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The gut is involved in the breakdown and resorption of food nutrients.  Interestingly, the large intestine is predominately involved in the resorption of water, transforming the semi-liquid stool into a firmer formed mass. The anus is in continuity with the skin and thus, diseases of the skin often affect the anus.   Biopsies of the small intestine are often to evaluate for malabsorption.   Biopsies of the large intestine are for both colitis and to rule out cancers.   The introduction of the flexible endoscope has revolutionized the technique of obtaining small biopsy specimens. 

Acute Appendicitis
Adenomatous Polyp-Colon
Anal Carcinoma
Appendiceal Adenocarcinoma
Appendiceal diverticula
Cancer of the Colon
Cancer of the Small Bowel
Carcinoid Tumors
Celiac Disease (Sprue)
Chronic Intestinal Pseudo-Obstruction
Collagenous Colitis
Diversion Colitis
Diverticular Disease (Diverticulosis and Diverticulitis)
Enteropathy-type T-cell Lymphoma
Familial Polyposis Syndromes (FAP, Gardner's Syndrome, Turcot's)
Hirschsprung Disease
Hyperplastic Polyps
Ischemic Colitis
Lymphocytic Colitis (Microscopic colitis)
Microvillous Inclusion Disease (Familial Microvillous Atrophy)
NSAID Colitis (Non-Steroidal Anti Inflammatory Drugs)
Pseudomembranous Colitis (Clostridium difficile associated colitis, Antiobiotic associated colitis)
Solitary Rectal Ulcer Syndrome (Mucosal Prolapse Syndrome)
Whipple Disease


Disease Associations  
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Gross Appearance and Clinical Variants  
Histopathological Features and Variants  
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Colonic disease in cirrhosis. An endoscopic evaluation in 412 patients.

Rabinovitz M, Schade RR, Dindzans VJ, Belle SH, Van Thiel DH, Gavaler JS.

Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania.

Gastroenterology 1990 Jul;99(1):195-9 Abstract quote

Colonic disease is relatively uncommon in cirrhosis.

To determine the prevalence of colonic lesions in cirrhosis of all types, cirrhotics evaluated for possible liver transplantation underwent combined pan upper endoscopy and colonoscopy. The patients were divided into two main groups, 248 with parenchymal liver disease (nonviral and viral) and 164 with cholestatic liver disease.

The prevalence of the various colonic lesions identified was: polyps, 8.4%; nonspecific edema, 19.9%; inflammatory changes, 11.6%; hemorrhoids, 25.2%; and rectal varices, 3.6%. Normal findings were present in 42.4%. Except for an increased prevalence (P less than 0.05) of edema and a reduced prevalence (P less than 0.001) of inflammatory changes in the parenchymal liver disease group, the prevalence for all other lesions was similar in the two groups. Esophageal varices were present in most patients with hemorrhoids and in all with rectal varices. The degree of portal hypertension and/or disease severity was associated with hemorrhoids but not with rectal varices.

The higher prevalence of inflammatory changes in the cholestatic group was because one fourth of this group had an inflammatory bowel disease.



Sampling error in the standard evaluation of endoscopic colonic biopsies.

Calhoun BC, Gomes F, Robert ME, Jain D.


Am J Surg Pathol 2003 Feb;27(2):254-7 Abstract quote

It is assumed that the diagnostic information in small gastrointestinal mucosal biopsies is obtained regardless of which side of the biopsy is sectioned. Based on this assumption, mucosal biopsies of the colon are embedded randomly with respect to the side of the biopsy that faces the microtome blade.

Our hypothesis is that reorienting ("flipping") the biopsy specimen 180 degrees and sectioning the opposite side might provide new diagnostic information in cases with no specific histopathologic diagnosis. Sixty-one consecutive cases with a clinical impression of a polyp and no histologic abnormality on three hematoxylin and eosin-stained slides (6-15 levels) were selected. Formalin-fixed, paraffin-embedded tissue was reoriented, and three additional hematoxylin and eosin-stained slides (6-15 levels) were evaluated. The side of the specimen initially sectioned was arbitrarily designated "A," and the side of the specimen sectioned after reembedding was designated "B." The slides were sequentially numbered 1-3, and the first slide on which the new diagnosis was evident was recorded. New diagnoses were made for 19 of 61 (31.1%) specimens from a total of 51 patients and included tubular adenomas (12 of 61; 19.7%) and hyperplastic polyps (7 of 61; 11.5%). In 17 of 19 specimens (89.5%), the new diagnosis was evident on the first slide.

Reembedding endoscopic colonic biopsies facilitates rendering a definitive diagnosis in cases of discordance between the clinical impression and the histologic impression. Routine examination of at least two sides of randomly oriented biopsy material could provide additional diagnostic, and sometimes critical, information.


Brunner Gland Hamartoma With Predominant Adipose Tissue and Ciliated Cysts.

Chatelain D, Maillet E, Boyer L, Checkouri G, Mourra N, Flejou JF.

Service d'Anatomie Pathologique, Hopital Saint-Antoine, Paris, France (Drs Chatelain, Mourra, and Flejou); Cabinet de Pathologie de Saint-Denis, Reunion, France (Dr Maillet); Service de Chirurgie Digestive et Gynecologique, Clinique Sainte-Clotilde, Reunion, France (Dr Boyer); and Cabinet de Gastroenterologie, Reunion, France (Dr Checkouri).

Arch Pathol Lab Med 2002 Jun;126(6):734-735 Abstract quote

We report an unusual case of Brunner gland hamartoma of the duodenal bulb with multiple ciliated cysts in a 43-year-old man. The patient presented with regurgitation. An endoscopy of the upper digestive tract revealed the presence of a pedunculated tumor of the first duodenum.

Surgical resection of the antrum and first duodenum was performed. The polypoid lesion measured 3.5 cm and was located in the submucosa. It was composed of predominant adipose tissue containing hyperplastic lobules of Brunner gland and cystic ducts lined by ciliated cells. Brunner gland hamartoma is a rare benign duodenal lesion; it is usually composed of mature but disorganized tissues and is found most commonly in the duodenum. The presence of ciliated cells in the gut mucosa is a rare phenomenon, which has already been described in the esophagus and stomach.

We report an unusual case of ciliated metaplasia in a duodenal Brunner gland hamartoma.

Enterocolic (Lymphocytic) Phlebitis: A Rare Cause of Intestinal Ischemic Necrosis
A Series of Six Patients and Review of the Literature

Emilia Saraga, M.D.; Hanifa Bouzourenne, M.D.

From the Institute of Pathology, CHUV, Lausanne, Switzerland.


Am J Surg Pathol 2000;24:824-829 Abstract quote

Vasculitis of the gastrointestinal tract is known to occur as part of a systemic process but also may be present in a localized form involving only the digestive tract.

We report the clinical and pathologic findings of six patients with intestinal ischemia and necrosis resulting from localized phlebitis associated with fresh and/or organized thrombosis of intramural mesenteric veins.

None of the patients showed clinical or laboratory evidence of systemic vasculitis. In all cases the arteries were not involved in the inflammatory process. Follow up ranged between 2 and 15 years without recurrence necessitating reoperation. This form of intestinal phlebitis is described in the literature under different terms but lymphocytic phlebitis, granulomatous phlebitis, necrotizing phlebitis, and myointimal venous hyperplasia are probably morphologic variants of the same entity.

We propose to unify the nomenclature and to use for this unusual clinicopathologic entity only the generic term of enterocolic (lymphocytic) phlebitis.


Benign Fibroblastic Polyps of the Colon: A Histologic, Immunohistochemical, and Ultrastructural Study

Eslami-Varzaneh, Fatima MD*; Washington, Kay MD, PHD†; Robert, Marie E MD*; Kashgarian, Michael MD*; Goldblum, John R MD‡; Jain, Dhanpat MD*

From *Yale University School of Medicine, New Haven, CT; †Vanderbilt University Medical Center, Nashville, TN; and ‡Cleveland Clinic Foundation, Cleveland, OH.


The American Journal of Surgical Pathology : Volume 28(3) March 2004 pp 374-378 Abstract quote

Mesenchymal proliferations presenting as mucosal polyps are relatively uncommon and are represented by gastrointestinal stromal tumors, smooth muscle and neural tumors, and inflammatory fibroid polyps.

In this report, we describe the clinicopathologic features of a distinctive type of mucosal polyp composed of cytologically bland spindled cells with fibroblastic features. Fourteen cases with histologic features of fibroblastic polyps were identified from our case files from January 2000 to December 2003. The clinical and endoscopic findings were reviewed. Immunohistochemistry using a panel of antibodies (vimentin, smooth muscle actin, desmin, CD31, CD34, Bcl-2, c-Kit, S-100, and epithelial membrane antigen) was performed in all cases, and electron microscopy was performed in two cases. The lesions were solitary in all cases and not associated with an identifiable polyposis syndrome. Associated adenomata and/or hyperplastic polyps at different sites were present in 10 cases and hyperplastic polyps were seen in close association in 3 cases. These polyps were characterized by a monomorphic spindle cell proliferation in the lamina propria, without necrosis or mitotic activity. The lesions were intimately associated with the muscularis mucosae and resulted in wide separation and disorganization of the colonic crypts.

Immunohistochemical analysis revealed strong and diffuse positivity for vimentin only. Weak and focal reactivity was noted in 2 cases for CD34 and smooth muscle actin, while staining for other antibodies was negative. Electron microscopy revealed sparse cytoplasmic organelles and many intermediate filaments. The histology and ultrastructural and immunohistochemical findings are suggestive of fibroblastic differentiation of these spindle cells.

In summary, these lesions represent a distinctive type of colonic mucosal polyp that should be distinguished from other stromal polyps of the gastrointestinal tract.


Inflammatory fibroid polyps of the gastrointestinal tract: evidence for a dendritic cell origin.

Pantanowitz L, Antonioli DA, Pinkus GS, Shahsafaei A, Odze RD.

Department of Pathology, Beth Israel Deaconess Medical Center and dagger Department of Pathology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA.

Am J Surg Pathol. 2004 Jan; 28(1): 107-14. Abstract quote  

SUMMARY: Inflammatory fibroid polyps (IFPs) are rare mesenchymal tumors of the gastrointestinal tract that consist of spindle-shaped stromal cells and an inflammatory infiltrate rich in eosinophils. Their etiology and histogenesis remain unknown. Based on previous reports of their immunoreactivity for CD34 and c-kit biomarkers, IFPs have been thought to be related to gastrointestinal stromal tumors (GISTs).

After reviewing the current literature and examining IFPs at the light microscopic level, we evaluated a series of IFPs using an extensive panel of immunohistochemical and in situ hybridization markers in an effort to gain insight into their etiology and histogenesis and to determine their true relationship to GISTs. Sixteen routinely processed IFP specimens (14 gastric, 1 ileal, and 1 rectal) were immunohistochemically stained for antibodies to CD34, HMB-45, desmin, smooth muscle actin, calponin, h-caldesmon, anaplastic lymphoma kinase, S-100 protein, epithelial membrane antigen, c-kit (CD117), stem cell factor (SCF/N19 or kit ligand), p53, bcl-2, cyclin D1, and human herpesvirus-8 (HHV8). In situ hybridization for Epstein-Barr virus-encoded RNA (EBER) was also performed. Ten cases were further evaluated for the dendritic cell markers fascin, CD21, CD23, and CD35. Stromal cells were diffusely positive for CD34 and fascin in all (100%) cases, and these stromal cells were, in addition, immunoreactive for calponin and smooth muscle actin in 88% and 25% of cases, respectively. CD35 was also found to be focally reactive in the stromal cells. Cyclin-D1 was overexpressed in all (100%) IFPs. All other immunohistochemical markers and EBER were negative in the stromal cells. These findings suggest that the proliferating stromal cells in IFPs are of dendritic cell origin, with some cases also exhibiting myofibroblastic features. Absence of c-kit, SCF, and h-caldesmon immunoreactivity fails to support a relationship to GISTs.

We also conclude that Epstein Barr virus and HHV8 are unlikely etiologic agents of IFPs. Overexpression of cyclin D1 in all cases suggests that a defect in cell-cycle regulation may be involved in the growth of IFPs.

CD10: A Valuable Tool for the Light Microscopic Diagnosis of Microvillous Inclusion Disease (Familial Microvillous Atrophy).

Groisman GM, Amar M, Livne E.

Department of Pathology (G.M.G., M.A.), Hillel-Yaffe Medical Center, Hadera, and the Department of Anatomy and Cell Biology (E.L.), Faculty of Medicine, Technion, Haifa, Israel.

Am J Surg Pathol 2002 Jul;26(7):902-7 Abstract quote

Microvillous inclusion disease (MID) is a specific disorder of the intestinal brush border that leads to intractable secretory diarrhea in infants. At present, electron microscopic analysis is required for its definitive diagnosis. However, this technique is not always available or feasible, and the diagnostic microvillous inclusions may not be evident in all specimens. Accordingly, the availability of a panel of histochemical and immunohistochemical stains displaying a specific staining pattern for MID will allow pathologists to reach a definitive diagnosis of this disorder without recourse to electron microscopy. CD10 is a membrane-associated neutral peptidase, shown to have a linear brush-border staining pattern in normal small intestine.

We studied the staining pattern of CD10 in small intestinal biopsies from six patients with MID and in 24 control cases (10 normal small intestine, 10 celiac disease, two autoimmune enteropathy, and two allergic enteropathy). All MID cases revealed prominent cytoplasmic CD10 immunoreactivity in surface enterocytes. In contrast, all control cases showed linear brush-border staining. Similar results were obtained with periodic acid-Schiff, polyclonal carcinoembryonic antigen, and alkaline phosphatase, three stains known to show cytoplasmic staining of surface enterocytes in MID. In conclusion, CD10 is a valuable tool for the diagnosis of MID. It may be used as part of a panel that includes other stains with a distinctive staining pattern in MID such as periodic acid-Schiff, polyclonal carcinoembryonic antigen, and alkaline phosphatase.

We suggest that the definitive diagnosis of MID can be reached when small bowel biopsies from infants with intractable diarrhea display cytoplasmic staining of surface enterocytes with the above-mentioned stains.

Pneumatosis intestinalis: a challenging biopsy diagnosis.

James Homer Wright Pathology Laboratory at the Massachusetts General Hospital, Harvard Medical School, Boston, MA.


Am J Surg Pathol. 2007 Oct;31(10):1469-75. Abstract quote

BACKGROUND: Pneumatosis intestinalis is characterized by the accumulation of gas in the gastrointestinal wall. The histopathologic diagnosis is easily made on resection specimens in which the presence of submucosal or subserosal empty spaces lined by histiocytes and giant cells presents little diagnostic dilemma. In biopsy material, though, the diagnosis is more challenging, as giant cells and histiocytes can be interpreted as granulomatous inflammation indicative of other conditions such as infection or Crohn disease.

DESIGN: Nine gastrointestinal biopsies diagnosed as pneumatosis intestinalis from 7 patients were reviewed. Clinical history, radiologic features, and endoscopic findings were obtained from patient records.

RESULTS: Five patients presented with blood in the stool (one also with diarrhea) and 2 patients were diagnosed after screening colonoscopies. The endoscopist frequently described polyps or raised mucosal folds (6 cases). In all biopsies submucosal cystic spaces lined by giant cells could be observed. The cysts were intact (2 biopsies), partially intact (5 biopsies), or collapsed (5 biopsies), with 3 biopsies showing 2 cyst architectural conformations. The arrangement of the giant cells lining a rounded or cleftlike space was the most helpful feature in distinguishing pneumatosis intestinalis from granulomatous colitis. Additional useful features included the recognition of "pseudolipomatosis" (n=4) and the presence of round empty spaces in the submucosa resembling fat (n=3). Nonspecific findings included variable inflammation, eosinophilia, mild gland disarray, vascular ectasia and edema, and mild melanosis coli. Two cases were initially given a diagnosis of granulomatous inflammation. One patient with acquired immunodeficiency syndrome and positive cytomegalovirus antigenemia assay had ischemic colitis on the biopsy and another had a subsequent resection with ischemic colitis. A third patient was treated for cytomegalovirus colitis. None had a history of or developed Crohn disease.

CONCLUSIONS: Pneumatosis intestinalis remains a challenging diagnosis on biopsy material, particularly because endoscopy usually does not suggest that diagnosis. The presence of giant cells in the submucosa, variable inflammation, and crypt disarray can be easily confused with Crohn disease. Attention to the arrangement of the giant cells lining intact, partial, or collapsed cysts is crucial to making the correct diagnosis. Although nonspecific by itself, pseudolipomatosis may also indicate the presence of gas within the tissue and suggest the diagnosis.

Salivary gland heterotopia in the rectum.

Downs-Kelly E, Hoschar AP, Prayson RA.

Department of Pathology, Cleveland Clinic Foundation, Cleveland, OH.

Ann Diagn Pathol 2003 Apr;7(2):124-6 Abstract quote

Heterotopic tissues in the submucosal region of the gastrointestinal tract are a well-described occurrence. In the rectal region, these most commonly involve gastric-type mucosa. Only rare reports of salivary gland-type tissue presenting as a submucosal rectal heterotopia have been previously reported.

This case report reviews the literature and details an occurrence of heterotopic salivary gland-type tissue in the rectal submucosa of a 31-year-old man who presented with intermittent bleeding and a rectal polypoid mass.


Dermoid Cyst (Mature Cystic Teratoma) of the Cecum Histologic and Cytologic Features With Review of the Literature

Maurice Joseph Schuetz III, MD and Tarik M. Elsheikh, MD

From the Department of Pathology, Ball Memorial Hospital, Muncie, Ind.

Arch Pathol Lab Med 2002;Vol. 126, No. 1, pp. 97–99. Abstract quote

The gastrointestinal tract is an unusual site for teratomas to occur. Only 4 prior cases of teratomas involving the cecum have appeared in the English literature, the latest published in 1977.

To the best of our knowledge, this is the first report to describe fine-needle aspiration cytologic findings in addition to histologic features of a mature cystic teratoma involving the gastrointestinal tract. A 30-year-old man presented with right upper quadrant abdominal pain and a palpable abdominal mass. Radiographic studies identified a mass lesion inferior to the liver and in close association with the ascending colon. Fine-needle aspiration biopsy showed scant keratinous material and anucleated squamous cells. Right colectomy revealed a cystic mass in the wall of the cecum that contained keratinous material and was lined by stratified granular squamous epithelium with sebaceous glands.

Clinical and pathologic features with review of the literature are presented, and the differential diagnosis for pericolic cystic masses is discussed in detail.


Florid Vascular Proliferation of the Colon Related to Intussusception and Mucosal Prolapse: Potential Diagnostic Confusion with Angiosarcoma

Neil R. Bavikatty, M.D., John R. Goldblum, M.D., Fadi W. Abdul-Karim, M.D., Surl L. Nielsen, M.D. and Joel K. Greenson, M.D.

Department of Pathology (NRB, JKG), University of Michigan Hospitals, Ann Arbor, Michigan; Department of Anatomic Pathology (JRG), The Cleveland Clinic Foundation, Cleveland, Ohio; Department of Pathology (FWA), University Hospitals of Cleveland, Cleveland, Ohio; and Department of Pathology (SLN), Sutter General Hospital, Sacramento, California

Mod Pathol 2001;14:1114-1118 Abstract quote

With the exception of angiodysplasia, vascular abnormalities of the intestines are unusual. We describe a florid benign vascular proliferation of the colon in five adult patients, three of whom presented with idiopathic intussusception.

In all cases, the proliferation was sufficiently exuberant to raise the possibility of angiosarcoma as a diagnostic consideration. The group included 2 males and 3 females with a median age of 43 years. Two patients were HIV positive. Four patients presented with a colonic mass; other symptoms at presentation included abdominal pain, diarrhea, bleeding, and bowel obstruction. In all cases, a florid lobular proliferation of small vascular channels lined by plump endothelial cells extended from the submucosa through the entire thickness of the bowel wall. The endothelial cells showed minimal nuclear atypia, and mitotic figures were infrequent. The overlying mucosa showed ulceration with ischemic-type changes, and had features of mucosal prolapse. A possible underlying arteriovenous malformation was identified in two cases. All patients were alive and well at last follow-up (interval, 6 months to 5 years).

The presence of intussusception or mucosal prolapse in all of the cases suggests repeated mechanical forces applied to the bowel wall as a possible etiologic factor. The role of HIV infection in the pathogenesis of these lesions remains to be determined.



Immunohistochemical study of myofibroblasts in normal colonic mucosa, hyperplastic polyps, and adenomatous colorectal polyps.

Adegboyega PA, Mifflin RC, DiMari JF, Saada JI, Powell DW.

Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA.

Arch Pathol Lab Med 2002 Jul;126(7):829-36 Abstract quote

CONTEXT: Myofibroblasts are distinct cells with characteristics of both smooth muscle cells and fibroblasts. Through their ability to secrete cytokines, chemokines, prostaglandins, growth factors, and matrix components, they are thought to play critical roles in inflammation, growth, repair, and neoplasia.

OBJECTIVE: The goal of this study was to identify the distinct cell populations of the lamina propria of normal colon and colorectal polyps.

DESIGN: We studied the expression of alpha-smooth muscle actin (alphaSMA), smooth muscle myosin (SMM), desmin, vimentin, and c-kit by intestinal mesenchymal (stromal) cells in the normal colonic mucosa (n = 5), as well as in hyperplastic polyps (n = 5), sporadic colorectal adenomas (n = 47), and adenomas from patients with familial polyposis (n = 36).

RESULTS: In the normal colonic mucosa, the pericryptal stromal cells were alphaSMA+, SMM+, desmin-, and vimentin+, defining them as myofibroblasts. In contrast, cells of the muscularis mucosae were alphaSMA+, SMM+, desmin+, and vimentin-, defining them as smooth muscle cells. alpha-Smooth muscle actin also highlighted direct connections between the muscularis mucosae and the pericryptal myofibroblasts, and vimentin immunostaining showed a network of connections between the alphaSMA+ pericryptal myofibroblasts and the alphaSMA- fibroblasts in the interstitium. In all hyperplastic polyps and adenomatous polyps, the interstitial stromal cells (fibroblasts) now also express alphaSMA and form a syncytium of alphaSMA+ networklike connections throughout the lamina propria. Stromal cells of sporadic adenomas demonstrated the same immunohistochemical staining characteristics displayed by adenomas from patients with familial polyposis and by hyperplastic polyps.

Conclusions.-These findings indicate that in normal colon, alphaSMA- fibroblasts are the predominant cell type in the lamina propria. However, the pericryptal (subepithelial) stromal cells are a distinct cell type (alphaSMA+ myofibroblast) that is immunophenotypically different from muscularis mucosae smooth muscle cells and are connected to the interstitial, nonpericryptal fibroblasts with which they exist as a network throughout the lamina propria of the normal colon. Furthermore, in both hyperplastic and neoplastic polyps, there are changes in nonpericryptal fibroblasts from vimentin+, alphaSMA-, and SMM- to vimentin+, alphaSMA+, and SMM+; thus, the interstitial fibroblasts are replaced by myofibroblasts. The factors that cause these changes and the origin of the myofibroblasts need to be determined to clarify the biology of colorectal tumorigenesis.


The clinical significance of focal active colitis in pediatric patients.

Xin W, Brown PI, Greenson JK.


Am J Surg Pathol. 2003 Aug;27(8):1134-8. Abstract quote

The clinical significance of focal neutrophilic infiltrates in crypt epithelium in colorectal biopsies or focal active colitis has been studied in adult populations, but little is known about this entity in children. The incidence of Crohn's disease in adult patients presenting with focal active colitis has varied between 0% and 13% in previous studies, whereas the incidence of infectious-type colitis has been reported to be nearly 50%.

We reviewed 31 cases of focal active colitis diagnosed in pediatric patients without a history of inflammatory bowel disease between 1989 and 2000. Pathologic variables studied included number and location of inflamed crypts and distribution and character of lamina propria inflammation. Clinical follow-up was obtained from patient charts. Two patients were lost to follow-up. Follow-up on the remaining 29 patients ranged from 4 months to 7 years with a mean of 4.2 years. Eight patients (27.6%) developed Crohn's disease. Nine patients (31%) appeared to have acute infectious-type colitis, one with C. difficile. Eight patients (27.6%) had focal active colitis, which did not correlate with their symptoms or ultimate clinical diagnosis. These were termed idiopathic focal active colitis. Two patients were found to have allergic colitis, one had ulcerative colitis, and one had Hirschsprung's disease.

Pediatric patients with focal active colitis have a much higher incidence of Crohn's disease than adults with same entity. Hence, it is important to document the presence of focal active colitis in pediatric patients.

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Last Updated October 5, 2007

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