آزمايشگاه رز - Ackerman Atlas(chaptr15)

Small Intestin

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Figure 15.1 Peyer patches are a characteristic feature of the ileum. When large, they may resemble polyps macroscopically and can distort the overlying mucosa

Figure 15.2 The ileocecal valve often contains abundant adipose tissue

Figure 15.3 Paneth cells have large, red, supranuclear granules. In contrast, neuroendocrine cells in the crypts have smaller granules that are subnuclear and darker red to magenta (arrow). This biopsy also contains pigmented macrophages indicating melanosis duodeni

Figure 15.4 This biopsy shows nodular submucosal Brunner glands. When prominent, they may distort the overlying villous architecture

Figure 15.5 Heterotopic pancreas containing a focus of acinar paren- chyma. The abundant ductal epithelium invested by smooth muscle creates a lobular appearance

Figure 15.6 Polypoid gastric heterotopia occurring in the first portion of the duodenum. Parietal and chief cells are easily seen

Figure 15.7 Long congenitally atretic segment of small bowel

Figure 15.8 A, Meckel diverticulum showing marked passive congestion resulting from mechanical venous obstruction. B, Another example contains gastric epithelium with an ulcer. C, Heterotopic gastric mucosa within a Meckel diverticulum. D, This example contains both gastric and pancreatic tissue. (B, Courtesy Dr. George F. Gray, Jr.)

Figure 15.9 Meckel diverticulum complicated by the development of a carcinoid tumor, the cut surface of which has a characteristic yellow color after formalin fixation

Figure 15.10 Multiple Jejunal Diverticula. They are typically located along the mesenteric border. (Courtesy of Dr RA Cooke, Brisbane, Australia. From Cooke RA, Stewart B. Colour Atlas of Anatomical Pathology. Edinburgh: Churchill Livingstone; 2004.)

Figure 15.11 This endoscopic photo of the duodenum in celiac disease shows mucosal "mosaicism" and loss of normal folds. (Courtesy Dr. Rhonda Yantiss.)

Figure 15.12 A, This biopsy from a patient with untreated celiac disease shows total villous atrophy, but concomitant crypt hyperplasia maintains the thickness of the mucosa. There is also a lymphoplasmacytic infiltrate in the lamina propria and a decrease in goblet cells at low power. B, Intraepithelial lymphocytes are prominent in both surface and crypt epithelium

Figure 15.13 Subepithelial collagen deposition, villous atrophy, and increased intraepithelial lymphocytes are seen in this biopsy from a patient with collagenous sprue (Masson trichrome stain)

Figure 15.14 A, Transmural enteropathy-associated T-cell lymphoma involving the mucosa, muscularis propria, and serosa. B, Another case shows an infiltrative lymphoma with overlying villous atrophy. C, High-power view showing a mixture of cell sizes and significant pleomorphism. (A, Courtesy Dr. Scott Owens.)

Figure 15.15 A biopsy from a patient with tropical sprue featuring mild villous blunting, a lymphoplasmacytic infiltrate in the lamina propria, and increased intraepithelial lymphocytes

Figure 15.16 Whipple Disease. A, Endoscopic view of the small bowel showing white lipid-filled plaques in the mucosa. B, Similar changes are seen in a resection specimen. C, On biopsy, the lamina propria is packed with histiocytes and empty round spaces; the latter contained lipid material that has been extracted during tissue processing. D, PAS stain highlights the macrophages. E, Cut surface of mesenteric lymph nodes massively involved by Whipple disease

Figure 15.17 Marked cytoplasmic vacuolization of the glandular epithelium of small bowel in abetalipoproteinemia

Figure 15.18 Large, deep, well-circumscribed duodenal peptic ulcer in the first portion of the duodenum

Figure 15.19 A, Low-power view of peptic duodenitis showing egress of Brunner glands into the mucosa, a plasmacytic infiltrate in the lamina propria, and mild villous blunting. B, Higher-power view shows neutrophils within the epithelium and lamina propria, as well as surface gastric metaplasia. (Courtesy Dr. Wendy Frankel.)

Figure 15.20 A, Necrotizing and lymphocytic phlebitis with associated thromboses in the small bowel. B, Another case shows a mesenteric vein with marked mural scarring, luminal narrowing, and lymphocytic inflammation

Figure 15.21 A polypoid lesion composed of small, proliferating, granula- tion tissue-like capillaries in portal enteropathy

Figure 15.22 Dieulafoy lesion, defined as a solitary ulcer that erodes into a large submucosal artery, is most often found in the stomach but is rarely seen in the small bowel

Figure 15.23 So-called aphthoid ulcers, an early feature of Crohn disease

Figure 15.24 Gross Appearance of Crohn Disease. A, Note the segmental nature of the inflammation and the sharp demarcation between involved and uninvolved areas. B, The combination of ulceration and elevated remnants of mucosa results in a typical cobblestone appearance. C, The rigidity of the wall and the flattening of the mucosa are characteristic; note the linear fissuring ulcers. D-E, Fibrotic strictures and stenoses are common. (A, C-E, Courtesy Dr. George F. Gray, Jr.)

Figure 15.25 Microscopic Appearance of Crohn Disease. A, Superficial mucosal erosion (arrow) and active inflammation associated with lymphoid follicles constitutes an early lesion. B, Extensive pyloric metaplasia in a case of duodenal Crohn disease. C, lleocecal Crohn disease showing transmural inflam- mation and fibrosis, along with a fissuring ulcer and markedly thickened muscularis mucosae. D, Small epithelioid granulomas in Crohn disease, associated with prominent lymphoid aggregates

Figure 15.26 A biopsy from an ileal pouch in a patient with ulcerative colitis showing villous blunting, expansion of the lamina propria by a mixed inflammatory infiltrate, and overlying ulcer debris

Figure 15.27 A, Multiple CMV inclusions (arrows) in a small bowel biopsy from a liver transplant patient with diarrhea. B, CMV inclusions (arrows) within endothelial cells with associated thrombosis and luminal occlusion in a case of CMV vasculitis

Figure 15.28 A, Duodenal biopsy in an AIDS patient with MAI, showing villous distension and blunting by an infiltrate of foamy macrophages. B, Ziehl-Neelsen stain highlights numerous organisms within macrophages

Figure 15.29 Yersinia enterocolitica infection featuring ulcerated mucosa, a markedly thickened wall, and numerous small, epithelioid granulomas associated with abundant transmural lymphoid tissue

Figure 15.30 A, Cryptosporidiosis featuring small basophilic spheres beneath the luminal epithelium in a small bowel biopsy. B, The organisms will stain with methenamine silver as well

Figure 15.31 A, A duodenal biopsy from an AIDS patient with micro- sporidiosis shows increased intraepithelial lymphocytes and surface epithelial disarray. A subtle vacuolization of the surface epithelium is a clue to the presence of the organisms. B, A modified trichrome stain stains the spores a bright red, aiding in identification

Figure 15.32 A, Giardia are typically seen at the surface of the duodenal epithelium (arrows); some have likened their appearance to "falling leaves." Note the minimal associated inflammatory changes. B, At higher power the distinctive pearshape can be appreciated

Figure 15.33 Strongyloidiasis larvae (arrow) within the crypt epithelial cells in a small bowel biopsy

Figure 15.34 A, Duodenal biopsy from a case of mycophenolate toxicity shows increased plasma cells and eosinophils in the lamina propria, along with increased intraepithelial lymphocytes. B, Another case shows numerous apoptotic epithelial cells at the base of the mucosa (arrows)

Figure 15.35 Chemotherapy-induced injury featuring crypt atrophy, marked regenerative nuclear atypia, and neutropenia. The nuclear changes should not be mistaken for dysplasia or viral infection

Figure 15.36 Olmesartan-associated enteropathy featuring marked villous atrophy, increased intraepithelial lymphocytes, and increased plasma cells and eosinophils in the lamina propria

Figure 15.37 Ipilimumab-induced enteritis showing near total destruction of the mucosa secondary to a lymphoplasmacytic infiltrate

Figure 15.38 A, Radiation enteritis with mucosal ulceration, active inflammation, and fibrosis of the lamina propria. B, Vessels are ectatic and may contain fibrin thrombi

Figure 15.39 A, Dense infiltration of the mucosa and submucosa of the jejunum by a virtually pure eosinophilic population. B, In this case, the muscle wall was heavily involved

Figure 15.40 Duodenal biopsy in autoimmune enteritis featuring villous blunting, a dense plasmacytic infiltrate, loss of goblet cells, and scattered apoptotic epithelial cells

Figure 15.41 A, Sections of the small bowel in a case of common variable immunodeficiency show villous blunting with a mild increase in intraepithelial lymphocytes; apoptotic epithelial cells are visible even at low power. B, Higher-power view shows increased apoptotic epithelial cells (arrows) and an absence of plasma cells

Figure 15.42 A, Outer aspect of small bowel in intussusception. B, Intussusception of small bowel caused by an adenocarcinoma. The tumor, located at the tip of the intussusceptum, is ulcerated and necrotic

Figure 15.43 Amyloid involving the lamina propria (A) and small vessels (B) in the duodenum

Figure 15.44 A, Pedunculated Brunner gland nodule. B, Lobules of benign, normal-appearing Brunner glands are separated by fibrous stroma. (A, Courtesy Dr. George F. Gray, Jr.)

Figure 15.45 Duodenal adenoma, resembling colonic tubular adenoma

Figure 15.46 A, A duodenal pyloric adenoma composed of tightly packed tubules resembling pyloric glands. There is minimal inflammation. B, The nuclei are basally located, with small nucleoli

Figure 15.47 A, Large lobulated Peutz-Jeghers polyp. B, Whole mount view shows lobules of benign epithelium supported by arborizing bands of smooth muscle. C, Higher-power view shows benign, focally dilated glands devoid of atypia, separated by bundles of smooth muscle. (A, Courtesy Dr. George F. Gray, Jr.)

Figure 15.48 A, Juvenile polyp in which cystically dilated spaces are grossly apparent. B, Histologically the polyp features cystically dilated glands filled with inspissated mucus and inflammatory debris, along with supporting stroma that also contains inflammation. (A, Courtesy Dr. George F. Gray, Jr.)

Figure 15.49 Small bowel adenocarcinomas with an infiltrative growth pattern, producing a "napkin-ring"-like lesion (A) and a nodular, polypoid growth pattern (B). (Courtesy Dr. George F. Gray, Jr.)

Figure 15.50 Small bowel adenocarcinoma, intestinal type, underlying a large villous adenoma

Figure 15.51 Multiple carcinoid tumors of small bowel presenting as small sessile polyps. (Courtesy of Dr RA Cooke, Brisbane, Australia. From Cooke RA, Stewart B. Colour atlas of anatomical pathology. Edinburgh, 2004, Churchill Livingstone.)

Figure 15.52 Cut surface of carcinoid tumor of the ileum. The tumor is solid, yellow, and accompanied by marked thickening of the muscularis propria

Figure 15.53 A, lleal WNET showing an organoid pattern composed of nests of tumor cells. The mucosa overlying the tumor is intact. Retraction artifact is prominent around the larger tumor nests. B, The nuclei are round with a finely speckled chromatin pattern and indistinct nucleoli. C, Marked fibrosis is often associated with WNET. D, Vascular invasion within the wall of the small bowel

Figure 15.54 A, WNET of small bowel. Argentaffin reaction (Fontana- Masson). B, Argyrophil reaction (Sevier-Munger)

Figure 15.55 Jejunal WNETS often feature prominent eosinophilic cytoplasmic granules that contain serotonin

Figure 15.56 A and B, Gangliocytic paraganglioma of duodenum showing areas of spindle cells, nested epithelioid-appearing cells, and scattered ganglion-like cells (B, high power).

Figure 15.57 A, Spindled GIST arising in the wall of the ileum. B, Skeinoid fibers are commonly found in small bowel GISTs (arrows)

Figure 15.58 A and B, Gross appearance of inflammatory fibroid polyp

Figure 15.59 A, Submucosal-based inflammatory fibroid polyp with spindled stroma, prominent vessels, and a mixed inflammatory infiltrate. B, Eosinophils are typically prominent. C, Vessels are often surrounded by "onion-skin" fibrosis; this example also has prominent stromal hyalinization

Figure 15.60 A, Cut surface of small bowel lipoma. B, Duodenal lipoma with overlying nodule of Brunner glands. (A, Courtesy Dr. George F. Gray, Jr.)

Figure 15.61 A, Lymphangioma involving small bowel and adjacent mesentery. B, Low-power appearance of lymphangioma showing pre- dominantly submucosal involvement

Figure 15.62 Extranodal marginal zone lymphoma of duodenum with plasmacytoid features, showing destruction of the normal mucosal architecture (A) and lymphoepithelial lesions (arrow, B)

Figure 15.63 Primary follicular lymphoma of the small bowel featuring transmural extension of neoplastic follicles

Figure 15.64 A, Gross appearance of malignant lymphoma involving the ileum in a diffuse fashion and resulting in polypoid prominence of the transverse mucosal folds. B, Malignant lymphoma of small bowel presenting as a circumferential ulcerated lesion that resulted in stenosis. C, This diffuse growth pattern in a segment of small bowel resembles a garden hose. (B and C, Courtesy Dr. George F. Gray, Jr.)

Figure 15.65 A, An infiltrate of mast cells expands the lamina propria of the duodenum in this patient with systemic mastocytosis. The mast cells have a "fried egg" appearance and there are scattered admixed eosinophils. B, CD117 stain highlights the mast cells

Figure 15.66 Large blood-filled cystic lesion in the wall of the small bowel due to endometriosis. There is also hyperplasia of smooth muscle, a very common finding. (Courtesy of Dr RA Cooke, Brisbane, Australia. From Cooke RA, Stewart B. Colour Atlas of Anatomical Pathology. Edinburgh: Churchill Livingstone; 2004.)

Figure 15.67 Malignant melanoma metastatic to small bowel, which can be deeply pigmented grossly

(A) or amelanotic (B). C, Metastatic melanoma undermining the duodenal mucosa