GIT Pathology

08/12/2015

Microscopic Colitis
If can be seen on colonoscopy, it is unlikely to be microscopic
colitis
Uncommon but not unheard of
Collagenous Colitis
o Inflammatory infiltrates
o Increase collagen deposition
Lymphocytic Colitis
o Increase intraepithelial lymphocytes
o Surface epithelial damage
o Consider drug reaction
o Association with celiac disease
All other colitides are endoscopically visible
Erosion defect of part of mucosa. Ulcer involves the whole depth of
the mucosa
UC
Abscess
Crohns
Erosions

Ulcers
Small collection of macrophages/ histiocytes -> granuloma

Main differences between Crohns and UC

1. Distribution
2. Depth of inflammation and ulcers
3. Complications
4. Histology
Autoimmune Gastritis
Loss of oxyntic (parietal) cells -> HCl and Intrinsic Factor
Hypochlorhydria and vitamin B12 deficiency
2-9% prevalence of gastric carcinoids; 2-3x increase in
prevalence of adenocarcinoma
Carcinoid Syndrome
Serotonin production ^
Flushing
Diarrhea
Cardiac Symptoms Tricuspid Insufficiency Pulmonary Stenosis
Coeliac disease

TGA-ab very sensitive

Biopsies

Herpes Simplex Esophagitis

MAHA
Microangiopathic hemolytic anemia
Mechanical damaging of RBC
the endothelial layer of small vessels is damaged with resulting
fibrin deposition and platelet aggregation. As red blood cells
travel through these damaged vessels, they are fragmented
resulting in intravascular hemolysis
o Fibrin
o Mechanical valves
o Thrombotic Thrombocytopenia Purpura /Hemolytic Uremic
Syndrome
Myeloid Stem Cells > Myeloblast > Promyelocyte > Myelocyte >
Metamyelocyte > Neutrophil
RBC, WBC, Platelets

AML is when they arrest growth at myeloblast

CML is when growth continues to metamyelocyte

Lymphoid stem cells > Lymphoblast > Lymphocyte > Plasma Cell
ALL is when growth arrests at lymphoblast
CLL or Lymphoma is when growth continues to lymphocytes
Myeloma when growth matures all the way to plasma cells
Myeloproliferative neoplasms (MPN)
Polycythemia Rubra Vera
Chronic Myeloid Lymphoma
Myelofibrosis
Essential Thrombocytopenia
Myelodysplastic Syndrome
Bone marrow > Also myeloid stem cells < Apoptosis because
cells are dysplastic
Blood > RBC, WBC, Platelets
Anaemia +- Neutropenia +- Thrombocytopenia
No organomegaly
No proliferation in any cell line
Erythrocyte Sedimentation Rate
Acute phase reactant
High ESR > Rouleaux ++

Rouleaux
o Stack of coins appearance of RBC
o RBC are negatively charged
o Anything that neutralizes RBC negative charge causes
rouleaux formation
o High serum proteins
Fibrinogen
Immunoglobulins

Transfusion Medicine

Blood components
o Whole blood
o RBC
4 degrees
35 days shelf life
1 unit PCT increase Hb by 1g/dL
Hb 7g/dL shown to be well tolerated
o Platelets
22 degrees
5 days shelf life
Pooled platelets (multiple donors) 1 raises plt count
by 10

Cell separated platelets (single donor) 1 raises plt

count by 60
Indications
<10 if no bleeding or fever
<20 if fever or sepsis
<50 if bleeding
<100 if CNS bleeding or need for neurosurgery
o Plasma and plasma related components
-70 degrees
FFP
All clotting fx
Indications
Correction of coagulopathy in DIC
(controversial)
Correction of coagulopathy in pts with liver dz
going for procedures
Used for plasma exchange in TTP
Massive transfusion
For warfarin reversal in major bleed if 4 factor
PCC not available
Cryoprecipitate
Higher concentration VWF and fibrinogen
Cryosupernatant
Factor concentrates
Immunoglobulins

Hazards of Transfusion
Early
o Haemolytic transfusion reaction
Early ABO
Abdo/back pain, pain at infusion site
Late Rh
o Febrile non-haemolytic transfusion reaction
o Allergic reaction
Urticaria, rash, wheeze
Must distinguish from anaphylaxis
Consider other causes of allergy if not clearly related
to transfusion
Ab against donor plasma proteins
o Anaphylactic reaction
o Circulatory overload
o Bacterial Contamination
Usually platelets because stored at room temp (22
degrees)
ICU
o Air embolism
o Transfusion related acute lung injury (TRALI)
Acute respi failure within 6 hours of transfusion

Bilat infiltrates on CXR

P/F ratio less than 300
No evidence of fluid overload or another cause
Anti HLA Ab in the donor (Usually females, has
children)
Ab cause activation of recipient neutrophils in
pulmonary vasculature causing capillary leak
o Transfusion Associated Graft vs Host dz
Late
o Infective transmission HIV, Hep B, Hep C
HIV 1 in 6 million
Hep B 1 in 1 million
Hep C 1 in 70 million

Transfusion related GVHD

Recipient with suppressed T cell function receives blood
Blood contains viable lymphocytes
Lymphocytes from transfused blood attacks recipients tissue
Cell mediated immune attack

Sarcomas
o Pain mass functional deficit

o Any age
o Limbs, retroperitoneum, h&n
o Deep seated (deep to fascia) and large tumours (>5cm)
more likely to be malignant or aggressive -> second
opinion
o vs superficial or small more likely to be benign or low
grade
o Site: extremities better prognosis vs retroperitoneum
o Nodal mets rare (except synovial sarcoma, epithelioid
sarcoma
o Mets to lung
Imaging not very much for diagnosis. More for relationship with
surrounding structures
Pathological classification
Lineage based
Grading based
o Prognostic fx and indicator of mets risk in adults
o But some tumours are ungradable
o Context is important in determining likely behavior (age,
size, site)
Low
Limited mets ability
Locally less aggressive
Intermediate
Low to intermediate mets potential

 Locally aggressive
High
High mets potential
Locally aggressive
o French Federation of Cancer Centers Sarcoma Group
Genetic based
Morphological
Immunohistochemistry
Molecular Techniques
o Conventional Karyotyping
o FISH
o PCR
o DNA Sequencing

o Sarcoma with simple genetic alterations (uniform)

Ewing Sarcoma
Recurrent translocation
o Sarcoma with complex and unbalanced karyotypes
Pleomorphic liposarcoma
Sebaceous Cyst

Lipoma
Superficial
Head, neck, back
Circumscribed
Homogenous and yellow
Delicate fibrous septa
Soft and greasy
Easily shelled out no adherent to surrounding tissue
Mature adipocytes
Liposarcoma
Low grade - Highly recurrent but low rate of metastasis
High grade
Nerve Sheath Tumour
Schwannoma
Cirrhosis
1. Necrosis
2. Regeneration
3. Fibrosis

4. Loss of lobular architecture

Thyroid
Capsule
o Margin
o Well defined
o Regular/ irregular
Cut Surface
o Uniform/ non-uniformed (variegated)
o Necrosis/ hemorrhage
o Colour
o Consistency
o Solid/cystic
Invasion
o Direct
Metastasis
Blood Draws
Blood Culture
Blue citrate prevents consumption of coagulation factors
o PT/PTT

Yellow has gel that separates cells and serum

o Group cross match
o Similar to Red
Red (plain) - serum
o RP
o LFT
o Ca
o Lipids
o HIV
o Biochem
o Group Cross match
Green Lithium heparin used in A&E, ICU settings
o Stat samples
o RP
o Electrolytes
o Toxic Drugs
Purple potassium EDTA
o FBC
Grey fluoride oxalate
o Plasma venous glucose

Biochemical hypoglycemia
Glucose <2.5 mmol/L
Glucose normal fasting range is 3-6 mmol/L
Insulin should be undetectable in hypoglycemia
Endogenous C peptide detected
Exogenous C peptide undetected
Whipples Triad
S&S of hypoglycemia
Associated glucose <2.5g
Relief of symptoms when glucose is administered

Exfoliative cytology
Brushings, washings, lavage
o Bronchial
Brushing scrape
Washing Saline Proximal
(BAL) Lavage Distal specimens that bronchoscope
cannot reach
Brushing, washing, biopsy often done tgt,
complimentary
Brushing, washing surface only

Biopsy deeper
But biopsy may have sampling error.
o Biliary
ERCP
o GI
Fluids to r/o or confirm malignancies
o Pleural
o Peritoneal
o Urine
Urothelial CA
TURBT
o CSF
o Synovial

FNA Cytology
Palpable lesions
Deeper lesions
o US
o CT
o EUS
o EBUS

Rapid On-site Evaluation (ROSE)

o Smears on slides
o Adequacy
Triage
o Microb culture
o Cell block
Converting cyto specimen to histo specimen

Cells
Cellularity
Dispersed (inflammatory cells)
Cluster (epithelial cells)
Papillary Clusters (Papillary tumours)
Pleomorphism (malignancy)
Nucleus cytoplasmic ratio
Keratinized cell has orange cytoplasm (SCC)
Signet ring cells cytoplasm is vacuolated (stomach most
common)
Pigments bile or melanin
Colloid folds on itself (velvety creases) in the thyroid. More
colloid more benign
Mucin thin film
Spindle shaped stromal lesion GIST
Nuclear grooves + nuclear inclusion = papillary CA