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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 5
| Issue : 3 | Page : 121-124 |
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Lower gastrointestinal endoscopy: A clinicopathological analysis
Guheina A R. Ashour, Abir A Muftah, Nabeia A Gheryani
Department of Pathology, Faculty of Medicine, University of Benghazi, Benghazi, Libya
| Date of Submission | 08-Mar-2021 |
| Date of Acceptance | 29-Aug-2021 |
| Date of Web Publication | 11-Oct-2021 |
Correspondence Address:
Dr. Guheina A R. Ashour
Department of Pathology, Faculty of Medicine, University of Benghazi, Benghazi
Libya
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ljms.ljms_16_21
Background: Histopathological examination of endoscopic biopsy specimens support diagnosis, monitoring the course of the diseases and recognize complications. The aim of this study was to determine the type and frequency of histopathological change in colonic biopsies and its correlations with age and sex. Materials and Methods: Two hundred and fifty-eight colonic biopsies were collected from January 2016 to December 2017. The tissue was subjected to histopathological examination, the data collected and statistically analyzed. Results: Neoplastic colonic lesions form 52% and nonneoplastic form 48%. Cases of adenocarcinoma form 39.1%, nonspecific colitis form 29.1%, adenoma form 12.8%, ulcerative colitis was seen in 7.4% of cases, hyperplastic polyps form 6.2%, and Crohn's disease from 5.4%. Most of adenocarcinomas were moderately differentiated, the grade was higher in females (P = 0.032). Most of nonspecific colitis cases showed mild inflammation. Most of the adenomas were tubular type. More than 90% of neoplastic lesions were in patients above 40 years and 45.5% of inflammatory bowel disease (IBD) cases were present in the age group of between 20 and 39 years (P = 0.001). Most of the cases of adenomas were seen in the age group between 40 and 80 years and (P = 0.018) Conclusion: Adenocarcinoma is the most frequent abnormality, mainly above 40 years of age. IBDs were seen below 40 years of age. In general, in all lesions, males were more affected than females except in cases of IBD and moderately differentiated adenocarcinoma.
Keywords: Adenocarcinoma, adenoma, hyperplastic polyps, inflammatory bowel disease, nonspecific colitis
How to cite this article:
R. Ashour GA, Muftah AA, Gheryani NA. Lower gastrointestinal endoscopy: A clinicopathological analysis. Libyan J Med Sci 2021;5:121-4 |
| Introduction | |  |
Colonic biopsy obtained by colonoscopy is an important tool for the quick and accurate diagnosis of many large bowel diseases. It helps in reducing this dilemma associated with the overlapping of colonic diseases. Moreover, it has a crucial role for detecting of colorectal cancer.[1],[2],[3] However, interpretation of colorectal biopsies is challenging.[4] For example, the use of endoscopic biopsies for the diagnosis of inflammatory bowel disease (IBD) and identification of dysplastic and neoplastic changes associated with the inflammatory processes is a fundamental step to choose treatment strategy as the disease is chronic and may simulate other colitides.[5] Furthermore, the detection of cellular atypia associated with adenomatous polyps to recognized precancerous lesion can be easily made by endoscopic biopsies, and the early diagnosis of this lesions helps to cut the progression from adenoma to adenocarcinoma.[6] Some other lesions such as hyperplastic polyps, which are incidental finding during colonoscopy, are biopsied to differentiate them from the similar endoscopic looking adenomatous polyps that carry risk of malignant change.[7] Hyperplastic polyps may also coexist with other types of neoplastic polyps.[8]
In this study, the specimens of colorectal biopsies were reviewed to reveal the histological type and frequency of colonic lesions and to determine its correlations with age and sex.
| Materials and Methods | | |
A series comprised 258 consecutive cases of colonic biopsies from a private histopathology laboratory in Benghazi have been included in this retrospective study. The cases were collected from January 2016 to December 2017. Patients of different ages and both sexes were included. The tissue biopsies were fixed in 10% formalin and routinely processed. The colonic tissues were prepared as full-face sections, 4 μ thickness using formalin-fixed paraffin-embedded tissue blocks. The slides were stained using hematoxylin and eosin stain. The slides were assessed by a professional pathologist. The age was subcategorized into five groups with interval of 10 years between the groups. The cases are grouped according to the colonic lesions into histologic subtypes: adenocarcinoma, adenoma, hyperplastic polyp, nonspecific colitis, and IBD (ulcerative colitis and Crohn's disease).[9],[10]
Statistical analysis
The statistical analysis was performed using the IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, N.Y., USA). The continuous variables expressed as mean ± standard deviation, whereas the categorical variables expressed as numbers and percentages. The Chi-square tests were applied to reflect the correlation between the different groups, age and sex. P value was considered a statistically significant value when it was <0.05.
| Results | | |
Gender, age, and histologic type are available for 258, 251, and 258 samples, respectively. Histopathological types were neoplastic lesions in 134 (52%) and nonneoplastic lesions in 124 (48%). The benign neoplastic lesions were 12.8% and malignant neoplastic lesions were 39.1% of the total cases. Adenocarcinoma represented the higher frequency in this cohort while hyperplastic polyp was the least frequent lesion. Nonspecific colitis showed the second higher percentage. Both adenoma and IBD were equal, as shown in [Figure 1]. | Figure 1: Types and percentage of different histopathological changes in colonic biopsies
Click here to view |
Adenocarcinoma was classified according to their differentiation into well, moderate, and poorly differentiated adenocarcinoma. Moderately differentiated carcinoma constituted 61.4% of all carcinomas cases. However, well and poorly differentiated carcinoma accounted 26.7% and 10.9%, respectively. Signet ring represented only in one case.
Adenomas were subdivided according to histological types to tubular, villous, and tubulovillous adenoma. Approximately, 54.5% of adenomas were tubular type, whereas both villous and tubulovillous adenomas showed 45.5% of the adenoma cases. Dysplastic changes were absent in 60.6% of these adenomas and almost all of these cases were belonging to a tubular type; on the other hand, mild and moderate dysplasia exhibited in the rest of the adenomas (39.4%). Around 66.7% of tubular adenomas showed no dysplastic changes. Conversely, 66.6% of villous adenomas exhibited mild-to-moderate dysplasia. Noticeably, 83.3% of the tubulovillous adenomas revealed no dysplasia.
Hyperplastic polyps were 6.2% of the cases, microscopically showed epithelial proliferation characterized by a superficial serrated architecture and variably elongated crypts.
Crohn's disease represented in 5.4% of cases and ulcerative colitis represented in 7.4% of cases, the two conditions referred to as IBD in which protracted inflammatory process results in injury to different layers of the tract wall.
In case of nonspecific colitis, most of the patients (59%) had mild inflammation. Moderate inflammation was in 34.2% of the cases, whereas severe inflammation was present in 6.8% of the cases.
Association of gender with other parameters
This series showed a slightly higher frequency of colonic lesions in male 132 (51.2%) than female 126 (48.8%) with a male-to-female ratio of 1.1:1. Interestingly, all the colonic lesions were more frequent in male than female except the inflammatory bowel disease; about 60.6% of IBD cases were expressed in female. Although Crohn's disease distributed equally between both genders, 68.4% of ulcerative colitis cases were females [Figure 2]. There is a statistically significant correlation between gender and differentiation of adenocarcinoma (P = 0.032). Although 81.8% of poorly differentiated carcinoma in male, only 18.2% of the same category was expressed in female. Similarly, well-differentiated carcinoma was higher in male (63%) compared with female (37%). Conversely, moderately differentiated carcinoma was higher in female (58.1%). | Figure 2: Distribution of histopathological changes on the patients' gender
Click here to view |
Tubular and tubulovillous adenomas were common in male than female while the villous adenoma seems to be slightly more in female. Moreover, about two-third of cases with mild dysplasia was expressed in male. Other categories of dysplasia were equal in both gender.
Nonspecific colitis was higher in male than female. In addition, all grades of inflammation were increased in male.
Association of age with other parameters
Regarding age, the mean age of all cases was 50 ± 19 years (range: 4–88) with the median age of 50 years. The highest age frequency (more than two-thirds of cases) was between 40 and 80 years. Interestingly, there was a statistically significant correlation between age and the histologic type of the colonic lesions (P = 0.001). More than 90% of adenoma and adenocarcinoma lesions were in patients above 40 years, 97% and 92.8%, respectively. Conversely, the inflammatory lesions including nonspecific colitis and IBD had the highest frequency in the age group below 40 years. Although the inflammatory lesions occurred more in the age group below 40 years, the cases of severe inflammation occurred in the age group above 40 years. Cases of hyperplastic polyp were equally divided between age groups from 20 to 80 years [Figure 3]. | Figure 3: Distribution of histopathological changes on the patients' age groups (P = 0.001)
Click here to view |
Furthermore, there was a statistically significant correlation between the different age groups and the types of adenoma (P = 0.018). While all cases of tubular adenoma and 88.9% of villous adenoma presented in the age group between 40 and 80 years, 66.7% of tubulovillous cases were in the age group between 40 and 60 years. Most cases of mild dysplasia and all cases of moderate dysplasia were found age group between 40 and 80 years. In addition, cases of moderate and poorly differentiated carcinoma expressed more in higher age group between 40 and 80 years. However, all cases of well-differentiated carcinoma almost divided equally between the age group from 40 to 80 years.
| Discussion | | |
Colonic biopsy obtained during colonoscopy is a fundamental step in the diagnosis of all lower gastrointestinal diseases.[2],[9] In this study, male gender was slightly more than female gender (1.1:1) with mean age was 50 ± 19 years and high frequency age group between 40 and 80 years. Comparing to this study, a study performed by Makaju et al. revealed that the mean age of the patients was 41.2 years with high frequency age group between 20 and 40 years and male was 2.4 folds more than females.[9] Another study was done by Shefali et al. showed that the high frequency age group between 21 and 70 years male-to-female ratio of 1.8:1.[10] In addition, a study accomplished by Padma and Pramila revealed that, males were about two folds higher than females, with most affected age groups between 21and 70 years.[2]
In the current work, the neoplastic lesions represented in 52% of cases and nonneoplastic lesions were in 48% of cases. The benign lesions were 12.8% and malignant lesions were 39.1%. In compare to this, a study carried out by Padma and Pramila displayed that the malignant lesions represented 37.9% and the benign lesions represented 10.2%, whereas the nonneoplastic lesions were 51.8%.[2] Furthermore, in a study performed by Shefali et al. showed that the neoplastic lesions were 57.2%; the benign lesions were 14.4%, the malignant lesions and nonneoplastic lesions were of equal percent (42.8%).[10] Another study done by Rangaswamy et al. revealed that the nonneoplastic lesions were detected in 76.6% and the neoplastic lesion were detected in 23.4% of cases.[11]
Colorectal cancer represents the third common cancer in the world (10.2%) and the second in Libya (10.7%) after the breast and lung and breast, respectively.[12],[13] In the present work, the most common lesion was adenocarcinoma, which represented (39.1%). The moderately differentiated type was the most common and significantly related to female gender. Moderate and poorly differentiated carcinomas were seen in 40–80 years' age group. In compare to these findings, a study performed by Elzouki et al. showed that most of cases of adenocarcinoma were occurred between 50 and 70 years of age with males were more affected than females in all grades of tumor differentiation.[14] Another study carried by Shefali et al. revealed that adenocarcinoma was seen in 42.8% of cases, and moderately differentiated tumor was slightly more than well-differentiated one. The moderately differentiated adenocarcinoma was detected in age groups between 31 and 70 years of age. Males were affected more than females except in the cases of poorly differentiated carcinoma, where the female patients were slightly more affected.[10] In addition, a study performed by Padma and Pramila showed the well-differentiated adenocarcinoma was seen in more than half of the cases, moderately differentiated type was seen in about third of the cases and poorly differentiated type was the least detected tumor. The common age group at the presentation was 41–60 years.[2]
Colonic polyps are mainly benign unless dysplastic change occurs, and the malignancy will be detected if the dysplasia were of high grade. Adenoma form about 10% of polyps whereas hyperplastic polyps are very common (75%–90%).[7],[15],[16] In the current work, adenoma represented in 12.8% of cases, the tubular type of adenomas was the commonest, and most of cases had no dysplastic change, the villous adenoma was the second and most of cases showed either mild or moderate dysplasia. The tubulovillous adenoma was the least common type with no dysplastic change in most of the cases. Males were affected more in cases of tubular and tubulovillous adenoma. Females were slightly affected more in cases of villous adenomas. Mild dysplastic change was seen more in males. In cases of tubular and villous adenoma, a significantly common age group was 40–80 years, whereas 40–60 years were the age group of the tubulovillous adenoma. The similar findings were seen in a study by Shefali et al.[10] In addition, a study done by Valarini et al. showed that the tubular adenoma was the predominant type.[6] In contrast to this, a study was done by Padma and Pramila showed only two cases of adenoma, one with dysplasia.[2]
Hyperplastic polyps were the least finding (6.2%) in this work, males affected more than females, and they were seen in age groups between 20 and 80 years. Correspondingly, a study carried by Shefali et al. showed that the hyperplastic polyps were 3% of the total cases, distributed in the age groups between 21 and 70 years with male predilection.[10] In addition, Padma and Pramila did a study revealed hyperplastic polyps in 3% of cases.[2]
The IBD may affect colon and it is important to distinguish between ulcerative colitis, Crohn's disease and other colitides, as each case has a different therapeutic strategy.[17] In the present study, the IBD represented in 12.8% of cases, ulcerative colitis was more frequent than Crohn's disease. In general, females were more and commonly the affected patients were below 40 years of age. Specifically, Crohn's disease was equally affected both genders, whereas ulcerative colitis was more in females. In agreement to these findings, similar findings in a study done by Shefali et al. showed the ulcerative colitis was more common than Crohn's disease and most of the cases were in the age groups under 40 years; however, male predilection was noticed in the study.[10] Similarly, the finding in the study done by Rangaswamy et al. and Padma and Pramila showed the ulcerative colitis was more common than Crohn's disease.[2],[11]
Cases that had no specific features of any type of colitis on histopathology were indicated as nonspecific colitis.[18] In this work, nonspecific colitis was the second common lesion in colonic biopsy series; males were preponderated, inflammation was mild in most of the cases and occurred in ages below 40 years, moderate and severe inflammation were seen in older ages. The similar finding in the study accomplished by Shefali et al.[10] Furthermore, in a study done by Padma and Pramila and Makaju et al. revealed nonspecific colitis was the second common lesion.[2],[9]
| Conclusion | | |
Histopathologic examination of colonic biopsies is an important implement helps to verify the diagnosis and to detect the lesions that are difficult to diagnose by clinical and colonoscopy only. The common lesion was the adenocarcinoma followed by nonspecific colitis, then IBD and adenoma. The least finding was hyperplastic polyps.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
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