histopathological spectrum of colonic mucosal …

Nazia et al. European Journal of Biomedical and Pharmaceutical Sciences

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303

HISTOPATHOLOGICAL SPECTRUM OF COLONIC MUCOSAL BIOPSY SPECIMENS

IN A TERTIARY CARE HOSPITAL

Dr. Nazia Aslam Hungund*1 and

2Dr. Thejasvi Krishnamurthy

1Postgraduate, Department of Pathology, Kempegowda Institute of Medical Sciences, Bengaluru.

2Associate Professor, Department of Pathology Kempegowda Institute of Medical Sciences, Bengaluru.

Article Received on 26/10/2020 Article Revised on 16/11/2020 Article Accepted on 06/12/2020

INTRODUCTION

A variety of disorders affect the large bowel, which

include inflammatory, idiopathic, infectious and

neoplastic diseases.[1]

Colonoscopy is an endoscopic visual examination of the

colonic mucosa with flexible optic fibres. It is a simple

procedure that helps in assessing the lesions clinically

and can provide histopathological confirmation with

guided biopsy.[2]

In developing countries, where Tuberculosis (Tb) and

infective colitis are more common, the diagnosis of

Inflammatory Bowel Disease (IBD) becomes a big

challenge.[2]

Biopsies aid in identifying neoplastic lesions, assessing

prognosis in IBD, determining changes in bowel habits,

evaluating symptoms of pain, bleeding, weight loss,

chronic constipation and diarrhea. They play a vital role

not only in diagnosis, but also in follow up and treatment

of inflammatory bowel disease and malignancies.[3]

To evaluate colonic lesions, correlation of

histopathological findings, along with clinical

presentation and colonoscopy diagnosis becomes very

useful. And this helps in definitive diagnosis and prompt

treatment of patients with colonic lesions.[2]

AIMS AND OBJECTIVES

To study the histomorphological spectrum of

colonoscopic biopsies.

To correlate them with clinical presentation and

colonoscopic diagnosis.

MATERIALS AND METHODS

This retrospective study was undertaken in the

department of Pathology, KIMS Hospital Bengaluru, for

the past three years, from January 2017 to December

2019. One hundred and fourteen biopsies received in the

SJIF Impact Factor 6.044 Research Article ejbps, 2021, Volume 8, Issue 1, 303-311.

European Journal of Biomedical AND Pharmaceutical sciences

http://www.ejbps.com

ISSN 2349-8870

Volume: 8

Issue: 1

303-311

Year: 2021

*Corresponding Author: Dr. Nazia Aslam Hungund

Postgraduate, Department of Pathology, Kempegowda Institute of Medical Sciences, Bengaluru.

DOI: https://doi.org/10.17605/OSF.IO/CBH9T

ABSTRACT

Introduction: Colonoscopy with biopsy is the diagnostic tool of choice in evaluating patients with colorectal

pathologies. Biopsies help in diagnosing neoplastic lesions, assessing prognosis in Inflammatory Bowel Disease

(IBD), exploring changes in bowel habits, evaluating symptoms of pain, bleeding, weight loss, chronic

constipation and diarrhea. Objectives: To study the histomorphological spectrum of colonoscopic biopsies. To

correlate them with clinical presentation and colonoscopic diagnosis. Methods: This retrospective study includes

all colonoscopic biopsies received in the Department of Pathology, KIMS Bengaluru from January 2017 to

January 2020. All biopsies were processed routinely and studied. Results: Out of 114 biopsies, 98 were non

neoplastic and 16 neoplastic. The most common presenting complaint for neoplastic lesions was per rectal

bleeding, and pain abdomen for non-neoplastic lesions. Non-specific colitis (38.78%) was the commonest non

neoplastic lesion, followed by ulcerative colitis (27.55%), ulcers (7.14%), granulomatous inflammation (7.14%).

Males (67.34%) showed a higher preponderance than females (32.66%). Among neoplastic lesions, benign lesions

accounted for 25% of the total neoplastic cases and 75% composed malignant lesions; adenocarcinoma being the

most common entity. Neoplastic lesions showed equal distribution in males and females.

Conclusion: Histopathological interpretation on colonic biopsies is a cornerstone in diagnosing and managing

patients with colonic lesions. Colonoscopic diagnosis correlated well with histopathology in carcinomas and

granulomatous lesions. IBD showed a sensitivity of 93.75% and a specificity of 78.2 %. Mucosal biopsies should

be a part of evaluation of patients with recurrent abdominal pain and bleeding per rectum, even if colonoscopy is

normal.

KEYWORDS: Colonoscopy, Biopsy, Histopathology.



304

Histopathology section, Central laboratory were studied.

Only those cases where the patient’s age, sex, clinical

details, and colonoscopic findings were available were

included in our study.

Biopsies, fixed in 10 percent formalin, were received

with respective request forms containing relevant clinical

details. The tissue bits were counted, measured and

processed as per routine histopathology processing. From

each paraffin block, a 4 micron thick section was

prepared using a rotatory microtome. All slides were

stained with Hematoxylin and Eosin.

These slides were studied under light microscope and

after correlation with colonoscopy findings, a final

diagnosis was established. The concordance and

discordance between the colonoscopy findings and

histopathological findings was recorded, tabulated, and

analyzed.

This study was approved by the institutional ethical

committee (KIMS/IEC/A030/M/202).

RESULTS

Among all the colonoscopic biopsies examined during

the stipulated period of time, 75 were males and 39 were

females, giving a male-female ratio of 1.92:1.

Non neoplastic lesions affected the large bowel more

commonly, accounting for 98 of the total cases

(85.96%); 16 cases were neoplastic (14.04%). The most

common presenting complaint was per rectal bleeding

for neoplastic lesions, and pain abdomen for non

neoplastic lesions.

Biopsies were performed for all age groups, with the

youngest being a 6 year old, and the oldest being an 87

year old male. Age distribution of the lesions is

summarized in Table 1. Median presenting age for

common lesions is shown in Table 2.

Table 1: Age Distribution of Lesions.

Sr. No Age Distribution No. of Cases

1 0-20 7

2 20-30 16

3 30-40 26

4 40-50 14

5 50-60 14

6 60-70 23

7 70-80 12

8 80-90 2

Table 2: Association between Median Age and

Common Lesions.

Lesion Median Age

Non specific colitis 48

Ulcerative colitis 43

Granulomatous inflammation 31

Polyps 47

Adenocarcinoma colon 66

Non Neoplastic Lesions.

Fig 1: Distribution of Non neoplastic lesions.

Out of 98 non-neoplastic lesions, Non Specific colitis

was found to be the commonest lesion in 38 cases

(38.78%), followed by ulcerative colitis in 27 cases

(27.55%). Non neoplastic lesions were found in all age

groups with male-female ratio of 2.12:1.

Cases of nonspecific colitis showed oedema and mixed

inflammatory cell infiltrate in the lamina propria. Surface

ulceration and granulation tissue response were seen in

some of the cases. Few cases showed occasional glands

with mucin depletion.



305

Fig 2: Descending colon – Normal study.

Fig 3: Caecum – Normal study.

Figures 2 and 3: Show a normal study on colonoscopy, seen in a 45 year old female at our centre.

Ulcerative Colitis on colonoscopy showed loss of normal

mucosal and vascular pattern, erythema, friability and

granularity, along with multiple ulcers at the rectum,

sigmoid and descending colon. Continuous and

circumferential involvement was noted (Fig 4).

Fig 4: Colonoscopic image showing loss of normal mucosal and vascular pattern, along with multiple

serpenginous ulcers with mucus at the rectum, sigmoid and descending colon, suggestive of ulcerative colitis.

On histopathology, it was characterized by architectural

crypt distortion and atrophy, along with features of

cryptitis and crypt abscess. Glandular regenerative atypia

and depleted mucin was noted in most of the cases.

Lamina propria showed dense mixed inflammatory cell

infiltrate; predominantly lymphoplasmacytic type.

Epithelial denudation, focal ulceration and lymphoid

aggregated were also seen in some of the cases (Fig 5,6).

Basal plasmacytosis was one of the characteristic feature.

Fig 5: Ulceration and Cryptitis seen in ulcerative

Colitis. H&E 40X.

Fig 6: Crypt Branching seen in Ulcerative Colitis.

H&E 100 X.



306

3 cases diagnosed as Crohn’s colitis showed

microgranulomas and lymphocytic infiltrate in the

mucosa and submucosa, along with features of mucosal

atrophy, cryptitis, crypt distortion and mucus depletion

(Fig 7). 2 of the cases showed focal regenerative change.

Fig. 7: Histomorphological image showing Crypt

distortion and microgranulomas in Crohns disease.

H&E 40X.

Granulomatous inflammation was characterized by

epitheloid cell granulomas and lymphoplasmacytic

infiltrate in the lamina propria. Langhans giant cells and

foci of necrosis were noted as well (Fig 8). One of the

cases showed a pseudopolyp with regenerative change.

Fig 8: Histomorphological image showing

Granulomatous inflammation with epitheloid cell

granulomas and Langhans giant cells. H&E 40X.

Solitary Rectal Ulcer syndrome (SRUS) showed

irregular glands lined by benign epithelium. Splaying of

muscularis mucosae, fibrosis, congested blood vessels,

and sparse mononuclear cell infiltrate was noted in the

lamina propria.

Inflammatory polyps showed a polypoidal structure lined

by columnar cells. The stroma showed dilated glandular

structures filled with mucin with dense interstitial

inflammation.

Neoplastic Lesions

Adenomatous polyps accounted for 31.25% (5 cases) of

all neoplastic lesions. Architectural patterns included

tubular (1 case), villous (3 cases) and tubulo villous

adenomas (1 case) (Fig 9a,9b). Mean age at the time of

presentation was 51.7 years. There were 3 males and 2

females.

These polyps were lined by columnar epithelium, with

crowding and stratification, and showed varying degrees

of dysplasia. Bleeding per rectum was the most common

presentation.

Fig. 9a: Histopathological image showing

Tubulovillous adenoma H&E. 100 X.

Fig. 9b: Histopathological image of Tubulovillous

adenoma showing dysplasia. H&E 400.



307

Amongst 16 colonoscopic biopsies diagnosed as

malignant lesions, 11 cases were adenocarcinomas,

accounting for 68.75% of all neoplastic cases. Majority

of the adenocarcinomas were well differentiated with 1

case revealing signet ring cell morphology. Male: female

ratio was 1.2:1. Mean age of presentation was 57.14

years. Majority of the cases were in the age group of 55-

65 years.

Carcinomas on colonoscopy were seen as a cauliflower

growth with ulceration and luminal narrowing (Fig:10)

and as stricturous growths (Fig 11). Fig 12a and 12b

show a large circumferential irregular growth at the

rectum, suggestive of carcinoma.

Fig 10: Colonoscopic image showing a Cauliflower

growth with ulceration at the descending colon

with luminal narrowing, suggestive of Ca

Descending colon.

Fig 11: Colonoscopic image showing a Stricturous

growth at the Sigmoid colon.

Fig 12a,b: Colonoscopic image showing Large circumferential irregular growth at the rectum, suggestive of

Carcinoma.

Adenocarcinomas were characterized by predominantly

glandular architecture, lined by cells showing atypical

nuclei with frequent mitosis. Few also showed

intervening desmoplastic stroma. Based on the degree of

differentiation, they were graded as well differentiated,

moderately differentiated and poorly differentiated. (Fig

13). One of them showed typical signet ring morphology

with abundant mucin and peripherally pushed

hyperchromatic nucleus.



308

Fig. 13: Histomorphological image showing moderately differentiated Adenocarcinoma colon. H &E 100 X.

Our study showed a lower mean age of distribution in

adenomas than adenocarcinomas. Malignant tumors have

a long natural history, and present at a later age

explaining adenoma- carcinoma sequence.

Table 3: Correlation between Colonoscopy and Histopathological Diagonosis.

Co

lon

osc

op

ic D

iag

on

osi

s

Histopathological Diagnosis

Diagonosis

No

n s

pec

icif

ic c

oli

tis

Ulc

era

tiv

e C

oli

tis

Cro

hn

s D

isea

se

Ulc

er

Gra

nu

lati

on

Tis

sue

Tu

ber

cu

lar

typ

hil

itis

Infl

am

ato

ry P

oly

p

Ses

sile

ser

rate

d p

olp

/

Ad

eno

ma

tou

s p

oly

p

Ad

eno

carc

ino

ma

co

lon

SR

US

Ba

cter

ial

co

liti

s

Co

lla

gen

ou

s co

liti

s

Am

oeb

ic c

oli

tis

Pse

ud

om

ela

no

sis

coli

Eo

sin

op

hil

ic C

oli

tis

1 Normal study 15 0 0 0 0 0 0 0 0 1 0 1 0 1 0

2 IBD 8 9 1 3 2 0 1 0 0 0 0 0 0 0 0

3 ?UC 5 17 0 0 0 0 0 0 0 0 0 0 0 0 0

4 Quiescent Crohns 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

5 Ileocaecal Kocks/Tb 1 0 0 1 1 4 0 0 0 0 0 0 0 0 0

6 Ulcer 4 0 0 1 2 0 0 0 0 0 1 0 1 0 0

7 Nodular mucosa 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0

8 ?Carcinoma colon 0 0 0 0 0 0 0 0 9 0 0 0 0 0 0

9 Impacted faecal matter 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0

10 Polyp 0 1 0 0 0 0 3 5 0 0 0 0 0 0 0

11 Perforation with mass 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

12 Oedematous mucosa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

13 Mass 0 0 0 0 0 2 0 0 2 0 0 0 0 0 0

14 SRUS 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0

15 Small pinhead erosions 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

16 Stricture 3 0 0 1 0 0 0 0 0 0 0 0 0 0 0

17 Haemorroids 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0



309

Fig 14: Depicts concordance and discordance with colonoscopy.

Table 4: Cohen’s Kappa values comparing common HPE Diagnosis with Colonoscopy.

HPE Diagnosis Cohen's Kappa Kappa Interpretation p-value

Non specicific colitis 0.4694 Moderate agreement 0.002

IBD 0.6955 Substantial agreement 0.017

Granulomatous Inflamation (?Tb) 0.8148 Almost perfect agreement 0.789

Neoplastic lesions 1.0000 Perfect agreement 1.000

The overall concordance rate between Histopathology

and Colonoscopy was substantial with a Kappa value of

0.7449.

DISCUSSION

The histomorphological profile of colorectal biopsies has

a wide spectrum, ranging from infections, inflammatory

conditions, precancerous lesions to colorectal

malignancies.[3]

Visual inspection of the colon and terminal ileum by

colonoscopy, along with biopsy plays an important role

in diagnosis and in determining disease activity.[1]

Colonoscopy is also considered a gold standard for

cancer surveillance, which is the third prevalent cancer in

men and women.[3]

It is safe and simple with no serious

complications and has been available since the 1970s.[3]

Colonic mucosal biopsies obtained from colonoscopy

play a pivotal role in the diagnosis of patients with

IBD.[3]

In our study, we observed an incidence of 30.61% for

IBD, among non neoplastic lesions, 27 cases being

Ulcerative Colitis and 3 being Crohns Disease. This

estimate is similar to the studies conducted by Qayyum

et al, Shama Vk et al, and Rangaswamy et al (24.4% of

non neoplastic lesions).[4,5]

The prevalence of IBD was high in the 30th

and the 40th

decade (median age 43 years) with diarrhea and

abdominal pain being the most common presenting

symptom. This is in line with studies conducted by

Badmapriya et al, Sood et al and Abhilash SC et al.[2,6,7]

Our study showed an equal distribution of IBD in males

and females. This is almost similar to a study conducted

by Badmapriya et al, where male to female ratio was

1.04:1.[6]

At present, an increased incidence of Ulcerative colitis

has been reported, considering the availability of better

diagnostic facilities, or due to rapid westernization of life

styles, including dietary habits and environmental

changes caused by industrialization and urbanization,

ultimately leading to intestinal epithelial dysfunction,

abnormal mucosal immune responses and altered gut

microbia.[6,7,8]

It is important to document dysplasia on colonic biopsy

with ulcerative colitis, as it is a significant predictor not

only of coexisting carcinoma, but also of their risk of

subsequent development of colorectal carcinoma. These

patients would require follow up and different modality

of treatment.[3]

Periodic surveillance of these patients helps in reducing

the risk of colorectal cancer, which is the most feared

long term complication of Ulcerative colitis.[1,9]



310

Granulomatous lesions showed a higher preponderance

in females than in males. This correlates with studies

conducted by Geeta et al, Das P et al, Abdul Kareem et

al and Aljebreen AM et al. Mean age of presentation of

granulomatous lesions was 35 years, similar to studies

done by Phillipo et al and Karve et al.[3,10,11,12]

We were

able to demonstrate Acid Fast bacilli on only one of our

seven cases.

Nonspecific colitis was found to be the commonest non

neoplastic lesion in our study (38 cases), accounting for

38.78%. This is in accordance with studies conducted by

Rajbhanderr M et al, Shefali H leave et al, and

Deshpande V et al.[13]

Among neoplastic lesions, benign lesions accounted for

31.25% of cases and malignant lesions for 68.75%.

Adenomas of the colon were the most commonly

diagnosed benign entity and Adenocarcinoma was its

malignant counterpart. One of the cases also showed

signet ring type morphology. This is in accordance with

study series of Shefali et al, Laishram RS et al and

Shyamal Kumar et al, wherein the most common

histological grades were well differentiated and

moderately differentiated.[3,14]

Majority of cases fell in

the age group of 55 to 65 years, similar to these studies.

As seen in Fig 14, in our study, colonoscopic diagnosis

correlated well with histopathology in carcinomas and

granulomatous lesions. IBD showed a positive

correlation in 28 cases and false positive in 19 cases.

Colonoscopy is very useful for screening and early

detection of colorectal lesions, as these lesions produce

very vague symptoms.[1]

Precise diagnosis requires

knowledge of the classic morphological features of the

disease processes, as well as a number of atypical

pathological presentations, that may cause a

misdiagnosis.[15]

Table 5 shows the Sensitivity and Specificity of

colonoscopy for common lesions which was derived

from Table 3 data.

Table 5: Sensitivity and Specificity.

Sensitivity (%) Specificity (%)

Ulcerative Colitis 93.75 78.41

Granulomatous lesions 100 91.59

Neoplastic lesions 100 100

High sensitivity in detecting neoplastic and

granulomatous lesions can be attributed to obvious gross

findings of a growth/mass and ulcers during

colonoscopy.

According to literature, reasons for discordance between

colonoscopy and histopathology could be attributed to

use of conventional white light colonoscopy which

shows normal mucosa on colonoscopy but presence of

inflammation on histology. Incomplete biopsies due to

technical errors which could be due to adhesions due to

previous surgeries, diverticulosis, tortuosity, angulation

or fixation of bowel loops; ineffective sedation could

also play a role.[16]

Patient errors such as inadequate

bowel preparation, discomfort and intolerance, low body

mass, female sex, and young age, along with operator

factors, such as competency of the technician/surgeon

also contributes to dissonance.[16]

Typical colonoscopic findings of longitudinal ulcers in

Crohns disease and transverse ulcers in Tb aren’t always

present. Also, overlapping histomorphological features

exist between the two. Hence, differentiating between the

two requires correlation of clinical features,

colonoscopy, radiology and treatment response.

Availability of all the findings becomes necessary for a

better diagnosis.[1]

Endoscopic diagnosis of amoebic colitis mimics other

forms of colonic disease, such as Crohns, which can

again lead to discordance.[17]

CONCLUSION

Histopathological interpretation on colonic mucosal

biopsies has taken a cornerstone in the diagnosis and

management of patients with colonic lesions.

Colonoscopic diagnosis correlated well with

histopathology in carcinomas and granulomatous lesions

(particularly TB). IBD showed a positive correlation in

28 cases and false positive in 19 cases, thus showing a

sensitivity of 93.75% and a specificity of 78.2%.

Mucosal biopsies should be a part of evaluation of

patients with recurrent abdominal pain and bleeding per

rectum, even if colonoscopy is normal.

Accurate knowledge and acquaintance of normal

colonoscopy is also essential to better understand the

pathological findings within the colon.

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