1.Histopathology Flashcards
A 70 year old lady presents to her GP complaining of tight chest pain, which radiated to her left arm and was relieved by rest. Her ECG revealed some ST depression
Stable Angina - by effort
occurs at rest / minimal exertion
unstable angina
occurs during rest Due to coronary spasm ST elevation during attack: resolves as pain subsides.
Prinzmetal’s / variant: Rx: CCB + long-acting nitrate
A 63 year old obese, diabetic male presents to A and E with tight chest pain at rest, which radiated to the left arm and lasted for less than 20 minutes. The CK was not raised.
Acute Coronary Syndrome but not MI - in MI the CK would be otherwise raised. ACS = unstable angina + evolving MI Divided into: ST elevation or new onset LBBB NSTEMI
A 68 year old man presents with sudden onset chest pain, which radiated to the back. On examination the patient was shocked, with a hemiplegia and the chest X-ray showed mediastinal enlargement.
aortic dissection - not AAA
Kussmaul’s sign: ↑JVP ̄c inspiration Quiet heart sounds S3 Hepatosplenomegaly Ascites, oedema Sarcoid Systemic sclerosis Haemochromatosis Amyloidosis Primary: endomyocardial fibrosis Eosinophilia (Loffler’s eosinophilic endocarditis) Neoplasia: carcinoid (→ TR and PS)
restrictive pericaditis
Radio-femoral delay + weak femoral pulse Hypertension Systolic murmur / bruit heard best over left scapula
aortic coarctation
A 65 year old man is in hospital after suffering an acute myocardial infarction. The house officer hears a pansystolic murmur on auscultation.
Cardiac tamponade: Left ventricular free wall rupture Beck’s triad (↓BP, ↑JVP, muffled heart sounds) Pulsus paradoxus Papillary muscle / chordae → MR PSM Pulmonary oedema. Septum PSM ↑JVP Heart failure
A 28 year old sportsman presents to A&E with severe chest pain and breathlessness. He has a history of asthma. There is a systolic murmur on examination.
LVOT obstruction from asymmetric septal hypertrophy AD inheritance (but 50% sporadic) β-myosin heavy chain mutation commonest Ask re family Hx of sudden death
A 46 year old women presents to A&E out of breath and with severe chest pain. On examination a mid systolic click late systolic murmur is revealed.
Myxomatous degeneration refers to a pathological weakening of connective tissue. The term is most often used in the context of mitral valve prolapse, which is known more technically as “myxomatous mitral valve degeneration.” Myxo= connective tissue The degeneration occurs in conjunction with an accumulation of dermatan sulfate, a glycosaminoglycan, within the connective tissue matrix of the valve. The exact mechanism is unknown. In many cases, the degeneration is limited to the mitral valve and follows a benign course. When associated with systemic diseases, like Marfan syndrome, the degeneration is more extensive and involves other heart valves. The valves can become sufficiently distorted to cause insufficiency and regurgitation. Myxomatous degeneration is the most common cause of pure mitral valve insufficiency[citation needed].
A 10 year old boy presents with skin rash and joint pain in his elbows and knees. His mother tells you that he recently had a sore throat. On examination he is found to have an ejection systolic murmur and a friction rub.
Acute Rheumatic Fever Diagnosis: - ASOT antibody titre -Scarlet Fever -GABHS postive throat swab -DNAs B tire.
A 69 year old woman is suffering from sudden onset fever and malaise. There is no previous history of heart disease. Auscultation reveals a heart murmur. She later develops sepsis.
Acute Bacterial Endocarditis What’s the difference between acute and subacute endocarditis? p.121 of the PATH handbook Organism Staph Aureus Strep Pyogenes Subacute: Strep Viridians Staph Epidermis HACEK
A 40 year old man presents with a sharp chest pain. He has a pericardial friction rub, diminished heart sounds and a raised JVP.
Pericarditis
A 25 year old man presents with palpitations. Chest X-ray shows an enlarged heart and echocardiogram shows thickening of the septum.
Cardiomyopathy (Hypertrophic)
A 75 year old diabetic female with a history of 4 myocardial infarctions presents with shortness of breath and ankle swelling. She was found to have an enlarged liver and echocardiogram demonstrated a dilated heart.
Cardiac Failure
clinical examination may or may not reveal a new murmur. An embolic stroke may be the first feature to suggest the diagnosis Associated with hypercoaguable states, malignancy
Non-bacterial thrombotic Endocarditis. Small bland vegetations attachted to the lines of closure.
A 39 year old Nepalese man presents with severe watery diarrhoea. He is found to have hypokalaemia and, surprisingly, a metabolic acidosis. A RUQ mass is detected by contrast-enhanced spiral CT scanning. Stool bicarb is high and urine anion gap is negative.
VIPomA
● Skin bronzing (melanin deposition) ● Diabetes ● Hepatomegaly with micronodular cirrhosis Cardiomyopathy ● Hypogonadism ● Pseudogout
Haemochromatosis
Hyperinsulinaemic hypoglycaemia
Iatrogenic insulin, sulfonylurea excess, insulinoma
Presentation: severe epigastric (or central) pain radiating to back, relieved by sitting forward, vomiting prominent NB: Amylase only transiently increased. Serum lipase is more sensitive. Can result in formation of pseudocyst (a pathological collection of fluid), associated with alcoholic pancreatitis. Histology – Coagulative necrosis
Pancreatitis
65 year old female with a large, cystic mass on tail of pancreas imaged using computed tomography. Further cytology reported the presence of epithelium
Cystadenoma
The commonest cause of acute pancreatitis in the UK.
Alcoholism
Inflammatory condition of the exocrine pancreas that results in injury to acinar cells.
Pancreatitis
ERCP finding due to incomplete fusing of pancreatic buds.
Pancreas Divisum
The commonest head of the pancreas cancer
Ductal Carcinoma of the Pancreas
Trousseau’s syndrome (25%)- recurrent superficial thrombophlebitis
Ductal Carcinoma of the Pancreas
is a fluid filled collection contained within a well-defined capsule of fibrous or granulation tissue or a combination of both. It does not possess an epithelial lining.
Pancreatic pseudocyst
A breach in mucosa which extends through muscularis mucosa into submucosa or deeper
Peptic ulcer
Present in almost all patients with duodenal ulcer and 70 % with gastric ulcer.
H. pylori infection
Around 10 % eventually get primary lymphoma (less often, carcinoma) of the gut if not properly treated. HLA B8 is linked with this.
Coeliac disease
The commonest cause of oesophagitis.
GORD
Re-epithelialisation by metaplastic columnar epithelium with goblet cells
Barrett’s oesophagus
A 40 year old male complaining of a long history of burning epigastric pain, worse on lying flat. Endoscopy and biopsy reveals inflamed squamous lining and increased basal cell proliferation.
GORD
A 38 year old female with Rheumatoid Arthritis presents with a single episode of malaena. Investigations reveal erosions through out the stomach and a neutrophilic infiltrate in the superficial mucosa
Acute Gastritis
A 30 year old female complaining of diarhorrea and weight loss. Biopsy of duodenum shows increased intraepithelial cytotoxic T cells.
Coeliac Disease
A 60 year old male complaining of epigastric pain relieved by antacids and meals. He has a positive CLO test.
Duodenal Ulcer
A 65 year old male with a long history of epigastric pain. Endoscopy reveals 3.2cm of columnar metaplasia in the lower oesophagus. Goblet cells are seen.
Barretts Oesophagus
Associated with Barrett’s oesophagus so usually seen in distal 1/3 Other risk factors incl: smoking, obesity, prior radiation therapy Most common in Caucasians, M>>F
oEsophageal Adenocarcinoma
Type of gastrtis (neutrophils) insult e.g. aspirin, NSAIDs, corrosives (bleach), acute H. pylori, severe stress (burns)
acute gastritis
lymphocytes and plasma cells) insult e.g. H-pylori tends to be Antral, AI e.g. pernicious anaemia, ETOH, smoking
chronic gastritis
A 70 year old woman has progressive low retrosternal dysphagia, initially to solids and now also to liquids. She complains of chest pain and weight loss over the last 3 months. A social history reveals that she has been a heavy smoker for many years and drinks around 20 units of alcohol a week.
Carcinoma of the oesophagus
A 26 year old man presents with watery diarrhoea, abdominal cramps, nausea, vomiting and a low grade fever. It started 3 days after eating some undercooked meat at a barbecue.
cryptospiorosis
A 66 year old man complaining of epigastric pain undergoes an endoscopy. The mucosa appears reddened in the antrum of the stomach. 13C is detected on a urea breath test.
Helicobacter pylori
A 58 year old female presents with malnutrition. She complains of abdominal pain, weight loss and arthritis. She has steatorrhoea. A jejunal biopsy showed periodic acid-Schiff (PAS)-positive macrophages
Whipple’s disease: Whipple’s disease Whipple’s disease is a rare multi-system disorder caused by Tropheryma whippelii infection. It is more common in those who are HLA-B27 positive and in middle-aged men Features malabsorption: diarrhoea, weight loss large-joint arthralgia lymphadenopathy skin: hyperpigmentation and photosensitivity pleurisy, pericarditis neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus
A 35-year-old man presents with a long history of epigastric burning pain, made worse at night and when drinking hot liquids. Recently he has had difficulty swallowing solids. Endoscopy shows lower oesophageal erosions and strictures and pH demonstrates acidity.
Bulbar Palsy
A 20-year-old student gives an 8 hour history of very frequent vomiting and epigastric cramping. O/E she is pale and shivering. Her serum WBC is normal
S. aureus
A 30-year-old woman presents with haematemesis and diarrhoea. She has recurrent peptic ulceration and is taking omeprazole. Despite this, she has persistently high serum gastrin levels. Endoscopy shows a large 3cm actively bleeding ulcer in the duodenum.
Zollinger Ellison
A 50-year-old women presents with chest pain associated with regurgitation of solids and liquids equally, both occurring after swallowing. Diagnosis is confirmed by a characteristic ‘beak like’ tapering of the lower oesophagus on barium swallow and manometry shows failure of relaxation of the LOS.
Achalasia
A 65-year-old woman presents with a 3 month history of anorexia, weight loss and epigastric pain. Blood tests reveal an iron deficiency anaemia. Endoscopy shows a thickened rigid gastric wall known as ‘leather bottle stomach’ indicating infiltration into all layers of the gastric wall. Numerous signet ring cells on biopsy diffusely infiltrate the mucosa.
Adenocarcinoma
A 45 year old woman presents with large tongue and swelling of the legs. She has a high BP and urine dipstick reveals protein +++.The tissue from renal biopsy stains with Congo red dye and shows apple green birefringence under polarised light
Renal amyloidosis
A 28 year old woman presents with malaise, weight loss, an erythematous rash on the face and joint pains. Both antinuclear antibodies (ANA) and double-stranded DNA (dsDNA) antibodies were found in the serum.
. Systemic lupus erythematous
A 55 year old woman presents with severe, unremitting headache with scalp tenderness. Her ESR and CRP are raised. A biopsy reveals giant cells.
Temporal arteritis
A 40 year old man with previous hepatitis B infection presents with weight loss, muscle aches and abdominal pain. On examination he has high BP and urine dipstick reveals blood + and protein +
Polyarteritis nodosa
A 30 year old Afrocaribbean woman presents with tender red nodules on the shins and legs. She also has joint pains in her feet and hands. Her blood test reveals a raised angiotensin converting enzyme (ACE) and Ca2+ level.
Sarcoidosis
A 60 year old man, currently undergoing treatment for long-standing chronic renal failure, complaining of tingling in his wrist & hand when he wakes in the morning.
Haemodialysis associated amyloidosis
A 70 year old woman is referred to hospital with signs of peripheral oedema and hepatosplenomegaly. Hospital investigations demonstrate a degree of bone erosion and high levels of circulating kappa uniform light chain
myloma associated amylodosis
A 32 year old man presents with a painless, enlarged axillary lymph node. Slight hepatosplenomegaly is noted on examination. Whilst the patient denies experiencing any night sweats, weight loss or fevers, bloods on admission show a raised ESR and abnormal liver biochemistry.
hodkins lymphoma
A 64 year old woman with a history of chronic rheumatological disease presents to her GP complaining of abdominal discomfort – which is found to be due to hepatosplenomegaly. An ensuing liver biopsy stains positive with Congo Red stain.
Reactive amylodosis
This is a secondary amyloidosis due to impaired clearance of b2m across dialysis membranes that causes carpal tunnel syndrome.
Beta -2-microglobulin amyloidosis is associated with haemodialysis.
Massive splenomegaly:
common in the UK – CML, myelofibrosis (ie haematological) common worldwide – malaria, kala-azar (ie infectious)
Moderate
Portal hypertension, lymphoma, CLL, thalassaemia and metabolic diseases e.g Gaucher’s
Mild
Infection (viral e.g. EBV, hepatitis or bacterial e.g infective endocarditis, miliary TB)
A 63 year old lady presents to A and E with acute abdominal pain. She has been vomiting. On examination her abdomen is distended and you hear tinkling bowel sounds. Abdominal X-ray shows an inverted U loop of bowel.
sigmoid volvulus
A 70 year old gentlemen presents to his GP with left sided colicky abdominal pain which is relieved by defecation. He admits to passing constipated stools.
diverticular disease
A 65 year old lady presents to A and E with left sided abdominal pain which is relieved by defecation. On examination her abdomen is tender over the left iliac fossa and she is pyrexial. Her ESR and WCC are both raised.
diverticulitis
A 68-year-old man presents with rectal bleeding of bright red blood and constipation. He previously has been diagnosed with polyps in his colon and recently has lost a lot of weight. An abdominal examination reveals a mass in the right lumbar region which is non-tender
colon carcinoma
A 25-year-old woman complains of right iliac fossa pain, diarrhoea and weight loss worsening over several weeks. Laparotomy reveals an oedematous, reddened terminal ileum and a biopsy uncovers transmural inflammation with the presence of granulomas
Crohn’s
A 35-year-old woman presents with diarrhoea and lower abdominal pain. Examination of her stools reveals blood and mucus. A biopsy reveals a continuous superficial ulceration of the colon.
Ulcerative colitis
Seen at 50-60yrs, thought to be caused by shedding of epithelium cell buildup
Hyperplastic Polyp
Found sporadically in some genetic/acquired syndromes Juvenile polyps are focal malformations of mucosa and lamina propria, vast majority in those <5yrs old, mostly in rectum bleeding. Usually solitary, but up to 100 found in juvenile polyposis (AD) that may require colectomy to stop haemorrhage. Also seen in Peutz-Jeghers syndrome (AD - LKB1) = multiple polyps, mucocutaneous hyperpigmentation, freckles around mouth, palms and soles. Have increased risk of intussusception and of malignancyregular surveillance of GI tract, pelvis and gonads.
Hamartomatous polyp
A 77 year old man was referred by his G.P. after reporting the passing of large volumes of mucus. Endoscopy revealed a 6cm sessile cauliflower-like mass covered by dysplastic columnar epithelium in the rectum. His serum potassium is 3.3 mmol/l.
villous adenoma
A 62 year old housewife returns to your outpatient clinic following another incidence of the passing of blood. Previous sigmoidoscopy, DRE and barium enema’s have failed to identify any lesion and she denies weight loss and diarrhoea. However, blood tests show a microcytic anaemia.
angiodysplasia- angiodysplasia is a small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions are often multiple, and frequently involve the cecum or ascending colon, although they can occur at other places.
An 84 year old gentleman presents to A&E after suffering acute cramp-like abdominal pain lasting several hours which was followed shortly by rectal bleeding. Colonoscopy showed an oedematous thickening of the bowel wall with areas of necrotic ulceration which was confined to the mucosal layers. On examination, the gentleman was found to have an irregularly irregular heart beat.
ischemic collitis
A 34 year old female presents with diarrhoea, abdominal pain and weight loss. Colonoscopy reveals inflammation of the mucosa which has a cobblestoned appearance. Biopsy showed transmural involvement and the presence of non-caseating granulomas.
Crohn’s disease
Your consultant is urgently called away from out-patients and asks you to break bad news to a patient. He is distracted and has little time to inform you about the case but mentions that the original presentation was for rectal bleeding and the patient has a 40% chance of surviving 5 years.
Adenocarcinoma Duke’s stage C1
A 65 year old heavy smoker. He has been progressively short of breath over a few years. He has a smooth liver edge 2 cms below the costal margin.
severe emphysema
A 60 year old woman is found to have hepatomegaly. She has a history of moderate alcohol use. She had an anterior MI 2 years ago. On examination she has ankle oedema, elevated JVP and 3 spider naevi on her chest.
congestive heart failure
A 78 year old woman attends complaining of widespread itching. Examination reveals hepatosplenomegaly. The patient appears plethoric with no lymphadenopathy.
Polycythemia Rubra Vera
A 50 year old with haemophilia and hepatitis C presents with weight loss and abdominal discomfort. He is mildly icteric with features of chronic liver disease and a large left lobe of the liver.
cirrhosis with hepatoma
A 73 year old woman attends complaining of recent onset of tiredness. She is pale and has hepatosplenomegaly and generalised lymphadenopathy in the neck, axillae and groins.
CLL
The disorder is characterized by bruising, fatigue, anemia, low blood platelet count and enlargement of the liver and spleen, and is caused by a hereditary deficiency of the enzyme glucocerebrosidase (also known as glucosylceramidase), which acts on glucocerebroside. When the enzyme is defective, glucocerebroside accumulates, particularly in white blood cells and especially in macrophages (mononuclear leukocytes). Glucocerebroside can collect in the spleen, liver, kidneys, lungs, brain, and bone marrow.
Gaucher’s disease
Prehepatic: Portal vein thrombosis
Factor V laiden
