis and sclerosing cholangitis.
Normal small-bowel histology, showing mucosal villi and crypts, lined
by columnar cells.
Normal colon histology, showing flat mucosal surface and abundant
vertically oriented crypts.
Crohn disease of ileum, showing narrowing of the lumen, bowel wall
thickening, serosal extension of mesenteric fat ("creeping fat"), and
linear ulceration of the mucosal surface (arrowheads).
Crohn disease of the colon; a deep fissure extending into the muscle
wall, a second, shallow ulcer (on the upper right), and relative
preservation of the intervening mucosa. Abundant lymphocyte
aggregates are present, evident as dense blue patches of cells at the
interface between mucosa and submucosa.
Crohn disease of the colon. A noncaseating granuloma is present in the
lamina propria of an uninvolved region of colonic mucosa (arrow).
Comparison of the distribution patterns of Crohn disease and ulcerative
colitis, as well as the different conformations of the ulcers and wall
thickenings.
Ulcerative colitis. Ulcerated hemorrhagic surface with knobby
pseudopolyps.
Ulcerative colitis. Low-power micrograph showing marked chronic
inflammation of the mucosa with atrophy of colonic glands, moderate
submucosal fibrosis, and a normal muscle wall.
Toxic megacolon. Complete cessation of colon neuromuscular activity
has led to massive dilatation of the colon and black-green discoloration
signifying gangrene and impending rupture.
Ulcerative colitis. Microscopic view of the mucosa, showing diffuse
active inflammation with crypt abscess and glandular architectural
distortion.
note
Sclerosing cholangitis is one of the extra-
intestinal manifestations of inflammatory
bowel disease and is seen most frequently
with ulcerative colitis. Usually if colectomy
was performed because of increasing risk for
adenocarcinoma, extraintestinal manifestation
of UC can still occur.
note
SLE is not associated with sclerosing
cholangitis.
Wilson disease can produce chronic hepatitis
and fibrosis, but not sclerosing cholangitis.
Hepatitis B infections can produce chronic
hepatitis and cirrhosis, but not sclerosing
cholangitis.
AAT (Alpha-1-antitrypsin deficiency
deficiency) can lead to chronic hepatitis and
cirrhosis, but not sclerosing cholangitis.
TUMORS OF THE SMALL
INTESTINE (Brief list)
Hyperplastic polyps

Hamartomatous polyps.
Juvenile polyps
Peutz-Jeghers polyps
Neoplastic Epithelial Lesions.
Adenoma*
Adenocarcinoma*
* Benign and malignant counterparts of the most common neoplasms in the intestines; virtually all lesions are in the
colon.
Brief list of main ca
Mesenchymal Lesions
Gastrointestinal stromal tumor (GIST) (gradation
from benign to malignant)
Lymphoma
OTHERS
Kaposi sarcoma
Few important points
The HNPCC syndrome (Hereditary non-polyposis
colon carcinoma syndrome) is accompanied by
fewer polyps with an appearance of the polyps in
middle age.
Gardner syndrome is another disease associated
with the APC gene and includes multiple colonic
polyposis, but is less common and is
accompanied by extraintestinal lesions such as
osteomas of bone.
In Peutz-Jeghers syndrome, the polyps are of the
hamartomatous variety, not adenomatous.
A few importanct points
Adenomatous polyposis Persons with familial
polyposis caused by the APC gene should
have a colectomy for this reason: By late
childhood to young adulthood, one or more of
the polyps will give rise to a malignancy.
Tumors of the S and L
bowel
Adenomas occur usually in the region of the
ampulla of Vater in the small bowel.
Large numbers of adenocarcinomas of SB
occur in the duodenum.
Major risk for adeno ca is CD.
Other conditions familial adenomatous
polyposis, Peuts Jeghers syndrome and
hereditary nonpolyposis colorectal cancer.
Adenoma of the ampulla of Vater, showing exophytic tumor at the
ampullary orifice.
Tumors of LB and rectum
Most common malignant tumors in the
Western countries.
Called polyps generally tumors mass that can
turn to malignant lesions.
Adenomatous polyp are true precursors of
carcinoma.
Adenomas
Non-neoplastic colonic polyps. A, Hyperplastic polyp; high-power view
showing the serrated profile of the epithelial layer.
B, Peutz-Jeghers polyp; low-power view showing the splaying of smooth
muscle into the superficial portion of the pedunculated polyp.
Pedunculated adenoma showing a fibrovascular stalk lined by normal
colonic mucosa and a head that contains abundant dysplastic epithelial
glands, hence the blue color with the H & E stain
. A small focus of adenomatous epithelium in an otherwise normal
(mucin-secreting, clear) colonic mucosa, showing how the dysplastic
columnar epithelium (deeply stained) can populate a colonic crypt and
create a tubular architecture.
Familial Syndromes Sessile adenoma with villous architecture. Each
frond is lined by dysplastic epithelium.
Portion of a villous frond with dysplastic columnar epithelium on the
left and normal colonic columnar epithelium on the right.
Familial adenomatous polyposis in an 18-year-old woman. The mucosal
surface is carpeted by innumerable polypoid adenomas.
LB and rectum
Hyperplastic polyps
Hemartomatous polyps.
Cowdens syndrome genetic autosominal
dominant syndrome (germ line mutation).
Cronkhite-Canada syndrome non hereditary
disorder with GI hemartomous polyposis and
ectoderminal abnormalities likes alopecia, skin
pigmentation nail atrophy .
LB and rectum.
Adenomas : tubular, villous or mixed.
Clinical impact of malignant change in an
adenoma depends on: a) High grade
dysplasia (ca in situ).
b) intramucosal
carcinomawith lamina propria invasion
Note: invasive
adenocarcinoma arising from a sessile polyp
cannot be resected by polypectomy.
Colorectal carcinoma.
Highest death rates in US, Australia etc.
Some clinical correlations such as the diet
factor and high cholesterol intake are
associated with potential carcinogens.
Carcinoid tumors. In appendiceal and rectal
areas these usually do not metastasize even
though they may show extensive local spread.
Carcinoma of the cecum. The fungating carcinoma projects into the
lumen but has not caused obstruction.
Carcinoma of the descending colon. This circumferential tumor has
heaped-up edges and an ulcerated central portion. The arrows identify
separate mucosal polyps.
Invasive adenocarcinoma of colon, showing malignant glands
infiltrating the muscle wall.
Carcinoid tumor. A, Multiple protruding tumors are present at the
ileocecal junction.
The tumor cells exhibit a monotonous morphology, with a delicate
intervening fibrovascular stroma.
Electron micrograph showing dense core bodies in the cytoplasm.
Liver
Benign neoplasm: Cavernous hemangiomas
most common.
Liver cell adenomas derived from
hepatocytes.
Malignant tumors uncommon in North
America but are about 40% of cancers in other
parts of the world.
a) hepatacellular carcinomas
Liver cell adenoma. A, Resected specimen presenting as a pendulous
mass arising from the liver.
Microscopic view showing cords of hepatocytes, with an arterial
vascular supply (arrows) and no portal tracts.
Hepatocellular carcinoma. A, Autopsied liver showing a unifocal,
massive neoplasm replacing most of the right hepatic lobe in a
noncirrhotic liver; a satellite tumor nodule is directly adjacent.
In this microscopic view of a well-differentiated lesion, tumor cells are
arranged in nests, sometimes with a central lumen, one of which
contains bile (arrow). Other tumor cells contain intracellular bile
pigment.
Note
Hepatic adenomas are rare, are more often
related to oral contraceptive use in women.
Focal nodular hyperplasia is a rare finding not
associated with chronic alcoholism.
Lithiasis does not typically complicate
cirrhosis.
Hepatocellular carcinoma occurs most often in
the setting of cirrhosis (which is most often
from chronic alcoholism and from chronic viral
hepatitis B and C).
Fibrolamellar carcinoma. A, Resected specimen showing a demarcated
nodule in an otherwise normal liver.
Microscopic view showing nests and cords of malignant-appearing
hepatocytes separated by dense bundles of collagen.
Less common is the cholangiocarcinoma (bile
duct).
Hepatoblastoma in childhood most common
malignancy in that age group. (epithelial and
mixed epithelial and mesenchymal types).
Angiosarcoma
Metastatic tumors far more common in liver
than primary.
Cholangiocarcinoma. A, Autopsied liver showing a massive neoplasm in the right
hepatic lobe and innumerable metastases permeating the entire liver. B,
Microscopic view showing tubular glandular structures embedded in a dense
sclerotic stroma.

2008 Elsevier
Cholangiocarcinoma
Autopsied liver massive neoplasm in R
hepatic lobe and innumerable metastasis
permeating entire liver.
Tubular glandular structures embedded in a
dense sclerotic stroma.
Multiple hepatic metastases from a primary colon adenocarcinoma.
Gall bladder
Carcinoma of the gallbladder.
Woman more than man
7th decade of life
Poor prognosis.
Gallbladder adenocarcinoma.
The opened gallbladder contains a large, exophytic tumor that
virtually fills the lumen.
Malignant glandular structures are present within a densely fibrotic
gallbladder wall.
Pancreas
Congenital cyst and pseudocyst.
Cystic neoplasms
Pancreatic carcinoma; 4th leading cause of
death in the world one of the highest
mortalities preceded only by lung, colon, and
breast ca. .
Pancreatic pseudocyst. A, Cross-section through this previously
bisected lesion revealing a poorly defined cyst with a necrotic brown-
black wall. B, Histologically, the cyst lacks a true epithelial lining and
instead is lined by fibrin and granulation tissue.
A pseudocyst is a complication of chronic
pancreatitis seen most frequently in persons
with a history of chronic alcoholism. The
pseudocyst is an area of necrosis with a wall
composed of granulation tissue.
Note
An acute pancreatitis leads to inflammation
with swelling, necrosis, and hemorrhage of the
pancreas, but not a pseudocyst.
Islet cell adenomas are not cystic. They are
often so small that they are difficult to image.
Most are non-functional, but some may
secrete hormones such as insulin or gastrin.
Metastases are most often multiple solid
masses and this is rare in the pancreas.
Serous cystadenoma. A, Cross-section through a serous cystadenoma.
Only a thin rim of normal pancreatic parenchyma remains. The cysts
are relatively small and contain clear, straw-colored fluid. B, The cysts
are lined by cuboidal epithelium without atypia.
PANCREATIC CARCINOMA
Infiltrating ductal adenocarcinoma of the
pancreas, more commonly known as
"pancreatic cancer," is the fourth leading
cause of cancer death in the United States,
preceded only by lung, colon, and breast
cancers.
PANCREATIC CARCINOMA
Pancreatic cancer has one of the highest
mortality rates of any cancer. It is estimated
that in 2004, approximately 30,000 Americans
will be diagnosed with pancreatic cancer, and
virtually all of them will die from it. The 5-year
survival rate is a dismal, less than 5%.
Carcinoma of the pancreas. A, A cross-section through the head of the pancreas
and adjacent common bile duct showing both an ill-defined mass in the
pancreatic substance (arrowheads) and the green discoloration of the duct
resulting from total obstruction of bile flow. B, Poorly formed glands are present
in densely fibrotic stroma within the pancreatic substance; there are some
inflammatory cells.
NOTE
Adenocarcinoma of the head of pancreas
produces extrahepatic biliary obstruction with
an elevation predominantly of the direct
bilirubin along with an elevation in alkaline
phosphatase. This results in the classic finding
of 'painless jaundice'.
Note
Cystic fibrosis leads to atrophy of pancreatic
acinar tissue, but without biliary tract
obstruction.
Hepatitis would increase the transaminases
(AST and ALT) markedly.
Hemolysis should result in an elevated indirect
bilirubin, without liver enzyme elevation. In
older persons an autoimmune hemolytic anemia
is often of the 'cold' variety with an underlying
hematologic malignancy such as a lymphoma.