Contributed by Felicia D. Allard, M.D. and Claudio Luchini, M.D., Ph.D.
Ampullary ductal carcinoma
Firm gray-white thickening
Contributed by Felicia D. Allard, M.D.
Intestinal type adenocarcinoma
Signet ring cell morphology
Adenocarcinoma arising from IPTN
Ampullary duct carcinoma
Pancreaticobiliary phenotype
CDX2 pancreatobiliary phenotype
CK7 pancreatobiliary phenotype
CK20 pancreatobiliary phenotype
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Suspicious growth with jejunal stricture
Near obstructing mass distal to duodenal bulb
Irregular and ulcerated jejunal lesion (capsule endoscopy)
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Jejunal
submucosal tumor
with overlying
normal mucosa
Jejunal tumor invading adherent transverse colon
Ileal tumor with ulceration
Contributed by Krutika S. Patel, M.B.B.S., M.D. and Annika L. Windon, M.D.
Well differentiated adenocarcinoma
Moderately and poorly differentiated adenocarcinoma
Mucinous adenocarcinoma
Lymph node metastasis
Higher stage carcinomas
Ileal adenocarcinoma arising in Crohn's disease
Signet ring adenocarcinoma
Adenocarcinoma arising in a tubulovillous adenoma
Lymphovascular invasion
Perineural invasion
Cytokeratin 7
Cytokeratin 20
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Duodenal adenocarcinoma and normal mucosa
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Endoscopy
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Raised lesion at ampulla of Vater
Contributed by Raul S. Gonzalez, M.D. and @Andrew_Fltv on Twitter
Ampullary adenoma with low grade dysplasia
Adenoma
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Ampullary adenoma with high grade dysplasia
Ampullary adenoma
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Pap
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Duodenum
Local anatomy (called common duct)
Papilla
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Ileum and terminal ileum
Contributed by Grigory Demyashkin, M.D., Ph.D. and Suhail Muzaffar, M.B.B.S.
6 - 8 week embryo
Small intestine - normal (duodenum)
Contributed by Archana Shenoy, M.D.
Duodenal biopsy
Colon biopsy
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Ulcers - site unspecified
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Duodenum showing cobblestone pattern
Contributed by Hany Al Khedr, M.D.
Duodenal bulb polyp endoscopy
Contributed by Divya Sharma, M.D.
Brunner glands in submucosa
Glands within fibrous stroma
Bland cuboidal cells
Foveolar metaplasia
Dilated ducts
Mature adipocytes
Fibrous septa
Modified Marsh-Oberhuber classification of histologic findings in celiac disease:
| Marsh type | IEL/100 enterocytes: jejunum | IEL/100 enterocytes: duodenum | Crypt hyperplasia | Villi |
| 0 | < 40 | < 30 | Normal | Normal |
| 1 | > 40 | > 30 | Normal | Normal |
| 2 | > 40 | > 30 | Increased | Normal |
| 3a | > 40 | > 30 | Increased | Mild atrophy |
| 3b | > 40 | > 30 | Increased | Marked atrophy |
| 3c | > 40 | > 30 | Increased | Complete atrophy |
| 4 | > 40 | > 30 | Atrophic | Severe (flat) |
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Diagnostic flowchart
in case of suspected
gluten related disorder
Diagnostic approach of refractory disease
Contributed by Erdener Özer, M.D., Ph.D.
Normal versus flattened mucosa
Contributed by Erdener Özer, M.D., Ph.D., Arzu Ensari, M.D., Ph.D. and Case #127
Normal versus Marsh type IIIb / IIIC
Response to gluten free diet
Collagenous sprue
56 year old woman
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RCD type 2
Celiac Disease: A Fairly Advanced Lecture for Primary Healthcare Providers
Case #398
H&E images
Contributed by @RaulSGonzalezMD on Twitter
Contributed by @RaulSGonzalezMD on Twitter (see original post here)">
Common variable immunodeficiency syndrome
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Longitudinal ulcers,
cobblestone appearance
and aphthous ulcers
Lymphoid follicles with red ring sign
Contributed by Elias Makhoul, D.O.
Small intestine with ulcer
Creeping fat
Stricture
Fistula
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Terminal ileum: mucosal (inflammatory) pseudopolyps
Terminal ileum: cobblestone change
Thickened bowel wall and fat wrapping
Contributed by Mary Wong, M.D., M.B.A.
Transmural inflammation with granulomas
Noncaseating granulomas
Pyloric metaplasia
Ulceration with overlying stricture
Case #240
Various images
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Various images
Case #240
H&E
Trichrome
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Jejunal diverticula
Contributed by Raul S. Gonzalez, M.D.
Endoscopy
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Acute duodenal ulceration
Contributed by Raul S. Gonzalez, M.D.
Gastroduodenal junction resection
Contributed by Raul S. Gonzalez, M.D.
Granulation tissue
Adjacent mucosa
Fibrinous ulcer
Helicobacter infection in duodenum
Severe duodenal peptic ulcer
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Mucin filled cysts (PAS diastase)
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CT scan
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Periampullary submucosal tumor
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Tumor near ampulla
Contributed by Raul S. Gonzalez, M.D.
Submucosal tumor
Nests and trabeculae
Epithelioid cells
Spindled cells
Ganglion cells
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Life cycle
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Duodenal giardiasis on endoscopy
Contributed by Centers for Disease Control and Prevention
Giardia
Contributed by Iresha Vithanage, M.B.B.S., M.D., Saroona Haroon, M.B.B.S., Bobbi Pritt, M.D.,
Emily Fernholz, MLS (ASCP), Suhail Muzaffar, M.B.B.S. and Bilal Karim Siddiqui, M.D. (Case #157)
Normal villous morphology
Giardia organisms in intervillous spaces
Kite and pear shaped Giardia
Giardia trophozoites
along surface of
foveolar epithelial cells
Sickle shaped trophozoites
Trichrome stained stool specimen, Giardia duodenalis
Giardia trophozoites
Giardiasis tutorial
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Guidelines for risk assessment of primary GIST
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Duodenal GIST
Jejunal GIST
Ileoileal intussusception - small bowel GIST
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Small bowel GIST
Endoscopy of ulcerated mass
Contributed by Shefali Chopra, M.D.
Adherent small bowel
Hemorrhage & cystic change
Contributed by Shefali Chopra, M.D.
Relation to overlying mucosa
Skeinoid fibers
Spindle cell morphology
Therapy effect
CD117
DOG1
Contributed by Shefali Chopra, M.D.
Diff-Quik, spindle cells
Pap, spindle cells
Cell block, spindle cells
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KIT mutations
Small bowel GIST
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33 year old man with HGM in ileum
12 year old girl with extensive HGM
Case #124
Intraluminal polyp
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33 year old man with HGM in ileum
14 year old boy with HGM in ileum
Contributed by Khalid Amin, M.D.
Ileal polypoid lesion
Gastric glands
Jejunal polypoid lesion
Underlying antral glands
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Ampulla of Vater and related structures
Ampulla, papilla and sphincters
Contributed by Raul Gonzalez, M.D.
Normal ampullary mucosa and submucosa
Ampullary submucosal glands / ductules
Contributed by Danielle Hutchings, M.D.
Jejunum
Contributed by Danielle Hutchings, M.D.
Layers of small intestine
Villi
Paneth cells
Brunner glands
Peyer Patches
Submucosa
Muscularis propria
Microvilli and goblet cells
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Microvillus of small intestine
Small intestine: histology
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Duodenal hyperplastic polyp
Contributed by Hanni Gulwani, M.D.
CMV pouchitis: biopsy of postcolectomy pouch in 38 year old man with ulcerative colitis
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Various images
Contributed by Claudia Mendez, M.D.
Inflammatory fibroid polyp
Contributed by Claudia Mendez, M.D.
4x
10x
40x
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IAPN gross / histologic correlation
Contributed by Felicia D. Allard, M.D.
Pancreatobiliary type IAPN
Intestinal type IAPN
Paneth and goblet cells
Intestinal IAPN with high grade dysplasia
Pancreaticobiliary phenotype tubular growth
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IAPN phenotype immune profiles
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IAPN gross / histologic correlation
Contributed by Felicia D. Allard, M.D.
Pancreatobiliary type IAPN
Intestinal type IAPN
Paneth and goblet cells
Intestinal IAPN with high grade dysplasia
Pancreaticobiliary phenotype tubular growth
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Gentle reduction of the ileoileal intussusception
Contributed by Krutika S. Patel, M.B.B.S., M.D.
CT scan
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Infarcted small intestine
Marked hyperemia
Early ischemic enteritis
Resected ischemic jejunal segment
Contributed by Krutika S. Patel, M.B.B.S., M.D. and Madison Swaney, M.D.
Early ischemic changes
Ischemic changes
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Various images
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Various images
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Genotype phenotype correlations in JPS
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Magnetic resonance enterography of ileal polyp
Contributed by Milton Smith, M.D.
Juvenile polyps in duodenum
Large eroded juvenile polyp
Multiple juvenile polyps
Contributed by Divya Sharma, M.D., Rachel Sheridan, M.D. and Sara Szabo, M.D.
Surface erosion
Inflammatory stroma
Granulation tissue
Branching glands
Glandular hyperplasia
Glandular hyperplasia
Slit-like serrations and inflammation
Finger-like lobulation of glands
Low grade dysplasia
Ileal polyp, surface erosion
Ileal polyp, dilated glands
AFIP images
Esophageal leiomyomas
Contributed by @Andrew_Fltv on Twitter
Lipoma
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Large pedunculated polypoid lipoma
Contributed by @Andrew_Fltv on Twitter
Lipoma
Lipoma
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Circumscribed collection of mature adipocytes
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Hypoechoic on ultrasound
CT with submucosal fat
Multidetector CT
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Smooth ileocecal lesion
Contributed by Jian-Hua Qiao, M.D.
Thickened ileocecal valve
Donut shaped ileocecal valve
Contributed by Jian-Hua Qiao, M.D.
Unencapsulated submucosal adipose
Villi resembling terminal ileum mucosa
Unencapsulated submucosal adipose
Well defined crypts resembling cecal mucosa
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Markedly dilated lymphatics
Contributed by Monika Vyas, M.D.
Ectatic lymphatics
Dilated lymphatic channels
Polypoid lesion
Irregularly dilated lymphatics
Contributed by Haider A. Mejbel, M.D.
Lobular contour
Dilated lymphatics
Endothelial cells
Nuclear uniformity
CD31 expression
Contributed by Hanni Gulwani, M.D.
Lymphocytic ileitis: ileal biopsy from 28 year old man with chronic diarrhea
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Terminal ileum exhibiting
shows mucosal ulcers
due to nodular lymphoid
hyperplasia
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Various images
Contributed by Raul S. Gonzalez, M.D.
Low power
Intermediate power
High power
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Barium examination
Technetium 99m pertechnate scan (Meckel scan)
Contributed by Lizhi Zhang, M.D.
Giant Meckel diverticulum
Antimesenteric location
Luminal connection
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Meckel diverticulum with perforation
Contributed by Lizhi Zhang, M.D.
All layers of intestinal wall
Ectopic gastric mucosa
Ectopic pancreatic tissue
Case #106
Abdominal cavity
Small intestine
Case #106
Peritoneal surface
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TLR4 signaling in pathogenesis of necrotizing enterocolitis
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Various images
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Various images
Case #322
Mixed adenoneuroendocrine carcinoma
Line 2: CDX2 (left); chromogranin (middle); synaptophysin (right)
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Large cell neuroendocrine carcinoma
Small cell neuroendocrine carcinoma
Nests of small cells
with uniform round
nuclei with classic salt
and pepper chromatin
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PET / CT
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Ampullary NET on endoscopy
Contributed by Megan Kinn, D.O., M.S.
Ileal neuroendocrine tumor
Liver metastasis
Contributed by Megan Kinn, D.O., M.S.
Ileal NET extending to mucosa
Nests of tumor cells
Salt and pepper chromatin
Ki67
Contributed by Wei Zheng, M.D., Ph.D.
Ampullary NET
Trabecular and glandular architecture
Psammoma bodies
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Thickened bowel wall
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Normal colonoscopy
Duodenal villous atrophy
Duodenal fold attenuation
Contributed by David Hernandez Gonzalo, M.D.
Moderate villous atrophy and crypt hyperplasia
Increased intraepithelial lymphocytes
Focal active inflammation
Complete histologic recovery
Contributed by Mohamed Mostafa, M.D.
Surface foveolar metaplasia and Brunner gland hyperplasia
Foveolar metaplasia and lamina propria expansion
H. pylori associated peptic duodenitis
Surface foveolar metaplasia
Contributed by @RaulSGonzalezMD on Twitter
Contributed by @RaulSGonzalezMD on Twitter (see original post here)">
Helicobacter pylori colonizing foveolar metaplasia in the duodenum? bit.ly/38K3WT0 #pathology #PathTwitter #PathOutPic"Contributed by @RaulSGonzalezMD on Twitter (see original post here)">
Peptic duodenitis
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Axial T1 weighted image - enhancement of rounded PJP
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Hyperpigmented macules of the perioral area
Lobular duodenal polyp
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Duodenal dilatation, arborizing polyps
Arborizing polyps, pedunculated and sessile
Intraluminal polyp
Contributed by Krutika S. Patel, M.B.B.S., M.D. and @SueEPig on Twitter
Jejunal Peutz-Jeghers polyp
Tree-like arborization of smooth muscle
Distinct lobular configuration of epithelium
Bland epithelial component
Surface erosion
Epithelial misplacement
Peutz-Jeghers polyp
Small bowel, Peutz-Jeghers polyp
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Endoscopy
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Various images
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Various images
Contributed by @liverwei on Twitter
Pseudomelanosis duodeni
Case #231
Various images
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Various images
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Acute changes (mice)
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Acute cellular rejection (CT)
Acute cellular rejection (MRI)
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Endoscopic appearance of ACR
Contributed by Jen Rytych, M.D.
Mild ACR, mild inflammation
Focal villous blunting
Few apoptotic figures
Erosion and crypt dropout
Many apoptotic figures
Extensive ulceration
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Encapsulating thick,
white adherent
membrane encasing
small bowel
Contributed by Sajna V. M. Kutty, M.D. (Case of the Month #482)
Right colon limited resection for possible enteric duplication cyst in the distal ileum
Contributed by Sajna V. M. Kutty, M.D. (Case of the Month #482)
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Regional lymph nodes of the Ampulla of Vater
Pancreas / Ampulla of Vater staging
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Mild backwash ileitis in moderately active cecal chronic ulcerative colitis resection specimen; mucosa
of distal ileum is edematous and villi are slightly wider and flatter than normal; most of the active colitis
stops abruptly at transition point between the two mucosae; the two most distal villi have the greatest
degree of injury, including blunting, edema and neutrophils in the lamina propria and surface epithelium
Moderate backwash ileitis
Severe backwash ileitis
Terminal ileum inflammation: (A) grade
1, cryptitis; (B) grade 2, scattered
crypt abscesses; (C) grade 3, numerous
crypt abscesses; (D) grade 4, ulcer
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Contrast study
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Endoscopic findings
Contributed by John D. Paulsen, M.D. and Alexandros D. Polydorides, M.D., Ph.D.
Lamina propria macrophage infiltrate
Foamy macrophages
Positive PAS stain
Negative AFB stain
Negative GMS stain
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CSF cytospin with PAS
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Whipple disease, duodenum
T. whipplei bacteria
Bacterium (arrowhead)
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Gel electrophoresis of PCR products
Albores-Saavedra: 2016
Cheng: 2023
Greenson: 2019
IARC: 2019
Lamps: 2015
Montgomery: 2017
Montgomery: 2017
Montgomery: 2017
Odze: 2022
Srivastava: 2023
Yantiss: 2021
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