GA STR OIN TES TI N

AL PATHO LOG Y
Eso ph a gus
No rmal esophagus

This is a normal esophagus with the usual white to tan

smooth mucosa seen at the left. The
gastroesophageal junction (not an anatomic
sphincter) is at the center, and the stomach is at the
right.
No rmal esophagus

This is normal esophageal squamous mucosa at the left,

with underlying submucosa containing mucus glands
and a duct surrounded by lymphoid tissue. The
muscularis is at the right.
Ca ndida esophagit is

Tan-yellow plaques are seen in the lower esophagus,

along with mucosal hyperemia. The same lesions are
also seen at the upper right in the stomach.
Ac ute e so phagit is

Acute esophagitis is manifested here by increased

neutrophils in the submucosa as well as neutrophils
infiltrating into the squamous mucosa at the right.
He rpes simp lex
eso phagit is
LPO

HPO
 GROSS: The lower esophagus here shows sharply
demarcated ulcerations that have a brown-red base,
contrasted with the normal pale white esophageal
mucosa at the far left. Such "punched out" ulcers are
suggestive of herpes simplex infection.
 LPO: A herpetic ulcer is seen microscopically to have a
sharp margin. The ulcer base at the left shows loss of
overlying squamous epithelium with only necrotic
debris remaining.
 HPO: the squamous mucosa at the margin of the herpetic
ulcer shows pale pink "ground glass" inclusions within
squamous epithelial cells. Some of the inclusions are
clustered together-- multinucleation is another
common viral cytopathic effect.
 ENDOSCOPIC FINDING: there are rounded, erythematous
ulcerations of the lower esophagus
 Ba rrett's e so phagus
LPO

Pic 1

 LPO: Another cause for inflammation is a so-called

"Barrett's esophagus" in which there is gastric-type
mucosa above the gastroesophageal junction. Note the
columnar epithelium to the left and the squamous epithelium
at the right. This is "typical" Barrett's mucosa, because
there is intestinal metaplasia as well (note the goblet
cells in the columnar mucosa).
 Endoscopic view: In Pic 1, these two endoscopic views
demonstrate Barrett esophagus areas of mucosal Pic 2
erythema (white arrow) of the lower esophagus, with
islands of normal (black arrow) pale esophageal
squamous mucosa. If the area of Barrett mucosa extends
less than 2 cm above the normal squamocolumnar
junction, then the condition is called "short segment"
Barrett esophagus, as shown in Pic 2.
 Eso phageal va rices
(a) At the lower end of the esophagus
(which has been turned inside out at
autopsy) are linear dark blue
submucosal dilated veins known as
varices. In patients with portal
hypertension (usually micronodular
cirrhosis from chronic alcoholism),
(a) (b) the submucosal esophageal veins
become dilated (form varices).
These varices are prone to bleed.
(b) Here is another varix near the
gastroesophageal junction that is
dark red black because it has been
bleeding. (The esophagus has been
turned inside out.) The plexus of
veins also involves some of the
upper stomach, but it is generically
(c) (d) called the esophageal plexus of
veins and, hence, bleeding here is
termed esophageal variceal
bleeding.
(c) Below the squamous mucosa is an
elongated, inflamed varix.
(d) Inflammation and hemorrhage is
seen here in the region of a ruptured
varix of the esophagus.
(e) & (f) Endoscopic views of esophageal
varices are shown, with dilated veins
(e) (f) bulging into the lower esophageal
lumen.
 St omach, scleroderma
wit h fib rosis

(a) (b)

 Esophageal motility problems can occur in patients with progressive

systemic sclerosis (scleroderma) because the submucosa becomes
fibrotic. This occurs most often in the esophagus, but may also be seen
elsewhere in the GI tract. Here in the stomach, a trichrome stain
demonstrates a blue submucosa because of the extensive fibrosis.
 This radiograph taken following barium swallow demontrates a
stricture (arrow) in the lower esophagus, with pooling of the contrast
above the point of stricture. Such stricture may complicate conditions
such as scleroderma, gastroesophageal reflux disease, or carcinoma.
Eso phageal c arcin oma

An ill-defined mass at the gastroesophageal junction

produces mucosal ulceration and irregularity, which led
to the clinical symptoms of pain and difficulty
swallowing.
 Eso phageal sq uamous
cell c arc in oma
(a)

 This irregular reddish, ulcerated

exophytic mid-esophageal
mass (arrow) as seen on the
mucosal surface is a squamous
cell carcinoma.
 At the upper left is a remnant of
squamous esophageal mucosa
that has been undermined by
an infiltrating squamous cell
carcinoma of the mid-
esophagus. Solid nests of
neoplastic cells are infiltrating
down through the submucosa
at the right. (b) (c)
 Infiltrating nests of neoplastic
cells have abundant pink
cytoplasm and distinct cell
borders typical for squamous
cell carcinoma.
 Endoscopic views of an
ulcerated mid-esophageal
squamous cell carcinoma
causing lumenal stenosis are
seen (d)
Sto ma ch
 St omach, norma l
GC

LC

E A

 This is the normal appearance of the stomach, which has

been opened along the greater curvature (GC). The
esophagus (E) is at the left. In the fundus can be seen the
lesser curvature (LC). Just beyond the antrum (A) is the
pylorus (P) emptying into the first portion of duodenum (D) is
at the lower right.
 St omach, pyl orus,
normal

A P D

(a) (b)

(a) This is the normal appearance of the gastric antrum (A) extending to the
pylorus (P) at the right of center. The first portion of the duodenum
(duodenal bulb) is at the far right.
(b) In the endoscopic views, the normal appearance of the pylorus is seen at
the left, with the first portion of the duodenum at the right.
St omach, fundus,
normal

This is the normal appearance of the gastric fundal mucosa,

with short pits lined by pale columnar mucus cells leading
into long glands which contain bright pink parietal cells that
secrete hydrochloric acid.
 Ac ute g astrit is

(a) (b)

(a) This is a more typical acute gastritis with a diffusely

hyperemic gastric mucosa. There are many causes for acute
gastritis: alcoholism, drugs, infections, etc.
(b) At high power, gastric mucosa demonstrates infiltration by
neutrophils.
Ga str opathy with
gast ric erosio ns

Here are some larger areas of gastric hemorrhage that could best be
termed "erosions" because the superficial mucosa is eroded away.
Such erosions are typical for the pathologic process termed
gastropathy, which describes gastric mucosal injury without
significant inflammation.
Ac ute g astric u lcer,
benig n  A 1 cm acute gastric ulcer
is shown in the upper
fundus. The ulcer is
shallow and sharply
demarcated, with
surrounding hyperemia. It
is probably benign.
However, all gastric ulcers
should be biopsied to rule
out a malignancy.
 The endoscopic
appearance of a similar
acute peptic ulcer in the
prepyloric region is
shown.
Ga str ic u lcers ,
endosc opy

Seen above are gastric ulcers of small, medium, and large

size on upper endoscopy. All gastric ulcers are biopsied,
since gross inspection alone cannot determine whether a
malignancy is present. Smaller, more sharply demarcated
ulcers are more likely to be benign.
 Ga str ic u lcer,
malig nant

Here is a much larger 3 x 4 cm gastric ulcer that led to the resection of the
stomach shown here. This ulcer is much deeper with more irregular
margins. Complications of gastric ulcers (either benign or malignant)
include pain, bleeding, perforation, and obstruction.
 Ac ute gastr ic u lcer
(a) (b)

(a) Microscopically, the ulcer here is sharply demarcated, with normal

gastric mucosa on the left falling away into a deep ulcer whose base
contains infamed, necrotic debris. An arterial branch at the ulcer base
is eroded and bleeding.
(b) The mucosa at the upper right merges into the ulcer at the left which
is eroding through the mucosa. Ulcers will penetrate over time if they
do not heal. Penetration leads to pain. If the ulcer penetrates through
the muscularis and through adventitia, then the ulcer is said to
"perforate" and leads to an acute abdomen. An abdominal radiograph
may demonstrate free air with a perforation.
Ac ute g astric u lcer
penetra tin g t o art ery

The ulcer at the right is penetrating through the muscularis and

approaching an artery. Erosion of the ulcer into the artery will lead to
another major complication of ulcers--hemorrhage. This hemorrhage
can be life threatening. Chronic blood loss may lead to an iron
deficiency anemia.
He lic obacter p ylo ri in
st oma ch

Gastritis is often accompanied by infection with Helicobacter

pylori. This small curved to spiral rod-shaped bacterium is
found in the surface epithelial mucus of most patients with
active gastritis. The rods are seen here with a methylene
blue stain.
Ac ute d uodenal u lcer

The strongest association with Helicobacter pylori is with

duodenal peptic ulceration--over 85% of duodenal ulcers.
Seen here is a penetrating acute ulceration (arrow) in the
duodenum just beyond the pylorus.
 An ti- parietal cell
autoantibody

Another association with gastritis is pernicious anemia. Chronic

atrophic gastritis is associated with autoantibodies that block
or bind intrinsic factor. Another type of autoantibody
demonstrated here is anti-parietal cell antibody. The bright
green immunofluorescence is seen in the paritetal cells of the
gastric mucosa.
Ga str ic
adenocarcin oma
Ga str ic
adenocarcin oma wit h
ulc eratio n

Here is a gastric ulcer in the center of the picture. It is shallow and is

about 2 to 4 cm in size.
Ga str ic
adenocarcin oma,
li nit is p la st ica This
typ e
is an example of
linitis plastica, a diffuse
infiltrative gastric
adenocarcinoma which
gives the stomach a
shrunken "leather bottle"
appearance with
extensive mucosal
erosion (white arrow)
and a markedly
thickened (black arrow)
gastric wall. This type of
carcinoma has a very
poor prognosis.
 The endoscopic view of
this lesion is shown, with
extensive mucosal
erosion.
Ga str ic
adenocarcin oma wit h
metast ase s

At autopsy, the thoracic cavity and abdominal cavity are both opened to
reveal the stomach just to the right and below the edge of liver in this
photograph. Gastric adenocarcinoma has infiltrated through the wall
and appears on the surface as irregular tan masses. The extensive
tumor in this case caused gastric outlet obstruction.
 Ga str ic
adenocarcin oma
LPO Medium power

(a) (b)
HPO, signet ring pattern
HPO

(c) (d)
(a) A moderately differentiated gastric adenocarcinoma is infiltrating up and into the submucosa below the
squamous mucosa of the esophagus. The neoplastic glands are variably sized.
(b) The neoplastic glands of gastric adenocarcinoma demonstrate mitoses, increased nuclear/cytoplasmic
ratios, and hyperchromatism. There is a desmoplastic stromal reaction to the infiltrating glands.
(c) This gastric adenocarcinoma is so poorly differentiated that glands are not visible. Instead, rows of
infiltrating neoplastic cells with marked pleomorphism are seen. Many of the neoplastic cells have clear
vacuoles of mucin.
(d) This is a signet ring cell pattern of adenocarcinoma in which the cells are filled with mucin vacuoles that
push the nucleus to one side, as shown at the arrow.
Cyt okera tin p osit ive
gast ric
adenocarcin oma

This is an immunoperoxidase stain with antibody to cytokeratin, which is

positive in the poorly differentiated neoplastic cells seen here infiltrating
through the gastric wall. Cytokeratin staining is typical for neoplasms of
epithelial origin (carcinomas).
Sma ll In te sti ne
 Normal mesentery
Seen here is a loop of bowel attached via the
mesentery. Note the extent of the veins. Arteries run
in the same location. Thus, there is an extensive
anastomosing arterial blood supply to the bowel,
making it more difficult to infarct. Also, the extensive
venous drainage is incorporated into the portal
venous system heading to the liver.

Normal terminal ileum

P
This is the normal appearance of terminal ileum. In
the upper frame, note the ileocecal valve (arrow),
and several darker oval Peyer's patches (P) are
P
present on the mucosa. In the lower frame, a
Peyer's patch, which is a concentration of
submucosal lymphoid tissue, is present. Note the
folds are not as prominent here as in the jejunum, as
evidenced by the colonoscopic view.
 No rmal sm all in te stin al
mucosa

This is the normal appearance of small intestinal mucosa with

long villi that have occasional goblet cells. The villi provide a
large area for digestion and absorption.
Ad hesi ons,
perito neum, sm all
in te st ine

This is an adhesion between loops of small intestine. Such adhesions are

typical following abdominal surgery. More diffuse adhesions may also
form following peritonitis.
Sm all i nte stin al
in farc tio n

The dark red infarcted small intestine contrasts with the light pink viable
bowel. The forceps extend through an internal hernia in which a loop of
bowel and mesentery has been caught. This is one complication of
adhesions from previous surgery. The trapped bowel has lost its blood
supply.
Ce cum, volvu lus

Volvulus is a twisting of the bowel. Volvulus is most common in adults,

where it occurs with equal frequency in small intestine (around a twisted
mesentery) and colon (in either sigmoid or cecum which are more
mobile). In very young children, volvulus almost always happens in the
small intestine.
Isc hemic ente ritis
(a) The small intestinal mucosa demonstrates
marked hyperemia as a result of ischemic
enteritis. Such ischemia most often results
from hypotension (shock) from cardiac
failure, from marked blood loss, or from loss
of blood supply from mechanical obstruction
(a) (as with the bowel incarcerated in a hernia
or with volvulus or intussusception). If the
blood supply is not quickly restored, the
bowel will infarct.
(b) In LPO, the mucosal surface of the bowel
seen here shows early necrosis with
hyperemia extending all the way from
(b) mucosa to submucosal and muscular wall
vessels. The submucosa and muscularis,
however, are still intact.
(c) At higher magnification with more advanced
necrosis, the small intestinal mucosa shows
hemorrhage with acute inflammation in this
case of ischemic enteritis.
(c)
Pe rit onitis from bowe l
perforatio n

Perforation of GI tract (from lower esophagus to colon) can result in a

peritonitis as seen here at autopsy. A thick yellow purulent exudate
covers peritoneal surfaces. An ovarian carcinoma caused sigmoid
colonic obstruction (the sigmoid is the markedly dilated grey-black
bowel in the pelvis seen here) with perforation.
 Ca rcin oid tu mo r o f
sma ll i ntest in e
(a) Seen here at the ileocecal valve is a
tumor that has a faint yellowish
color. This is a carcinoid tumor.
Most benign tumors are incidental
submucosal lesions, though rarely
they can be large enough to
(a) obstruct the lumen.
(b) In LPO, the carcinoid tumor is seen
LPO here to be a discreet, though not
encapsulated, mass of multiple
nests of small blue cells in the
submucosa.
(c) At high magnification, the nests of
carcinoid tumor have a typical
(b) endocrine appearance with small
round cells having small round
HPO nuclei and pink to pale blue
cytoplasm. Rarely, a malignant
carcinoid tumor can occur as a
large bulky mass. Metastatic
carcinoid to the liver can rarely
result in the carcinoid syndrome.
(c)
 Me tasta sis t o sm all
in te st ine

The most common neoplasm in small bowel is a metastasis as seen here.

This mass caused local obstruction. Primary sites are often from
nearby colon, ovary, pancreas, and stomach.
Pr imary
adenocarcin oma,
ampull a

This adenocarcinoma arose in the ampulla of Vater. Primary small

intestinal carcinomas are very rare, but the majority of those that do
occur arise in the region of the ampulla, where they may become
symptomatic through biliary or pancreatic duct obstruction. The
appearance of such a mass on esophagogastroduodenoscopy is
seen, and following placement of a stent for drainage.
Leio myo sa rcoma o f
sma ll i ntest in e

This is a leiomyosarcoma of the small bowel. As with sarcomas in

general, this one is big and bad. Sarcomas are uncommon at this site,
but must be distinguished from other types of neoplasms.
 No n-Hodgkin 's
ly mphoma of sma ll
in te st ine
LPO HPO

In LPO, the large blue non-Hodgkin's lymphoma cells can be seen

infiltrating through the mucosa.
At high magnification, the non-Hodgkin's lymphoma cells have prominent
clumped chromatin and nucleoli with occasional mitotic figures.
Me ckel's d ive rtic ulum

Congenital anomalies of bowel consist mainly of diverticulae or atresias

which are often in association with other congenital anomalies. Seen
here is the most common congenital anomaly of the GI tract--a
Meckel's diverticulum. Remember the number 2: about 2% of people
have them; they are usually located 2 feet from the ileocecal valve.
Ce lia c spru e c omp ared
to norma l sma ll
in te st ine

Normal small intestinal mucosa is seen at the left, and mucosa

involved by celiac sprue at the right. There is blunting and
flattening of villi with celiac disease, and in severe cases a loss of
villi with flattening of the mucosa as seen here.
Ce lia c spru e,
sma ll i ntest in e

The small intestinal mucosa at high magnification shows marked chronic inflammation
in celiac sprue. There is sensitivity to gluten, which contains the protein gliaden,
found in cereal grains wheat, oats, barley, and rye. Removing foods containing
these grains from the diet will cause this gluten-sensitive enteropathy to subside.
The enteropathy shown here has loss of crypts, increased mitotic activity, loss of
brush border, and infiltration with lymphocytes and plasma cells (B-cells sensitized
to gliaden).
Gia rdia la mbli a,
sma ll i ntest in e

This is an example of infectious diarrhea due to Giardia lamblia infection

of the small intestine. The small pear-shaped trophozoites live in the
duodenum and become infective cysts that are excreted. They
produce a watery diarrhea. A useful test for diagnosis of infectious
diarrheas is stool examination for ova and parasites.
Cr yp tosp orid io sis ,
sma ll i ntest in e

This is another infectious agent that is becoming more frequent in

immunocompromised patients, particularly those with AIDS. The
small round blue organisms at the lumenal border are cryptosporidia.
Cryptosporidiosis produces a copious watery diarrhea.
Col on an d
A ppe ndi x
 Norm al c olonic views with
Cecum and
colonoscopySplenic flexure
appendiceal orifice

Cecum Sigmoid colon

Ascending colon Rectum

Transverse colon
 No rmal colonic m ucosa

Note the crypts that are lined by numerous goblet cells. In the submucosa
is a lymphoid nodule. The gut-associated lymphoid tissue as a unit
represents the largest lymphoid organ of the body.
Pse udome mb ra nous
coli tis
LPO

(b)

HPO

(a)

(c)
(a) The mucosal surface of the colon seen here is hyperemic and is partially covered
by a yellow-green exudate. The mucosa itself is not eroded.
(b) In LPO, the pseudomembrane is seen to be composed of inflammatory cells,
necrotic epithelium, and mucus in which the overgrowth of microorganisms takes
place. The underlying mucosa shows congested vessels, but is still intact.
(c) At higher magnification, the overlying pseudomembrane at the left has numerous
inflammatory cells, mainly neutrophils.
Ap pendix , normal

This is the normal appearance of the appendix against the

background of the cecum. The colonoscopic view of the
appendiceal orifice between the fork of two haustral folds
in the cecum is seen below.
 Ac ute a ppendic itis LPO

(a) (b)
Medium power HPO

(c) (d)
(a) Seen here is acute appendicitis with yellow to tan exudate and hyperemia, including the
periappendiceal fat superiorly, rather than a smooth, glistening pale tan serosal surface.
(b) In LPO, acute appendicitis is marked by mucosal inflammation and necrosis.
(c) The mucosa shows ulceration and undermining by an extensive neutrophilic exudate.
(d) Neutrophils extend into and through the wall of the appendix in a case of acute
appendicitis.
 Co lo n, adenomatous
polyp ( tu bula r
adenoma) (a) This lesion is called a "tubular
adenoma" because of the rounded
nature of the neoplastic glands that
form it. It has smooth surfaces and
is discreet.
(b) This small adenomatous polyp
(tubular adenoma) on a small stalk
(a) is seen microscopically to have
more crowded, disorganized glands
than the normal underlying colonic
mucosa. Goblet cells are less
numerous and the cells lining the
glands of the polyp have
hyperchromatic nuclei. However, it
is still well-differentiated and
circumscribed, without invasion of
the stalk, and is benign.
(c) (c) This adenomatous polyp has a
(b) hemorrhagic surface (which is why
they may first be detected with stool
occult blood screening) and a long
narrow stalk. The size of this polyp--
above 2 cm--makes the possibility
of malignancy more likely, but this
polyp proved to be benign.
(d) The colonoscopic appearance of
rectal polyps that proved to be
tubular adenomas

(d)
Co lo n, mult iple
adenomatous p olyps

Here are multiple adenomatous polyps of the cecum. A small

portion of terminal ileum appears at the right.
Co lo n, famil ia l
adenomatous p olyposis

This is familial polyposis in which the mucosal surface of the

colon is essentially a carpet of small adenomatous polyps.
Co lon, fa mi lial
aden oma tou s po lypo si s
(G ardn er's sy nd rom e)

Here is another example of polyposis with numerous small polyps

covering the colonic mucosa. In this particular case, there were
osteomas of the skull, a periampullary adenocarcinoma, and
epidermal inclusion cysts. Thus, this is a case of Gardner's
syndrome. As with familial adenomatous polyposis, the
inheritance pattern is autosomal dominant.
Co lon, ade noma tous polyp
(t ubular adeno ma)
comp are d to norma l
mu cosa

A microscopic comparison of normal colonic mucosa on the left and

that of an adenomatous polyp (tubular adenoma) on the right is
seen here. The neoplastic glands are more irregular with darker
(hyperchromatic) and more crowded nuclei. This neoplasm is
benign and well-differentiated, as it still closely resembles the
normal colonic structure.
Co lo n, vill ous
adenoma, c omposit e

 Note that this type of adenoma is sessile, rather than pedunculated,

and larger than a tubular adenoma (adenomatous polyp). A villous
adenoma averages several centimeters in diameter, and may be up
to 10 cm.
 Microscopically, a villous adenoma is shown at its edge on the left,
and projecting above the basement membrane at the right. The
cauliflower-like appearance is due to the elongated glandular
structures covered by dysplastic epithelium. Though villous
adenomas are less common than adenomatous polyps, they are
much more likely to have invasive carcinoma in them (about 40% of
villous adenomas).
 On colonoscopy, a sessile polyp is seen
Co lo n, adenocarcinoma

 An encircling adenocarcinoma (arrow) of the rectosigmoid

region is seen here. There is a heaped up margin of tumor at
each side with a central area of ulceration. This produces the
bleeding that allows detection through a stool guaiac test.
Normal mucosa appears at the right. The tumor encircles the
colon and infiltrates into the wall. Staging is based upon the
degree of invasion into and through the wall.
 The colonoscopic views of a smaller rectal adenocarcinoma,
but still with an ulcerated surface, are shown above.
 The barium enema technique instills the radiopaque barium
sulfate into the colon, producing a contrast with the wall of the
colon that highlights any masses present . In this case, the
classic "apple core" lesion is present (arrow), representing an
encircling adenocarcinoma that constricts the lumen.
Co lo n, adenocarcinoma

adenocarcinoma arising in villous adenoma

 Co lo n, adenocarcinoma
LPO Medium power

The neoplastic glands are long and frond-like, similar to those seen Microscopically, a moderately differentiated adenocarcinoma of
in a villous adenoma. The growth is primarily exophytic (outward colon is seen here. There is still a glandular configuration, but the
into the lumen) and invasion is not seen at this point. glands are irregular and very crowded. Many of them have lumens
containing bluish mucin.

Medium power HPO

Here is an adenocarcinoma in which the glands are much larger At high magnification, the neoplastic glands of adenocarcinoma
and filled with necrotic debris. have crowded nuclei with hyperchromatism and pleomorphism. No
normal goblet cells are seen.
 Col on, descendi ng,
adenocarci noma ** check
MRI

 The encircling mass of firm adenocarcinoma in this colon at the left is

typical for adenocarcinomas arising in the descending colon. A change
in stool or bowel habits can be created by the mass effect.
 By colonoscopy, a fungating, ulcerating mass is seen.
 This CT image of the abdomen demonstrates an encircling mass
involving the colon (arrow) ****
Sig mo id colo n,
dive rticulo sis
The sigmoid colon at the right
appears lighter in color than the
adjacent small intestine and has a
band of taenia coli (T) muscle
running longitudinally. Protruding
from the sigmoid colon are multiple
rounded bluish-gray diverticula
(arrow). Diverticula are much more
common in the colon than in small
T intestine, and they are more
common in the left colon, and they
are more common in persons living
in developed nations in which the
usual diet has less fiber.
 Co lo n, dive rtic ulo si s
(a) (b)  Several diverticula are seen
along the length of the
descending colon. Focal
weaknesses in the bowel wall
and increased lumenal pressure
contribute to the formation of
diverticula.
 The colon has been opened to
reveal the presence of non-
inflamed diverticula. Each has an
opening (arrow) to the colonic
lumen through a narrow neck.
 The surface of the colon is
(c) (d) hyperemic because of
inflammation as a result of
diverticulitis. The erosion of the
mucosa by the stool in the
diverticula can produce
inflammation and hemorrhage.
 This diverticulum has become
inflamed and has ruptured
outward, seen as the dark brown
irregular tract extending down
from the mucosal surface here.
Co lo n, dive rtic ulo si s

Colonoscopic views of diverticula

At low magnification, a colonic

diverticulum has a central lumen
with surrounding mucosa, while the
wall (lacking a muscularis) is
attenuated. The narrow neck of the
diverticulum may become eroded.
Pr ola pse d true
hemorrhoid s

Seen here is the anus and perianal region with prominent prolapsed true (internal)
hemorrhoids. Hemorrhoids consist of dilated submucosal veins which may thrombose and
rupture with hematoma formation. External hemorrhoids form beyond the intersphincteric
groove to produce an "acute pile" at the anal verge. Chronic constipation, chronic
diarrhea, pregnancy, and portal hypertension enhance hemorrhoid formation.
Hemorrhoids can itch and bleed (usually bright red blood, during defacation). Seen on the
right is on colonoscopy are views of hemorrhoids at the anorectal junction.
Inf la mma tor y
Bowel Dis ea se
 Cr ohn's d is ease
TERMINAL ILEUM

Though any portion of the gastrointestinal tract may be involved with Crohn's disease, the small
intestine--and the terminal ileum in particular--is most likely to be involved. The middle portion of
bowel seen here has a thickened wall and the mucosa has lost the regular folds. The serosal surface
demonstrates reddish indurated adipose tissue that creeps over the surface. Serosal inflammation
leads to adhesions. The areas of inflammation tend to be discontinuous throughout the bowel. The
endoscopic appearance with colonoscopy, demonstrating mucosal erythema and erosion, is seen

This is another example of Crohn's disease involving

the small intestine. Here, the mucosal surface
demonstrates an irregular nodular appearance with
hyperemia and focal superficial ulceration.
 Cr ohn's
SMALL INTESTINE
d is ease
One complication of Crohn's disease is fistula formation. Seen
here is a fissure extending through mucosa at the left into
the submucosa toward the muscular wall, which eventually
will form a fistula. Fistulae can form between loops of bowel,
bladder, and skin. With colonic involvement, perirectal
fistulae are common.

COLON

Microscopically, Crohn's disease is characterized by transmural

inflammation. Here, inflammatory cells (the bluish infiltrates)
extend from mucosa through submucosa and muscularis
and appear as nodular infiltrates on the serosal surface with
pale granulomatous centers.

At high magnification the granulomatous nature of the

inflammation of Crohn's disease is demonstrated here with
epithelioid cells, giant cells, and many lymphocytes.
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LEFT: This gross appearance is characteristic for ulcerative colitis. The most intense
inflammation begins at the lower right in the sigmoid colon and extends upward and
around to the ascending colon. At the lower left is the ileocecal valve with a portion
of terminal ileum that is not involved. Inflammation with ulcerative colitis tends to be
continuous along the mucosal surface and tends to begin in the rectum. The mucosa
becomes eroded, as in this photograph, which shows only remaining islands of
mucosa called "pseudopolyps".
RIGHT: At higher magnification, the pseudopolyps can be seen clearly as raised red
islands of inflamed mucosa. Between the pseudopolyps is only remaining
muscularis.
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LEFT: Here is another example of extensive ulcerative colitis (UC). The

ileocecal valve is seen at the lower left. Just above this valve in the cecum is
the beginning of the mucosal inflammation with erythema and granularity. As
the disease progresses, the mucosal erosions coalesce to linear ulcers that
undermine remaining mucosa.
RIGHT: Colonoscopic views of less severe UC are seen, with friable,
erythematous mucosa with reduced haustral folds.
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Pseudopolyps (arrow) are seen here in a case of severe ulcerative colitis.

The remaining mucosa has been ulcerated away and is hyperemic. A
colonoscopic view of active ulcerative colitis, but not so eroded as to
produce pseudopolyps, is seen on the right image.
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LPO HPO

 LPO: Microscopically, the inflammation of ulcerative colitis is confined

primarily to the mucosa. Here, the mucosa is eroded by an ulcer that
undermines surrounding mucosa.
 HPO: At higher magnification, the intense inflammation of the mucosa is
seen. The colonic mucosal epithelium demonstrates loss of goblet
cells. An exudate is present over the surface. Both acute and chronic
inflammatory cells are present.
 Ch ronic u lc erativ e
coli tis with cryp t
absc esse s
Medium power HPO

 LEFT: The colonic mucosa of active ulcerative colitis shows "crypt abscesses"
in which a neutrophilic exudate is found in glandular lumens. The
submucosa shows intense inflammation. The glands demonstrate loss of
goblet cells and hyperchromatic nuclei with inflammatory atypia.
 RIGHT: Crypt abscesses are a histologic finding more typical with ulcerative
colitis. Unfortunately, not all cases of inflammatory bowel disease can be
classified completely in all patients.
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coli tis with dysp la sia

Over time, there is a risk for adenocarcinoma with ulcerative colitis.

Here, more normal glands are seen at the left, but the glands at
the right demonstrate dysplasia, the first indication that there is a
move towards neoplasia.

Gigi  - sec D – ustmed2007