GIT Pathology Lab 3

Colon, Adenomatous Polyp on Long Stalk, Gross

• This adenomatous polyp has a 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. In the
endoscopic view on colonoscopy seen below, there is a large pedunculated polyp on a long
stalk.
GIT Pathology Lab 3

Colon, Familial Adenomatous Polyposis, Gross

• This is familial polyposis coli. The mucosal surface of the colon is essentially a carpet of small
adenomatous polyps. Of course, even though they are small now, there is a 100% risk over
time for development of adenocarcinoma, so a total colectomy is done, generally before age
20. Patients with this disorder inherit a faulty adenomatous polyposis coli (APC) gene.

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GIT Pathology Lab 3

Colon, Familial Adenomatous Polyposis, Gross

• This is familial adenomatous polyposis (FAP) in a patient who had the adenomatous polyposis
coli (APC) gene. The inheritance of the faulty APC tumor suppressor gene occurs in an
autosomal dominant fashion.

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GIT Pathology Lab 3

Colon, Familial Adenomatous Polyposis (Plenk-

Gardner syndrome), Gross
• 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 Plenk-Gardner
syndrome. As with familial adenomatous polyposis, the inheritance pattern is autosomal
dominant, with a faulty adenomatous polyposis coli (APC) gene.

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GIT Pathology Lab 3

Colon, Hereditary Non-Polyposis Colon Carcinoma

(HNPCC) Syndrome, Gross
• Here are multiple adenomatous polyps of the cecum. A small portion of terminal ileum appears
at the right. This is a patient with hereditary non-polyposis colon carcinoma (HNPCC)
syndrome. Compared to adenomatous polyposis coli (APC), in HNPCC there are fewer polyps
and an older age for development of carcinoma. The defect in HNPCC is the inheritance, in an
autosomal dominant fashion, of a faulty DNA mismatch repair gene, and most HNPCC tumors
demonstrate microsatellite instability (variations in dinucleotide repeat sequences).

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GIT Pathology Lab 3

Adenomatous polyp, tubular adenoma

• 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.

1st picture

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GIT Pathology Lab 3

Colon, Villous Adenoma, Composite Gross

• The gross appearance of a villous adenoma is shown above the surface at the left, and in
cross section at the right. 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. On colonoscopy, a sessile polyp is seen
below.

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GIT Pathology Lab 3

• Colon, Villous Adenoma, Composite Gross

[ENDOSCOPY]

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GIT Pathology Lab 3

Colon, Villous Adenoma, Composite Low Power

Microscopic
• 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 harbour invasive carcinoma
in them (about 40% of villous adenomas).

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GIT Pathology Lab 3

Colon, Adenocarcinoma, Gross

• An encircling adenocarcinoma 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 below.

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GIT Pathology Lab 3

Colon, Adenocarcinoma, [ENDOSCOPY]

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GIT Pathology Lab 3

Colon, Descending, Adenocarcinoma, Gross

• 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 in the views
below.

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GIT Pathology Lab 3

Colon, Descending, Adenocarcinoma,

[ENDOSCOPY]

13
GIT Pathology Lab 3

Colon, Adenocarcinoma, Gross

• Here is another example of an adenocarcinoma of colon. This cancer is more exophytic in its
growth pattern. Thus, one of the complications of a carcinoma is obstruction (usually partial).
Colonoscopic views of another ulcerating mass, a rectal adenocarcinoma, are seen below.

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GIT Pathology Lab 3

Colon, Adenocarcinoma, [ENDOSCOPY]

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GIT Pathology Lab 3

Colon, Adenocarcinoma Arising in Villous

Adenoma, Gross
• This is an adenocarcinoma arising in a villous adenoma. The surface of the neoplasm is
polypoid and reddish pink. Hemorrhage from the surface of the tumor creates a guaiac positive
stool. This neoplasm was located in the sigmoid colon, just out of reach of digital examination,
but easily visualized with sigmoidoscopy.

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GIT Pathology Lab 3

Colon, Adenocarcinoma, Low Power Microscopic

• The edge of the carcinoma arising in the villous adenoma is seen here. The neoplastic glands
are long and frond-like, similar to those seen in a villous adenoma. The growth is primarily
exophytic (outward into the lumen) and invasion is not seen at this point. Grading and staging
of the tumor is done by the surgical pathologist who will examine multiple histologic sections of
the tumor.

villous adenoma

adenocarcinoma

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GIT Pathology Lab 3

Colon, Adenocarcinoma, Medium Power

Microscopic
• Microscopically, a moderately differentiated adenocarcinoma of colon is seen here. There is
still a glandular configuration, but the glands are irregular and very crowded. Many of them
have lumens containing bluish mucin.

glands filled with mucin surrounded with

irregular overcrowded hyperchromatic nuclei
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GIT Pathology Lab 3

Colon, Adenocarcinoma, Medium Power

Microscopic
• Here is an adenocarcinoma in which the glands are much larger and filled with necrotic debris.

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GIT Pathology Lab 3

Colon, Adenocarcinoma, High Power Microscopic

• At high magnification, the neoplastic glands of adenocarcinoma have crowded nuclei with
hyperchromatism and pleomorphism. No normal goblet cells are seen.

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GIT Pathology Lab 3

Sigmoid Colon, Diverticulosis, Gross

The sigmoid colon at the right appears lighter in color than the adjacent small intestine and has
a band of taenia coli muscle running longitudinally. Protruding from the sigmoid colon are
multiple rounded bluish-gray diverticula. Diverticula are much more common in the colon than
in small 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.

21
GIT Pathology Lab 3

Colon, Diverticulosis, Gross

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.

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GIT Pathology Lab 3

Colon, Cut Surface, Diverticulosis, Gross

The colon has been opened to reveal the presence of non-inflamed diverticula. Each has
an opening to the colonic lumen through a narrow neck. Colonoscopic views of diverticula are
seen below.

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GIT Pathology Lab 3

Colon, Cut Surface, Diverticulosis, Gross

[ENDOSCOPY]

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GIT Pathology Lab 3

Colon, Cut Surface, Diverticulosis, Gross

Sectioning the colon reveals that the diverticula have a narrow neck. Peristalsis does not
empty them, so they become filled with stool.

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GIT Pathology Lab 3

Colon, Diverticulosis, Low Power Microscopic

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.

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GIT Pathology Lab 3

Colon, Diverticulitis, Gross

The surface of the colon is 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.

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GIT Pathology Lab 3

Colon, Diverticulitis with Perforation, Gross

This diverticulum has become inflamed and has ruptured outward, seen as the dark brown irregular
tract extending down from the mucosal surface here. This condition is a surgical emergency.

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GIT Pathology Lab 3

Colon, Diverticulitis with Perforation, Gross

• The probe is in the track of a ruptured sigmoid diverticulum. Also seen in the mouths of several
other diverticula below this is brown stool. Ruptured diverticula can produce an acute abdomen
with peritonitis requiring surgical intervention.

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GIT Pathology Lab 3

Prolapsed True Hemorrhoids, Gross

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 below is on colonoscopy are views of
hemorrhoids at the anorectal junction.

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GIT Pathology Lab 3

Prolapsed True Hemorrhoids, [ENDOSCOPY]

31
GIT Pathology Lab 3

Crohn Disease, Terminal Ileum, Gross

• This portion of terminal ileum demonstrates the gross findings with Crohn's disease. Though
any portion of the gastrointestinal tract may be involved with Crohn 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 below

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GIT Pathology Lab 3

Crohn Disease, Terminal Ileum, Gross

• This is another example of Crohn disease involving the small intestine. Here, the mucosal
surface demonstrates an irregular nodular appearance with hyperemia and focal superficial
ulceration. The distribution of bowel involvement with Crohn disease is irregular with more
normal intervening "skip" areas.

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GIT Pathology Lab 3

Crohn Disease, Colon, Low Power Microscopic

• Microscopically, Crohn 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.

granuloma near serosa

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GIT Pathology Lab 3

Crohn Disease, Colon, Low Power Microscopic

• On microscopic examination at high magnification the granulomatous nature of the
inflammation of Crohn disease is demonstrated here with epithelioid cells, giant cells, and
many lymphocytes. Special stains for organisms are negative.

35
GIT Pathology Lab 3

Crohn Disease, Small intestine, Medium Power

Microscopic
• One complication of transmural inflammation with Crohn 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 even skin. With colonic involvement, perirectal fistulae are common.

36
GIT Pathology Lab 3

Chronic Ulcerative Colitis, Gross

• 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".

37
GIT Pathology Lab 3

Chronic Ulcerative Colitis, Gross

• At higher magnification, the pseudopolyps can be seen clearly as raised red islands of
inflamed mucosa. Between the pseudopolyps is only remaining muscularis. However, the
process is primarily mucosal, without transmural inflammation and without fistula formation.

38
GIT Pathology Lab 3

Chronic Ulcerative Colitis, Gross

• 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. Colonoscopic views of less severe UC are seen
below, with friable, erythematous mucosa with reduced haustral folds.

39
GIT Pathology Lab 3

Chronic Ulcerative Colitis, Gross [ENDOSCOPY]

40
GIT Pathology Lab 3

Chronic Ulcerative Colitis, Gross

Pseudopolyps 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 below

41
GIT Pathology Lab 3

Chronic Ulcerative Colitis, [ENDOSCOPY]

42
GIT Pathology Lab 3

Chronic Ulcerative Colitis, Megacolon, Gross

• One serious complication of inflammatory bowel disease, and ulcerative colitis in particular, is
marked dilation of the colon, termed megacolon. Note the large circumference of the colon
shown here.

43
GIT Pathology Lab 3

Chronic Ulcerative Colitis, Low Power Microscopic

Microscopically, the inflammation of ulcerative colitis is confined primarily to the mucosa. Here,
the mucosa is eroded by an inflammatory process with ulceration that undermines surrounding
mucosa.

44
GIT Pathology Lab 3

Chronic Ulcerative Colitis, High Power Microscopic

• On microscopic examination 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.

45
GIT Pathology Lab 3

Chronic Ulcerative Colitis with Crypt Abscesses,

Medium Power Microscopic
• The colonic mucosa of active ulcerative colitis shows "crypt abscesses" in which a neutrophilic
exudate is found in glandular lumens of crypts of Lieberkuhn. The submucosa shows intense
inflammation. The glands demonstrate loss of goblet cells and hyperchromatic nuclei with
inflammatory atypia.

46
GIT Pathology Lab 3

Chronic Ulcerative Colitis with Crypt Abscesses,

High Power Microscopic
• Crypt abscesses are a histologic finding more typical with ulcerative colitis than Crohn
disease. Unfortunately, not all cases of inflammatory bowel disease can be classified
completely in all patients.

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GIT Pathology Lab 2

Chronic Ulcerative Colitis with Dysplasia, Medium

Power Microscopic
• 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.

Done By: Abdulmuhsen Methyab

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