2017 Annual Meeting

Evening Specialty Conference
Gastrointestinal Pathology

You Don't See That Every Day: Non-Routine Diagnosis in Routine Cases

March 8 2017, 7:30pm to 9:30pm

Rhonda Yantiss, MD
Audrey Lazenby, MD - Nicole Panarelli, MD - Joseph Misdraji, MD - Kenneth Batts, MD - Thomas Smyrk, MD

Pre-Meeting Materials

Case 1

Audrey Lazenby, MD

Clinical History:

GI Pathology Evening Speciality Conference. Case History The patient is an 80-year-old woman with a history of biliary colic starting at age 20 following a pregnancy. Two years prior, she presented to an outside hospital with fatigue and weakness and was found to be bacteremic with alpha-hemolytic streptococcus. Imaging showed a right hepatic lobe mass that involved hepatic segments V and VI, surrounded the gallbladder, and measured 9 x 7 cm. The mass was mostly cystic with debris and appeared radiographically typical of an abscess. The liver abscess was drained and the patient then completed 4 weeks of Ceftriaxone without recurrence. Culture from the drainage grew Streptococcus viridans, consistent with the blood cultures. At the current admission, she presented with fluctuating malaise, fatigue and intermittent epigastric/right upper quadrant pain. Multi-modality imaging demonstrated cholelithiasis with a contracted and inflamed gallbladder. Her pre-surgical evaluation was otherwise unremarkable and she scheduled for a laparoscopic cholecystectomy. During her surgery ,the duodenum was found to be adherent to the liver and numerous adhesions were found , thus the procedure was modified to an open cholecystectomy. Because of the extensive adhesions between the gallbladder and the liver, a subtotal cholecystectomy was performed with the distal gallbladder and cystic duct obliterated by extensive cautery. The non-intact gallbladder, measuring 1.9 x 2.7 x 1.2 cm and 4 yellow-tan multifaceted calculi were submitted for pathologic examination. A virtual slide of the gallbladder is provided for your evaluation.

Morphological Findings (click to enlarge):

Case 2

Nicole Panarelli, MD

Clinical History:

A 63 year-old man with no significant past medical history began to have abdominal cramps and loose bowel movements with mucus up to ten times daily six months prior to presentation. He was frequently woken from sleep by abdominal pain. He denied melena or hematochezia. An upper endoscopic exam revealed normal findings and a biopsy sample taken from the duodenum was unremarkable. Colonoscopy showed edematous and friable mucosa with vascular dilatation extending continuously from the rectum to the splenic flexure. Biopsy samples were obtained from the involved colonic segment. Representative images are provided. A computed tomography angiogram showed normal vasculature without atherosclerotic calcifications. He was treated with Asacol, which solidified his stools and decreased the frequency to five times per day. He presented to our institution for further management due to persistent abdominal pain and frequent bowel movements.

Morphological Findings (click to enlarge):

Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 6

Case 3

Joseph Misdraji, MD

Clinical History:

A 29 year old male presents with chronic abdominal pain. On CT scan, the appendix is markedly thickened, raising concerning for malignancy.

Morphological Findings (click to enlarge):

Figure 1 Scanned Low Power View
Figure 2 Malt Low Power View
Figure 3 Mucosa (Lower Right) and Submucosa
Figure 4 Deep Aspect of Muscularis Propria
Figure 5 Periappendiceal Connective Tissue
Figure 6 Mucosal Lymphoid Tissue Medium Power
Figure 7 Mucosal Lymphoid Tissue High Power

Case 4

Kenneth Batts, MD

Clinical History:

Middle aged male with longstanding ulcerative colitis which is well controlled medically undergoes colonoscopy for surveillance. Four prior surveillances showed mildly active to inactive colitis without dysplasia or neoplasia. Current exam shows four flat polyps in the rectum, the largest of which is 10 mm, all of which were removed. The endoscopic images of the largest polyp is shown. The histopathology is shown in the virtual image - the largest polyp is inked orange and the smaller polyps are not inked. The issues to consider are what name you would give the 10 mm polyp and how this polyp should impact patient management (if at all).

Morphological Findings (click to enlarge):

Figure 1

Case 5

Thomas Smyrk, MD

Clinical History:

21 year old male with ulcerative colitis not responding to medical therapy. Endoscopy showed pancolitis with a "carpet of pseudopolyps" in proximal transverse colon. Biopsy negative for dysplasia. Colectomy was performed for refractory disease. Gross exam showed a 6.5 x 4 x 3 cm polypoid mass in the proximal transverse colon.

Morphological Findings (click to enlarge):

Figure 1 Full thickness of bowel wall
Figure 2 Mucosa
Figure 3 Submucosa
Figure 4 Muscularis propria
Figure 5 Subserosa
Figure 6 Subserosa


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