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.

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.

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.

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.

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.

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 tanyellow 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.