Lower Gastrointestinal Pathology

Professor Neil A Shepherd

Gloucester and Cheltenham, UK

Sheffield Diagnostic Histopathology Course

16 June 2010
 The lower gastrointestinal tract

• where does it begin and end?

• 15 cases

• no picking on people but can we be a bit interactive?

• hand-out with full discussion and references

• you will get a full copy of this lecture with all of its marvellous
additional data……
Morson and Dawson’s
Gastrointestinal
Pathology
________________

Fourth Edition

Published in January 2003

704 pages,
559 illustrations (with 402 in full colour)
ISBN: 0 632 04204 4
Hardback £175.00
 CONTEXT

CONTEXT
CONTEXT
 Case 1

76M. Loose stool and weight loss. Duodenal biopsies.

 Duodenal biopsy:
indications, interpretation and implications
• commonest indication in the UK for duodenal biopsy is iron
deficiency or iron deficiency anaemia

• it is most often undertaken with a potential diagnosis of coeliac

disease in mind

• for the diagnosis of coeliac disease, duodenal biopsy remains the

gold standard

• serological methods (anti-endomysial antibody (EMA) and tissue

transglutaminase (TTG)) show only 90-95% sensitivity and
specificity

• TTG has improved things, is a good initial screen for CD but there
is still intra-laboratory variation
 BSG guidelines:
Management of iron
deficiency anaemia;
2000 (rev 2005)

see www.bsg.org.uk
 Duodenal biopsies for ‘malabsorption’

960 duodenal biopsies

802 normal/minimal abnormality

62 (6.5%) coeliac disease
20 (2%) raised IELs but normal villous architecture
6 giardiasis

38 non-specific duodenitis
32 miscellaneous

Gloucestershire audits 2005-6 & 2006-7

 Duodenal biopsy for ‘malabsorption’

coeliac disease/gluten enteropathy/gluten sensitivity

giardiasis
other infections +/- immunodeficiency
Whipple’s disease
other rare causes of malabsorption (especially in children)

food allergy
bacterial overgrowth
‘mechanical’ causes of villous atrophy and inflammation
 Duodenal biopsies for coeliac disease

• patchiness

• national and international recommendations require a

minimum of four 3mm biopsies from D2 or beyond
 Italian multicentre coeliac study

• 665 children & adolescents with proven coeliac disease

• multiple duodenal biopsies (1 D1, 3-4 more distally)
• ALL patients had CD-type changes in D1
• 16 had normal biopsies more distally
• 20 had patchy lesions more distally

• no D1 lesions in 348 non-CD subjects

• recommend 2 biopsies from bulb and 2 more distally

Bonamico M et al. J Ped Gastro Nutr 2008; 47: 618-22.

 Case 1

Endoscopy showed white plaques & yellow irregular

mucosa with oedema
Case 1
Case 1
Duodenal biopsies – occasionally one sees an unusual
disease!!

Whipple’s disease – Tropheryma whippelii

 Case 1 - learning points

• Whipple’s disease is rare and mainly affects older men (M:F = 8:1)

• it is a multisystemic bacterial infection

• it may require a host abnormality of histiocytic function

• you’ll only see it in DHC courses and in the MRCPath exam!!

 Case 1

DIAGNOSIS:
WHIPPLE’S DISEASE
 Case 2

26M. Loose stool and low B12. Nodular appearance to

duodenum. Duodenal biopsies.
 Nodular appearance to duodenum

Usually first part of the duodenum

Diagnoses to consider:

1. Gastric heterotopia
2. Brunner’s gland hyperplasia
3. Lymphoid follicular hyperplasia
Case 2
Case 2
Case 2
Case 2
 Giardiasis in duodenal biopsies

• varying degrees of villous atrophy, chronic inflammation in the lamina

propria and modest intra-epithelial lymphocytic infiltrate may be seen

• BUT, in most cases of giardiasis (96% in one series), the duodenal

mucosa appears normal (apart from the bugs)

• a search for the parasite should be undertaken in all duodenal

biopsies, in patients presenting with diarrhoea and malabsorption,
whether the biopsies are morphologically normal or not

• the protozoan may be detected in gastric, jejunal, ileal and colonic

mucosa: these mucosae are also usually ‘normal’ in giardia infection

Oberhuber et al, 1997

Giardiasis in duodenal biopsies
Giardiasis ?
Massive infestation with giardiasis
 Case 2
Massive infestation by giardiasis and lymphoid follicular hyperplasia
– should trigger a thought....
 Case 2 - learning points

• duodenal nodulation has three common(ish) causes

• most duodenal biopsies with giardiasis are normal (apart

from the parasites!)

• if you see heavy giardia infestation, think immunoparesis

• in the exam, don’t relax (too much) when you spot an easy
case, especially if it’s an infection. There may be
two/multiple pathologies – especially in HIV/AIDS……
 Case 2

DIAGNOSIS:
NODULAR LYMPHOID HYPERPLASIA DUE TO
AGAMMAGLOBULINAEMIA WITH
MASSIVE INFESTATION BY GIARDIASIS