Prof. Dr. Faeza Aftan Dept of Pathology Col of Med Aliraqia University Oct. 21 st 2015 Small & Large Intestine IBD SMALL/LARGE INTESTINE NORMAL: Anat., Vasc., Mucosa, Endocr., Immune, Neuromuscular. PATHOLOGY: CONGENITAL ENTEROCOLITIS: DIARRHEA, INFECTIOUS, OTHER MALABSORPTION: INTRALUMINAL, CELL SURFACE, INTRACELL. (I)IBD: CROHN DISEASE and ULCERATIVE COLITIS VASCULAR: ISCHEMIC, ANGIODYSPLASIA, HEMORRHAGIC DIVERTICULOSIS/-IT IS OBSTRUCTION: MECHANICAL, PARALYTIC (ILEUS) (PSEUDO) TUMORS: BENIGN, MALIGNANT, EPITHELIAL, STROMAL Clinical Features Adults, celiac disease 30 and 60 Year Adults, celiac disease 30 and 60 Year silent celiac disease, silent celiac disease, anemia (due to iron deficiency, less, B12 and folate deficiency), diarrhea, bloating, and fatigue. anemia (due to iron deficiency, less, B12 and folate deficiency), diarrhea, bloating, and fatigue. Pediatric celiac disease6 and 24 months Pediatric celiac disease, 6 and 24 months dermatitis herpetiformis Dermatitis Herpitiformis (DH) T cell lymphoma, S Int Ca. Sq cell ca. esophagus Causes of subtotal villous atrophy Coeliac Dis Giardiasis Lymphoma DH Tropical sprue (Enviromental enteropathy) AIDS Others Cystic Fibrosis Lungs of a cystic fibrosis. Extensive mucous plugging the tracheobronchial tree. The parenchyma is consolidated by both secretions &pneumonia; the greenish discoloration is the Pseudomonas infections. Cystic fibrosis in the pancreas. The ducts are dilated and plugged with eosinophilic mucin, and the parenchymal glands are atrophic and replaced by fibrosis __ Pancreatic insufficiency, ___ Malabsorption Malabsorptive Diarrhea Irritable bowel syndrome (IBS); chronic, relapsing abdominal pain, bloating, and changes in bowel habits. - Stress, Diet, GIT motility - No gross or Mic abnormalities. - Colitis, celiac disease, giardiasis, cancer, & IBD should be excluded. The Microscopic colitis, -collagenous colitis & -lymphocytic colitis, both cause chronic watery diarrhea. The intestines are grossly normal, and the diseases are identified by their histologic features. - Ass with Celiac & Autoimmune dis. Infectious Enterocolitis Vibrio cholerae secretes toxin that causes massive chloride secretion, H2O follows & diarrhea. Campylobacter jejuni. Salmonella and Shigella spp. are invasive, dysentery. Nontyphoid Salmonella cause ood poisoning. S. typhi cause systemic disease (typhoid fever). Pseudomembranous colitis ; AB allows C. difficile to grow & releases toxins, The inflammatory response volcanolike eruptions of PMN from colonic crypts that form mucopurulent pseudomembranes. Rotavirus is the most common cause of childhood diarrhea Parasitic and protozoal infections affect over half of the worlds population on a chronic or recurrent basis ENTAMOEBA HISTOLYTICA please do not drink the water. GIARDIA LAMBLIA please do not drink the water. Environmental (Tropical) Enteropathy Tropical enteropathy or tropical sprue Repeated bouts of diarrhea within the first 2 or 3 years of life Epidemic forms in developing countries NOT related to gluten No single infectious agent. RECOVERY with antibiotics CLOSTRIDIUM DIFFICILE (ANTIBIOTIC ASSOCIATED) COLITIS CLOSTRIDIUM DIFFICILE (ANTIBIOTIC ASSOCIATED) COLITIS NOSOCOMIAL CYTOTOXIN (lab test readily available) PSEUDOMEMBRANOUS (ANTIBIOTIC ASSOCIATED) COLITIS Clostridium difficile colitis. A, The colon is coated by tan pseudomembranes composed of neutrophils, dead epithelial cells, and inflammatory debris (endoscopic view). B, Pseudomembranes. C, Typical pattern of neutrophils emanating from a crypt is reminiscent of a volcanic eruption BACTERIAL OVERGROWTH SYNDROME One of the main reasons why normal gut flora is NOT usually pathogenic, they are constantly cleared by a NORMAL transit time BLIND LOOPS DIVERTICULA OBSTRUCTION Bowel PARALYSIS (I) IBD Idiopathic Idiopathic females, young adults. females, young adults. Western industrialized nations Western industrialized nations - Genetic factors. - Genetic factors. - The hygiene hypothesis; - The hygiene hypothesis; Early in life Limit mucosal IR & Early in life Limit mucosal IR & loss of intestinal epithelial barrier function - later in life, exposure of to - later in life, exposure of susceptible individuals to harmless triggers inappropriate IR harmless microbes triggers inappropriate IR The distinction between UC & CD is based, on - Distribution of the lesion - Morphology of disease (I) IBD Ulcerative Colitis disease begins in rectum & extends proximally (no skip lesions) does not involve small intestines superficial mucosal involvement (not transmural) crypt abscesses (microabscesses) and crypt distortion Pseudopolyp increased risk of colon cancer and toxic megacolon Crohn Disease transmural involvement fissures, fistulas, and obstruction segmental involvement (skip lesions) may involve small intestines (regional enteritis or ileitis) Granulomas Ulcerative Colitis proctitis Ulcerative proctitis or ulcerative proctosigmoiditis Pancolitis. Backwash ileitis. Pseudopolyps Toxic megacolon Increased cancer risk Active disease superf. Ulcer & hemorrhage Pseudopolyps UC infectious enteritis psychologic stress, smoking cessation in some patients, and smoking may partially relieve symptoms. Ulcerative Colitis PSEUDOPOLYPS Crypt Abscess Ulcerative Colitis Crohn disease Terminal ileum, ileocecal valve, and cecum. S. Int alone in 40% of cases; S Int & colon are both involved in 30% skip lesions Cobblestone Fissures Fistula tracts Strictures are common Crohns Disease Transmural inflammation Cobblestones Skip areas Scarring and stricture formation Fistulae Crohns Dis. Cobble stones Skip areas Crohns Dis. Scarring and stricture formation Transmural Crohn disease with submucosal and serosal granulomas (arrows). Crohns Dis Crohns Dis. Cobblestones Extraintestinal manifestations ; erythema nodosum, arthritis, uveitis, pericholangitis and ankylosing spondylitis. Indeterminate Colitis UC & CD Pathologic and clinical overlap between UC & CD. 10% of IBD patients Colonic disease in a continuous pattern (typical UC). However, patchy pattern, fissures, a family history of Crohn disease, perianal lesions, onset after cigarettes, or other features that are not typical of UC. Perinuclear anti-neutrophil cytoplasmic Abs are positive in 75% of UC, but only 11% with CD. Colitis-Associated Neoplasia The risk of dysplasia is related to : The risk of dysplasia is related to : The frequency & severity of active disease Duration, risk increases years after disease initiation. Pancolitis are at greater risk than those with only left- sided disease Primary sclerosing cholangitis, anti-TNF Ab Rx can suppress the development of colitis-associated cancers in experimental animals.