INTRODUCTION

TO PATHOLOGY

Objectives:
● Understands the role of pathology and its various subspecialities in the
diagnostic process with special emphasis on histopathology and
cytology.
● Understands the meaning of the terminology used during the study of a
disease like aetiology, pathogenesis, prognosis, sequelae, symptoms,
signs, incidence etc.

● Role of diagnostic pathology in disease management.

● Be aware of some of the principle techniques used in pathology like light

microscopy, cytology, immunohistochemistry and molecular pathology.

● Have a basic knowledge of the definition of autopsy and its indications.

Color Index:
Girl’s Slides
Important
Male’s Notes
Female’s Notes
Extra information
Definition of Pathology

Pathology
The study of disease by scientific methods. It is the study of changes
which occur in cells and tissues as a result of any injury to the cell or tissue.

Disease: An abnormality in structure or function of

any part of the body.

A disease can be physiological or psychological or

both

Parts of Pathology

1- Epidemiology

2- Etiology

3- Pathogenesis

4- Morphologic changes
Signs

5- Clinical features
Symptoms
Mnemonic: My Cat Plays Every
Evening

2
 1- Epidemiology
Definition
Study of the occurrence and distribution (Demographic of diseases in a population) and
the application of this knowledge to help the health system. It is the study of the patterns, causes,
and effects of disease conditions in various populations.

Factors in epidemiology
Occupation Geographic location
Which Part of the world a particular
● hardwood workers → nasal cancer (from disease is common in.
inhalation of wood dust etc.) I.e. Which country has more prevalence?
Age Sex ● aniline dye industry → urinary bladder cancer. Underdeveloped countries →
● workers in asbestos industry → asbestosis or malnutrition and infections like TB.
tumors like mesotheliomas. Developed countries → cardiac problems
● Dentist → Back Pain and obesity.

Socioeconomic strata Sequelae Prognosis

expected outcome of the
what is the social and financial status of Complications/
disease based on its severity.
the people affected by a particular disease. Consequence of the disease,
Race i.e. Rich → nutritional Diseases e.g. Word origin: “Sequence of
Bad prognosis → High grade
cancer
Diabetes. events”.
Good Prognosis → Common
Poor → Infectious Diseases e.g. TB. E.g. Scars
cold

Prevalence Incidence

The total number of cases of a particular The number of new cases of a disease a
disease in a particular population in a particular particular disease in a particular
period of time. population in a particular period of time
(immunization programmes affect the
incidence of a disease).

Probability of already having a disease The probability of developing a disease

Counts old and new cases Counts only new cases

E.g. hepatitis B is prevalent in Saudi Arabia. E.g. the incidence of influenza increases during hajj season
E.g. In Saudi Arabia, in 2018, 20 people have diabetes. in Saudi Arabia.
E.g. In Saudi Arabia, in 2018, 5 new people have diabetes.

Mortality rate: number or

percentage of people who have died in a
Morbidity rate: number or particular population in a particular
percentage of people who have the period of time.
disease. (Presence of an illness) E.g. high grade cancer =↑ Mortality rate
E.g. In Ksa, in 2017, 2 People died from
TB 3
1- Epidemiology (cont.)
Investigate the extent of a disease in a community.

Study natural pattern, history, and prognosis of a disease

Importance of
epidemiology

Identify causes & risk factors of a disease.

Provide good health care based on the findings.

To recommend and assist in various health programmes

to prevent or treat a disease (preventive and therapeutic
measures), e.g. immunizations and screening programs
for different disease etc.

To evaluate all health facilities and programs

Provide information on public health in order to help care

system and develop health facilities.

2- Etiology
Definition
● It is the cause of the disease.
● If the cause is unknown, We call it idiopathic/cryptogenic/essential etc.
● Diseases are classified depending on the etiology and pathogenic mechanism
involved. Diseases can be Congenital or acquired.

Cont. In the next page..

4
*An inflammation can be caused by an infection but not always.
An infection is caused by a foreign organism(bacteria, virus.etc)
Inflammation can be from an autoimmune disease or allergy

Type Basis Example

- Hemophilia: absence of blood clotting

factor VIII (X chromosome linked)
Genetic
1- Congenital - Down syndrome: extra chromosome 21
(a condition existing at - Inborn errors of metabolism
birth or before birth,
or that develops during
the first month of life) Non-genetic
Abnormal defect or deformity a child - Cleft lip/palate
is born with, associated with - Spina bifida
embryogenesis

Rheumatoid arthritis: inflammation of

Inflammatory* joints /arthritis

Atherosclerosis: Leads to: cerebrovascular

Vascular accident(stroke)/myocardial infarction(heart attack) or
immune mediated e.g. vasculitis

Neoplastic (Growth
Cancer
disorder)

- Alzheimer’s (Type of Dementia)

Degenerative
- Parkinson’s

- Certain drugs can cause liver or kidney failure,

Drug induced bone marrow suppression & skin rash.
- Alcohol can cause liver disease
(Therapeutic and - Paraquat poisoning damages the lungs
Recreational Drugs) - Excessive smoking causes lung and cardiac
2- Acquired problems.

Infective Viral, bacterial, fungal, parasitic diseases.

- Diabetes mellitus: a chronic disease Caused by

Error in the metabolism of carbohydrates
Metabolic
- Gout: a metabolic disorder caused by an error in the
metabolism of urate(uric acid)

Nutritional deficiency - Anemia

diseases - protein- energy malnutrition

- Neck: can cause thyroid cancer

Radiation - Skin: can cause skin cancer
(Squamous cell carcinoma)

- Road traffic accidents

Mechanical
- burns 5
3- Pathogenesis
*It is the transformation of Normal cells
into Abnormal cells, it helps to target the
problem, and drugs are given based on it

Definition

The steps that take place in the body once the problem begins, leading to tissue
injury (pathological manifestations) & eventually to morphologic changes
(changes in the gross or microscopic appearance of human tissue).

Pathogenic mechanisms
Four basic pathogenic mechanism (or steps) in a disease

Inflammatory Degenerative Carcinogenesis Immunological

(the transformation of normal
process process cells to malignant) process

4- Morphologic changes
Definition
● Structural changes that take place in cells or tissues due to any
disease. (appearance of illness)
● Diseases commonly have specific morphological changes (gross or
microscopic), helping in the diagnosis of the disease.

Types of morphological changes

Histological
Gross (macroscopic (microscopic
findings): findings):
Can be seen with naked eye. Can only be seen under
the microscope

6
5- Clinical Features
When an organ is damaged, its normal function will be affected, leading to
the development of certain clinical changes known as signs & symptoms.
(The combination of signs and symptoms is called as clinical features).

Symptoms Signs
Something experienced and reported by are findings discovered by the physician
the patient e.g. ‘I am feeling tired’, ‘I have during examination of the patient e.g.
a headache’, ‘I have a pain in my doctor finds a swelling somewhere or
stomach’ etc. Basically it is what the
doctor find a liver or spleen
Patient will tell the doctor.
enlargement while examining the
abdomen etc.
Basically it is what

1 2
the doctor will find
on examining
the patient.

THEREFORE IN MEDICINE,
PATHOLOGY DISEASES ARE STUDIED UNDER
THE FOLLOWING HEADINGS
(How you study Pathology):
Epidemiology • Definition
• Epidemiology of disease
Etiology (The cause • Etiology
leads to the beginning • Pathogenesis and pathophysiology
of the pathogenesis) • Morphology: it is divided into
- Gross/ macroscopic- visible to the
naked eye
Pathogenesis
- Microscopic- visible under a
microscope
Morphological or • Clinical features/presentation: signs and
chemical alteration symptoms
• Differential diagnosis (Which leads to final
Clinical Features diagnosis): is there any other
(Signs and Symptoms) alternative diagnosis/diagnoses with similar
findings?
• Treatment and management 7
• Prognosis
 Steps of studying a disease

Define the disease.

example the definition of gout: is a
1 metabolic disorder caused by an error in the metabolism of
urate(uric acid).

Epidemiology (age,sex,race...etc).
2

Clinical presentation: Symptoms (patient

3 complaints) or signs (Clinical features discovered by the
doctor).

Disease location: based on the signs and symptoms

4 you can have an idea of the organ or system affected by
the disease.

Testing: either pathological tests (biopsy) or

5 radiological tests (X-ray).

Differential diagnosis: making a list of all possible

6 diseases based on the results of tests and on the signs and
symptoms

Diagnosis: using the test and clinical presentation to

7 diagnose the disease

Treatment and Prognosis:

8 Treatment can be Surgery, drugs, counseling.
Prognosis is the predicted outcome of the disease.

8
Course Of Disease
1) How it starts?
2) What happens?
3) What does it lead to?
Definition
The course of a disease is the different stages in the natural history or
progression of a disease in the absence of any intervention.

The different stages in the natural history or course of a disease especially

infectious are as follows:

Latent (incubation/induction)
Exposure period.

A B
To causative organism or risk Is the time period from the
factor exposure to the development
of signs and symptoms

Onset of disease
The begging of signs and
C D Outcome (consequences) of
the disease
symptoms Following the clinical onset, the disease
may follow one of the following trends:
- Recovery/resolution of disease without
complication or sequelae. Person is back to
Sequelae vs Complications: normal health.
You can’t do much about sequelae - The disease recovery but with sequelae.
- Complications: development of
but with complications it gets worse complications in any disease can make things
and you have to deal with it worse.
- Death.

The diagnostic process & Role

Of Pathologist
• Any patient going to a clinic meets clinician who will take history and do
clinical examination. He may ask for radiological and pathological
examination in order to come to a diagnosis. E.g. Doctor comes into differential diagnosis,
take biopsy and orders a pathological microscopic examination.
• The common pathological examinations are blood, urine and stool tests.
Sometimes the patient is also asked to undergo a cytopathology or a
histopathology test or other special pathological tests in order to obtain an
accurate diagnosis.
• This way pathology plays an essential role in the diagnosis of a disease and management
and treatment of patient.
9
The Branches/Subdivisions
of Pathology
Histopathology: Study of tissue biopsied/exfoliated from body.
1
Cytopathology: Study of cell INDIVIDUAL morphology,
exfoliated or aspirated from body.
2
Hematology: A Study of blood, blood cells & bone marrow, used
in the diagnosis of anemias & leukemias.
3
Immunohistochemistry: A Special staining procedure is
used to detect antigens in the tissue. (just focus on the name)
4
Chemical pathology / clinical biochemistry: Is the
analysis of bodily fluids (blood, urine, etc) for diagnosis.
5

Microbiology: Is the study of microorganisms.

6

Immunology: Is the analysis of the immune system of the body.

7

Toxicology: Study of various poisonous and toxic substances.

8

Cytogenetics: Is a study of chromosomal abnormalities.

9
Molecular pathology: e.g. fluorescent in situ hybridization,
southern blot test.
10
Autopsy: see later.
11

10
 Histopathology
Histopathology
Is the study of tissues using light microscope. Tissues
are obtained by doing biopsies and excision of organs
by physicians & surgeons.

STEP 1

➔ Once the tissue is removed from the patient’s

body, it is immediately preserved (fixed) by
putting it in a container of formalin (10%
formaldehyde). The purpose of fixation is to
prevent autolysis and decomposition of the
tissue.
➔ Tissue is processed in a special multistep way
and the end result is very thin slices of
stained tissue (4-6 microns) glued on a slide. STEP 2

The most commonly used routine stain is

Hematoxylin & Eosin stain. It gives the
nucleus a blue/violet color & the cytoplasm
a pink color.
Thin Slices of Tissue

The pathologist will look at the slide under

the microscope and give a diagnosis. SLIDE IS READY
Histopathology is usually the final/gold
standard of diagnosis.

NOTE: sometimes during surgery an urgent

diagnosis is needed INSTANTLY and tissue
is processed rapidly to give results in 20
minutes. This is called frozen section. (not
the best option, only in Emergency)

11
 Cytopathology
Cytopathology is the study of morphology of
individual cells which are obtained by scraping
(exfoliative cytology) or aspiration (fine-needle
aspiration cytology) from various parts of body.

Fine-needle Exfoliative
aspiration cytology (falling or scraping off)
(FNAC): cytology

In it the cells are obtained by The cells are scraped of any mucosa
aspiration/suction of cells from using a spatula (e.g. cervix and oral
affected organ or tumor mass cavity) or the cells exfoliate (fall off)
using a needle. The cells themselves and collect in the
obtained are put on a slide, respective fluids/secretion (e.g.
stained and examined under a sputum and in urinary tract disease
microscope. the cells which exfoliate collect in the
urine, e.g. Pap smear)

❖ The morphology of the cells are studied and a diagnosis made from it. It is used
for the purpose of:
➢ Screening for cancer e.g. cervical cytology is used in the screening of
carcinoma of cervix.
➢ Diagnosing cancer

❖ The advantage of cytologic techniques when compared to histopathological

techniques is that the procedure is cheap, takes less time and requires no
anesthesia.

Fine needle aspiration cytology (suction of cells) Exfoliative cytology:

12
 Autopsy
It is a sub-specialty of pathology which
Definition involves examining a dead body

❖ An autopsy is done to:

➔ To determine the cause of death (this is the main reason why autopsy is
done). It can be performed in any of the following situations:
◆ Homicidal
◆ Suicidal
◆ Accidental
◆ To identify the disease
❖ To provide useful information about various disease.
❖ To do research.
❖ Also it can be used as a tool to educate students, surgeons etc

❖ Who does the autopsy? The pathologist. (in Homicide forensics does it)

Some instruments in Pathology:

❖ There are different diagnostic instruments used in pathology.

❖ Some of the instruments used in pathology are:

Immunofluorescent Electron microscope:

microscope: magnifies up to two
uses a special blue million times, which is
filter and a fluorescent much higher than a light
dye to identify various microscope. It enables us
antigens in a tissue. It to see cell structure like
does this by using mitochondria,
antibodies tagged with endoplasmic reticulum,
fluorescent dye against viral particles etc. It is
tissue antigens. It is also called as ultra
used in diagnosing structural studies. It is an
immunological expensive technique.
diseases.

Light microscope:

13
Clinical Cases
Hemophilia Down syndrome (mongolism)
Congenital (Genetic) Congenital (Genetic)
Symptoms: excessive bleeding. Example of an 8 years old boy:
Caused by: deficiency of factor 8 Symptoms: slanting eyes
(coagulation factor) the gene responsible /cognitive impairment /short neck
for clotting is absent /short structure /one crease in the
(inherited) almost exclusively in palm of the hand / large tongue.
males, rarely in Females Diagnosis: down syndrome (21
while females can only carry and trisomy show by karyotype).
transmit it to the male offsprings

Eczema
Cleft lip and palate
Inflammatory disease
Congenital malformation
Example: my hand is
(non-genetic)
always red and feels hot.
Example of an boy with a cleft
Symptoms: redness
lip and palate
,Swelling ,presence of
NOT INHERITED
exudate, pruritus (itch)
Treatment: surgery
Could be caused by:
Allergy /Infection/
Autoimmune disease
He has: eczema/
dermatitis (allergic)
It isn't caused by
infection , it’s caused by
an allergy

Atherosclerosis: Dementia or alzheimer’s

Vascular disease Degenerative disease
one of the major vascular diseases occur in elderly 80-95 years olds
Caused by: accumulation of lipid in It’s a deterioration in the function
blood vessels that gather and and structure or cells or tissues
eventually blocks it because of an aging process
Leads to: cerebrovascular Example:80 years old man ‫ﯾﺮوح‬
accident(stroke)/myocardial ‫ﯾﺼﻠﻲ ﻛﻞ ﯾﻮم و ﻣﺮة ﻣﺎ رﺟﻊ ﺑﻌﺪﯾﻦ اﺗﺼﻠﻮا اﻟﺸﺮطﺔ‬
infarction(heart attack) ‫ﻋﻠﻰ أھﻠﮫ و ﻗﺎﻟﻮا اﻧﮫ ﺿﺎﯾﻊ ﻣﺎ ﯾﻌﺮف وﯾﻦ ﺑﯿﺘﮫ وﻣﻮ‬
‫ﻋﺎرف ﯾﺮﺟﻊ‬
Symptoms: unable to recall near
memories and remote
memories/small brain size
Caused by: degeneration of the
hippocampus area cells (atrophy of
brain)
14
Cont.

Parkinson’s disease
Degenerative disease
signs/symptoms: affects elders/expressionless
face/hand shivering/tremors
Caused by: Loss(degeneration) of cells in the
substantia nigra

Hemorrhagic skin rash bacterial meningitis

Drug induced disease Infective disease
Example: girl with Sore throat, doctor Symptoms: headache/ high body
gives her antibiotic, after taking the pills temperature(39.5)/stiff neck/ fear of light
she suffers from (hemorrhagic skin rash) (photophobia)
Drug induced(toxins) Caused by: a bacteria called streptococcus
can cause diseases: in liver/ pneumoniae (pneumococcus)
kidneys/lungs/mostly rash

Diabetes Gout
Metabolic disease Metabolic disease
Most common one mainly targets joints (especially the
Caused by: Error in the feet joints)
metabolism of carbohydrates Caused by: An error in the
metabolism of urate (uric acid) OR
Harms: skin/kidney/liver/eye purine protein which form uric acid
found in dna in nuclear material and it
causes formation of urate crystals
(uric acid crystals) which accumulate
in joints and cause inflammation

15
T/F Qs: SAQs:
1- Idiopathic means a known cause ( … ) 1- How do Etiology & Pathogenesis differ?
2- The beginning of signs and symptoms is the 2- What’s the cause of Gout disease, and the
outcome of the disease ( … ) sites of it?
3- Incidence is the total number of cases for a 3- Define Autopsy, and reason to do it, and the
disease ( … ) benefits from it.
4- Eczema/Dermatitis is a metabolic disease students learning.
(…) 4- F, inflammatory disease
3- examining a dead body, determine cause of death, researches +
2- error in the metabolism of certain protein(purine) or urate(uric acid).
3- F, prevalence
the disease.
2- F, Onset of a disease
1- Etiology is the cause of disease, and pathogenesis is steps leading to
1- F, Idiopathic is an unknown cause

MCQs:
3- "In Saudi Arabia, There are 10
1- Signs:
Tuberculosis patients per 100,000" .
This is an example of:
A- features of illness that the patient notice.
B- are findings discovered by the physician
A- Morbidity rate
during examination.
B- Prognosis
C- complications and sequences
C- Sequelae
D- stages of pathogenesis
D- Mortality rate

2- Atherosclerosis/myocardial 4- which of the following is correct about

infarction: prevalence:

A- Inflammatory A- it counts new cases only

B- congenital inherited B- it gives you an idea of how many people
C- Vascular disease already have the disease
D- Drug induced C-It helps us determine how lethal the disease
is.
D-It helps determine how likely a person is to
get a disease
1- B, 2- C, 3- A, 4- B

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