LOWER GI PATHOLOGY

Lower gastrointestinal pathology

Professor Neil A Shepherd Dr Panagiota Kitsanta Gloucester & Cheltenham, UK

FRCPath Part 2 Surgical Course Gloucestershire Cellular Pathology Laboratory

Case 1

Gloucestershire Cellular Pathology Laboratory

Clinical history 66F. 46mm mass in mid jejunum.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 1: Diagnosis Small intestinal GIST with skeinoid fibres

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Correct diagnosis with clinical correlation and relevance/prognosis. You only see skeinoid fibres in small intestinal GISTs. Molecular analysis, etc.

2.5

Good description, give differential diagnosis. Good immuno knowledge.

2.0

Mediocre description and misdiagnosis.

1.5

1.0

Case 2

Gloucestershire Cellular Pathology Laboratory

Clinical history 68M. Colectomy and ileal pouch for UC. Ileal pouch biopsies.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case2: Diagnosis Typical ileal pouch changes – so-called adaptive changes.

This is not ‘pouchitis’.

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Correct diagnosis with clinical correlation. More likely to see these changes in UC than in FAP and in other conditions where pouch surgery is used.

2.5

Good description and appropriate summary.

2.0

Mediocre description and misdiagnosis of ‘pouchitis’.

1.5

1.0

Case 3

Gloucestershire Cellular Pathology Laboratory

Clinical history 58F. Non-resolving collection on CT. Laparotomy shows ileal tumour 106mm in diameter.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 3: Diagnosis

Fibromatosis/desmoid tumour

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Correct diagnosis. Good description of immuno findings. Beta-catenin, etc.

2.5

Good description and differential diagnosis. Appropriate immunos.

2.0

Description OK but lacks direction.

1.5

Dogmatic diagnosis of GIST or other spindle cell tumour

1.0

Case 4

Gloucestershire Cellular Pathology Laboratory

Clinical history 86F. Mucous cyst 13mm in diameter in appendix.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 4: Diagnosis Low grade appendiceal mucinous tumour (LAMN) with rupture and serosal involvement

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Talk about management and prognosis versus MACA; current concepts of such mucinous tumours of the appendix

2.5

Good description. Correct diagnosis.

2.0

Incomplete description. Miss serosal involvement. Old fashioned diagnosis of mucinous cystadenoma.

1.5

Call it a benign mucocoele.

1.0

Case 5

Gloucestershire Cellular Pathology Laboratory

Clinical history

16M. Acute appendicitis.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 5: Diagnosis

Neuro-endocrine tumour (? carcinoma – yes, I think so….) of the appendix with adverse prognostic features

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Clinical significance and prognosis. MDTM discussion – consideration of further surgery.

2.5

Appropriate description and diagnosis. Miss aggressive features.

2.0

Miss diagnosis or lack conviction

1.5 1.0

Case 6

Gloucestershire Cellular Pathology Laboratory

Clinical history 44F. Chronic diarrhoea. Colonoscopy shows proctitis to 20cm with normal proximal colon.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Diagnosis Chronic inflammatory bowel disease in keeping with chronic ulcerative colitis in a ‘proctitis’ (or strictly ‘distal colitis’) distribution

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Good discussion of CIBD differential diagnosis and distribution of disease with terminology of UC distribution.

2.5

Suggest CIBD and reasonable discussion.

2.0

Poor description; no definitive CIBD.

1.5

Dogmatic dysplasia.

1.0

Case 7

Gloucestershire Cellular Pathology Laboratory

Clinical history 75F. Profuse diarrhoea. Single longitudinal deep linear ulceration in sigmoid colon only at colonoscopy.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 7: Diagnosis Collagenous colitis.

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Dissertation on the endoscopic abnormalities one can see in collagenous colitis.

2.5

Good description. Correct diagnosis.

2.0

Describe but too much reliance on endoscopic abnormalities and suggestions of Crohn’s disease, etc.

1.5 1.0

Case 8

Gloucestershire Cellular Pathology Laboratory

Clinical history 68M. Rectal bleeding. Diverticulosis at colonoscopy.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 8 Diagnosis Diverticular colitis

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Description of implications of diverticular colitis.

2.5

Good description. Differential diagnosis of DC and CIBD.

2.0

Too dogmatic diagnosis of CIBD, especially Crohn’s disease

1.5 1.0

Case 9

Gloucestershire Cellular Pathology Laboratory

Clinical history 30F. Abdominal pain with chronic diarrhoea and bleeding.

Mild patchy erythema at sigmoidoscopy.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 9 Diagnosis

Equivocal for CIBD and more chronic infective-type colitis

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Full CPC discussion and how to differentiate CIBD from chronic infective colitis

2.5

Good description and differential diagnosis

2.0

Poor description and too dogmatic diagnosis.

1.5

Call it dysplasia….

1.0

Case 10

Gloucestershire Cellular Pathology Laboratory

Clinical history 66F. Rectal bleeding. Inflammatory polyps in transverse colon and mild inflammation in rectum.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 10 Diagnosis Chronic inflammatory bowel disease favouring ulcerative colitis

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

CIBD favouring UC. Good suggestions for further management.

2.5

CIBD with appropriate differential diagnosis

2.0

Suggest differential diagnosis but lack direction.

1.5

Dogmatic dysplasia.

1.0

Case 11

Gloucestershire Cellular Pathology Laboratory

Clinical history 67M. Rectal bleeding and diarrhoea. Severe inflammatory changes to 30cm at sigmoidoscopy.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 11 Diagnosis Chronic inflammatory bowel disease favouring ulcerative colitis with epithelial changes either reactive or ‘mucosa indefinite for dysplasia’

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5 3.0

Ask more about history – is this an index endoscopy for potential CIBD? Reactive changes or ‘mucosa indefinite for dysplasia’ and further management = treat and repeat…...

2.5

Sensible diagnosis of CIBD ulcerative colitis-type and discussion of epithelial changes

2.0

Suggestion/diagnosis of low grade dysplasia.

1.5

Dogmatic diagnosis of high grade dysplasia

1.0

Case 12

Gloucestershire Cellular Pathology Laboratory

Clinical history 52M. PR bleeding. 11mm caecal polyp at colonoscopy.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 12 Diagnosis Sessile serrated lesion with dysplasia

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Discussion about classification and distribution of serrated pathology and its implications. Discussion about BCSP.

2.5

Serrated pathology with dysplasia.

2.0

Miss one of serrated pathology or adenoma-like pathology.

1.5

Overgrade dysplasia or call it malignant.

1.0

Case 13

Gloucestershire Cellular Pathology Laboratory

Clinical history 47F. 17mm polyp in sigmoid colon.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 13 Diagnosis Sigmoid colonic adenoma with epithelial misplacement

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Correct diagnosis. Good discussion of current BCSP issues with this diagnosis.

Immunos useless for EM v cancer. Implications of ‘margin involvement’

2.5

Good description and differential diagnosis of EM versus cancer. Spot mucinous cyst at margin.

2.0

Description only without differential diagnosis.

1.5

Dogmatic diagnosis of malignancy.

1.0

Case 14

Gloucestershire Cellular Pathology Laboratory

Clinical history 63M. BCSP. Two rectal polyps at colonoscopy.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 14 Diagnosis Leiomyoma (or smooth muscle tumour….) of the muscularis propria and ‘mixed’ polyp with classical adenoma and (traditional) serrated adenoma

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Get both diagnoses. Dissertation on serrated pathology and classification.

Prognosis of leiomyoma of MM, etc. BCSP issues.

2.5

Both diagnoses but little discussion of the implications.

2.0

Miss one of the two diagnoses.

1.5

Miss one of the two diagnoses and get the other wrong…..

1.0

Case 15

Gloucestershire Cellular Pathology Laboratory

Clinical history

60F. BCSP. 10mm sigmoid colonic polyp at colonoscopy.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 15 Diagnosis Post-inflammatory polyp

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5 3.0

Correct differential diagnosis and favour post-inflammatory polyp with a good list of potential causes.

2.5

Reasonable description and differential diagnosis, including juvenile polyp.

2.0

Dogmatic JP (age against…)

1.5

Dysplasia.

1.0

Case 16

Gloucestershire Cellular Pathology Laboratory

Clinical history

22F. Multiple polyps. Large rectal polyp removed.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 16 Diagnosis Atypical juvenile polyp

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5 3.0

‘Atypical juvenile polyp’. Likely polyposis. Good discussion of types. Favour JP. Talk about autosomal dominant and inheritance. Molecular biology of polyposis syndromes. Prognosis and prophylactic surgery.

2.5

Good description. Suggest polyposis. Favour JP. Suggest possible LGD.

2.0

Over-confident Peutz-Jeghers or other polyp. Spell Peutz-Jeghers wrong (only joking…) . Too confident dysplasia.

1.5

Poor description and no summary or diagnosis.

1.0

Case 17

Gloucestershire Cellular Pathology Laboratory

Clinical history 76M. PR bleeding with anal pain. Multiple inflammatory-type looking polyps at sigmoidoscopy.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 17 Diagnosis Low grade lymphoma. This is actually mantle cell lymphoma.

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5 3.0

Classical presentation of MCL is with malignant lymphomatous polyposis.

Good discussion of lymphomas of the gut, especially colon (primaries mainly MZL and MCL). Don’t forget secondary involvement (eg follicular and HL).

2.5

Describe well and suggest diagnosis and appropriate immunohistochemistry.

2.0 1.5 1.0

Benign diagnosis such as benign lymphoid polyps, CIBD

Case 18

Gloucestershire Cellular Pathology Laboratory

Clinical history 85M. Obstructing ascending colonic tumour. Right hemicolectomy.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 18 Diagnosis Serrated-type adenocarcinoma, diverticular disease with adenoma and carcinoma involving a diverticulum and malakoplakia

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Indicate serrated tumour. Spot malakoplakia.

2.5

Good description with two correct diagnoses.

2.0

Description only. Miss less important diagnoses.

1.5

Wrong diagnosis such as adenoma. Miss important diagnoses (such as cancer).

1.0

Case 19

Gloucestershire Cellular Pathology Laboratory

Clinical history 59M. Previous colectomy for ulcerative colitis. Now proctectomy and ileal pouch construction.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 19 Diagnosis Combination of ulcerative colitis and diversion proctitis causing mimicry of Crohn’s disease.

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Suggest correct diagnosis and indicate crucial review of previous histology.

Dissertation on effects of diversion.

2.5

Good description with reasonable differential diagnosis.

2.0

Lack direction and understanding of the issues.

1.5

Overcall as dogmatic Crohn's disease (unless review of previous histology suggested)

1.0

Case 20

Gloucestershire Cellular Pathology Laboratory

Clinical history 66F. Haemorrhoids. Associated polypoid lesion at anorectal junction.

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Gloucestershire Cellular Pathology Laboratory

Case 20 Diagnosis Inflammatory cloacogenic polyp

Gloucestershire Cellular Pathology Laboratory

Marking scheme 3.5

3.0

Discussion about mucosal prolapse and its effects.

2.5

Good approach with good diagnosis.

2.0

Differential diagnosis with less confidence.

1.5

Overcalling dysplasia/adenoma

1.0

Any comments or questions?

Gloucestershire Cellular Pathology Laboratory