Premala Anthony Singh

Colonic mucosa in patients with portal hypertension

Background and Aims: To do a histomorphometric study of vascular changes in colonic mucosa of patients with portal hypertension (PHT) and to find their association with clinical and upper and lower gastrointestinal endoscopic observations.

Changing pattern of oral cavity lesions and personal habits over a decade: Hospital based record analysis from Allahabad

Aim: To do a prospective clinicohistological study of premalignant and malignant lesions of the oral cavity, and compare it with a 10-year retrospective data, especially in terms of incidence, age distribution, personal habits, and site and type of lesion. Material and Methods: Sections from 776 lesions of the oral cavity, which included 647 lesions of a 10-year (1993 – 2003) retrospective study and 129 lesions of a one-year (2003 – 2004) prospective study, were observed clinically, and a histological correlation was carried out. Results: Premalignant lesions included 78 cases of leukoplakia, 68 cases of oral submucous fibrosis, and 76 cases of squamous papilloma. Their incidence has increased in the last decade from 0.15 to 0.53. These lesions commonly presented in the fourth decade of life, as white patches in leukoplakia and oral submucous fibrosis, and as a growth in squamous cell papilloma. Squamous cell carcinoma was the commonest lesion (57%). Its incidence has increased significantly in the last decade. The mean age of presentation was the sixth decade. A personal history of tobacco chewing was given by most of the patients in the retrospective group, while the use of pan masala was found to be maximum in the prospective group. The overall agreement between the clinical and histological diagnosis was 95.36% (740 / 776) and the kappa coefficient of agreement was 0.9256. Conclusion: Histology along with a detailed clinical workup was found to be a useful, reliable, and accurate diagnostic technique for lesions of the oral cavity. An increase in premalignant lesions in the prospective study, associated with increased pan masala intake is alarming and needs to be taken care of.

Histological changes to palatal and paratubal muscles in oral submucous fibrosis

Oral submucous fibrosis (OSMF) is prevalent in the Indian subcontinent. In a large number of patients conductive deafness due to eustachian tube dysfunction has been found. The present study was, therefore, planned to assess the histopathological changes in palatal and paratubal muscles in oral submucous fibrosis. Incisional biopsy from the soft palate was taken in clinically proven cases of OSMF. In most of the cases, signs of chronic inflammation and fibrosis were seen in the submucosa. Dysplasia was noticed in seven (13.2 per cent) patients. Degenerative changes in palatal/paratubal muscles were found in the form of loss of cross striations in seven (13.2 per cent), oedematous muscle fibres in five (9.4 per cent) and atrophy in five (9.4 per cent) cases. It was concluded that there was definite involvement of palatal and paratubal muscles in OSMF. This could explain the eustachian tube dysfunction in these patients.

Helicobacter pylori in areas of gastric metaplasia in the gallbladder and isolation of H. pylori DNA from gallstones

Aims: To assess if the areas of gastric metaplasia in the gallbladder are colonised by Helicobacter pylori and to conduct a molecular study of gallstones for presence of H. pylori DNA. Methods: Sections from 111 gallbladders with evidence of gastric metaplasia on H&E and Alcian blue–periodic acid‐Schiff (pH 2.5) stain were stained with Loefflers methylene blue and Warthin Starry stain for demonstration of H. pylori. Presence of H. pylori was confirmed by immunohistochemistry. Formalin fixed mucosal tissues and gallstones from 11 cases showing heavy colonisation were subjected to molecular analysis. Results: Helicobacter pylori was present in 50 of 111 (45%) sections with gastric metaplasia. Areas adjacent to gastric metaplasia in gallbladder showed acute inflammation (6%) and lymphoid follicle formation in 58% of cases with H. pylori that were significantly higher than those seen in sections without H. pylori. In molecular study, 8 of 11 gallstones showed 16S rDNA. Amplification of material from one stone showed positivity for atpA, efp, mutY, ppa, trpC, UreI and vacA genes. Phylogenetic affiliation study of the isolates indicated that H. pylori sequence from the gallstones clustered with Indian strains of H. pylori. No considerable difference was observed in phylogenetic affiliations of eight stones studied. Conclusion: H. pylori colonises areas of gastric metaplasia in gallbladder producing histological changes similar to those seen in gastric mucosa. Isolation of H. pylori DNA from gallstones further support its presence in the gallbladder.

Preoperative sonographic diagnosis of acute appendicitis caused by Ascaris lumbricoides

Acute appendicitis caused by Ascaris lumbricoides is an uncommon variant of a common disease. We describe a case in which sonography was used for preoperative diagnosis of ascaris appendicitis.

A comparative evaluation of scoring systems for assessing necro-inflammatory activity and fibrosis in liver biopsies of patients with chronic viral hepatitis.

INTRODUCTION To compare the five scoring systems in assessing grading and staging of liver biopsies from patients with chronic viral hepatitis and their problems and pitfalls. MATERIALS AND METHODS Liver biopsies from 25 patients with chronic viral hepatitis were studied. Sections were stained with Haematoxylin and Eosin, Reticulin and Massons Trichrome stains. Van Gieson, Perls and Shikatas Orcein stains were used as and when required. Coded histological sections were scored independently by three histopathologists using the Knodell Histology Activity Index (HAI), the Scheuer scoring system, Ishaks system, Metavir system and Ishak modified HAI. RESULTS There were 15 males and 10 females. Their mean age was 51.24 years. On histological examination, hepatocytes showed degenerative changes with varying grades of necrosis (spotty and confluent). Widening of portal tracts with varying severity of mononuclear inflammatory infiltrate and interface hepatitis was observed. Fibrosis appeared as periportal, portal-portal and portal-central septa. A significant agreement was found by kappa statistics for both grading (p< 0.001) as well as staging (p < 0.001) among all the five scoring systems. Lobular activity was the only parameter that showed some discrepancy. No significant intra observer difference was observed. CONCLUSION It is concluded that all the scoring systems are equally good for grading and staging in the hands of an experienced hepatopathologists.

Microscopic colitis in patients presenting with chronic diarrhea

AIM To investigate the prevalence of microscopic colitis among patients presenting with chronic watery diarrhea. MATERIAL AND METHODS Colonic biopsies from 400 patients presenting with chronic watery diarrhea and other symptoms pertaining to lower gastrointestinal tract were studied. After a detailed clinical history and thorough physical examination full length colonoscopy was done using flexible colonoscope. Colonic biopsies were taken from abnormal and normal areas. Three to five micron thick sections were cut and stained with hematoxylin and eosin and Massons trichrome stain to highlight sub epithelial collagen. RESULTS Fifteen out of 400 (3.7%) colonic biopsies from patients presenting with chronic diarrhea had evidence of microscopic colitis. Five out of fifteen biopsies (33%) were diagnosed as collagenous colitis, 10 biopsies (67%) had evidence of lymphocytic colitis; 14/400(3.5%) histologically normal biopsies were taken as controls to compare various demographic and risk factors. Ten out of 15 patients (67%) were clinically diagnosed as irritable bowel syndrome. In the remaining five an infective etiology was suspected. On colonoscopy12/15 (80%) had no abnormality and 3/15 (20%) had mild hyperemia. CONCLUSION A possibility of microscopic colitis should be considered while examining colonoscopic biopsy of a patient with chronic watery diarrhea and normal colonoscopy to avoid the misdiagnosis that may affect the treatment of patients.

Factors influencing colonic involvement in patients with amebic liver abscess

BACKGROUND The frequency of colonic involvement in patients with amebic liver abscess has not been studied in detail. The factors influencing colonic involvement also are unknown. METHODS Seventy-one patients with amebic liver abscess were studied. Colonoscopy was performed in all patients. RESULTS Abdominal pain and fever were the most common presenting manifestations. Ten patients (14%) had diarrhea at admission. Ten other patients had a history of diarrhea during the preceding 2 months. Thirty-nine (55%) patients had colonic ulcers. Colonic ulcers were present in 18 of the 20 (90%) patients with ongoing diarrhea or a history of recent diarrhea, and in 21 of 51 (41%) patients without diarrhea (p<0.001). Thirty (42%) patients had small, discrete ulcers in the cecum, the ascending colon, or the region of the hepatic flexure. Nine patients had large, multiple ulcers with surrounding inflammation. In these patients, the ulcers were present either in the left colon (n=7) or throughout the colon (n=2). The mean (standard deviation) age of patients with 5 or more ulcers was significantly greater than that of patients with fewer than 5 ulcers (49.8 [14.6] years vs. 37 [11.7] years; p<0.05). Multiple ulcers were noted in 7 of the 10 patients (70%) with diarrhea at admission and in two of the 61 patients (3%) in whom diarrhea was not a presenting symptom (p<0.001). No association was noted between the location of the abscess in the liver and the colonic lesions. CONCLUSIONS Colonic ulcers are a common finding, occurring in more than half of patients with amebic liver abscess. They are more likely to be present if the patient has diarrhea as a presenting symptom or has had diarrhea in the recent past. Multiple, large, and left-sided ulcers are more common in elderly patients and in those in whom diarrhea is the presenting symptom. However, there is no association between the location of the abscess in the liver and colonic lesions.

Should fine needle aspiration biopsy be the first pathological investigation in the diagnosis of a bone lesion? An algorithmic approach with review of literature

Background Fine needle aspiration biopsy (FNAB) is gaining increasing popularity in the diagnosis of musculoskeletal lesions; and in many patients, a definitive diagnosis can be rendered from aspiration smears alone. Its applicability in bone pathology, however, has been controversial due to a high percentage of inadequate smears, difficulty in evaluation of tissue architecture and nonspecific results in the diagnosis of primary bone lesions. In this study, the value of aspiration as the first pathological investigation in the diagnosis of a bone lesion was evaluated. Methods 91 cases of clinically suspected cases of bone lesions were aspirated over a period of two years. Direct or cytospin smears were fixed in 95% alcohol and stained by Hematoxylin and Eosin or air-dried and later fixed in methanol for May Grŭnwald Giemsa staining. Results Of the 91 patients who were subjected to FNAB, 81 were considered satisfactory and 10.9 % (10) were inadequate\inconclusive for diagnosis. Cyto-histological concordance was obtained in 78.5 % (51/65) patients. Positive and negative predictive values were 87.5% and 97.2 % respectively. Sensitivity as a preliminary diagnostic technique was 93.3%, whereas specificity was 94.5 %. Overall, diagnostic accuracy was 94.2 %. Metastatic lesions were detected with 100% accuracy. Two cases were reported as false positive and one case as false negative. Conclusion Cytology provides valuable information to the clinician to make an informed decision regarding appropriate therapy. We conclude that time-consuming and costly investigations may be reduced by choosing FNAB as the initial pathological diagnostic method for skeletal lesions of unknown origin. The choice of radiological examinations, laboratory tests and surgical biopsies can be determined after the FNAB diagnosis.

Diagnosing Helicobacter pylori by imprint cytology : Can the same biopsy specimen be used for histology?

Imprint cytology of the gastric mucosa has been found to be very simple, inexpensive, and rapid for diagnosing Helicobacter pylori infection. However, there is a fear that preparing imprint smears may damage the biopsy specimen for subsequent histologic examination. This study was planned to investigate whether this damage happens. Four antral biopsy specimens were obtained from each of the 100 patients undergoing upper gastrointestinal endoscopy. Imprint smears were made from two biopsy specimens, which were then fixed in 10% formal saline and sent for histologic study. The third and fourth biopsy specimens were directly fixed in 10% formal saline for histologic examination. Two pathologists examined the imprint smears. Agreement between the two observers was observed in 97% of cases. Beyond‐chance agreement was good with a kappa index of 0.90. H. pylori organisms were seen in 82% of biopsy specimens from which imprint smears were prepared and in the same percentage of biopsy specimens that were processed directly. The pathologists could not identify the histologic sections from which imprints were made. It is concluded that imprint cytology is an excellent method of diagnosing H. pylori infection and that preparing imprint smears does not alter the quality of the tissue. The same biopsy specimen can be used for histologic studies. Diagn. Cytopathol. 1998;18:330–332.