Gastrointestinal Pathology I Case Studies

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OBJECTIVES:

  • Recognize major gross and microscopic features that distinguish benign and malignant lesions of the gastrointestinal tract.
  • Correlate the pathologic appearances with the clinical signs and symptoms.
  • Determine the clinical course and the prognosis of ulceration and malignancy in the gastrointestinal tract.

CASE 1:

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Clinical History:

A 62-year-old man had a 2 month history of increasing difficulty swallowing. He found it more difficult to eat, and he had lost 5 kg during this time. He also had a history of both alcohol abuse and cigarette smoking. On upper GI endoscopy a mass lesion was seen (image 1.1). Surgery was performed. The mass is shown in image 1.2 in the esophagectomy specimen. It was 3 cm in diameter and appeared to extend through the muscular wall. On the surface it was ulcerated. The low and high power microscopic appearances are shown in images 1.3 and 1.4.

Image 1.1

Image 1.2

Image 1.3

Image 1.4

Questions:

  1. What is the diagnosis?
  2. What are typical presenting symptoms?
  3. What are contributing factors for development of this lesion?
  4. What is the prognosis?


CASE 2:

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Clinical History:

This 55-year-old man had suffered from episodes of "heartburn" with sub-sternal chest pain from chronic reflux esophagitis for several decades (image 2.1). He then presented with dysphagia developing over the past month. On upper GI endoscopy a mass lesion was found in the lower esophagus, and biopsies were taken (image 2.2). Based upon the biopsy findings, a partial esophagectomy was performed. The mass lesion extended into the muscular wall and ulcerated the overlying surface mucosa (image 2.3). The predisposing lesion which developed from reflux is shown in image 2.4 and 2.5. The precursor lesion is seen in image 2.6, and the mass lesion in image 2.7.

Image 2.1

Image 2.2

Image 2.3

Image 2.4

Image 2.5

Image 2.6

Image 2.7

Questions:

  1. What is the diagnosis?
  2. Where is this lesion arising?
  3. What is the major predisposing condition for lesions such as this that are known to arise within the esophagus?


CASE 3:

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Clinical History:

A 55-year-old woman, with a history of epigastric pain relieved by food, complained of episodes of hematemesis that have occurred in the past week. Upper GI endoscopy with biopsies was performed (image 3.1). The specimen shown here is from the subsequent partial gastrectomy (image 3.2). The lesion appears as a cup-shaped ulcer filled with blood clot. The ulcer, which was found to extend almost through the gastric wall, is lined by necrotic debris and acute inflammatory cells overlying a base of granulation tissue and fibrosis (images 3.3 and 3.4) with a large vessel at the base (image 3.5).

Image 3.1

Image 3.2

Image 3.3

Image 3.4

Image 3.5

Questions:

  1. What is the diagnosis?
  2. What is the cause of the hematemesis?
  3. Why should biopsy of such lesions be performed?
  4. What does the adjacent gastric mucosa show?
  5. What infectious agent can increase the risk for these findings?
  6. What drug therapy could help prevent this condition?


CASE 4:

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Clinical History:

A 60-year-old man complained of anorexia, vomiting, and vague abdominal pain accompanied by weight loss of 15 kg over the past two months. Physical examination revealed supraclavicular lymphadenopathy. An abdominal CT scan revealed that the stomach wall was thickened (image 4.1). He became progressively cachectic and died. At autopsy, the stomach was diffusely thickened and leather-like (image 4.2). Microscopic sections of the gastric wall are shown in images 4.3 and 4.4.

Image 4.1

Image 4.2

Image 4.3

Image 4.4

Questions:

  1. What is the diagnosis?
  2. What are some predisposing factors for this lesion?
  3. What is the typical prognosis?


CASE 5:

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Clinical History:

A 20-year-old woman presented to the emergency room with only a one day history of lower abdominal pain, nausea with anorexia, and fever. On physical examination, there was periumbilical pain. Under active observation over the next couple of hours, the pain migrated to the right lower quadrant, with rebound tenderness. Her vital signs showed T 38.5 C, P 90, R 18, and BP 110/70 mm Hg. Her WBC count was 11,500 with 76% polys, 6% bands, 14% lymphs, and 4% monos. A pregnancy test was negative. A stool sample was negative for occult blood. A urinalysis was normal. The radiographic finding on abdominal CT scan is seen in image 5.1. A laparoscopic procedure was performed and the gross appearance of the lesion is shown in image 5.2. The microscopic appearance is seen in images 5.3 and 5.4.

Image 5.1

Image 5.2

Image 5.3

Image 5.4

Questions:

  1. What diagnosis do you suspect?
  2. What should be done next?
  3. What is seen prominently in the tissue section?
  4. What could happen if this is not promptly treated?


CASE 6:

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Clinical History:

A 43-year-old man came in to the emergency room because of intense abdominal pain associated with abdominal swelling which had developed over the past two days. A plain film radiograph of the abdomen showed numerous dilated loops of small intestine. A laparotomy was performed. The lower ileum was found to have a palpable mass lesion involving the muscular wall that obstructed the lumen (image 6.1). A segmental resection of ileum was performed. The opened bowel specimen from surgery shows a segment of buckled small bowel. At the apex of the buckle, the mucosa is ulcerated. Beneath this can be seen the lesion (images 6.2 to 6.3).

Image 6.1

Image 6.2

Image 6.3

Questions:

  1. What is the diagnosis?
  2. What are common sites for this lesion?
  3. What are more typical etiologies for intestinal obstruction in adults?
  4. What syndrome may be associated with this neoplasm?


CASE 7:

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Clinical History:

This 48-year-old man was taken by his wife to the emergency room late one evening after he began vomiting large quantities of bright red blood. She related that he had a long history of alcohol abuse. Upper GI endoscopy localized the source of the bleeding to the lower esophagus near the gastroesophageal junction (image 7.1). His condition could not be stabilized, despite multiple blood product therapy, and he died a day later. The lesion at autopsy is shown (image 7.2). Sections reveal the microscopic appearance seen here (images 7.3 and 7.4). Another physical manifestation of this condition is seen in image 7.5. A therapeutic procedure is shown in image 7.6.

Image 7.1

Image 7.2

Image 7.3

Image 7.4

Image 7.5

Image 7.6

Questions:

  1. What is the diagnosis?
  2. What causes this to happen?
  3. What are therapeutic options?
  4. What is the differential diagnosis of acute upper GI hemorrhage?
  5. Is blood product therapy futile with massive GI bleeding?


CASE 8:

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Clinical History:

A 48-year-old man has had vague abdominal discomfort for a number of years. There is no history of hematemesis, but he has occasional nausea and vomiting. An upper GI endoscopy is performed. There is no evidence for ulceration or a mass lesion, and gastric biopsies are taken. Images 8.1 and 8.2 demonstrate the gastric mucosa at low and high magnification. The surface of the gastric mucosa at high magnification is seen in images 8.3 and 8.4.

Image 8.1

Image 8.2

Image 8.3

Image 8.4

Questions:

  1. What is the diagnosis?
  2. What are the organisms seen above the mucosa?
  3. What is the prognosis?
  4. What pharmacologic agent(s) can have a similar effect?

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