HISTOPATHOLOGICAL DISTRIBUTION OF THE GASTROINTESTINAL TRACT LESIONS

1* 2 3 4 5 Mrinalini Singh , Santosh Upadhyaya Kafle , Neeta Kafle , Amrita Sinha , Prasun Rajbhandari ISSN: 2542-2758 (Print) 2542-2804 (Online) 1529 Birat Journal of Health Sciences Vol.6/No.2/Issue 15/May-Aug., 2021 Received : 22 June, 2021 Accepted : 14 July, 2021 Published : 04 November 2021


Introduc on
Gastrointes nal (GI) diseases are common and can affect any por on of the gastrointes nal tract from the mouth to the anus. Diseases can just show clinical condi ons like stomach pain, cons pa on, diarrhea which can be selflimi ng. But some mes disease may be life-threatening like malignancy. Biopsy is necessary for confirmatory diagnosis and further treatment of the pa ent. So histopathologic examina on should be done for all surgical procedures for confirma on and categoriza on of GI disorders.

Objec ves
This study was done to find out the various pa erns of lesions of the gastrointes nal tract with its commonest age group and sex involvement

Methodology
This was a prospec ve study of all the surgically resected GI ssue received in the Department of Pathology Histopathology unit in Birat Medical College and Teaching Hospital (BMCTH) st th from 1 February 2021 to 30 April 2021. The hematoxylin and eosin stain slides of the GI ssue received were studied and the lesions were diagnosed on their histomorphology. According to organ, age and sex, the lesions were categorized. The data were entered in Microso excel and the percentage value was calculated.

Conclusions
The study iden fies that gastrointes nal lesions comprise of the most common biopsies received in the histopathology department. Early diagnosis of premalignant and malignant lesions can improve the overall survival rate of pa ents.

KEYWORDS
Adenocarcinoma, Chronic cholecys s, Gastrointes nal disease. GIT are common. The various biopsies from the GIT include cholecystectomies, appendicectomies, colonoscopy biopsies from colonic and rectal mucosa and endoscopic biopsies from oesophagus, duodenal and gastric mucosa. Other biopsies sites are from lesions of the oral cavity, surgical ssues or resected specimens from the pancreas, liver, esophagus, pharynx, small and large bowel along with rectum and anal canal. The GIT lesions are common and the pa ent may remain asymptoma c for many years or may present with non -specific signs and symptoms like abdominal pain, diarrhea, cons pa on, nausea, weight loss and jaundice. Many of the clinical symptoms like repeated chronic pain in abdomen, abdominal discomfort, dyspepsia, cons pa on or repeated a acks of diarrhea and feeling like nausea can affect the quality of life of pa ents. All these symptoms are present because of some pathology in the gastrointes nal tract. Since many of the GIT lesions present with similar signs and symptoms, it becomes difficult to 2 diagnose them clinically. For confirmatory diagnosis of gastrointes nal lesions histopathological examina on is needed. Lesions like gallstone disease, chronic gastri s, and acute appendici s are very commonly encountered in the Nepalese popula on. Though many diagnos c modali es are used for diagnosing GIT lesions like ultrasonography, endoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and Magne c resonance cholangiopancreatography (MRCP) but s ll histopathology 3 remains the gold standard for confirmatory diagnosis. Most of the lesions are inflammatory and benign but some can be cancerous which is life-threatening. The research data suggest that 20% of new cancer cases worldwide are of GIT and in the Nepalese popula on prevalence of gastric cancer 4 is 9.3% in males and 5.7% in females. The lesions of GIT develop with a sequence of metaplasia, dysplasia which can some mes lead to carcinoma. So if precancerous lesions like dysplasia which have the poten ality to turn into cancer are diagnosed earlier it can help the trea ng physician and can improve the survival rate of the pa ent. Such types of precancerous lesions are found on the en re gastrointes nal tract. With the advancement of endoscopy and colonoscopy ny 1-2mm biopsies can be taken. Earlier histopathologic diagnosis especially in cases of ulcers either benign or malignant can prevent further progression of the disease. Studies have shown that surgically resected cancers that are confined to GIT mucosa 5 show 100% five year-survival rate. To find out the depth of invasion histopathologic diagnosis is a must. Delay in the diagnosis can lead to a decreased survival rate of the pa ent. This study was therefore done to find out the various pa erns and sites in GIT of inflammatory, benign and malignant lesions with its commonest age group and sex involvement.

METHODOLOGY
This was a prospec ve study done inthe Department of Pathology Histopathology unit in Birat Medical College Teaching Hospital (BMCTH). All of the surgically resected GIT st ssues sent in proper fixa ve from 1 February 2021 to th 30 April 2021 were included in the study. GIT samples not sent in proper fixa ves were excluded from the study .The study was conducted a er taking approval from the Ins tu onal Review Commi ee (IRC) of BMCTH. All the surgically resected GIT ssue received in the histopathology department were rou nely grossed and paraffin embedded sec ons were made. Microscopic examina on of Hematoxylin and Eosin (H&E) stained slides was done. Wherever necessary, special stains like ZiehlNelson (ZN) stain for tuberculosis bacilli and Giemsa stain for confirma on of organism Helicobacter Pylori (H.Pylori) were done. According to organ, age and sex the lesions were categorized. The microscopic diagnoses were further reconfirmed by other pathologists in the department who all are also the coauthors of this study. The data were entered in Microso Excel and sta s cal analysis were done.

RESULTS
There were a total of 344 cases. Out of which 146(42.44%) were male and 198(57.56%) were female. Most common age range for GI lesion was 41 to 60 years comprising 126 (36.62%) cases. Total 332(96.51%) were inflammatory and benign lesions, 9(2.61%) were malignant tumors and 3(0.88%) were premalignant lesions. Maximum numbers of cases were of cholecystectomies ssue. In almost all the pa ents cholecystectomy was done because of gallstones disease. There were a total of160 cases of gall bladder ssue. Out of which 122(76.25%) were female and the rest 38(23.75%) were male. Most common range of age group for cholecystectomy ssue was 41-60 years comprising of 60(37.5%) cases. (Table1). The maximum numbers of cholecystectomy specimen where of inflammatory and benign lesions. Various pa erns of different types of cholecys s where of 156 (97.50%). There was one (0.6%) malignant tumor which was adenocarcinoma of gall bladder ( Figure 1) and three (1.9%) premalignant lesions consis ng of low-grade biliary intra epithelial neoplasia. (Table2). Total Appendix biopsies received during the study period were 95. Out of which (53.69) %) were male and 44(46.31%) were female pa ents. Acute suppura ve appendici s was the commonest diagnos c lesion. It comprised 50(52%) of the total appendix received. (Table 3). Maximum number of appendici s comprising of 41(43.15%) cases were seen in the younger age group 1-20 years. Total 34 endoscopy biopsies were received. Out of which 21(61.77%)were male and 13(38.23%)were female. Most of the biopsies were from the stomach comprising of 31(91%) of total endoscopy biopsies. (Table 4). Two cases were from duodenum and one case was from oesophagus. Maximum number of cases comprising of 30 (88%) were inflammatory and benign lesions and only four (12%) cases comprised malignant tumor adenocarcinoma of stomach. Two of the cases of chronic gastri s also showed H.Pylori organism on Giemsa stain (Figure 2). Colonoscopy biopsies received during me period of study comprised of 29 cases. (Table 5) Out of which 18(62.07%) were male and 11 (37.93%) were female. Twenty-seven (93%) were benign and inflammatory lesions and two (7%) were malignant tumors revealing adenocarcinoma of rectum. Most of the cases 22 (76%) were from colon and seven cases (24%) were from rectum. Most of the cases were of Inflammatory bowel disease (IBD). Out of total 18 cases of IBD six showed histologic features of Crohn's (CD) disease ( Figure 3) and the other five showed histologic features of Ulcera ve Coli s (UC). Rest of the seven cases of IBD on histologic examina on could not be categorized specifically as UC or CD. In such cases a repeat biopsy sample was advised. Only 7% of the cases were of malignant tumor comprising of adenocarcinoma of rectum. Total 16 oral biopsy ssues were received. Out of which 12(75%) were male and 4 (25%) were female. Inflammatory and benign lesion comprised of 15(94%). Commonest lesion was mucocele which comprised a total of 08(50%) cases. One (6%) case was malignant tumor squamous cell carcinoma of the tongue. (Table 6).
Ten surgical resected ssues were received from various organs of GIT. (Table7). There was one resected biopsy of rectal mass measuring 9 cm in maximum diameterin a35 year old female pa ent (Figure 4) which showed Mucinous adenocarcinoma on microscopy examina on( Figure 5)and one resected ssue of colonic mass in a 30 year old male was received which showed histologic features of submucosal Lipoma ( Figure 6).One pancrea c ssue of female pa ent aged 20 years old reveal histologic features of Chronic Pancrea s and one case was of a Simple Hepa c Cyst of the liver . Cyst measured 3x2x1 cm and the pa ent was a 60 year old female. Three biopsies were of hemorrhoids and three biopsies were from the Fistula in Ano all were male pa ents. The fistulous tract histologically was surrounded by granula on ssue.   Table 6: Distribu on of (16) lesions of oral biopsy according to histopathology Table 3: Distribu on of (95) lesions of appendix according to histopathology      Table 7: Distribu on of (10) lesions of GIT according to histopathology

DISCUSSION
Gallbladder disease chronic cholecys s because of gall stones was the most common lesion in our study. Chronic cholecys s because of cholesterol gall stones are increasing in Nepal because of a sedentary lifestyle, obesity, diabetes 6 and a non-vegetarian diet. We know from previous studies that risk of gall stones are 4 mes more in people above 40 7 years as compared to young people. We found in our study that 105(65%)of our pa ents with gall stone disease were above 40 years of age. In our study 122(78%) of gall bladder disease were in female gender. Searching the literature also shows that female sex develops gallstones more commonly 8 than men. Acute appendici s is more common during first and the 9 second decade of life. We found in our study that 38(42%) of pa ents of acute appendici s were between 1-20 years of age. In total 90 cases of appendix ssue were received we did not find any malignant tumor. This finding is in correla on with various other studies which also show that 10 cancers of appendix are rare. In our study out of 24 cases of confirming gastri s on histologic examina on, we could demonstrate only two cases confirming H Pylori organism on Giemsa stain. H Pylori has been associated with ssue damage in pa ents with 11 ac ve and chronic gastri s. H Pylori organism is also the 12 major cause of chronic gastri s. In underdeveloped countries detec on of this organism is not so common 13 because it causes patchy involvement of gastric mucosa. and colorectal carcinoma in 5 place . We also saw that a er gastric cancer second common cancer was carcinoma of the rectum.

CONCLUSIONS
The study iden fies that gastrointes nal lesions are common and comprise of the most common biopsies received in the histopathology department. Histopathologic examina ons are necessary for the early diagnosis of the GI disease. Most of the GI lesions are benign. The commonest lesion occurring in GIT is Chronic Cholecys s because of gallstones disease. Acute Appendici s is the commonest lesion occurring in the younger age group of 1-20 years. Malignant lesions are less common. Early diagnosis of premalignant and malignant lesions can help the trea ng doctor and can increase the overall survival rate of pa ents by maintaining a good quality of life.

RECOMMENDATIONS
All the surgically resected GIT ssue must be submi ed for histopathologic examina on. Early detec on of lesions may prevent the disease from further progression.

LIMITATION OF THE STUDY
The study was conducted in a short period. If we would have studied for longer dura on the data of our study could have been more authen c. Immunohistochemistry is must especially in the categoriza on of malignant lesions. In the study we have not applied Immunohistochemistry. If we could have applied Immunohistochemistry we could have been more confident in our diagnosis. Some mes especially in endoscopy and colonoscopy biopsies the ssue submi ed may be from the edge of the lesion and may not be the true representa ve of the lesion. In such cases biopsy report may not be true representa ve of the disease. Comparison of biopsy report with endoscopy and colonoscopy findings along with radiologic data should be done. If there is suspicion of malignancy a repeat biopsy sample should be submi ed.

ACKNOWLEDGEMENT
The author will like to thank all the laboratory staff of the histopathology department of BMCTH for their support.