Acute Small Bowel Obstruction and Small Bowel Perforation as a Clinical Debut of Intestinal Endometriosis: A Report of Four Cases and Review of the Literature.

Endometriosis is a quite common pathology, however, intestinal endometriosis is a rare condition, which typically occurs with chronic symptoms. Its acute presentation is very infrequent. We herein report four cases of intestinal endometriosis, in which the clinical debut occurred acutely: two as an acute small bowel obstruction and two as a small bowel perforation. None of the cases had a preoperative diagnosis of endometriosis. The interest of these cases lies in this exceptional form of presentation, such as a surgical acute abdomen. Therefore, intestinal endometriosis should be taken into account in the differential diagnosis of an acute obstructive or perforative process of the small or large bowel.

Guía práctica para el diagnóstico de displasia y de carcinoma colorrectal en la enfermedad inflamatoria intestinal / Practical guidelines for the diagnosis of dysplasia and colorectal carcinoma in idiopathic inflammatory bowel disease

El importante y significativo incremento de la incidencia de la enfermedad inflamatoria intestinal (EII) en la población europea ha supuesto la creación de unidades clínicas multidisciplinarias y guías prácticas de manejo y estandarización de los informes anatomopatológicos. Recientemente hemos publicado una guía interpretativa de biopsias endoscópicas con sospecha de EII. Sin embargo, el apartado de diagnóstico de lesiones preneoplásicas quedó pendiente y lo abordamos en este documento. El riesgo de carcinoma de colon se halla aumentado en la EII, en la que la displasia epitelial (DE) constituye la manifestación histológica inicial del proceso neoplásico. Su diagnóstico, la gradación y el control determinan las pautas de cribado y manejo del paciente. En este artículo procedemos a revisar: las definiciones de DE, las clasificaciones macroscópicas y microscópicas así como su repercusión en el establecimiento del tratamiento, la distinción entre DE secundaria a EII y adenoma esporádico, la utilidad de la inmunohistoquímica en los estudios histopatológicos además de los protocolos de estudio macroscópico de piezas de colectomía y de disección submucosa endoscópica provenientes del tratamiento quirúrgico de la DE o del carcinoma asociado a EII (AU)

The important, significant increase in the incidence of inflammatory bowel disease (IBD) in the European population has led to the creation of multidisciplinary clinical units and guidelines for specific aspects of Pathology reporting. Recently we published guidelines for the interpretation of endoscopy biopsies in which there was a suspicion of IBD. However, pre-neoplastic diagnosis was not included and is explained here. The risk of colon carcinoma increases in IBD and epithelial dysplasia (ED) is the initial histological manifestation of neoplasia. Diagnosis, grading and control determine guidelines for screening and patient management. We have revised the following: definition of ED, macroscopic and microscopic classifications and their significance in the choice of treatment, the distinction between ED secondary to IBD and sporadic adenoma, the usefulness of immunohistochemistry in histological studies and the protocols for macroscopic examination of submucosal dissection specimens from endoscopy and colectomy during the surgical treatment of ED or carcinoma associated with IBD (AU)

Pathological features and diagnosis of intraductal papillary mucinous neoplasm of the pancreas.

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a noninvasive epithelial neoplasm of mucin-producing cells arising in the main duct (MD) and/or branch ducts (BD) of the pancreas. Involved ducts are dilated and filled with neoplastic papillae and mucus in variable intensity. IPMN lacks ovarian-type stroma, unlike mucinous cystic neoplasm, and is defined as a grossly visible entity (≥ 5 mm), unlike pancreatic intraepithelial neoplasm. With the use of high-resolution imaging techniques, very small IPMNs are increasingly being identified. Most IPMNs are solitary and located in the pancreatic head, although 20%-40% are multifocal. Macroscopic classification in MD type, BD type and mixed or combined type reflects biological differences with important prognostic and preoperative clinical management implications. Based on cytoarchitectural atypia, IPMN is classified into low-grade, intermediate-grade and high-grade dysplasia. Based on histological features and mucin (MUC) immunophenotype, IPMNs are classified into gastric, intestinal, pancreatobiliary and oncocytic types. These different phenotypes can be observed together, with the IPMN classified according to the predominant type. Two pathways have been suggested: gastric phenotype corresponds to less aggressive uncommitted cells (MUC1 -, MUC2 -, MUC5AC +, MUC6 +) with the capacity to evolve to intestinal phenotype (intestinal pathway) (MUC1 -, MUC2 +, MUC5AC +, MUC6 - or weak +) or pancreatobiliary /oncocytic phenotypes (pyloropancreatic pathway) (MUC1 +, MUC 2-, MUC5AC +, MUC 6 +) becoming more aggressive. Prognosis of IPMN is excellent but critically worsens when invasive carcinoma arises (about 40% of IPMNs), except in some cases of minimal invasion. The clinical challenge is to establish which IPMNs should be removed because of their higher risk of developing invasive cancer. Once resected, they must be extensively sampled or, much better, submitted in its entirety for microscopic study to completely rule out associated invasive carcinoma.

Guía para la interpretación de biopsias endoscópicas con sospecha de enfermedad inflamatoria intestinal idiopática / Guidelines for the endoscopic biopsy diagnosis of suspected idiopathic inflammatory bowel disease

El reciente aumento en la incidencia de enfermedad inflamatoria intestinal (EII) entre la población europea ha dado lugar a la creación en hospitales de unidades multidisciplinares específicas con protocolos definidos que comprometen a los anatomopatólogos. El consiguiente aumento en el número de biopsias requiere establecer unas pautas, tanto sobre los criterios estándar como sobre la nomenclatura, para facilitar el diagnóstico y mejorar el informe. Dichas pautas tienen como finalidad la sistematización, paso a paso, de la interpretación de las biopsias con objetivos que evalúan la confianza diagnóstica a cada nivel. Los distintos pasos determinarán si existe enfermedad en la mucosa intestinal, si la enfermedad es crónica y/o activa y, si la presencia de una EII se considera probable, si se puede diagnosticar la enfermedad como un Crohn (EC) o bien como colitis ulcerosa (CU). Se considerarán los cambios en la arquitectura celular que indican la cronicidad de la enfermedad, los cambios inflamatorios que se pueden graduar en un índice de actividad, el diagnóstico diferencial con otros tipos de colitis y las características microscópicas necesarias para clasificar la colitis como EC o CU. Además, se proponen ejemplos de la comunicación del diagnóstico histopatológico y se analizan algunos de los frecuentes errores en la interpretación microscópica (AU)

The lately increasing cases of inflammatory bowel disease (IBD) in the European population have triggered the creation of specific multidisciplinary units in hospitals, and protocols and consensus of specific action that keep pathologist struggling with. Consequently, the increasing demand of endoscopy biopsies reports calls for a set of standard criteria and nomenclatures in guides which help to resolve diagnosis difficulties and improve the precision in communicating the final reports. This guide intends to systematize the interpretation of this kind of biopsies and to reach the diagnosis objectives step by step, assessing the confidence of diagnosis in every level. These steps are summarized in determining if there is disease of ileocolic mucosa, if the disease is chronic and/or active, if the disease can be diagnosed as IBD or if it is necessary to rule out other types of colitis, and, if a IBD is considered likely true, if it could be diagnoses as Crohn's disease (CD) or ulcerative colitis (UC). Among the different assessed issues are the architectural changes which define chronicity of the disease, the inflammatory changes which can be graduated in activity index, the differential diagnosis with other types of colitis and the microscopic features which make possible classify this colitis as CD or UC. In addition, examples in the communication of the histopathology diagnosis are proposed and many frequent errors in microscopic interpretation are commented (AU)

Asociación entre hiperhomocisteinemia y esteatosis hepática en pacientes con hepatitis crónica C / Association of hyperhomocysteinemia with liver steatosis in patients with chronic hepatitis C

Fundamento y objetivo: La esteatosis hepática en la hepatitis crónica C (HCC) se relaciona con factores virales, metabólicos y posiblemente genéticos. El objetivo de este estudio es conocer si la hiperhomocisteinemia y el polimorfismo de la metilentetrahidrofolato reductasa (MTHFR)-C677T se asocian a esteatosis hepática en pacientes no alcohólicos con HCC. Pacientes y método: Se estudiaron 54 pacientes consecutivos diagnosticados de HCC mediante biopsia, con consumo de alcohol menor de 40g/semana, y sin otras causas de enfermedad hepática. Todas las variables se obtuvieron al tiempo de la biopsia. En 128 sujetos sanos, con edad y sexo similares a los pacientes, también se determinó el polimorfismo de la MTHFR-C677T. Resultados: Se encontró esteatosis hepática en 33 pacientes (61%), siendo en 30 de grado leve. En los pacientes con esteatosis existía una prevalencia más elevada de hiperhomocisteinemia (61% frente al 24%, p=0,008) y el sobrepeso tendía a ser más prevalente (61% frente al 33%, p=0,05). Todos los pacientes con genotipo 3 del virus C tenían esteatosis. La carga viral, actividad inflamatoria y fibrosis hepática no fueron diferentes en los pacientes con y sin esteatosis. El polimorfismo de la MTHFR-C677T fue similar en controles y casos, y en los casos con y sin esteatosis. La regresión logística múltiple mostró que la hiperhomocisteinemia se asociaba a esteatosis hepática tras ajustar por edad y sexo (odds ratio [OR] 3,94, intervalo de confianza del 95% [IC 95%] 1,09-14,29) y por sobrepeso (OR 4,43, IC 95% 1,27-15,51). Conclusiones: En pacientes no alcohólicos con HCC, la esteatosis hepática de grado leve es frecuente y se asocia a hiperhomocisteinemia. No se comprueba asociación de la esteatosis con el polimorfismo de la MTHFR-C677T (AU)

Background and objectives: Liver steatosis in chronic hepatitis C (CHC) is related to viral and metabolic factors and likely to genetic factors. The aim of this study was to know if hyperhomocysteinemia and methylenetetrahydrofolate reductase (MTHFR)-C677T polymorphisms are associated with liver steatosis in nonalcoholic patients with CHC.Patients and method: In 54 consecutive patients with CHC, alcohol consumption less than 40g/week, and no other causes of liver disease, a liver biopsy was performed. All variables were obtained at the time of biopsy. MTHFR-C677T was also performed in 128 healthy subjects, with age and gender similar to the patients. Results: Liver steatosis was found in 33 patients (61%), 30 of them having a mild degree. Hyperhomocysteinemia was more prevalent in patients with steatosis (61% vs 24%; p=0.008) and overweight tended to be more prevalent in the same patients (61% vs 33%; p=0.05). All patients with virus C genotype 3 had steatosis. Viral load, liver inflammatory and fibrosis score were not different in patients with and without steatosis. MTHFR-C677T polymorphism was similar in controls and cases and in cases with and without steatosis. A multiple logistic regression showed that hyperhomocysteinemia was associated with liver steatosis after adjustment for age and sex (OR: 3.94; 95% CI: 1.09-14.29), and adjustment for overweight (OR: 4.43; 95% CI: 1.27-15.51). Conclusions: In nonalcoholic patients with CHC mild liver steatosis is frequent, and is associated with hyperhomocysteinemia. An association between steatosis and MTHFR-C677T polymorphism was not found (AU)

[Association of hyperhomocysteinemia with liver steatosis in patients with chronic hepatitis C]. / Asociación entre hiperhomocisteinemia y esteatosis hepática en pacientes con hepatitis crónica C.

BACKGROUND AND OBJECTIVES: Liver steatosis in chronic hepatitis C (CHC) is related to viral and metabolic factors and likely to genetic factors. The aim of this study was to know if hyperhomocysteinemia and methylenetetrahydrofolate reductase (MTHFR)-C677T polymorphisms are associated with liver steatosis in nonalcoholic patients with CHC. PATIENTS AND METHOD: In 54 consecutive patients with CHC, alcohol consumption less than 40g/week, and no other causes of liver disease, a liver biopsy was performed. All variables were obtained at the time of biopsy. MTHFR-C677T was also performed in 128 healthy subjects, with age and gender similar to the patients. RESULTS: Liver steatosis was found in 33 patients (61%), 30 of them having a mild degree. Hyperhomocysteinemia was more prevalent in patients with steatosis (61% vs 24%; p=0.008) and overweight tended to be more prevalent in the same patients (61% vs 33%; p=0.05). All patients with virus C genotype 3 had steatosis. Viral load, liver inflammatory and fibrosis score were not different in patients with and without steatosis. MTHFR-C677T polymorphism was similar in controls and cases and in cases with and without steatosis. A multiple logistic regression showed that hyperhomocysteinemia was associated with liver steatosis after adjustment for age and sex (OR: 3.94; 95% CI: 1.09-14.29), and adjustment for overweight (OR: 4.43; 95% CI: 1.27-15.51). CONCLUSIONS: In nonalcoholic patients with CHC mild liver steatosis is frequent, and is associated with hyperhomocysteinemia. An association between steatosis and MTHFR-C677T polymorphism was not found.

Protocolo y guía para el diagnóstico histopatológico de carcinoma hepatocelular. Subprotocolo de Anatomía Patológica para un protocolo general hospitalario de hepatocarcinoma / Protocol and guidelines for the histopathological diagnosis of hepatocellular carcinoma

Este protocolo-guía para el diagnóstico histopatológico del carcinoma hepatocelular es un documento de trabajo de la Subcomisión de Tumores Digestivos del Hospital 12 de Octubre que pretende consensuar un acuerdo intrahospitalario para la utilización de las nomenclaturas acreditadas en la literatura de forma que sean homogéneas y uniformes para evitar malentendidos que lleven a conductas diferentes en el manejo de pacientes con el mismo tipo de lesión. Asimismo, intenta informar a clínicos y radiólogos de lo que pueden esperar del diagnóstico citohistológico de los posibles especimenes de un paciente con diagnóstico sospechado o confirmado de carcinoma hepatocelular

This protocol for the histopathological diagnosis of hepatocellular carcinoma is an internal use document of the Subcommitte of Digestive Tumours of the Hospital 12 de Octubre that intends a consensus in the use of accredited nomenclatures to obtain uniform and homogeneous interpretations aiming analogous and correct managements in patients with similar types of lesions. The protocol also aims to give useful information to clinicians and radiologists about what can they expect of a cyto-histological diagnosis in the specimens of a patient with suspected or confirmed diagnosis of hepatocellular carcinoma

Protocolo y guía para el diagnóstico histopatológico de carcinoma hepatocelular. Subprotocolo de Anatomía Patológica para un protocolo general hospitalario de hepatocarcinoma / Protocol and guidelines for the histopathological diagnosis of hepatocellular carcinoma

Este protocolo-guía para el diagnóstico histopatológico del carcinoma hepatocelular es un documento de trabajo de la Subcomisión de Tumores Digestivos del Hospital 12 de Octubre que pretende consensuar un acuerdo intrahospitalario para la utilización de las nomenclaturas acreditadas en la literatura de forma que sean homogéneas y uniformes para evitar malentendidos que lleven a conductas diferentes en el manejo de pacientes con el mismo tipo de lesión. Asimismo, intenta informar a clínicos y radiólogos de lo que pueden esperar del diagnóstico citohistológico de los posibles especimenes de un paciente con diagnóstico sospechado o confirmado de carcinoma hepatocelular

This protocol for the histopathological diagnosis of hepatocellular carcinoma is an internal use document of the Subcommitte of Digestive Tumours of the Hospital 12 de Octubre that intends a consensus in the use of accredited nomenclatures to obtain uniform and homogeneous interpretations aiming analogous and correct managements in patients with similar types of lesions. The protocol also aims to give useful information to clinicians and radiologists about what can they expect of a cyto-histological diagnosis in the specimens of a patient with suspected or confirmed diagnosis of hepatocellular carcinoma

Protocolo e información sistematizada para los estudios histopatológicos relacionados con el carcinoma esofágico / Protocol and standardized information in histopathological reporting for esophagic carcinoma and related esophagic conditions

Este protocolo es el resultado de un consenso multidisciplinario entre patólogos, digestólogos,cirujanos y oncólogos de un mismo hospital. Está basado en la revisión de la literatura científicarelevante y en la experiencia profesional orientadas a buscar la mayor efectividad en eldiagnóstico y la mejor adecuación en la conducta terapéutica de las situaciones preneoplásicas,premalignas y malignas del esófago y de la unión gastroesofágica. Para ello propone unas normasen el uso de la terminología internacional, en el manejo de los distintos especímenes (biopsiaendoscópica, resección endoscópica y pieza de resección quirúrgica) y en el esquema diagnósticoa seguir por el patólogo. Su finalidad es que el informe histopatológico ofrezca la informaciónútil, precisa y estandarizada que es necesaria para una comunicación adecuada y claraentre clínicos y patólogos en orden a establecer una uniformidad en los procesos de diagnóstico,de seguimiento (evaluación y control periódico) y de estadificación

This protocol is the result of a multidisciplinary consensus among pathologists, digestive physicians,surgeons and oncologists from the same hospital. It is based on a review of relevant scientificliterature and on professional experience in order to achieve the greatest effectiveness in diagnosisand appropriateness in the management of preneoplastic, premalignant and malignant conditionsof the esophagus and the gastroesophagic junction. Guidelines are proposed in the use ofinternational terminology, proper handling and dissection of various types of specimens (endoscopicbiopsy, endoscopic excision and surgical resection) and the surgical pathology report. The aimof the histopathologic report is to offer useful, accurate and standardized information, necessary foran adequate and clear communication among clinicians and pathologists to achieve a uniformity inmethodologic approach to diagnosis, follow-up and staging of esophageal neoplasms

Protocolo e información sistematizada para los estudios histopatológicos relacionados con el carcinoma esofágico / Protocol and standardized information in histopathological reporting for esophagic carcinoma and related esophagic conditions

Este protocolo es el resultado de un consenso multidisciplinario entre patólogos, digestólogos, cirujanos y oncólogos de un mismo hospital. Está basado en la revisión de la literatura científica relevante y en la experiencia profesional orientadas a buscar la mayor efectividad en el diagnóstico y la mejor adecuación en la conducta terapéutica de las situaciones preneoplásicas, premalignas y malignas del esófago y de la unión gastroesofágica. Para ello propone unas normas en el uso de la terminología internacional, en el manejo de los distintos especímenes (biopsia endoscópica, resección endoscópica y pieza de resección quirúrgica) y en el esquema diagnóstico a seguir por el patólogo. Su finalidad es que el informe histopatológico ofrezca la información útil, precisa y estandarizada que es necesaria para una comunicación adecuada y clara entre clínicos y patólogos en orden a establecer una uniformidad en los procesos de diagnóstico, de seguimiento (evaluación y control periódico) y de estadificación

This protocol is the result of a multidisciplinary consensus among pathologists, digestive physicians, surgeons and oncologists from the same hospital. It is based on a review of relevant scientific literature and on professional experience in order to achieve the greatest effectiveness in diagnosis and appropriateness in the management of preneoplastic, premalignant and malignant conditions of the esophagus and the gastroesophagic junction. Guidelines are proposed in the use of international terminology, proper handling and dissection of various types of specimens (endoscopic biopsy, endoscopic excision and surgical resection) and the surgical pathology report. The aim of the histopathologic report is to offer useful, accurate and standardized information, necessary for an adequate and clear communication among clinicians and pathologists to achieve a uniformity in methodologic approach to diagnosis, follow-up and staging of esophageal neoplasms