Lesions of the large intestine comprise a broad spectrum of inflammatory, infectious, premalignant, and malignant disorders and are a significant cause of gastrointestinal morbidity worldwide. Colonoscopy with biopsy has become the cornerstone for the evaluation of colorectal lesions, allowing direct visualization of mucosal abnormalities and targeted tissue sampling for histopathological examination, which remains the gold standard for definitive diagnosis. Histopathological assessment not only confirms the nature of the lesion but also distinguishes non-neoplastic, premalignant, and malignant conditions, thereby guiding appropriate clinical management and improving patient outcomes [1–3].

The spectrum of large intestinal lesions varies according to age, sex, environmental factors, and geographic distribution. Non-neoplastic lesions, including infectious and inflammatory colitis, are encountered more frequently, whereas adenomatous polyps and colorectal carcinoma represent important premalignant and malignant lesions requiring early detection and treatment. Correlation of colonoscopic findings with histopathological diagnosis enhances diagnostic accuracy, as some lesions may have similar endoscopic appearances but distinct microscopic features [4–6].

The present study was undertaken to evaluate the histopathological spectrum of large intestinal lesions in colonoscopic biopsy specimens and to assess the correlation between endoscopic and histopathological findings, thereby emphasizing the diagnostic value of biopsy in the management of colorectal diseases.

AIMS

To study the histopathological spectrum of various large intestine and rectum lesions found in endoscopic biopsy specimens.

OBJECTIVES

1. To determine the various large intestine and rectum lesions found in endoscopic biopsy specimens.
2. To study and stratify the various large intestine and rectum lesions into benign, inflammatory, and neoplastic categories.

MATERIAL AND METHODS

Sample size - 25 large intestine and rectum biopsies.

Study design - Prospective study.

Place of study - Pathology Department, MGM's Medical College and Hospital, Navi Mumbai.

Inclusion criteria - All large intestine and rectum endoscopic biopsies of all age and sex.

Exclusion criteria - Resection specimens. Liver and gallbladder specimens. Patients not willing to give consent. Inadequate biopsies.

The present study is a prospective evaluation of large intestine and rectum endoscopic biopsies and histopathological diagnosis of the biopsies. The study included 25 large intestine and rectum biopsies from patients who presented to the Department of Surgery with various symptoms including constipation, diarrhea, bleeding per rectum, abdominal pain, weight loss, etc. All relevant clinical details including age, sex, clinical presentation, endoscopic findings, and histopathological diagnosis of patients were noted in the proforma prepared for this study.

Staining Technique - All endoscopic biopsies taken from different sites were submitted to the histopathology laboratory in 10% buffered formalin and were oriented and embedded with the mucosa downwards. After overnight fixation in formalin, dehydration was carried out with graded alcohol, followed by clearing in xylene, paraffin embedding, and section cutting on a rotary microtome. Sections of 3 µ thickness were prepared and stained with hematoxylin and eosin (H&E). All biopsies were evaluated for morphological changes with special reference to atrophy, dysplasia, metaplasia, neutrophilic infiltration, lymphoid infiltration, and malignant changes.

Hematoxilin and Eosin Procedure - Sections were dewaxed and rehydrated through graded alcohol to water, and fixation pigments were removed. Sections were stained in alum hematoxylin for 5 minutes and washed in running tap water until blueing was observed (≤5 minutes). Differentiation was performed in 1% acid alcohol for 5–10 seconds, followed by washing in tap water until blueing recurred; blueing was completed by dipping in an alkaline (ammonia water) solution followed by a 5-minute tap water wash. Sections were then counterstained in 1% eosin Y for 30 seconds to 1 minute, dehydrated through 2–3 changes of absolute alcohol, cleared through 2–3 changes of xylene, and mounted with Dibutyl Phthalate Polystyrene Xylene (DPX). Result: nucleus stains blue; cytoplasm and connective tissue stain in shades of pink.

Statistical analysis  - All categorical variables were expressed as frequency and percentage, while quantitative variables with symmetrical distribution were expressed as mean ± SD. Comparisons between categorical variables were performed using tests appropriate to the distribution of the data. Statistical significance was defined as p < 0.05, where applicable. All analyses were carried out using standard statistical software (MS Excel).

Study design and place of study - A one-and-a-half-year prospective study of gastrointestinal biopsies was conducted in the Histopathology Section, Department of Pathology.

RESULTS AND OBSERVATIONS

Table 1. Age-wise Distribution of Large Intestine and Rectum Cases

Graph 1. Age-wise Distribution of Large Intestine and Rectum Cases

Large intestine and Rectum disorders are most frequently seen in the middle-aged population; the age-wise distribution shows the greatest number of patients in the 41–60 year range, followed by the 21–40 year group, indicating a significant frequency in younger persons as well. The 0–20 year age group shows that these disorders are still present in the paediatric and adolescent population, albeit less commonly. No cases were reported in individuals older than 80 years, and the proportion in the 61–80 year group was comparatively smaller. Overall, middle-aged and younger adults were more likely to have large intestine lesions, with the 41–60 year group showing the highest incidence.

Younger age groups, particularly those under 40 years, showed a higher prevalence of benign lesions, suggesting that infections and inflammatory bowel disorders primarily affect younger individuals. Malignant lesions were distributed across all age groups; one instance in a patient under 40 years indicates early-onset colorectal cancer, though the majority of malignant cases remained in middle-aged or older patients, consistent with known epidemiology.

Table 2. Sex-wise Distribution of Large Intestine and Rectum Cases

Graph 2.  Sex-wise Distribution of Large Intestine and Rectum Cases

Of the 25 cases, males predominated (17 cases) over females (8 cases). Non-neoplastic lesions were the most frequent findings overall (19 cases), with males contributing more of these (12 cases) than females (7 cases). Premalignant and neoplastic lesions totaled six cases, five of which occurred in males and only one in females. Overall, the data indicate a male predominance in both non-neoplastic and premalignant/neoplastic lesions of the large intestine, with a notably higher incidence of neoplastic and premalignant disease among males.

Table 3. Distribution of Non-Neoplastic Lesions of the Large Intestine and Rectum

The distribution of histological diagnoses shows that inflammatory and non-neoplastic diseases predominate, accounting for 76% of all cases. Mild to moderate colitis was the most common finding (16%), followed by ulcerative colitis (12%) and infective colitis (8%). Smaller proportions (4% each) of other inflammatory conditions — proctitis, acute-on-chronic colitis with eosinophilic changes, and chronic non-specific colitis — reflect a wide range of inflammatory bowel pathology. Polypoidal lesions such as juvenile retention polyps, hyperplastic polyps, and benign adenomatous polyps each accounted for 4% of cases, indicating a comparatively lower occurrence of benign neoplastic or pre-neoplastic lesions. Uncommon conditions such as inflammatory bowel disease and pseudomelanosis coli each accounted for 4% of cases.

Table 4. Distribution of Neoplastic Lesions of the Large Intestine and Rectum

Malignant lesions accounted for 8% of the 25 cases, equally distributed (4% each) between poorly differentiated adenocarcinoma and high-grade dysplasia with foci of invasive adenocarcinoma. Although less common than non-neoplastic lesions, this distribution underscores the clinical relevance of neoplastic findings and the importance of early detection and histological examination.

Table 5. Distribution of Premalignant Lesions of the Large Intestine and Rectum

Graph 3.  Distribution of Benign, Pre-malignant and Neoplastic Lesions of the Large Intestine and Rectum

Premalignant lesions comprised 16% of total cases, with adenomatous polyps forming the majority — adenomatous polyp with low-grade dysplasia was the most common (8%), followed by adenomatous polyp with mild-to-moderate focal dysplasia (4%). Adenocarcinoma in situ accounted for 4% of cases, representing an early stage of malignant transformation confined to the epithelium. While neoplastic lesions were less frequent overall than non-neoplastic conditions, the notable presence of premalignant and early malignant changes emphasizes the role of histopathological examination in timely diagnosis and prevention of progression to invasive carcinoma.

Table 6. Correlation of Endoscopic Findings with Histopathological Findings of Large Intestine and Rectum Cases

The comparison between endoscopic/colonoscopic impressions and histological diagnoses shows general concordance. Histopathological diagnoses such as infective colitis, ulcerative colitis, and mild-to-moderate colitis correlate reasonably well with endoscopic findings of colitis, ulceration, and inflammatory change. However, endoscopy frequently yields only a tentative or nonspecific diagnosis, subsequently clarified by histology. Polypoidal lesions identified on endoscopy (e.g., rectal polyp, sigmoid polyp) correspond well with histological findings such as juvenile polyp, hyperplastic polyp, and adenomatous polyp, although the precise nature (dysplasia/atypia) can only be determined microscopically. In cases of mass lesions or growths — such as a fungating mass or rectal mass — histopathology confirmed malignancy or high-grade dysplasia, indicating a strong correlation in identifying neoplastic lesions. Several discordances, in which endoscopic impressions suggested inflammatory disease while histology revealed a different or more specific diagnosis, highlight the limitations of endoscopy alone. Overall, histological examination remains the gold standard for definitive diagnosis, particularly in differentiating inflammatory, premalignant, and malignant lesions, even though endoscopy remains valuable for initial assessment and localization.

Table 7. Comparison of Age/Sex, Clinical Features, and Histopathological Diagnosis of Large Intestine and Rectum Cases

Male patients outnumbered female patients overall. Diarrhoea, abdominal pain, mucus in stool, and bleeding per rectum were the most common clinical presentations, indicating that bowel-related symptoms predominate. These symptoms were most often linked to non-neoplastic and inflammatory disorders such as ulcerative colitis, chronic non-specific colitis, infective colitis, and mild-to-moderate colitis. Premalignant lesions — including adenomatous polyps with low-grade or focal dysplasia and adenocarcinoma in situ — frequently presented with altered bowel habits, occult blood in stool, and mild abdominal discomfort. Malignant lesions, including adenocarcinoma in situ and poorly differentiated adenocarcinoma, were associated with more severe symptoms such as weight loss, malena, and recurrent bleeding per rectum. Overall, benign and inflammatory lesions were associated with milder gastrointestinal symptoms, while premalignant and malignant lesions showed more concerning features — bleeding, anaemia, and weight loss — with increasing severity in older age groups.

PICTURES

Figure 1. Endoscopy image –? Inflammatory Bowel Disease

Figure 2. Ulcerative colitis (40x, H & E)

Figure 3. Ulcerative colitis (40x, H & E)

Figure 4. Endoscopy image –Inflammatory Ascending and Sigmoid colon

Figure 5.and 6. Pseudomelanosis coli (10x and 40x, H & E)

Figure 7. Endoscopy image –Moderate to severe left sided colitis? Ulcerative Colitis

Figure 8. Inflammatory Bowel Disease (10x, H & E)

Figure 9. Endoscopy image –Rectal polyp and multiple colonic polyp

Figure 11. Adenomatous Polyp (40x, H & E)

Figure 12. Adenomatous Polyp (10x, H & E)

DISCUSSION 

The present study evaluates the histopathological spectrum of 25 large intestine lesions based on colonoscopy biopsies and correlates them with clinical and endoscopic findings.

Age wise distribution -

The age group of 41–60 years had the highest number of cases in this study, accounting for 11 of the 25 biopsies (44%), followed by the 21–40 year group (7 cases). Non-neoplastic, inflammatory lesions predominated in patients under 40 years, while all six premalignant and neoplastic lesions occurred in patients above 40 years, with one exception in the 61–80 year bracket. This pattern is consistent with the generally accepted view that inflammatory and infective colonic disorders present earlier in life, whereas dysplastic and malignant transformation accumulates with advancing age. No cases were recorded beyond 80 years in this series, likely reflecting the smaller number of very elderly patients referred for colonoscopic biopsy at this centre.

Sex wise distribution -

A male predominance was observed in the present series, with a male-to-female ratio of approximately 2:1 (17 vs. 8 cases). This predominance was more pronounced among premalignant and neoplastic lesions, where males accounted for five of the six cases. This finding is in keeping with the widely reported higher incidence of colorectal neoplasia in men, which has been attributed to a combination of lifestyle factors and differences in healthcare-seeking behaviour, though the small sample size in this study limits the strength of this inference.

Spectrum of non neoplastic lesions -

Non-neoplastic, inflammatory lesions constituted the largest category in this study (76% of cases), with mild to moderate colitis (16%) and ulcerative colitis (12%) being the most frequent diagnoses. This predominance of inflammatory pathology reflects the common clinical presentation of colonic biopsies performed for diarrhoea, mucus in stool, and bleeding per rectum, symptoms that are frequently attributable to infective or idiopathic inflammatory bowel disease rather than neoplasia. The presence of a case of pseudomelanosis coli, a benign pigmentary change usually associated with chronic laxative use, and a case of eosinophil-rich colitis further illustrates the diagnostic breadth that histopathology can resolve beyond a nonspecific endoscopic impression of "colitis."

Spectrum of premalignant and  neoplastic lesions -

Premalignant lesions were identified in 16% of cases, predominantly adenomatous polyps with low-grade or focal dysplasia, along with a single case of adenocarcinoma in situ. Neoplastic lesions accounted for 8% of cases, comprising one poorly differentiated adenocarcinoma and one case of high-grade dysplasia with foci of invasive adenocarcinoma. Although numerically small, this combined premalignant-to-malignant fraction (24% of all cases) underscores the importance of biopsy in every colonoscopically abnormal mucosa, since dysplastic and early malignant lesions cannot be reliably distinguished from benign polyps or inflammatory lesions on gross endoscopic appearance alone.

Endoscopic histopathological correlation -

Correlation between endoscopic impression and final histopathological diagnosis was generally good for mass lesions and polypoidal growths, where endoscopic suspicion of malignancy was consistently confirmed on histology. Correlation was comparatively weaker for inflammatory lesions, where endoscopic descriptors such as "colitis" or "suspected inflammatory bowel disease" were often nonspecific and required histopathological examination to differentiate infective colitis, chronic non-specific colitis, and ulcerative colitis from one another. This reinforces the established principle that colonoscopy is primarily a tool for lesion detection and localization, while histopathology provides the definitive diagnostic categorization necessary for clinical decision-making.

Clinico - pathological correlation -

Bowel-related symptoms — diarrhoea, abdominal pain, mucus in stool, and bleeding per rectum — were the predominant presenting complaints across the cohort and were most closely associated with non-neoplastic inflammatory lesions. Premalignant lesions more often presented with subtler features such as altered bowel habits and occult blood loss, while malignant lesions were associated with more alarming features, including weight loss, malena, and persistent rectal bleeding. This gradient of symptom severity across the non-neoplastic–premalignant–neoplastic spectrum is consistent with the natural history of colorectal disease and supports a low threshold for biopsy in patients presenting with these warning features, particularly in the middle-aged and elderly population.

CONCLUSION

This prospective study of 25 large intestine and rectal endoscopic biopsies demonstrates that non-neoplastic inflammatory lesions form the predominant histopathological category (76%), with mild to moderate colitis and ulcerative colitis being the most common diagnoses. Premalignant and neoplastic lesions, though less frequent (24% combined), occurred predominantly in males and in patients above 40 years of age, highlighting these as higher-risk groups warranting careful endoscopic and histopathological evaluation. While colonoscopic impression correlated well with histopathology for mass and polypoidal lesions, it was frequently nonspecific for inflammatory conditions. These findings reaffirm that histopathological examination of colonoscopic biopsies remains indispensable for accurate diagnosis, appropriate risk stratification, and timely management of colorectal disease, and that endoscopy and histopathology should be regarded as complementary rather than interchangeable diagnostic tools.

Ethics approval and consent to participate

The study was approved by the Institutional Ethics Committee prior to commencement.

List of abbreviations

CRC: Colorectal Carcinoma; DPX: Dibutyl Phthalate Polystyrene Xylene; GI: Gastrointestinal; H&E: Hematoxylin and Eosin; IBD: Inflammatory Bowel Disease; M:F: Male to Female Ratio; SD: Standard Deviation

Data Availability

The data sets used and analyzed during the current study are available from the corresponding author on reasonable request

Conflicts of Interest

None declared.

Funding Statement

Nil.

Authors' contributions

UM conceived and supervised the study, served as lab director, and reviewed slide morphologies. AA performed tissue preparation, H&E staining, data analysis, and drafted the manuscript. VS assisted in tissue processing and critical analysis. All authors read and approved the final manuscript

Acknowledgments

The authors express their gratitude to the technical staff of the Histopathology Laboratory, Department of Pathology, and the Department of Surgery at MGM Medical College and Hospital for their consistent support.

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