the surgical pathology of how not to sprue-up a small ...€¦ · tropical sprue?chronic...
TRANSCRIPT
![Page 1: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/1.jpg)
The surgical pathology of malabsorption
By Joel K. Greenson, M.D.
How not to sprue-up a small bowel biopsy
![Page 2: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/2.jpg)
DISEASES OF MALABSORPTIONDEFINITIONS
?Malabsorption:– Used broadly to describe impaired uptake by
the small intestine of one or more nutrients.
?Malabsorption Syndrome:– A group of clinical findings that typically
includes diarrhea, steatorrhea, weight loss, malnutrition, etc.
![Page 3: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/3.jpg)
*
![Page 4: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/4.jpg)
![Page 5: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/5.jpg)
![Page 6: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/6.jpg)
![Page 7: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/7.jpg)
![Page 8: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/8.jpg)
![Page 9: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/9.jpg)
![Page 10: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/10.jpg)
![Page 11: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/11.jpg)
![Page 12: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/12.jpg)
Disorders of MalabsorptionClassification
?Normal mucosal histology
?Non-specific inflammatory and architectural changes
?Demonstrable infectious agents
?Immunodeficiency present
?Misc. entities with characteristic findings
![Page 13: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/13.jpg)
Celiac Disease
?Also known as:– Childhood Celiac Disease– Adult Celiac Disease– Sprue, Non-tropical Sprue, Celiac Sprue– Gluten -Sensitive Enteropathy, Gluten -
Induced Enteropathy– Idiopathic Steatorrhea
![Page 14: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/14.jpg)
Cause of Celiac Disease
Alcohol InsolubleGlutenin
Alcohol SolubleGliadin
Water InsolubleFractionGluten
Water SolubleFraction
StarchFat
FiberProtein
Wheat Flour
![Page 15: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/15.jpg)
Celiac DiseaseHistopathology - prior to Tx
?Flat biopsy with surface damage
?Increased Intraepithelial lymphocytes
?Increased lamina propria inflammation
– Plasma cells
?Increased crypt mitoses
![Page 16: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/16.jpg)
![Page 17: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/17.jpg)
![Page 18: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/18.jpg)
![Page 19: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/19.jpg)
![Page 20: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/20.jpg)
![Page 21: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/21.jpg)
Celiac DiseaseHistopathology - Shortly after Tx
?Marked clinical improvement
?Surface epithelium restored
?Slight return of villi
?Other findings unchanged
![Page 22: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/22.jpg)
Gluten Free Diet - 2 Weeks
![Page 23: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/23.jpg)
Celiac DiseaseHistopathology - Long term Tx
?Continued clinical improvement
?Further return of villi
?Mitotic rate subsides
?Chronic inflammation subsides
![Page 24: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/24.jpg)
![Page 25: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/25.jpg)
![Page 26: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/26.jpg)
![Page 27: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/27.jpg)
Celiac DiseaseGluten Challenge
?Epithelial lymphocytes increase
?Epithelial damage to upper villi
?Full-blown lesion develops later
![Page 28: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/28.jpg)
![Page 29: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/29.jpg)
Celiac DiseasePathogenic Factors
?Genetic Aspects– Familial Occurrence (11-22% first degree relative)– Identical Twin Concordance (70%)– HLA Associations (DR3, DQw2, B8)?Environmental Factors
– Dietary Gluten– Twin non-concordance rate of 30%; separate onsets– ?Viral exposure (Adenovirus type 12)
![Page 30: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/30.jpg)
Serologic MarkersIn Celiac Disease
95-100%60-100%Anti-endomysium
95-100%42-100%Anti-reticulin
85-100%31-100%Anti-gliadin
SpecificitySensitivityMarker
Tissue Transglut 85-100% 92-97%
![Page 31: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/31.jpg)
Celiac DiseaseVariant and Overlap Forms
?Latent Celiac Disease– No symptoms, but histologic changes?Collagenous Sprue
– May also have Collagenous Colitis?Dermatitis Herpetiformis
– May have sprue-like small bowel biopsy without malabsorption
– Histology often less severe
![Page 32: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/32.jpg)
CD Iceberg
latent
normal
Diseased mucosa
Normal mucosa
DQ2___________________________
___________________________
___________________________ CD
![Page 33: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/33.jpg)
Celiac DiseaseComplications
?Refractory Celiac Disease– Malabsorption that responds to gluten
withdrawal initially, but is later unresponsive
?Refractory Sprue– Malabsorption that is unresponsive to
gluten withdrawal from the start
![Page 34: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/34.jpg)
Celiac DiseaseComplications
?Refractory Celiac Disease?Ulcers of Small Bowel?Malignancy
– T cell Lymphoma of gut and regional nodes– Adenocarcinoma of small bowel– Squamous cell carcinoma of esophagus and
oropharynx
![Page 35: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/35.jpg)
Small Intestinal Ulcers In Celiac Disease
![Page 36: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/36.jpg)
![Page 37: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/37.jpg)
Malabsorption
Remain Well
Benign Ulcer Refractory Celiac Disease Lymphoma
Deterioration
Response No Response(Refractory Sprue)
Gluten Free Diet
Sprue-like Changes
![Page 38: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/38.jpg)
Celiac DiseaseHistologic Mimics
?Celiac-related– Dermatitis Herpetiformis– Lymphoma– Collagenous Sprue?Other Substance Sensitivities
– Soy protein?General
– Peptic duodenitis– Tropical Sprue, Bacterial overgrowth– Autoimmune enteropathy, Lymphocytic enterocolitis– Microvillus inclusion disease, Crohn’s disease
![Page 39: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/39.jpg)
![Page 40: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/40.jpg)
![Page 41: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/41.jpg)
![Page 42: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/42.jpg)
![Page 43: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/43.jpg)
![Page 44: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/44.jpg)
Normal Architecture Increased IELs
?Gluten Sensitive Enteropathy– Early type 1 lesion or treated sprue?Other food hypersensitivity?H. Pylori (usually only in bulb)?Autoimmune conditions (RA, SLE, MS, Graves,
Hashimoto’s, Diabetes?Post-infection?Drugs (NSAIDs)
![Page 45: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/45.jpg)
![Page 46: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/46.jpg)
![Page 47: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/47.jpg)
![Page 48: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/48.jpg)
Tropical Sprue
?Chronic malabsorption after infectious diarrhea commonest in tropical regions
?Bacterial overgrowth with B-12 and Folate deficiencies -often responds to antibiotics and vitamin supplements
?Biopsy findings are variable
– Sprue-like changes with less intense damage than full blown celiac disease
– Both Jejunum and Ileum involved
![Page 49: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/49.jpg)
![Page 50: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/50.jpg)
![Page 51: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/51.jpg)
Stasis Syndrome(Bacterial Overgrowth)
?Crohn’s Disease?Diverticular Disease?Scleroderma?Pseudo-obstruction?Post-Surgical
– Blind loop or Pouch– Entero-enterostomy– Afferent loop– Fistulae- Adhesions/partial obstruction
![Page 52: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/52.jpg)
Bacterial OvergrowthBiopsy Findings
?Irregular Villi
?Surface cell damage
?Plasmacytosis
?Neutrophils
?Crypt Hyperplasia
?“Doesn’t fit”
![Page 53: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/53.jpg)
![Page 54: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/54.jpg)
![Page 55: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/55.jpg)
Pathophysiology of Stasis
Malapsorption
Bile SaltDeconjugation
Malabsorption
EpithelialInjury
Anemia
B-12 Deficiency
Bacterial Overgrowth(Esp. Anaerobes)
StasisSmall Intestine
![Page 56: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/56.jpg)
Disorders of MalabsorptionClassification
?Normal mucosal histology
?Non-specific inflammatory and architectural changes
?Demonstrable infectious agents
?Immunodeficiency present
?Misc. entities with characteristic findings
![Page 57: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/57.jpg)
![Page 58: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/58.jpg)
Whipple’s Disease
?Described by George Whipple in 1907 as “intestinal lipodystrophy”
– Whipple described rod shaped bacteria within lymphoid tissues and thought they might cause the disease
?Subsequently thought to be a lipid storage disorder until advent of EM in the early 1960’s
![Page 59: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/59.jpg)
Whipple’s Disease
?741 patients reported as of 1988, many multiple times
?20,000 authors reported these patients
?This works out to 27 authors per patient
– (a fairly high CV bulk ratio)
![Page 60: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/60.jpg)
Whipple’s Disease
?Clinical Presentation:– Most patients are middle-aged white males– ? T cell defect, Associated with HLA-B27– Present with diarrhea, malabsorption, weight
loss and abdominal pain– Systemic and neurologic symptoms may
overshadow GI complaints– May present with only CNS symptoms
![Page 61: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/61.jpg)
Whipple’s DiseaseHistopathology
?Blunted and distorted villi– Contain macrophages, neutrophils, lipid
droplets, and dilated lacteals?Foamy macrophages fill the lamina propria
– Granular PAS positive diastase resistant inclusions
– May see PAS + rods in extracellular areas– AFB negative
![Page 62: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/62.jpg)
![Page 63: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/63.jpg)
![Page 64: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/64.jpg)
![Page 65: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/65.jpg)
![Page 66: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/66.jpg)
![Page 67: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/67.jpg)
?Silver stains may help highlight intact bacteria
– May find bacteria in epithelium, endothelium, lymphocytes, even fibroblasts
?EM shows phagosomes stuffed with bacteria in various phases of digestion
?PAS+ macrophages remain for years, but intact bacteria should disappear soon after start of Tx
Whipple’s DiseaseHistopathology
![Page 68: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/68.jpg)
![Page 69: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/69.jpg)
![Page 70: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/70.jpg)
?Lymph nodes, liver, heart, brain, eyes, and colon may all have foamy macrophages andgranulomatous foci– May or may not be PAS+– Much harder to diagnose than Small bowel bx– May mimic Sarcoidosis clinically and
pathologically
Whipple’s DiseaseExtra-intestinal Pathology
![Page 71: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/71.jpg)
![Page 72: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/72.jpg)
?False Positives:– Mycobacteria avium/intracellulare– Muciphages (rectal biopsy)– Lymph nodes (other PAS+ substances)?False Negatives:
– Sampling error– Submucosal form of disease– May have no histologic involvement but be PCR+
Whipple’s DiseaseDiagnostic Pitfalls
![Page 73: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/73.jpg)
![Page 74: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/74.jpg)
![Page 75: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/75.jpg)
![Page 76: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/76.jpg)
![Page 77: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/77.jpg)
![Page 78: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/78.jpg)
![Page 79: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/79.jpg)
![Page 80: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/80.jpg)
Muciphages
PAS Alcian Blue
![Page 81: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/81.jpg)
![Page 82: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/82.jpg)
![Page 83: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/83.jpg)
?Small Bowel Biopsy– PAS stain– EM or Silver stain?Blood Smear?PCR
– Tissue or blood
Whipple’s DiseaseDiagnostic tests/Ancillary studies
![Page 84: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/84.jpg)
![Page 85: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/85.jpg)
?Giardia lamblia - first protozoa discovered in the human intestine– Described by Leeuwenhoek in 1681 ( in his own stools)?Most prevalent gut parasite in the U.S. (7.4%)?May be endemic or epidemic
– 23% of American travelers to Leningrad found to be infected over a 4 year period
– Often spread by children via day care/school
Giardiasis
![Page 86: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/86.jpg)
?Fecal/oral spread- contaminated drinking water- intimate contact, “gay bowel disease”
?Children and patients withagammaglobulinemia, hypogammaglobulinemia,IgA deficiency, and/or achlorhydria are at increased risk?Immunosupressed patients more likely to have chronic infection
GiardiasisEpidemiology
![Page 87: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/87.jpg)
?Clinical Symptoms:
–Acute diarrhea with greasy foul smelling stools, no blood
-Abdominal distention, bloating, pain, and flatulence
-Weight loss and malabsorption
Giardiasis
![Page 88: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/88.jpg)
?Trophozoites are identifiable on H&E stained sections
- Ventral view: pear shaped body with 2 nuclei
- Lateral view: Sickle shaped body
- “Smudgy blue-grey blobs” that mimicextravesated mucus
- Clumped together between villi or attached to epithelial surface, rare reports of invasion
GiardiasisHistopathology
![Page 89: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/89.jpg)
![Page 90: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/90.jpg)
![Page 91: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/91.jpg)
![Page 92: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/92.jpg)
![Page 93: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/93.jpg)
GiardiasisHistopathology
?Special stains may help bring out details of organism: trichrome, giemsa, PTAH or PAS?Touch preps of biopsy may also help?Inflammatory response is quite variable:
– Some have normal biopsies, some have minor non-specific changes
– Some get sprue-like changes, particularlyhypogammaglobulinemic patients
![Page 94: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/94.jpg)
![Page 95: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/95.jpg)
![Page 96: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/96.jpg)
GiardiasisBiopsy techniques/ancillary studies
?Organisms are best found in distal duodenal or proximal jejunal biopsies
?Duodenal fluid aspirate or String test may have better yield
?Cysts may be identified in Stool exam (both cysts and trophs in stool if diarrhea is severe)
?Stool antigen test available
![Page 97: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/97.jpg)
Cryptosporidia
?C. parvum is the species– Organism lives within brush border– Common in animals, may be a zoonosis?Healthy persons
– ?Asymptomatic carrier state– Endemic and epidemic infections– Self-limited diarrheal illness?Immunodeficient persons
– Chronic diarrhea, malabsorption
![Page 98: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/98.jpg)
![Page 99: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/99.jpg)
![Page 100: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/100.jpg)
![Page 101: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/101.jpg)
![Page 102: The surgical pathology of How not to sprue-up a small ...€¦ · Tropical Sprue?Chronic malabsorption after infectious diarrhea commonest in tropical regions?Bacterial overgrowth](https://reader030.vdocument.in/reader030/viewer/2022040605/5eace6a3dca378187c499f1c/html5/thumbnails/102.jpg)