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Monthly Archives: August 2010
Gastrointestinal Stromal Tumor
Gastrointestinal Stromal Tumors
GIST
Classification
– very low, low, intermediate and high risk of aggressive behavior
Microscopic Appearance
- spindle and epithelioid types
Immunohistochemistry
– CD117+ in 90%, CD34 + in 70%, SMA can be focally positive, desmin – ( positive in leiomoyomas)
Histogenesis
-can arise anywhere in the GI tract; 60-70% from stomach, 20-30% from the SI and <10% from the rest
-proliferation of the interstitial cells of Cajal
-association with c-kit and PDGFA genes - these are receptors with tyrosine kinase intracellular domains, and mutation causes their constitutive activation with activation of downstream signaling, leading to cell proliferation.
Differential Diagnosis
-leiomyomas
-leiomyosarcomas
-inflammatory fibroid polyp
-fibromatosis
-schwannoma
-inflammatory myofibrobastic tumor
-solitary fibrous tumor
Reporting
- report size, morphologic type, mitotic count per 50 HPFs , cellular atypia, presence of any necrosis
MIB count has been found to be correlative with prognosis:
0-9% low, 10-29% intermediate, 30% or higher – high risk.
Posted in GI
Tagged c-kit, Gastrointestinal Stromal Tumor, gi tract, gist, pdgfa, stromal tumor
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Lower Small Intestine Obstruction
Lower Small Intestine Obstruction
Causes
-post-operation adhesions
-malignancy
-Crohn’s
-hernias
Classification
-partial or complete
-strangulated (surgical emergency – leads to bowel ischemia) or non-strangulated
Posted in Small Intestine
Tagged , lower obstruction, lower small intestine obstruction, Small Intestine
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Ovarian Primary
Ovarian Primary
Features ( clinical gross micro or immunohistochemistry ) that differentiate primary ovarian cancer form colorectal metastasis to the ovary
Ovarian primary favored if:
No colon mass
Unilateral ovarian involvement
Single >5mm ( as opposed to multiple lesions <5mm) lesion
Certain morphologies – like serous – favor the ovarian origin
Pre-malignant lesion such as serous LMP adjacent to carcinoma
Lesions associated with certain ovarian malignancies – ie. endometriosis is associated with clear cell carcinoma, endometrioid carcinoma, carcinosarcoma MMMT, endocervical variant of mucinous LMP.
Ovarian neoplasms are typically CK7+, CK20 – , except for mucinous carcinomas with can be CK20 +
WT-1 helpful with ovarian serous carcinoma
Colon Cancer Prognostic Factors
Prognostic factors
-size
-depth of invasion
-lymph node status
Colon Cancer Risk Factors
Colon Cancer Risk Factors
Risk factors with high incidence
-age
-Ulcerative Colitis
-Crohn’s Disease
-FAP
-HNPCC
Posted in Colon
Tagged , colon cancer, Crohn’s Disease, FAP, hnpcc, prognostic factors, risk factors, Ulcerative Colitis
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Blind Loop Syndrome
Blind Loop Syndrome
Stasis syndrome or stagnant loop syndrome
Definition
-a condition in which part of the small intestine is bypassed and cut off from the normal flow of food and digestive juices. Bacterial overgrowth results, interfering with absorption of essential nutrients, often leading to diarrhea, weight loss and malnutrition.
Causes
- structural defect in or an injury to your small intestine – surgery such as Billroth II or Roux-en-Y, gastric bypass
-Crohn’s disease, intestinal lymphoma, scleroderma or diabetes – slowed transit time through intestine
-Diverticulosis of the small intestine
Presentation
Loss of appetite
Abdominal pain
Nausea
Fatty stools (steatorrhea) — frothy, foul-smelling stools indicating poor fat absorption
Bloating
An uncomfortable feeling of fullness after eating
Diarrhea
Unintentional weight loss
Complications
-abnormalites in normal bacterial flora cause poor deconjugation of bile salts, which are required for fat emulsification and digestion. Resultant steatorrhea and malabsorption of fat-soluble vitamins - ADEK
-damage to intestinal mucosa - malabsorption of most other nutrients
-B12 malabsorption
Posted in Small Intestine
Tagged , Blind Loop Syndrome, obstruction, stagnant loop syndrome, Stasis syndrome
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Solitary rectal ulcer syndrome
Solitary rectal ulcer syndrome and Mucosal Prolapse
Cause
-malfunction of the puborectalis muscle such that excessive straining on defecation results. This leads to mucosal prolapse that ultimately may ulcerate and form polypoid masses.
-prolapse polyps also occur in association with diverticular disease, at ostomy sites and adjacent to mass lesions.
- mucosal prolapse occurs at the anal verge, and forms a polyp – inflammatory cloacogenic polyp
Symptoms
- alternating diarrhea and constipation,
- pain and difficulty defecating
- rectal bleeding
Gross Appearance
- friable ulcerated polyps/ masses on the anterior rectal wall or at mouths of diverticula or stomas
Microscopic Appearance
-fibromuscular hyperplasia of the LP
-hyperplastic regenerative epithelium
-crypt distortion
-surface ulceration
-submucosal entrapment of crypts filled with mucin – colitis cystica profunda
Prognosis
-responds well to bulk laxatives and stool softeners, may require retropexy or resection
Syndromes associated with mucosal prolapse:
Solitary rectal ulcer syndrome
Inflammatory cloacogenic polyp
Colitis cystica profunda
Posted in Colon
Tagged Colitis cystica profunda, Inflammatory cloacogenic polyp, mucosal prolapse, Solitary rectal ulcer syndrome
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Lymphocytic Colitis
Lymphocytic Colitis
Microscopic Colitis
Clinical
-all ages, M=F
-cause unknown
-prolonged watery diarrhea
-associated with autoimmune disease in some patients (celiac sprue, arthritis and thyroiditis)
-normal colonoscopic exam
Microscopic Appearance
-generally involves the entire colon
-marked increase in lymphocytes in the surface and crypt epithelium
-absence of thickened subepithelial collagen layer
-chronic inflammation in the lamina propria
-no crypt distortion
-may have occasional foci of cryptitis or neutrophils in the surface epithelium
Differential Diagnosis
-collagenous colitis
-resolving infectious colitis
-chronic epithelial lymphocytosis associated with food or water-borne epidemics
-Crohn’s disease
-normal mucosa overlying a lymphoid aggregate
-lymphocytic enterocolits
** Always check the clinical history before making the diagnosis.
Prognosis
-most patients respond to symptomatic or antiinflammtory therapy. Those who don’t respond tend to also have sprue-like symptom may be classified as having lymphocytic enterocolitis
Posted in Colon
Tagged , celiac disease, celiac sprue, colitis, Colon, Lymphocytic Colitis, microscopic colitis
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Collagenous Colitis
Collagenous Colitis
Microscopic Colitis
Clinical
-middle –aged and older women, M:F= 1:10
-protracted watery diarrhea without systemic symptoms
-normal colonoscopic exam
Microscopic Appearance
-proximal colon more affected
-thickened subepithelial collagen layer usually >10uM (normal 2-3), best viewed by Masson trichrome, collagen also encircles the superficial capillaries
-chronic inflammation in the lamina propria
-no crypt distortion
-may have occasional foci of cryptitis or neutrophils in the surface epithelium
Differential Diagnosis
-lymphocytic colitis
-radiation colitis
-infectious colitis
-mucosal prolapse/SRUS
-ulcerative colitis
-chron’s
-normal mucosa with thick basement membrane
-enema effect
Prognosis
-most patients respond to symptomatic or anti-inflammtory therapy.
Posted in Colon
Tagged , colitis, Collagenous Colitis, colon inflammation, microscopic colitis
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Meckel’s Diverticulum
Meckel’s Diverticulum
- derived from the omphalomesenteric or vitelline duct – a true diverticulum which involves all layers of the intestinal wall
-most common malformation of the GI tract
-true diverticulum MUST include all three layers of the GI tract
Meckel’s Diverticulum rule of 2′s:
-2% (of the population)
- 2 feet (from the ileocecal valve)
- 2 inches (in length)
- 2% are symptomatic,
2 types of common ectopic tissue (gastric and pancreatic)
-the most common age at clinical presentation is 2
-males are 2 times as likely to be affected.
-Can present as intussusception, incarceration and perforation.
-the ectopic gastric tissue can cause peptic ulceration of the surrounding ileal mucosa
Posted in GI
Tagged , diverticula, diverticular disease, diverticulum, meckel, meckels diverticulum
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