Auto Text: “Insert Colon Diverticulitis”, “Insert Benign Bowel”, “Insert Ostomy”, or “Insert GI Anastomosis”
Diverticulosis/itis: The best way to demonstrate diverticula is to tie off each end of the colonic segment and inject formalin into the lumen until it is distended. The specimen is then submerged in a large volume of formalin and fixed overnight. When the specimen is then opened longitudinally the diverticula will be rigid and distended and easy to sample. This method should be used if there is suspected perforation of a diverticulum or a pericolonic inflammatory mass is evident. It is also possible to identify diverticula in specimens that have been opened longitudinally, pinned, and fixed in the usual fashion, although it is more difficult to get good sections. Remember that diverticula occur in three straight rows longitudinally along the length of the colon. These specimen can be cut same day after a couple hours of fixation. Look for evidence of serosal adhesions/discoloration as this is likely the site of a symptomatic diverticulum. Inspect the mucosal surface of all diverticula for reddening and take representative section of this area.
Ischemic Enteritis and Colitis: In these specimens the goal is to document the depth of ischemic change and its distribution. Sections of the proximal and distal margins are important, of course. In addition, close attention should be paid to the mesentery, with several sections taken to evaluate for possible vasculitis or thrombosis. Gross features of ischemia are: mucosal fold flattening, duskiness, grey/green/black discoloration, hyperemia, edema (slightly thickened wall), and wall thinning/perforation. These specimens should be cut fresh/same day.
GI Bleed: A right hemicolectomy is often performed in patients with lower GI bleeding when the exact source is unclear. The surgeon is operating under the assumption that an occult arteriovenous malformation (AVM) is present (these lesions occur most commonly in the right colon). Unfortunately, the AVM usually will collapse when the colon is resected and become undetectable grossly. The Surgical Pathologist is then faced with a completely unremarkable specimen. In this case a few representative sections of the terminal ileum, colon, and appendix should be submitted. On occasion, a diverticulum in the cecum may be the cause of bleeding, and the specimen should always be examined closely for this lesion, as well as for ulcers or polyps.
Mesenchymal Tumors: These lesions can be similar in appearance to leiomyomas of the uterus. They most often occur as submucosal or intramural masses. Important factors in distinguishing benign from malignant tumors include the size of the tumor and the presence of gross tumor necrosis, and therefore these features must be assessed accurately in the gross description. These tumors often undergo extensive central infarction, resulting in a large cyst filled with blood and necrotic debris and only a thin rim of viable tumor. For solid lesions one section should be submitted for every centimeter of the maximal dimension of the tumor, up to 20 sections. Representative sections of the rim should be obtained from the cystic lesions.
Triage & Gross
- Measure length & inner circumference(s)
- Describe findings
- Submit longitudinal proximal and distal margins
- Submit representative lesion
- Submit representative normal
