Bladder, ureter & renal pelvis

Other nonneoplastic

Intestinal metaplasia


Editorial Board Member: Bonnie Choy, M.D.
Deputy Editor-in-Chief: Maria Tretiakova, M.D., Ph.D.
Rugvedita Parakh, M.D.

Last author update: 18 July 2022
Last staff update: 18 July 2022

Copyright: 2003-2022, PathologyOutlines.com, Inc.

PubMed Search: Intestinal metaplasia

See also: Cystitis cystica / glandularis

Rugvedita Parakh, M.D.
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Cite this page: Parakh R, Tretiakova M. Intestinal metaplasia. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/bladderintestinalmetaplasia.html. Accessed December 9th, 2022.
Definition / general
  • Replacement of urothelium by benign colonic or small intestinal epithelium, with presence of mucin producing goblet cells
    Essential features
    • Intestinal or colonic metaplasia: glandular epithelium with mucin secreting goblet cells (single or aggregates) replacing surface mucosa and von Brunn nests
    • May coexist with cystitis glandularis, characterized by formation of glandular structures in lamina propria within von Brunn nests that have an innermost lining of columnar or cuboidal cells bound by transitional cells at periphery
    Terminology
    • Also called glandular metaplasia, colonic metaplasia or goblet cell metaplasia
    ICD coding
    • ICD-10:
      • N30.80 - other cystitis without hematuria
      • N30.81 - other cystitis with hematuria
    Epidemiology
    • Identified in 71 - 90% of bladders at autopsy (Acta Pathol Jpn 1981;31:545)
    • Incidence increases with age; mean age of diagnosis 57 years (range 23 - 81 years)
    Sites
    • Lamina propria of trigone is most affected (Mod Pathol 2006;19:1395)
    • Also seen in ureter and renal pelvis
    • Mostly focal process but occasionally diffuse
    Pathophysiology
    • Metaplastic reactive alteration induced by chronic inflammation or irritation
    Etiology
    • Variation of normal histology
    • Chronic inflammation, ureteral reimplantation, neurogenic bladder, bladder exstrophy, paraplegia, stones, long term catheterization (J Urol 1981;126:822, J Urol 1970;104:699)
    Clinical features
    • Incidental finding
    • Hematuria, dysuria, urgency or obstructive symptoms
    • Rare cases may form mass lesion (< 1 cm) with mucin extravasation; may be confused cystoscopically with neoplastic process or malignancy (Am J Surg Pathol 1996;20:1462)
    Diagnosis
    • Cystoscopy finding of irregular or minimally elevated mucosa in a symptomatic patient
    • Microscopic findings of intestinal type epithelium with goblet cells replacing urothelium
    Prognostic factors
    • Long term follow up of intestinal metaplasia has confirmed a benign behavior (Urology 2008;71:915, Urology 1997;50:427)
    • If associated with dysplastic changes, considered as a harbinger of adenocarcinoma; close follow up is warranted (Clin Cancer Res 2007;13:6232)
    • If the lesion is extensive on initial transurethral resection, it is prudent to suggest area to be re-resected
    Case reports
    • 20 year old man with adenocarcinoma arising in residual native bladder in association with intestinal metaplasia and dysplasia of bladder mucosa, 17 years following gastrocystoplasty (J Pediatr Urol 2010;6:525)
    • 49 year old man with hematuria and radiologic abnormalities with no visible lesions (J Surg Case Rep 2018;2018:rjy193)
    • 60 year old man with spina bifida with bladder adenocarcinoma arising in intestinal metaplasia (Ann Diagn Pathol 2007;11:453)
    Treatment
    • May regress completely if pathogenic factor is removed
    • Frequent monitoring if symptoms persist or if associated with dysplasia
    Gross description
    Microscopic (histologic) description
    • Replacement of urothelium by tall columnar cells
    • Presence of goblet cells (single or aggregates) within von Brunn nests; variable presence of Paneth cells (small, intestine-like) or neuroendocrine cells (rare) (Mod Pathol 2006;19:1395)
    • May coexist with cystitis cystica or cystitis glandularis
    • Mucin may be occasionally extravasated into the stroma
    • No atypia, confined to the lamina propria, no involvement of muscularis propria
    Microscopic (histologic) images

    Contributed by Maria Tretiakova, M.D., Ph.D.
    Replacement of urothelium

    Replacement of urothelium

    Without dysplastic changes

    Without dysplastic changes

    Formation of cystic spaces

    Formation of cystic spaces

    GATA3

    GATA3


    CK20

    CK20

    CK20

    CK20

    CK20

    CK20

    HMWCK

    HMWCK



    Contributed by Rugvedita Parakh, M.D.
    Replacing urothelium

    Replacing urothelium

    Surface goblet cells

    Surface goblet cells

    Cytology description
    Positive stains
    Negative stains
    • CK7 (usually), HepPar1 (100%)
    • GATA3, HMWCK
    • Note: in the urinary bladder, intestinal metaplasia and typical cystitis glandularis have sharply contrasting immunoprofiles despite similar morphology (Mod Pathol 2006;19:1395)
    Electron microscopy description
    • Cystitis cystica:
    • Not needed for routine diagnostic purposes
    Molecular / cytogenetics description
    Sample pathology report
    • Bladder, biopsy:
      • Bladder mucosa with intestinal metaplasia (see comment)
      • Comment: No evidence of dysplasia or malignancy in submitted tissue.
    Differential diagnosis
    Board review style question #1

    The term intestinal metaplasia is recommended over cystitis glandularis to denote the presence of which of the following?

    1. Columnar cells
    2. Cuboidal cells
    3. Goblet cells
    4. Paneth cells
    Board review style answer #1
    C. Goblet cells. According to updated criteria, lesions containing mucin secreting goblet cells are classified as intestinal metaplasia and the term cystitis glandularis is discouraged.

    Comment Here

    Reference: Intestinal metaplasia
    Board review style question #2
    Which of the following features is considered to be a feature of intestinal metaplasia?

    1. Dysplasia (cytologic atypia)
    2. Invasion of muscularis propria
    3. Paneth cells
    4. Presence of dissecting mucin
    Board review style answer #2
    C. The presence of Paneth cells is a small intestinal type of metaplastic change. The other features, such as the presence of dissecting mucin, cytologic atypia and invasion of muscularis propria, are helpful to evaluate presence of dysplastic changes or malignancy (well differentiated adenocarcinoma).

    Comment Here

    Reference: Intestinal metaplasia
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