CASE 1

Clinical History:

A 31-year-old woman has had a 10 year history of intermittent, bloody diarrhea. Radiographic studies and sigmoidoscopy revealed a friable, ulcerated colonic mucosa extending to the splenic flexure (image 1.1). The descending colon along with sigmoid colon and rectum were resected. The gross specimen shown in image 1.2 is from another case with even more severe disease, in which the ulceration extends nearly to the ileocecal valve. Image 1.3 reveals the appearance of the mucosa on closer inspection. Microscopic examination reveals the appearance seen in images 1.4 and 1.5.

Image 1.1

Image 1.2

Image 1.3

Image 1.4

Image 1.5

Questions:

1. What are the major differential diagnoses?
2. What is the diagnosis here?
3. What is the course of this disease and what kinds of complications can develop?
4. What treatment is available?
5. What psychosocial issues can you identify for this illness?

CASE 2

Clinical History:

A 27-year-old man has had recurrent attacks of abdominal pain, diarrhea, and low-grade fever for several months. He has also developed steatorrhea. Colonoscopy revealed erythema and erosions of the terminal ileum (image 2.1). Radiographic studies demonstrate an enteroenteric fistula that bypassed much of the small intestine, which was the cause of the malabsorption and steatorrhea (image 2.2). He was taken to surgery where a portion of small intestine was resected. The gross specimen is shown in image 2.3. The microscopic appearance is seen in images 2.4 and 2.5).

Image 2.1

Image 2.2

Image 2.3

Image 2.4

Image 2.5

Questions:

1. What is the diagnosis?
2. Could the patient also have colonic involvement?
3. What is the course of this disease and what kinds of complications can develop?

CASE 3

Clinical History:

Following heart transplantation for idiopathic dilated cardiomyopathy, this 40-year-old woman developed acute cellular rejection, as shown on endomyocardial biopsy. Her immunosuppressive therapy was increased. She then developed bacterial and fungal sepsis. She was treated with antimicrobial therapy, including clindamycin. She then developed diarrhea. A colonoscopy was performed (image 3.1). Her condition worsened, she became toxic, and a colectomy was performed, with the appearance seen in image 3.2. The microscopic appearance is seen in images 3.3 and 3.4.

Image 3.1

Image 3.2

Image 3.3

Image 3.4

Questions:

1. What is the diagnosis?
2. What laboratory testing can be performed to make the diagnosis?
3. What is the pathogenesis of this lesion?

CASE 4

Clinical History:

A 45-year-old man was found to have a stool positive for occult blood during a routine physical examination. A colonoscopy was performed and a 1.3 cm diameter polypoid lesion on a short stalk was found in the descending colon, along with a smaller 0.5 cm polyp in the sigmoid region (image 4.1). Both were resected. The gross photograph shows another case of a patient with several of these lesions (image 4.2). Another patient with a different gross appearance is shown in image 4.3. The low power microscopic view of the polyps is seen in image 4.4 and the high power appearance in image 4.5.

Image 4.1

Image 4.2

Image 4.3

Image 4.4

Image 4.5

Questions:

1. What is the diagnosis?
2. This is thought to be a precursor for what lesion?
3. Name a syndrome in which the patient has hundreds of these polyps (A gross photograph of such a patient is shown in image 4.4).
4. Name a syndrome that not only has hundreds of these polyps, but also has osteomas, desmoids, and other extracolonic manifestations.

CASE 5

Clinical History:

A 44-year-old emergency medical technician has been feeling fatigued for months. He just doesn't have the same level of energy he used to have. He remembers that he had experienced an episode of jaundice about 10 years ago, but that episode resolved and he has been healthy since. A CBC reveals that he is not anemic. A chemistry panel reveals normal serum electroytes, but he has an elevated alanine aminotransferase of 132 U/L and aspartate aminotransferase of 113 U/L. He has a total bilirubin of 1.3 mg/dL with direct bilirubin of 0.8 mg/dL. His total protein is 5.4 g/dL with albumin of 2.9 g/dL. A liver biopsy is performed.

Image 5.1

Image 5.2

Image 5.3

Questions:

1. What is suggested by the clinical laboratory and biopsy findings?
2. What is the differential diagnosis?

Further History:

A hepatitis panel revealed the following:

1. How do you explain these additional laboratory findings?
2. What complications of this disease are illustrated by images 5.4 and 5.5?

Image 5.4

Image 5.5

CASE 6

Clinical History:

A 63-year-old man sought medical help because of increasing abdominal girth over many months along with a recent episode of vomiting blood. Serum chemistries showed sodium 120 mmol/L, potassium 4.2 mmol/L, chloride 99 mmol/L, CO2 20 mmol/L, glucose 75 mg/dL, total protein 6.2 g/dL, albumin 1.9 g/dL, total bilirubin 5.0 mg/dL, AST 190 U/L, ALT 123 U/L, and protime 18 seconds (control 12). A gross photograph (image 6.1) shows how his liver and spleen would appear. The microscopic section is also representative of his liver. It shows a diffusely disorganized architecture with nodules of hepatocytes with focal cholestasis and surrounded by fibrous bands with bile duct proliferation (images 6.2 and 6.3). At high magnification, globular eosinophilic material is seen in some hepatocytes (image 6.4).

Image 6.1

Image 6.2

Image 6.3

Image 6.4

Questions:

1. What is the diagnosis? What do the clear vacuoles in the hepatocytes represent? What is the clumped eosinophilic material seen in some of the swollen hepatocytes?
2. What is the probable etiology?
3. Correlate the clinical and laboratory findings in this patient.
4. What are potential complications of this disease?
5. What does an elevated blood ammonia signify?
6. Is a transplant indicated?

CASE 7

Clinical History:

A 40-year-old woman developed increasingly severe abdominal pain over a two day period. In the emergency room, physical examination demonstrated board-like rigidity of her abdomen along with extreme tenderness. A plain film radiograph of the abdomen demonstrated dilated loops of bowel, several radiopaque gallstones in the gallbladder, but no free air. The total bilirubin was 3.8 mg/dL, AST 25 U/L, ALT 30 U/L, albumin 3.5 g/dL, total protein 5.8 g/dL, glucose 120 mg/dL, calcium 7.8 mg/dL, phosphorus 3.3 mg/dL, and lipase 2,250 U/L. The gross photograph depicts the process (image 7.1). The microscopic appearance is seen in images 7.2 and 7.3.

Image 7.1

Image 7.2

Image 7.3

Questions:

1. What is the diagnosis?
2. What is the probable etiology?
3. What is the course and what are the possible complications? (One complication is pictured in image 7.4).

CASE 8

Clinical History:

A 40-year-old woman was told that she had "hepatitis" when she recently tried to donate blood. She is asymptomatic and denies intravenous drug abuse or any known exposure to individuals with hepatitis. On laboratory testing, the hepatitis C antibody test is positive, and her serum is positive for hepatitis C viral RNA by PCR. Her hepatitis A IgG and IgM are negative. Tests for hepatitis B are negative. A liver biopsy is performed.

Image 8.1

Image 8.2

Image 8.3

Questions:

1. What is the microscopic appearance?
2. In the old nomenclature of chronic hepatitis, what would this be?
3. What are risk factors for her disease?
4. What are complications of this disease?
5. What treatment is available for this disease?

CASE 9

Clinical History:

A 45-year-old man has become increasingly short of breath over the past year. He has also noted a darker color to his skin, even though he has a job in a bank and does not go out in the sun much. He has worsening joint pain, but no joint deformity. His physician notes a firm liver edge on physical examination, but no abdominal pain or masses. A stool sample is negative for occult blood. Laboratory findings include: sodium 148 mmol/L, potassium 4.2 mmol/L, chloride 97 mmol/L, CO2 24 mmol/L, urea nitrogen 19 mg/dL, creatinine 1.2 mg/dL, glucose 178 mg/dL, total protein 5.9 g/dL, albumin 3.4 g/dL, alkaline phosphatase 30 U/L, AST 43 U/L, ALT 40 U/L, and total bilirubin 0.8 mg/dL. The gross appearance of organs of a patient at autopsy with the same underlying condition are shown in image 9.1.

Image 9.1

Image 9.2

Image 9.3

Image 9.4

Image 9.5

Questions:

1. What underlying condition do you suspect?
2. What laboratory test finding in his history given above is most significant?
3. What other laboratory test on his serum would be abnormal?
4. What special stain would you perform on a liver biopsy?
5. What other pigments could be present in liver?

Image 9.6

Questions:

1. What complication will develop in the liver if he is untreated?
2. Describe the pathologic findings that you expect to be present in this patient.
3. What diseases may produce the gross and microscopic findings in the liver as seen in this case?

CASE 10

Clinical History:

A 56-year-old woman has a routine physical examination performed by her physician, and the only abnormal finding is a positive stool occult blood test. She is referred to a gastroenterologist for a colonoscopy. Laboratory findings include a CBC that shows WBC count 7760/uL, Hgb 12.1 g/dL, Hct 35.2%, MCV 84 fL, and platelet count 209,000/uL. Following colonoscopy with biopsy, a laparotomy with segmental resection of the colon is performed.

Image 10.1

Image 10.2

Image 10.3

Image 10.4

Image 10.5

Image 10.6

Questions:

1. What is your diagnosis?
2. What do the laboratory test findings in this history suggest?
3. If the lesion extends into the pericolonic fat, what is the Duke's stage?
4. Is there a genetic basis for this condition?