Anexo 2: Fotos PUC y UTAH de Colitis Ulcerosa, Enfermedad de Chron y Apendicitis

Colitis Ulcerosa Idiopatica (PUC)

COLITIS ULCERATIVA IDIOPATICA:

Pieza quirrgica de intestino grueso,

fijada en formalina. Desde el recto hasta

el ngulo heptico la mucosa se observa

difusamente hipermica y hemorrgica,

con lceras lineales irregulares que

circunscriben reas de mucosa

remanente, solevantadas por el intenso

infiltrado inflamatorio

("pseudoplipos"). El ciego y el colon

ascendente sin lesin macroscpica

COLITIS ULCERATIVA IDIOPATICA: Acercamiento de la mucosa, en que se

observa el detalle de la alternancia de

lceras con reas de mucosa

tumefactas.

COLITIS ULCERATIVA IDIOPATICA: Corte

histolgico a bajo aumento de mucosa de

intestino grueso. La lmina propia se aprecia

hipermica y con denso infiltrado

predominantemente linfocitario. Se observan

criptas deformadas y dilatadas, con abundante

exudado de polinucleares en el lumen, y entre

clulas epiteliales. El epitelio con menor

proporcin de clulas caliciformes, en algunas

criptas aparece aplanado o ausente. En la

porcin inferior de la cripta central se observa

que los polinucleares infiltran la lmina propia

subyacente.

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COLITIS ULCERATIVA IDIOPATICA:

Corte histolgico a bajo aumento que

muestra al centro una zona de mucosa

solevantada, con intensa inflamacin

("pseudoplipo"); est delimitada a la

izquierda por la comisura de una lcera, y

a la derecha, por mucosa regenerada.

COLITIS ULCERATIVA IDIOPATICA CON REGENERACION: Acercamiento de

mucosa de intestino grueso sin hiperemia

ni hemorragias, que muestra reas

solevantadas y deprimidas, revestidas por

mucosa regenerada, que en el centro forma

un puente de mucosa.

COLITIS ULCERATIVA IDIOPATICA Y

ENFERMEDAD DE CROHN:

Comparacin, a muy bajo aumento,

entre los caracteres de la colitis

ulcerativa idioptica en el panel

superior, y la iletis de la enfermedad de

Crohn, en el panel inferior.

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Enfermedad de Chron (UTAH)

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's

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

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

The etiology for Crohn disease is

unknown, though infectious and

immunologic mechanisms have been

proposed. The NOD2/CARD15gene produces a bacterial lipopolysaccharide receptor in

mucosal Paneth cells, and mutations in this gene affect activation of nuclear factor kappa B

that is part of an innate immune response. CD patients generally have a pANCA negative /

ASCA positive serologic pattern. There is a bimodal incidence for CD and an increased

incidence in women and persons of Caucasian race.

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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 adjacent

to fat. Note the granulomatous inflammation.

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.

The clinical manifestations of CD are variable and can

include diarrhea, fever, and pain, as well as

extraintestinal manifestations of arthritis, uveitis,

erythema nodosum, and ankylosing spondylitis.

One complication of transmural

inflammation with Crohn disease is fistula

formation. Seen here is a fissure extending

through mucosa into the submucosa toward

the muscular wall, which eventually will

form a fistulous tract. Fistulae can form

between loops of bowel, bladder, and even

skin. With colonic involvement, perirectal

fistulae are common.

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Colitis ulcerosa UTAH

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".

At higher magnification, the pseudopolyps can be

seen clearly as raised red islands of inflamed

mucosa. Between the pseudopolyps is only

remaining muscularis.

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.

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

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. The

resulting ulceration often has a flask shape

(Erlenmeyer flask...triggering flashbacks to

organic chemistry).

On microscopic examination at higher

magnification, the intense inflammation of the

mucosa is seen. The colonic mucosal epithelium

demonstrates loss of goblet cells. The shape of the

crypts is distorted. An exudate is present over

the surface. Both acute and chronic inflammatory

cells are present.

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.

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Crypt abscesses are a histologic finding more

typical with ulcerative colitis. Unfortunately,

not all cases of inflammatory bowel disease

can be classified completely in all patients.

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.

Apendicitis UTAH

This appendix was removed surgically. The

patient presented with abdominal pain that

initially was generalized, but then localized to the

right lower quadrant, and physical examination

disclosed 4+ rebound tenderness in the right

lower quadrant. The WBC count was elevated at

11,500. Seen here is acute appendicitis with

yellow to tan exudate and hyperemia, including

the periappendiceal fat superiorly, rather than a

smooth, glistening pale tan serosal surface.

This is the tip of the appendix from a patient with

acute appendicitis. The appendix has been sectioned

in half. The serosal surface at the left shows a tan-

yellow exudate. The cut surface at the right

demonstrates yellowish-tan mucosal exudation with a

hyperemic border.

Microscopically, acute appendicitis is marked by mucosal

inflammation and necrosis.

Here, the mucosa shows ulceration and

undermining by an extensive neutrophilic exudate.

Neutrophils extend into and through the wall of the

appendix in a case of acute appendicitis. Clinically,

the patient often presents with right lower quadrant

abdominal pain. Rebound tenderness is noted on

physical examination. An elevated WBC count is

usually present.