Ulcerative lesion 4 6-2016

Ulcerative lesion 4 6-2016

1. ULCERATIVE LESIONS OF INTESTINE Dr. Roopa Urs Assistant professor

2. Histology of duodenum

3. Histology of jejunum

4. Histology of ileum

5. Payer’s patches

6. Electron microscopy- villi

7. Colonic mucosa

8. What are the ulcerative lesions? Duodenal Ulcer Amoebic ulcer Typhoid ulcer Tuberculous ulcer Bacillary dysentry Viral -CMV -AIDS

9. IBD -Ulcerative colitis - Crohns disease Carcinoma Others GVHD- Graft Verses Host Disease Hyperplastic tuberculosis Behcet’s syndrome

10. Small Bowel INFLAMMATORY: Duodenal Peptic Ulcer Marginal Ulcer Small Bowel Ulcer Inflammatory Bowel Disease - Crohn’s disease, Ulcerative Colitis Celiac Disease Ulcerative Jejunitis Tuberculosis Typhoid NEOPLASTIC: Malignant Lymphoma of small bowel Adenocarcinoma

11. Large Bowel INFLAMMATORY: IBD Ischemic Colitis Necrotizing Enterocolitis Amoebic Colitis TB CMV Colitis Behcet’s Colitis Solitary Rectal ulcer NEOPLASTIC: Adenocarcinoma

12. Duodenal Peptic Ulcers Young men Causes- H.pylori Stress, spicy food NSAID- aspirin Cigarette smoking Heavy drinking Chemotherapy/Radiation therapy Symptoms- Burning sensation, bloating, hunger,

13. Pathogenesis Alteration in the balance b/w acid production and mucosal defence barrier resulting in damage to the lining epithelium.

14. GROSS Chronic duodenal ulcer Proximal duodenum few centimeters of pyloric valve n involve anterior duodenal valve Solitary <0.3cm Shallow 0.6cm- deeper ulcers Round , oval, sharply punched out defect Mucosal margin may overhang the base slightly Base is smooth and clean as a result of peptic digestion of exudate Blood vessels+

15. MICROSCOPY Active ulcers the base may have thin layer of fibrinoid debris underlaid by neutrophilic inflammatory infiltrate. Beneath this active granulation tissue infiltrated with mononuclear leucocyte and a fibrous or collagenous scar forms the ulcer base Vessel wall thickened, occasionally thrombosed Scarring – entire thickness, pucker surrounding mucosa

16. MICROSCOPY Low-power cross-section view of a duodenal ulcer crater with an acute inflammatory exudate in the base

17. Complications Bleeding Perforation Cancer

18. AMOE BIC ULCER Amoebiasis is caused by Entamoeba histolytica (ameba ) D ysentery-causing protozoan parasite spread by fecal-oral transmission. Pathogenesis. -E. histolytica cysts, which have a chitin wall and four nuclei, are the infectious form because they are resistant to gastric acid. -Cysts release trophozoites , the ameboid forms, which reproduce under anaerobic conditions without harming the host.

19. Morphology of amoebic ulcer C ecum and ascending colon, followed by the sigmoid colon, rectum, and appendix.

20. Discrete areas of ulceration covered by exudate , with normal intervening mucosa

21. MICROSCOPY- Ulcer shows inflammatory infiltrates and granulation tissues . Trophozoites of amoebae can mimic the appearance of macrophages because of their comparable size and large number of vacuoles. Amoebic ulcer-fan out laterally to create a flask-shaped ulcer with a narrow neck and broad base. E rythrophagocytosis . Special stains: - PAS- positive. - Iron Hematoxylin -positive.

22. Entamoeba histolytica

23. COMPLICATIONS: Parasites may penetrate splanchnic vessels and embolize to the liver to produce amoebic liver abcesses . Amebic liver abscesses , which can exceed 10 cm in diameter, have a scant inflammatory reaction at their margins and a shaggy fibrin lining. Amebae may also spread via the bloodstream into the kidneys and brain .

24. SALMONELLOSIS- Typhoid ulcer Causative agent- S. typhimureum . S. paratyphi .

25. PATHOGENESIS: Salmonella possess virulence genes that encode a type III secretion system capable of transferring bacterial proteins into enterocytes . The transferred proteins activate host cell Rho GTPases , bacterial uptake that allow bacterial growth within phagosomes . In addition, flagellin , the core protein of bacterial flagellae , activates TLR5 on host cells and increases the local inflammatory response

26. GROSS Usually affects ileum and colon. It present as longitudinal ulcer over the peyers patches. Typhoid ulcer

27. MICROSCOPY - Neutrophils accumulate within the superficial LP & macrophages containing bacteria, RBCs, nuclear debris mix with lymphocytes n plasma cells in LP. Mucosal shedding create oval longitudinal ulcers - Blunting of villi - Mucosal congestion and edema

28. CLINICAL FEATURES A norexia , abdominal pain, bloating, nausea, vomiting, and bloody diarrhea. Blood cultures are positive in > 90 % of affected individuals during the febrile phase. In chronic phase- Rose spots , small erythematous maculopapular lesions, are seen on the chest and abdomen.

29. Extra-intestinal complications including encephalopathy, meningitis, seizures, endocarditis , myocarditis , pneumonia, cholecystitis and Salmonella osteomyelitis .

30. TUBERCULAR ULCER Causative agent- Mycobacterium tuberculosis Mostly affects the ileum or ileocaecal junction May or may not be associated with TB elsewhere Intestinal tuberculosis contracted by the drinking of contaminated milk. In countries where milk is pasteurized, intestinal TB is caused by the swallowing of coughed-up infective material in patients with advanced pulmonary disease

31. MORPHOLOGY OF TUBERCULAR ULCER GROSS - Transverse ulcer in the direction of lymphatics - muliple and circumferential - Ulcer leads to fibrosis which cause stenosis and obstruction

32. MICROSCOPY CASEATING GRANULOMA - Shows central caseous necrosis surrounded by granuloma - Granuloma composed of epitheloid cells, langhans giant cells and lymphocytes. - AFB/ ZN Stain positivity.

33. TB- microscopy

34. BACILLARY DYSENTRY- Clostridium toxin It affects colon CAP LESION- Small yellow white plaque like lesions PSUEDOMEMBRANE FORMATION- fibrino purulent necrotic debris

35. GROSS

36. MICROSCOPY Epithelium- denuded Superficial LP- dense neutrophilic infiltrate, occasional fibrin thrombi within capillaries Damaged crypts are distended by mucopurulent exudate forming Mushroom/ Volcano fibrinous exudates.

37. BACILLARY DYSENTRY- Campylobacter jejuni It affects jejunum to ileum. Muiltiple superficial ulcer over the mucosa Microscopy - Cryptitis - Crypt abscess -Congestion -Ulceration

38. BACILLARY DYSENTRY- Campylobacter jejuni Crypt abscess

39. ULCERATIVE COLITIS It is a inflammatory bowel disease. It usually affects the rectosigmoid junction. Gross: - Irregular multiple ulcer - Multiple pseudopolyp - Continuos lesion with retrograde progression

40. UC- Inflammatory polyp

41. Microscopy : -Mucosal edema and hyperemia. -Crypt distortion -Crypt abscess -Mucosal depletion

42. UC- crypt abscess

43. CROHN’S DISEASE It is another inflammatory bowel disease. Affects ileum and proximal colon. Gross: -Long serpentine linear ulcer. -Cobblestone appearance. -Skip lesions. -Fissure and fistula. Microscopy shows non- caseating granuloma .

44. CROHNS DISEASE- Non caseating granuloma

45. CROHNS DISEASE ULCERATIVE COLITIS

46. CARCINOMATOUS ULCER Commonly affects the rectosigmoid area and affects any part of colon. Gross: - Single, firm, everted , large cauliflower shaped ulcer. Microscopy: -Shows malignant glands infiltrating to deep muscle area.

47. Carcinoma- gross

48. Carcinoma- microscopy

49. GRAFT VERSUS HOST DISEASE Usually occurs after bone marrow transplantation and rarely occurs following blood transfusion Symptoms include fever, skin rash, hepatitis, bone marrow suppression and the outcome is fatal. Pre-transfusion irradiation of all blood components containing lymphocytes will prevent GVHD

50. GVHD-Graft Verses Host Disease Any where in gastrointestinal tract. Features : -Crypt abscesses. -Inflammatory polyp. -Fibrosis. -Chronic inflammation.

51. BEHCET’S SYNDROME Affects large bowel. Shows multiple ulcers of various sizes, shape and depth. Microscopy shows lymphocytic vasculitis of submucosal veins.

52. Thank you