Systemic Pathology

The Alimentary System

Compiled by Dr Kristian Leisegang

School of Natural Medicine
University of the Western Cape

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Oesophagus

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This is a normal esophagus with the usual white to tan smooth mucosa seen
at the left.
The gastroesophageal junction (not an anatomic sphincter) is at the center,
and the stomach is at the right.
The upper GI endoscopic view of the transition from tan squamous mucosa3
to pink columnar mucosa is seen below.
This is normal esophageal squamous mucosa at the left, with underlying
submucosa containing mucus glands and a duct surrounded by lymphoid
tissue.
The muscularis is at the right. 4
 Acute esophagitis is manifested here by increased neutrophils in the
submucosa as well as neutrophils infiltrating into the squamous mucosa at
the right.
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These two endoscopic views demonstrate Barrett esophagus areas of
mucosal erythema of the lower esophagus, with islands of normal pale
esophageal squamous mucosa.
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 Another cause for inflammation is a so-called "Barrett's esophagus" in
which there is gastric-type mucosa above the gastroesophageal junction.
Note the columnar epithelium to the left and the squamous epithelium at
the right.
This is "typical" Barrett's mucosa, because there is intestinal metaplasia as7
well (note the goblet cells in the columnar mucosa).
Stomach

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This is the normal appearance of the stomach, which has been opened along
the greater curvature.
The esophagus is at the left.
In the fundus can be seen the lesser curvature.
Just beyond the antrum is the pylorus emptying into the first portion of
duodenum is at the lower right.
The normal appearance of the gastric fundus on upper GI endoscopy is
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shown below at the left, with the normal duodenal appearance at the right.
 This is the normal appearance of the gastric antrum extending to the
pylorus at the right of center.
The first portion of the duodenum (duodenal bulb) is at the far right.
In the endoscopic views below, the normal appearance of the pylorus is seen
at the left, with the first portion of the duodenum at the right. 10
This is the normal appearance of the gastric fundal mucosa, with short pits
lined by pale columnar mucus cells leading into long glands which contain
bright pink parietal cells that secrete hydrochloric acid.
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At high power, gastric mucosa demonstrates infiltration by neutrophils.
This is acute gastritis.
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 Associated with gastritis is pernicious anemia.
Chronic atrophic gastritis is associated with autoantibodies that block or
bind intrinsic factor.
Another type of autoantibody demonstrated here is anti-parietal cell
antibody.
The bright green immunofluorescence is seen in the paritetal cells of the13
gastric mucosa.
 A 1 cm acute gastric ulcer is shown here in the upper fundus.
The ulcer is shallow and sharply demarcated, with surrounding hyperemia.
It is probably benign.
However, all gastric ulcers should be biopsied to rule out a malignancy.
The endoscopic appearance of a similar acute peptic ulcer in the prepyloric14
region is seen below.
Seen above are gastric ulcers of small and large size on upper endoscopy.
All gastric ulcers are biopsied, since gross inspection alone cannot
determine whether a malignancy is present.
Smaller, more sharply demarcated ulcers are more likely to be benign.
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An acute duodenal ulcer is seen in two views on upper endoscopy.

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 Gastritis is often accompanied by infection with Helicobacter pylori.
This small curved to spiral rod-shaped bacterium is found in the surface
epithelial mucus of most patients with active gastritis.
The rods are seen here with a methylene blue stain. 17
Microscopically, the ulcer here is sharply demarcated, with normal gastric
mucosa on the left falling away into a deep ulcer whose base contains
infamed, necrotic debris.
An arterial branch at the ulcer base is eroded and bleeding. 18
The mucosa at the upper right merges into the ulcer at the left which is
eroding through the mucosa.
Ulcers will penetrate over time if they do not heal.
Penetration leads to pain.
If the ulcer penetrates through the muscularis and through adventitia,
then the ulcer is said to "perforate" and leads to an acute abdomen.
An abdominal radiograph may demonstrate free air with a perforation. 19
Intestines

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 Seen here is a loop of bowel attached via the mesentery.
Note the extent of the veins. Arteries run in the same location.
Thus, there is an extensive anastomosing arterial blood supply to the bowel,
making it more difficult to infarct.
Also, the extensive venous drainage is incorporated into the portal venous21
system heading to the liver.
This is the normal appearance of small intestinal mucosa with long villi that
have occasional goblet cells.
The villi provide a large area for digestion and absorption.
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Normal small intestinal mucosa is seen at the left, and mucosa involved by celiac
sprue at the right.
There is blunting and flattening of villi with celiac disease, and in severe cases a
loss of villi with flattening of the mucosa as seen here.

Celiac sprue has a prevalence of about 1:2000 Caucasians, but is rarely seen in
other races. Over 95% of affected patients will express the DQw2 23
histocompatibility antigen, which suggests a genetic basis.
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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Inflammatory Bowel Disease

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 This is an example of Crohn's disease involving the small intestine.
Here, the mucosal surface demonstrates an irregular nodular appearance
with hyperemia and focal superficial ulceration.
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 Microscopically, Crohn's 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. 27
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".
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At higher magnification, the pseudopolyps can be seen clearly as raised red
islands of inflamed mucosa.
Between the pseudopolyps is only remaining muscularis.
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Microscopically, the inflammation of ulcerative colitis is confined primarily
to the mucosa.
Here, the mucosa is eroded by an ulcer that undermines surrounding
mucosa. 30
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. 31
Tumours of the Small & Large
Intestines

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Here are multiple adenomatous polyps of the cecum. A small portion of
terminal ileum appears at the right.
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 This is familial polyposis in which 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. 34


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. 35
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,
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 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 produce37
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 here on colonoscopy are views of hemorrhoids at the anorectal 38
junction.
Appendix

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This is the normal appearance of the appendix against the background of
the cecum.
The colonoscopic view of the appendiceal orifice between the fork of two
haustral folds in the cecum is seen below. 40
 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
Seen here is acute appendicitis with yellow to tan exudate and hyperemia, including
the periappendiceal fat superiorly, rather than a smooth, glistening pale tan serosal41
surface.
Microscopically, acute appendicitis is marked by mucosal inflammation and
necrosis.
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Here, the mucosa shows ulceration and undermining by an extensive
neutrophilic exudate.
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