Segmental filiform-polyposis in a treated case of ulcerative colitis, colon: An unusual presentation raising a doubt of primary diagnosis?

Inflammatory bowel disease is broadly classified into Crohn's disease and ulcerative colitis. The standard criteria to distinguish between the two is the manner of the involvement of the bowel, with the former showing classical skip lesions and the latter having continuous involvement of the colon, most commonly affecting the rectum. However, some cases exhibit overlapping features. Herein, we report a treated case of ulcerative colitis presenting with patchy involvement of the colon in the form of peculiar segmental filiform polyposis spanned abruptly by an intervening normal mucosa. The clinico-radiologically suspicion of carcinoma colon with Crohn's colitis was considered. The clinicians and pathologists must be aware of such atypical presentations and should not be misled to change the diagnosis from ulcerative colitis to Crohn's colitis on the post-treatment resection specimens or endoscopic biopsies solely in view of the patchy filiform polyposis (FP), which poses a drastic impact on the patient's management.

Plexiform fibromyxoma of the stomach: An underrecognized entity!

Plexiform fibromyxoma (PF) is a recently described rare type of mesenchymal tumor of the stomach with only 123 cases reported in the literature. It is characterized by a peculiar plexiform growth pattern, myxoid stroma with arborizing microvasculature, and spindle-shaped myofibroblastic cells. We herein report a case of gastric PF in a 15-year-old boy, mimicking a gastrointestinal stromal tumor (GIST) due to overlapping clinicoradiological features. Distinct pathological and immunohistochemical features of PF do aid in distinction from GIST and other mesenchymal entities. Diagnosis is crucial as surgical resection is the mainstay of treatment unlike aggressive management in GIST. It is a benign entity with no local recurrence or distant metastasis reported so far, but confirmation of the same requires longitudinal observational studies with a larger sample size.

Giant hyperplastic gastric polyp: A diagnostic dilemma!!

Gastric hyperplastic polyps (GHP) account for a majority of benign gastric polyps. Most of the GHPs are <2 cm, asymptomatic, and incidentally detected on endoscopy or radiologically. With increasing size, these polyps manifest as upper gastrointestinal bleeding, iron deficiency anemia, and gastric outlet obstruction (GOO). We report an unusual case of giant GHP simulating gastric carcinoma and posing as a diagnostic challenge for the surgeons emphasizing the diagnostic role of histopathology. A 46-year-old female presented with clinical features of progressive GOO for 1 year. Endoscopy revealed an eccentric proliferative lesion in the antrum. Computed tomography showed a polypoidal, enhancing mural thickening involving distal body and antro-pyloric region measuring 8.4 cm × 6.6 cm × 1.8 cm. Subtotal gastrectomy was done in view of clinical features of GOO and having a clinical suspicion of malignancy. Gross examination showed a giant sessile hyperplastic polyp with lobulated surface. Microscopy revealed features of a large, sessile hyperplastic polyp without any evidence of dysplasia. The patient was symptomatically relieved and is on follow-up. To conclude, giant GHPs can mimic gastric carcinoma on endoscopy and radiology. The possibility of giant GHP should be kept in mind in the presence of an intensely contrast-enhancing polypoidal lesion in the gastric antrum. Long-term endoscopic follow-up is recommended.

Incidentally detected asymptomatic hepatitis C virus infection with significant fibrosis: Possible impacts on management

Background and Aims: Liver biopsy may be considered in patients with hepatitis C virus (HCV) infection to assess the severity of liver injury and stage of fibrosis, thereby guiding therapeutic decisions. In addition, advanced stage also necessitates surveillance for hepatocellular carcinoma. The aim of this study was to assess whether transaminase (alanine transaminase [ALT]) levels and RNA titers correlate with the histological activity index (HAI) and fibrosis (F) stage in asymptomatic patients with incidentally detected HCV (IDHCV). Patients and Methods: Retrospective evaluation of liver biopsies was done in 113 patients with IDHCV, diagnosed during routine screening. Decision of liver biopsy was made on the basis of age, genotype, acceptable clinical, hematological, and biochemical profiles, and willingness of the patients to undergo treatment. Serum ALT levels, HCV RNA titers, and genotypes were correlated with HAI and F stage. Results: Genotyping was done in 77 of the 113 patients, of which genotype 3 was seen in 43 and genotype 1 in 25 patients. A higher fibrosis stage (Ishak's >F2) was noted in 23.8% of the biopsies. Serum ALT showed a significant correlation with the HAI score on liver biopsy (P = 0.01) but not with the stage of fibrosis (P = 0.52). HCV RNA titers did not reveal any correlation with HAI score or fibrosis stage. Conclusion: Serum transaminases and HCV RNA titers are poor predictors of disease severity and fibrosis. Since HCV shows a slow disease progression, higher stage may predict a worse prognosis irrespective of the low viral RNA load. Liver biopsy may help guide therapeutic decisions in IDHCV infection.

Colorectal carcinoma up to the second decade of life: An 8‑year experience in a tertiary care center.

AIMS AND OBJECTIVES: To evaluate the demographic pattern, incidence, and histological characteristics of colorectal carcinomas (CRCs) in very young adults diagnosed in the center. MATERIALS AND METHODS: We retrieved and reviewed slides and data pertaining to all the cases of CRCs and “segregated into decade wise age‑groups” from the archives of Department of Pathology. Patients with age ≤20 years diagnosed during the last 8 years (2006–2013) were further evaluated. RESULTS: Totally, 590 cases of CRCs diagnosed over last 8‑year period, of which 4.2% (25 cases) presented in the study group (age ≤20 years) with a mean age of 17 years. About 50% of the tumors were either signet ring cell, mucin‑secreting or poorly differentiated carcinomas. Four cases occurred in a background of familial adenomatous polyposis (FAP), three of which showed high‑grade dysplasia, while in one case, carcinoma‑in‑situ was diagnosed. In all but two cases, rectum was the site of involvement except FAP cases in which colorectal location was noted. CRCs show a sharp rise in earlier age onset (≤40 years) and an increasing trend was followed in patients between age groups third, fourth, and fifth decades of life over the last 8 years. CONCLUSION: Colorectal carcinomas show an increasing trend in young age (≤40 years). This change may be attributed to dietary, lifestyle changes, and newer genetic alterations in developing countries. In very young age group (≤20 years), a higher grade and stage at the time of diagnosis and predominantly rectal involvements are the distinct features.

Diaphragm disease of the ileum: a case report.

Non-steroidal anti-inflammatory drugs induced diaphragm like lesions are a rare cause of small intestinal obstruction. They occur most commonly in elderly patients who have been consuming these drugs for prolonged periods for pain relief. We report the first case of ileal diaphragm disease from Asia. She responded well to localised resection of the diseased ileum. Intra-operative enteroscopy may be helpful in deciding the extent of intestinal resection.

Atypical TeratoidJRhabdoid Tumour of Brain

Primitive neuroectodermal tumor (PNET) / medulloblastoma (MB) are the most commonmalignant central nervous tumors of the first decade of life. Atypical teratoid / rhabdoid tumor (ATT / RT) is a tumor of infancy and childhood although occasional cases have also been described in adults. ATT/RT has a characteristic histopathological, immunocytochemical and ultrastructural features. ATT /RT is a rare tumor, incidence of which remains to be defined with only hundred published cases. The present report docurilents the clinical features, histological and immunohistochemical findings of a case of ATT / RT.

Histoplasmosis of the liver: a rare case.

A 39 year old male presented with history of fever and jaundice for 3 months. A liver biopsy showed numerous ovoid fungal bodies around 5 mm in size in the macrophages and Kupffer cells. A diagnosis of hepatic histoplasmosis was made which is an uncommon entity in our country.

Clinical, biochemical and histological profile of nonalcoholic steatohepatitis.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) has often been described in obese women with diabetes and/or hyperlipidemia. We evaluated the clinical, biochemical and histological profile of NASH. METHODS: 52 patients with persistently elevated ALT (>40 IU/L) for >6 months with no history of significant alcohol consumption and negative serological work-up for hepatitis B and C and HIV were enrolled. Twenty-five patients were diagnosed as having NASH and their clinical, biochemical, and histological profile was evaluated. RESULTS: Of the 25 patients with NASH (mean age 33 years), 24 were men. Three were obese, seven had hyperlipidemia and two had impaired glucose tolerance. Thirteen patients presented with pain in the right hypochondrium, three with fatigue and weakness, and nine were asymptomatic. No patient had evidence of portal hypertension or liver cell failure. Mild elevation of ALT was the most common biochemical abnormality. Twenty-three of the 25 patients had ALT/AST ratio >1.0. Liver histology revealed macrovesicular steatosis in all, with mild inflammatory activity in the majority (70%). Fibrosis was seen in 12 patients-portal fibrosis in six, periportal fibrosis in three and bridging fibrosis in another three patients. None of the patients had features of cirrhosis. None of the factors was found to be associated with fibrosis except serum AST level, which was significantly higher in patients with fibrosis as compared to those without (89 [52] vs. 54 [18] IU/L; p<0.05). CONCLUSIONS: NASH is often seen in men, in the absence of obesity, diabetes and hyperlipidemia, and its severity is better assessed by liver histology than clinical assessment.

Histological comparison of chronic hepatitis B and C in an Indian population.

Many studies have shown that steatosis, lymphoid aggregates or follicles and bile duct injury on histology are more consistently associated with chronic hepatitis C than chronic hepatitis B. We compared liver biopsies of 30 patients of chronic hepatitis B with an equal number of age matched patients with chronic hepatitis C. Steatosis, lymphoid aggregates or follicles and bile duct injury were noted in 66.6%, 36.6% and 26.6% cases respectively of chronic hepatitis B as compared to 70%, 33.3% and 30% cases respectively of chronic hepatitis C. Thus none of the features were considered distinctive of HCV infection.

Intra-abdominal lymphangioma--clinicopathological profile of a rare lesion.

Lymphangioma occurring in an intra-abdominal location is reported to be extremely rare. A series of 5 cases is presented and the differential diagnoses and diagnostic features discussed. None of the cases were diagnosed as lymphangioma clinically. It is suggested that their true incidence may be unknown due to both silent clinical course as well as lack of awareness of clinical and morphological features.