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HISTOPATHOLOGICAL SPECTRUM OF COLONIC MUCOSAL BIOPSY SPECIMENS
IN A TERTIARY CARE HOSPITAL
Dr. Nazia Aslam Hungund*1 and
2Dr. Thejasvi Krishnamurthy
1Postgraduate, Department of Pathology, Kempegowda Institute of Medical Sciences, Bengaluru.
2Associate Professor, Department of Pathology Kempegowda Institute of Medical Sciences, Bengaluru.
Article Received on 26/10/2020 Article Revised on 16/11/2020 Article Accepted on 06/12/2020
INTRODUCTION
A variety of disorders affect the large bowel, which
include inflammatory, idiopathic, infectious and
neoplastic diseases.[1]
Colonoscopy is an endoscopic visual examination of the
colonic mucosa with flexible optic fibres. It is a simple
procedure that helps in assessing the lesions clinically
and can provide histopathological confirmation with
guided biopsy.[2]
In developing countries, where Tuberculosis (Tb) and
infective colitis are more common, the diagnosis of
Inflammatory Bowel Disease (IBD) becomes a big
challenge.[2]
Biopsies aid in identifying neoplastic lesions, assessing
prognosis in IBD, determining changes in bowel habits,
evaluating symptoms of pain, bleeding, weight loss,
chronic constipation and diarrhea. They play a vital role
not only in diagnosis, but also in follow up and treatment
of inflammatory bowel disease and malignancies.[3]
To evaluate colonic lesions, correlation of
histopathological findings, along with clinical
presentation and colonoscopy diagnosis becomes very
useful. And this helps in definitive diagnosis and prompt
treatment of patients with colonic lesions.[2]
AIMS AND OBJECTIVES
To study the histomorphological spectrum of
colonoscopic biopsies.
To correlate them with clinical presentation and
colonoscopic diagnosis.
MATERIALS AND METHODS
This retrospective study was undertaken in the
department of Pathology, KIMS Hospital Bengaluru, for
the past three years, from January 2017 to December
2019. One hundred and fourteen biopsies received in the
SJIF Impact Factor 6.044 Research Article ejbps, 2021, Volume 8, Issue 1, 303-311.
European Journal of Biomedical AND Pharmaceutical sciences
http://www.ejbps.com
ISSN 2349-8870
Volume: 8
Issue: 1
303-311
Year: 2021
*Corresponding Author: Dr. Nazia Aslam Hungund
Postgraduate, Department of Pathology, Kempegowda Institute of Medical Sciences, Bengaluru.
DOI: https://doi.org/10.17605/OSF.IO/CBH9T
ABSTRACT
Introduction: Colonoscopy with biopsy is the diagnostic tool of choice in evaluating patients with colorectal
pathologies. Biopsies help in diagnosing neoplastic lesions, assessing prognosis in Inflammatory Bowel Disease
(IBD), exploring changes in bowel habits, evaluating symptoms of pain, bleeding, weight loss, chronic
constipation and diarrhea. Objectives: To study the histomorphological spectrum of colonoscopic biopsies. To
correlate them with clinical presentation and colonoscopic diagnosis. Methods: This retrospective study includes
all colonoscopic biopsies received in the Department of Pathology, KIMS Bengaluru from January 2017 to
January 2020. All biopsies were processed routinely and studied. Results: Out of 114 biopsies, 98 were non
neoplastic and 16 neoplastic. The most common presenting complaint for neoplastic lesions was per rectal
bleeding, and pain abdomen for non-neoplastic lesions. Non-specific colitis (38.78%) was the commonest non
neoplastic lesion, followed by ulcerative colitis (27.55%), ulcers (7.14%), granulomatous inflammation (7.14%).
Males (67.34%) showed a higher preponderance than females (32.66%). Among neoplastic lesions, benign lesions
accounted for 25% of the total neoplastic cases and 75% composed malignant lesions; adenocarcinoma being the
most common entity. Neoplastic lesions showed equal distribution in males and females.
Conclusion: Histopathological interpretation on colonic biopsies is a cornerstone in diagnosing and managing
patients with colonic lesions. Colonoscopic diagnosis correlated well with histopathology in carcinomas and
granulomatous lesions. IBD showed a sensitivity of 93.75% and a specificity of 78.2 %. Mucosal biopsies should
be a part of evaluation of patients with recurrent abdominal pain and bleeding per rectum, even if colonoscopy is
normal.
KEYWORDS: Colonoscopy, Biopsy, Histopathology.
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Histopathology section, Central laboratory were studied.
Only those cases where the patient’s age, sex, clinical
details, and colonoscopic findings were available were
included in our study.
Biopsies, fixed in 10 percent formalin, were received
with respective request forms containing relevant clinical
details. The tissue bits were counted, measured and
processed as per routine histopathology processing. From
each paraffin block, a 4 micron thick section was
prepared using a rotatory microtome. All slides were
stained with Hematoxylin and Eosin.
These slides were studied under light microscope and
after correlation with colonoscopy findings, a final
diagnosis was established. The concordance and
discordance between the colonoscopy findings and
histopathological findings was recorded, tabulated, and
analyzed.
This study was approved by the institutional ethical
committee (KIMS/IEC/A030/M/202).
RESULTS
Among all the colonoscopic biopsies examined during
the stipulated period of time, 75 were males and 39 were
females, giving a male-female ratio of 1.92:1.
Non neoplastic lesions affected the large bowel more
commonly, accounting for 98 of the total cases
(85.96%); 16 cases were neoplastic (14.04%). The most
common presenting complaint was per rectal bleeding
for neoplastic lesions, and pain abdomen for non
neoplastic lesions.
Biopsies were performed for all age groups, with the
youngest being a 6 year old, and the oldest being an 87
year old male. Age distribution of the lesions is
summarized in Table 1. Median presenting age for
common lesions is shown in Table 2.
Table 1: Age Distribution of Lesions.
Sr. No Age Distribution No. of Cases
1 0-20 7
2 20-30 16
3 30-40 26
4 40-50 14
5 50-60 14
6 60-70 23
7 70-80 12
8 80-90 2
Table 2: Association between Median Age and
Common Lesions.
Lesion Median Age
Non specific colitis 48
Ulcerative colitis 43
Granulomatous inflammation 31
Polyps 47
Adenocarcinoma colon 66
Non Neoplastic Lesions.
Fig 1: Distribution of Non neoplastic lesions.
Out of 98 non-neoplastic lesions, Non Specific colitis
was found to be the commonest lesion in 38 cases
(38.78%), followed by ulcerative colitis in 27 cases
(27.55%). Non neoplastic lesions were found in all age
groups with male-female ratio of 2.12:1.
Cases of nonspecific colitis showed oedema and mixed
inflammatory cell infiltrate in the lamina propria. Surface
ulceration and granulation tissue response were seen in
some of the cases. Few cases showed occasional glands
with mucin depletion.
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Fig 2: Descending colon – Normal study.
Fig 3: Caecum – Normal study.
Figures 2 and 3: Show a normal study on colonoscopy, seen in a 45 year old female at our centre.
Ulcerative Colitis on colonoscopy showed loss of normal
mucosal and vascular pattern, erythema, friability and
granularity, along with multiple ulcers at the rectum,
sigmoid and descending colon. Continuous and
circumferential involvement was noted (Fig 4).
Fig 4: Colonoscopic image showing loss of normal mucosal and vascular pattern, along with multiple
serpenginous ulcers with mucus at the rectum, sigmoid and descending colon, suggestive of ulcerative colitis.
On histopathology, it was characterized by architectural
crypt distortion and atrophy, along with features of
cryptitis and crypt abscess. Glandular regenerative atypia
and depleted mucin was noted in most of the cases.
Lamina propria showed dense mixed inflammatory cell
infiltrate; predominantly lymphoplasmacytic type.
Epithelial denudation, focal ulceration and lymphoid
aggregated were also seen in some of the cases (Fig 5,6).
Basal plasmacytosis was one of the characteristic feature.
Fig 5: Ulceration and Cryptitis seen in ulcerative
Colitis. H&E 40X.
Fig 6: Crypt Branching seen in Ulcerative Colitis.
H&E 100 X.
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3 cases diagnosed as Crohn’s colitis showed
microgranulomas and lymphocytic infiltrate in the
mucosa and submucosa, along with features of mucosal
atrophy, cryptitis, crypt distortion and mucus depletion
(Fig 7). 2 of the cases showed focal regenerative change.
Fig. 7: Histomorphological image showing Crypt
distortion and microgranulomas in Crohns disease.
H&E 40X.
Granulomatous inflammation was characterized by
epitheloid cell granulomas and lymphoplasmacytic
infiltrate in the lamina propria. Langhans giant cells and
foci of necrosis were noted as well (Fig 8). One of the
cases showed a pseudopolyp with regenerative change.
Fig 8: Histomorphological image showing
Granulomatous inflammation with epitheloid cell
granulomas and Langhans giant cells. H&E 40X.
Solitary Rectal Ulcer syndrome (SRUS) showed
irregular glands lined by benign epithelium. Splaying of
muscularis mucosae, fibrosis, congested blood vessels,
and sparse mononuclear cell infiltrate was noted in the
lamina propria.
Inflammatory polyps showed a polypoidal structure lined
by columnar cells. The stroma showed dilated glandular
structures filled with mucin with dense interstitial
inflammation.
Neoplastic Lesions
Adenomatous polyps accounted for 31.25% (5 cases) of
all neoplastic lesions. Architectural patterns included
tubular (1 case), villous (3 cases) and tubulo villous
adenomas (1 case) (Fig 9a,9b). Mean age at the time of
presentation was 51.7 years. There were 3 males and 2
females.
These polyps were lined by columnar epithelium, with
crowding and stratification, and showed varying degrees
of dysplasia. Bleeding per rectum was the most common
presentation.
Fig. 9a: Histopathological image showing
Tubulovillous adenoma H&E. 100 X.
Fig. 9b: Histopathological image of Tubulovillous
adenoma showing dysplasia. H&E 400.
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Amongst 16 colonoscopic biopsies diagnosed as
malignant lesions, 11 cases were adenocarcinomas,
accounting for 68.75% of all neoplastic cases. Majority
of the adenocarcinomas were well differentiated with 1
case revealing signet ring cell morphology. Male: female
ratio was 1.2:1. Mean age of presentation was 57.14
years. Majority of the cases were in the age group of 55-
65 years.
Carcinomas on colonoscopy were seen as a cauliflower
growth with ulceration and luminal narrowing (Fig:10)
and as stricturous growths (Fig 11). Fig 12a and 12b
show a large circumferential irregular growth at the
rectum, suggestive of carcinoma.
Fig 10: Colonoscopic image showing a Cauliflower
growth with ulceration at the descending colon
with luminal narrowing, suggestive of Ca
Descending colon.
Fig 11: Colonoscopic image showing a Stricturous
growth at the Sigmoid colon.
Fig 12a,b: Colonoscopic image showing Large circumferential irregular growth at the rectum, suggestive of
Carcinoma.
Adenocarcinomas were characterized by predominantly
glandular architecture, lined by cells showing atypical
nuclei with frequent mitosis. Few also showed
intervening desmoplastic stroma. Based on the degree of
differentiation, they were graded as well differentiated,
moderately differentiated and poorly differentiated. (Fig
13). One of them showed typical signet ring morphology
with abundant mucin and peripherally pushed
hyperchromatic nucleus.
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Fig. 13: Histomorphological image showing moderately differentiated Adenocarcinoma colon. H &E 100 X.
Our study showed a lower mean age of distribution in
adenomas than adenocarcinomas. Malignant tumors have
a long natural history, and present at a later age
explaining adenoma- carcinoma sequence.
Table 3: Correlation between Colonoscopy and Histopathological Diagonosis.
Co
lon
osc
op
ic D
iag
on
osi
s
Histopathological Diagnosis
Diagonosis
No
n s
pec
icif
ic c
oli
tis
Ulc
era
tiv
e C
oli
tis
Cro
hn
s D
isea
se
Ulc
er
Gra
nu
lati
on
Tis
sue
Tu
ber
cu
lar
typ
hil
itis
Infl
am
ato
ry P
oly
p
Ses
sile
ser
rate
d p
olp
/
Ad
eno
ma
tou
s p
oly
p
Ad
eno
carc
ino
ma
co
lon
SR
US
Ba
cter
ial
co
liti
s
Co
lla
gen
ou
s co
liti
s
Am
oeb
ic c
oli
tis
Pse
ud
om
ela
no
sis
coli
Eo
sin
op
hil
ic C
oli
tis
1 Normal study 15 0 0 0 0 0 0 0 0 1 0 1 0 1 0
2 IBD 8 9 1 3 2 0 1 0 0 0 0 0 0 0 0
3 ?UC 5 17 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Quiescent Crohns 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0
5 Ileocaecal Kocks/Tb 1 0 0 1 1 4 0 0 0 0 0 0 0 0 0
6 Ulcer 4 0 0 1 2 0 0 0 0 0 1 0 1 0 0
7 Nodular mucosa 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0
8 ?Carcinoma colon 0 0 0 0 0 0 0 0 9 0 0 0 0 0 0
9 Impacted faecal matter 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Polyp 0 1 0 0 0 0 3 5 0 0 0 0 0 0 0
11 Perforation with mass 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12 Oedematous mucosa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Mass 0 0 0 0 0 2 0 0 2 0 0 0 0 0 0
14 SRUS 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0
15 Small pinhead erosions 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
16 Stricture 3 0 0 1 0 0 0 0 0 0 0 0 0 0 0
17 Haemorroids 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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Fig 14: Depicts concordance and discordance with colonoscopy.
Table 4: Cohen’s Kappa values comparing common HPE Diagnosis with Colonoscopy.
HPE Diagnosis Cohen's Kappa Kappa Interpretation p-value
Non specicific colitis 0.4694 Moderate agreement 0.002
IBD 0.6955 Substantial agreement 0.017
Granulomatous Inflamation (?Tb) 0.8148 Almost perfect agreement 0.789
Neoplastic lesions 1.0000 Perfect agreement 1.000
The overall concordance rate between Histopathology
and Colonoscopy was substantial with a Kappa value of
0.7449.
DISCUSSION
The histomorphological profile of colorectal biopsies has
a wide spectrum, ranging from infections, inflammatory
conditions, precancerous lesions to colorectal
malignancies.[3]
Visual inspection of the colon and terminal ileum by
colonoscopy, along with biopsy plays an important role
in diagnosis and in determining disease activity.[1]
Colonoscopy is also considered a gold standard for
cancer surveillance, which is the third prevalent cancer in
men and women.[3]
It is safe and simple with no serious
complications and has been available since the 1970s.[3]
Colonic mucosal biopsies obtained from colonoscopy
play a pivotal role in the diagnosis of patients with
IBD.[3]
In our study, we observed an incidence of 30.61% for
IBD, among non neoplastic lesions, 27 cases being
Ulcerative Colitis and 3 being Crohns Disease. This
estimate is similar to the studies conducted by Qayyum
et al, Shama Vk et al, and Rangaswamy et al (24.4% of
non neoplastic lesions).[4,5]
The prevalence of IBD was high in the 30th
and the 40th
decade (median age 43 years) with diarrhea and
abdominal pain being the most common presenting
symptom. This is in line with studies conducted by
Badmapriya et al, Sood et al and Abhilash SC et al.[2,6,7]
Our study showed an equal distribution of IBD in males
and females. This is almost similar to a study conducted
by Badmapriya et al, where male to female ratio was
1.04:1.[6]
At present, an increased incidence of Ulcerative colitis
has been reported, considering the availability of better
diagnostic facilities, or due to rapid westernization of life
styles, including dietary habits and environmental
changes caused by industrialization and urbanization,
ultimately leading to intestinal epithelial dysfunction,
abnormal mucosal immune responses and altered gut
microbia.[6,7,8]
It is important to document dysplasia on colonic biopsy
with ulcerative colitis, as it is a significant predictor not
only of coexisting carcinoma, but also of their risk of
subsequent development of colorectal carcinoma. These
patients would require follow up and different modality
of treatment.[3]
Periodic surveillance of these patients helps in reducing
the risk of colorectal cancer, which is the most feared
long term complication of Ulcerative colitis.[1,9]
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Granulomatous lesions showed a higher preponderance
in females than in males. This correlates with studies
conducted by Geeta et al, Das P et al, Abdul Kareem et
al and Aljebreen AM et al. Mean age of presentation of
granulomatous lesions was 35 years, similar to studies
done by Phillipo et al and Karve et al.[3,10,11,12]
We were
able to demonstrate Acid Fast bacilli on only one of our
seven cases.
Nonspecific colitis was found to be the commonest non
neoplastic lesion in our study (38 cases), accounting for
38.78%. This is in accordance with studies conducted by
Rajbhanderr M et al, Shefali H leave et al, and
Deshpande V et al.[13]
Among neoplastic lesions, benign lesions accounted for
31.25% of cases and malignant lesions for 68.75%.
Adenomas of the colon were the most commonly
diagnosed benign entity and Adenocarcinoma was its
malignant counterpart. One of the cases also showed
signet ring type morphology. This is in accordance with
study series of Shefali et al, Laishram RS et al and
Shyamal Kumar et al, wherein the most common
histological grades were well differentiated and
moderately differentiated.[3,14]
Majority of cases fell in
the age group of 55 to 65 years, similar to these studies.
As seen in Fig 14, in our study, colonoscopic diagnosis
correlated well with histopathology in carcinomas and
granulomatous lesions. IBD showed a positive
correlation in 28 cases and false positive in 19 cases.
Colonoscopy is very useful for screening and early
detection of colorectal lesions, as these lesions produce
very vague symptoms.[1]
Precise diagnosis requires
knowledge of the classic morphological features of the
disease processes, as well as a number of atypical
pathological presentations, that may cause a
misdiagnosis.[15]
Table 5 shows the Sensitivity and Specificity of
colonoscopy for common lesions which was derived
from Table 3 data.
Table 5: Sensitivity and Specificity.
Sensitivity (%) Specificity (%)
Ulcerative Colitis 93.75 78.41
Granulomatous lesions 100 91.59
Neoplastic lesions 100 100
High sensitivity in detecting neoplastic and
granulomatous lesions can be attributed to obvious gross
findings of a growth/mass and ulcers during
colonoscopy.
According to literature, reasons for discordance between
colonoscopy and histopathology could be attributed to
use of conventional white light colonoscopy which
shows normal mucosa on colonoscopy but presence of
inflammation on histology. Incomplete biopsies due to
technical errors which could be due to adhesions due to
previous surgeries, diverticulosis, tortuosity, angulation
or fixation of bowel loops; ineffective sedation could
also play a role.[16]
Patient errors such as inadequate
bowel preparation, discomfort and intolerance, low body
mass, female sex, and young age, along with operator
factors, such as competency of the technician/surgeon
also contributes to dissonance.[16]
Typical colonoscopic findings of longitudinal ulcers in
Crohns disease and transverse ulcers in Tb aren’t always
present. Also, overlapping histomorphological features
exist between the two. Hence, differentiating between the
two requires correlation of clinical features,
colonoscopy, radiology and treatment response.
Availability of all the findings becomes necessary for a
better diagnosis.[1]
Endoscopic diagnosis of amoebic colitis mimics other
forms of colonic disease, such as Crohns, which can
again lead to discordance.[17]
CONCLUSION
Histopathological interpretation on colonic mucosal
biopsies has taken a cornerstone in the diagnosis and
management of patients with colonic lesions.
Colonoscopic diagnosis correlated well with
histopathology in carcinomas and granulomatous lesions
(particularly TB). IBD showed a positive correlation in
28 cases and false positive in 19 cases, thus showing a
sensitivity of 93.75% and a specificity of 78.2%.
Mucosal biopsies should be a part of evaluation of
patients with recurrent abdominal pain and bleeding per
rectum, even if colonoscopy is normal.
Accurate knowledge and acquaintance of normal
colonoscopy is also essential to better understand the
pathological findings within the colon.
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