Educational Case: Ischemic Disorders of the Gut in Adult Patients

Abstract

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040. ¹.

Keywords: blood supply of gut; gastrointestinal tract; ischemic disorders of the gut; organ system pathology; pathology competencies; vasculitis.

Figure 1.

A segment of small intestine displays a sharply demarcated zone of ischemic necrosis (left), typical of arterial insufficiency (gross image).

Figure 2.

Ischemic intestinal mucosa displays crypt loss and withered “crypts” with cytoplasmic depletion. The lamina propria appears hypereosinophilic due to leakage of serum proteins from injured mucosal blood vessels (A). Other areas contain regenerative crypts with easily identifiable mitotic figures (arrows; B). Hematoxylin and eosin; original magnification: ×400 (A-B).

Figure 3.

The medium-sized arteries show mixed inflammation in their walls and areas of fibrinoid necrosis (arrow; A). More advanced vascular lesions feature intimal proliferation with near-occlusion of the vessel lumen (B). Hematoxylin and eosin; original magnification: ×400 (A-B).

Figure 4.

Cytomegalovirus-associated vasculitis features mixed inflammation in and around vessel walls. Endothelial cells bearing “owl’s eye” inclusions (arrows) are the key to the diagnosis. Hematoxylin and eosin; original magnification: ×400.

Figure 5.

Enterohemorrhagic Escherichia coli infection produces ischemic colitis with crypt loss and lamina propria hyalinization. Prominent mucosal neutrophils are also characteristic of the infection. Hematoxylin and eosin; original magnification: ×400.

Figure 6.

Mucorales organisms migrate through a necrotic blood vessel wall in this infarcted intestinal segment. They have broad, pauci-septate hyphae that branch at random angles (shown by large arrows) and appear optically clear when sectioned transversely (shown by small block arrows). Hematoxylin and eosin; original magnification: ×400.

Figure 7.

Ischemic colonic mucosa overlies markedly thickened submucosal blood vessels (A). The vessels are expanded by amyloid deposits, which are deeply eosinophilic in hematoxylin and eosin (H&E) stains and show a characteristic “cracking” artifact (B). The deposits stain red with Congo red stains (C) and show “apple green” birefringence upon polarization (D). H&E (A and B); Congo red (C and D); original magnifications: ×40 (A), ×400 (B-D).