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Slide Seminar
Iatrogenic pathology of the gastrointestinal tract

September 3rd, 14.15-16.15 Auditorium VI
Chairpersons: Cord Langner (Austria) and Johanna Delladetsima (Greece)
Case 1
Presented by: Johanna Delladetsima, Athens , Greece

A 52 year-old male underwent colonoscopy due to a febrile watery diarrhea (6 episodes per day in the last two weeks). He had been transplanted 3 years ago due to end-stage renal failure attributed to focal segmental glomerulosclerosis. The immunosupressive regimen included Tacrolimus, Prednisolone and Mycophenolate mofetil (MMF). There was no previous history of GI pathology and kidney function was normal. No etiological diagnosis was established via hematological and biochemical tests, as well as stool cultures for enteric pathogens, examination for ova and parasites, and examination for Clostridium difficile toxins-A and B. Polymerase chain reaction (PCR) for cytomegalovirus (CMV) in serum samples obtained during the symptomatic period was negative.

Colonoscopy revealed subtle mucosal lesions such as erythema and small erosions in the right colon while left colon and terminal ileum showed oedema. Colonic biopsies were obtained.
Slide 1Slide 1 (HE) X40 Mucosa atrophy,crypt irregularitySlide 2 (HE) X100 Mucosa atrophy, crypt distortionSlide 3 (HE) X200 Mucosa inflammation, cryptitisSlide 4 (HE) X100 Dilated crypts, flat epitheliumSlide 5 (HE) X200 Crypt abscess, apoptotic bodiesSlide 6 (HE) X200 Crypt distortion and branching
Slide 7 (HE) X200 Crypt angulation Slide 8 (HE) X400 Crypt apoptotic bodies
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Case 2
Presented by: Louis Libbrecht, Gent, Belgium

A 67 year-old female underwent a gastroduodenoscopy during which a duodenal ulcus was detected and a biopsy was taken in the region of the ulcer. The patient was diagnosed with cirrhosis during a cholecystectomy 14 years ago and PBC was considered to be the etiology. 3 months before the gastroduodenoscopy, she underwent selective injection of Y90 microspheres in the hepatic artery of the right liver lobe in the setting of radioembolization treatment of multifocal hepatocellular carcinoma, which was diagnosed on imaging two months earlier. The patient was transplanted 4 months after the gastroduodenoscopy was performed
x40 HEx40 HE2x100 HEx200 HEx250 HEx400 HEx400 HE2
x100 nontumoralliverx200 livertumorx100 livertumor2x100 livertumor3
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Case 3
Presented by: Pedro Luis, Lisboa, Portugal

A 75 year-old female presented with abdominal pain and hematochezia. She underwent a colonoscopy that revealed multiple mucosal ulcerations suggestive of ischemic colitis. Colonic biopsies were performed. No other information was available at the time of the histological diagnosis. After the diagnostic report we received the clinical information that two days before the colonoscopy she presented at emergency room with a urinary tract infection and worsening of the chronic renal insufficiency that she had for 7 years. Because the patient had potassium levels of 6,2mEq/L she was treated with Sodium Sulfonated Polystyrene (Kayexalate), a cation-exchange resin. At the second day of treatment she started with bloody diarrhea. C. difficile toxin and Cytomegalovirus serology were negative.
Slide 1
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Case 4
Presented by: Robert Henry Riddell, Toronto Ontario, Canada

• F62. Upper GI bleed.
• Was endoscoped and a mass was found at the cardia, thought to be neoplastic and biopsied.
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Case 5
Presented by: Sibel Erdamar, Istanbul, Turkey

43 year old female was admitted to hospital due to bloody diarrhea (exceeding up 12 times a day in last 3 days), severe lower abdominal pain and cramping . In patient history, she declared that she went physician for tonsillitis 4 days ago and she had been taken amoxicilin/clavulonat 2000mg/day.  Her stool was cultured for common enteric pathogens and  tested for C. Difficile toxin A and B, which all were negative. In her stool specimen, Klebsiella Oxytoca was positive  using Mac Conkey agar plates.  Colonoscopy revealed segmental hemorrhagic colitis predominantly localized in ascending and transvers colon with rectal sparing. Colonic biopsies were performed.
Slide 1Slide 2Slide 3Slide 4Slide 5
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Case 6
Presented by: Miriam Cuatrecasas Freixas, MD. PhD, Barcelona, Spain

A 68-year-old male with a history of metastatic androgen-independent prostatic cancer presented with non-specific abdominal pain and dyspepsia. He underwent upper gastrointestinal endoscopy that showed no abonormal signs or lesions on the esophagic, gastric or duodenal mucosa on macroscopic inspection. Gastric biopsy specimens were taken to rule out Helicobacter pylori gastritis; no tissue from the oesophagus or duodenum was obtained.
Slide 1HE x2HE X100HE x400Ki-67 x100p53 x200
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Case 7
Presented by: Johanna Delladetsima, Athens , Greece

A 37-year old man was admitted to the hospital due to persistent diarrhea, abdominal pain and fever. The diarrhea was moderate to severe (>6 movements per day) composed of watery stools rarely accompanied by blood. The onset of diarrhea occurred 10 days after the 2nd dose of Ipilimumab (anti-CTLA-4mAbs) administration due to metastatic melanoma. Extensive work-ups, including serologic and stool microbiologic examination as well as testing for CMV by PCR-assay did not detect any causative factor.

Colonoscopy was performed and revealed mucosa erythema, friability and ulcers along the right colon and terminal ileum while transverse and left colon showed erythema and few erosions. Biopsies were taken from the terminal ileum, right and left colon and from the rectum.
Slide 1Slide 1 Right colon ulcerationsSlide 2 x100 (HE) Ulceration, lymphoid hyperplasiaSlide 3 x200 (HE) Mucin depleted atrophic cryptsSlide 4 x200 (HE) Crypt abscessesSlide 5 x200 (HE) Mild inflammatory changesSlide 6 x400 (HE) Intraepithelial lymphocytes
Slide 7 x400(HE) Mixed cryptitis, crypt abscessesSlide 8 x400(HE) Crypt base apoptotic bodies
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