2. Lower GI Pathology

Question 1

Intestinal obstruction
• Obstruction of the gastrointestinal tract may occur at any ____
• Collectively, ____, intestinal adhesions, intussusception, and
volvulus account for 80% of mechanical obstructions
• Clinical manifestations of intestinal obstruction include abdominal ____ and distention, vomiting, and constipation

Answer 1

level
hernias
pain

Question 2

• Hernias
• Any weakness or defect in the abdominal wall may permit protrusion of a serosa- lined pouch of ____ called a hernia sac
• Adhesions
• ____ bridges that develop between bowel segments, abdominal wall, or operative sites
• Volvulus
• Twisting of a loop of bowel about its ____ point of attachment resulting in both luminal and ____ compromise
• Intussusception
• A length of intestine “swallows” part of the bowel ____ to it; this swallowed portion is drawn down until it can go no further because of attachment to ____
• Most common cause of intestinal obstruction in children younger than ____ years of age

Answer 2

peritoneum
fibrous
mesenteric
vascular
proximal
mesentery
2

Question 3

Ischemic bowel disease

• Injury to the bowel caused by insufficient ____ regardless of etiology
• High mortality for ____ ischemic disease (70%)
• Mucosal or submucosal infarctions (mural) can follow ____
• Transmural infarction is caused by acute ____ obstruction
• Patients experience severe abdominal pain that persists for more than ____ to 3 hours

Answer 3

blood flow
acute
hypoperfusion
vascular
2

Question 4

Watershed zone
• Small bowel has collateral blood vessels in the ____ so that slow progressive blood loss can be tolerated
• However, intestinal segments at the ends of their respective arterial supplies are susceptible to ____; acute compromise of major vessel can lead to ____ of several meters of intestine
• The splenic flexure is an area of ____ blood supplies where both the superior and inferior ____ arterial circulations terminate
• During systemic hypotension, ischemic injury occurs most often at the ____ flexure

Answer 4

periphery
ischemia
infarction
overlapping
mesenteric
splenic

Question 5

Celiac disease
• Multisystem disorder caused by an immune response to dietary ____ and related proteins
• The ____ soluble part of gluten, gliadin, contains the most disease- producing components
• Presents most commonly between ages of ____ and 60
• Associated with chronic ____, bloating, or fatigue
• Characterized by anemia due to chronic ____ and vitamin malabsorption

Answer 5

gluten
alcohol
30
diarrhea
iron

Question 6

Celiac Disease

• Microscopic findings show variable degrees of ____ atrophy and chronic inflammation
• Complete resolution of gastrointestinal pathology with strict gluten- free ____
• Individuals with celiac disease have a higher rate of ____
• 20-fold higher risk for enteropathy-associated ____
• 30-fold higher risk for small intestinal ____
• 2- to 4-fold higher risk for oropharyngeal and esophageal ____

Answer 6

villous atrophy
diet
malignancy
T-cell lymphoa
adenocarcinoma
carcinoma

Question 7

Oral manifestations
• Can be associated with delay in dental ____, reduction of salivary flow, recurrent ____, angular cheilitis, and dental enamel defects in primary and permanent teeth
• Dental defects tend to occur ____ and chronologically in all four quadrants, with the most defects seen in the maxillary and mandibular ____ and ____
• Teeth may be ____ with white, yellow, or brown spots
• Other defects may include poor ____ formation, pitting or banding of teeth, and
mottled or translucent-looking teeth
• Dental enamel defects less frequently seen in ____, however in adults oral problems related to Celiac disease include
• Recurent ____, atrophic glossitis, xerostomia, or ____ of the oropharynx

Answer 7

eruption
aphthous stomatitis
symmetrically
incisors
molars
discolored
enamel
adults
aphthous stomatitis
SCC

Question 8

Infectious enteritis (Whipple’s disease)

• An infection caused by ____ (an actinomycete) that most commonly affects the ____
• Most common in white ____, particularly farmers who have occupational exposure to soil or animals
• Patients present with triad of diarrhea, weight loss, and arthralgia
• Microscopically, small intestine biopsy shows villi with lamina propria
containing foamy ____ which contain bacterial inclusions
• These accumulations cause ____ obstruction which leads to the malabsorptive diarrhea
• Most patients respond to ____ (trimethoprim and sulfamethoxazole)

Answer 8

tropheryma whipplei
proximal small bowel
males
macrophages
lymphatic
antibiotics

Question 9

Escherichia coli
• E. coli are bacilli that colonize the ____ gastrointestinal tract; most are nonpathogenic, but a subset cause human disease
• There are different classifications according to morphology, mechanism of pathogenesis, and in vitro behavior
• Enterotoxigenic E. coli
• Known as ____ diarrhea spread via contaminated ____ or water

• Enteropathogenic E.coli
• More common in the ____ population
• Enterohemorrhagic E. coli
• O157:H7
• Non-O157:H7
• Enteroinvasive E. coli
• Enteroaggregative E. coli
• May induce diarrhea and ischemic bowel disease

Answer 9

healthy
traveler’s
food
pediatric

Question 10

Enterohemorrhagic O157:H7
• Guts of ____ are a natural reservoir of this subtype of E.coli
• Especially cows that are standing around in ____ all day long
• E coli cannot survive long in ____
• Manure often is ends up in water systems

• Most common strain is ____
• 157th somatic antigen found on bacteria body
• 7th flagella antigen found
• Large outbreaks are associated with inadequately cooked ground ____
• Contaminated milk and vegetables are vehicles for infection
• O157:H7 strains are likely to cause ____ outbreaks, blood diarrhea, hemolytic- uremic syndrome, and ischemic colitis
• Antibiotics can kill the bacteria, but lead to increase of ____-like toxins that enhance the risk of ____ syndrome, especially in children

Answer 10

cows
manure
grass

O157:H7
beef
large
Shiga
hemolytic-uremic

Question 11

Pseudomembraneous colitis

• Due to a toxin produced by ____
• Also referred to as antibiotic-associated colitis
• While antibiotic-associated diarrhea may also be caused by other organisms such as Salmonella or Staphylococcus aureus only C.difficile causes ____
• Substantial number of cases have been associated with use of antibiotics, particularly ____ and clindamycin
• Likely disruption of the normal gut flora by ____ allows C.difficile overgrowth

Answer 11

clostridium difficile
pseudomembraneous colitis
lincomycin
antibiotics

Question 12

Pseudomembraneous colitis

• Risk factors for C.difficile include advanced ____, hospitalization, and antibiotic treatment
• As many as 30% of hospitalized adults are colonized by C.difficile, a rate tenfold greater than the ____
• Patients present with fever, ____, abdominal pain, cramps, watery diarrhea, and dehydration
• Bloody diarrhea is ____
• ____ or vancomycin are generally effective therapies

Answer 12

age
general population
leukocytosis
uncommon
metronidazole

Question 13

Enterobius vermicularis (pinworms)

• Most common ____ affecting humans
• School children and adolescents, especially those who live in ____, have the highest prevalence
• Worms do not invade tissue and live entire lives in ____, so generally asymptomatic
• However, adult worms living in intestine may migrate to the anal orifice at night and deposit ____ on the perirectal mucosa
• Irritation to eggs cause classic symptom is ____
• The infective larva-containing egg resides in dust and soil, and transmission is believed to be ____
• ____ and colitis have been described as secondary to pinworm infection
• Most infections clear ____ after several weeks
• ____ drugs may be indicated to prevent transmission to others, and for symptomatic cases

Answer 13

parasites
institutions
intestinal lumen
eggs
nocturnal pruritus ani
fecal-oral
appendicitis
spontaneously
antiparasitic

Question 14

Irritable bowel syndrome (IBS)
• Characterized by a group of symptoms that occur together
• Repeated abdominal ____, changes in bowel habits, which may be diarrhea,
constipation, or both, and bloating
• Despite very real symptoms, the gross and microscopic evaluation is ____ in most IBS patients
• Diagnosis is based on ____
• Peak prevalence of IBS is between ____ and 40 years of age and there is
a significant ____ predominance
• ____ disease must be ruled out

Answer 14

pain
normal
symptoms
20
female
inflammatory bowel disease

Question 15

IBD

• Inflammatory bowel disease (IBD) is a disease that causes ____ of the gastrointestinal tract
• The two disorders that comprise IBD are ____ and Crohn disease
• In ulcerative colitis inflammation is limited to the ____ and ____ and is limited to ____ or ____, i.e. just the inner layer of the bowel wall
• In contrast, inflammation in Crohn disease may involve any ____ of the GI tract, and often is ____, i.e. involving all layers of the bowel wall
• Most often diagnosed in people between ages ____ and 30 years

Answer 15

chronic inflammation
ulcerative colitis
colon
rectum
mucosa
submucosa
area
transmural
15

Question 16

IBD

Symptoms
• Inflammatory bowel disease symptoms can range from very mild to very severe
• They include diarrhea, blood in the stool, abdominal pain, fever, fatigue, and weight loss
• Some symptoms of IBD result from inflammation of parts of the body outside of the ____
• These include ____ pain/arthritis, eye/vision problems, certain types of rashes, and liver disease
• ____ manifestations

• Often, symptoms can be ____ and then suddenly worsen during a ____,
which can require extra treatment
• Flares can be very ____, even life-threatening, if untreated because they may lead to severe ____, bleeding, or bowel perforation

Answer 16

GI tract
joint
oral
stable
flare
dangerous
infection

Question 17

IBD

Treatment
• Treatment of IBD depends on how severe the disease is
• Mild disease is treated with ____ medications, which can be
taken either by mouth or as suppositories/enemas
• More severe disease is treated with ____ or immunosuppressant medications (often the same as those used for other ____ diseases)
• These can be taken by mouth, by injection under the skin, or by ____ infusion
• Flares often require ____ as extra treatment
• Patients with severe disease who do not get better with medications may require ____

• People with IBD that involves the colon are at increased risk of ____ and need to have routine colonoscopies throughout their lives

Answer 17

anti-inflammatory
immunomodulator
autoimmune
intravenous
steroids
surgery
colon cancer

Question 18

IBD

Oral manifestations
• Orofacial ____
• Granulomatous inflammation that can be seen in association with inflammatory
bowel disease, in particular ____ disease
• Most frequent site of involvement is the ____, which present as persistent swelling
• Intraoral sites may present as hyperplastic mucosa in the mandibular ____

• Deep, granulomatous-appearing ulcers
• Often appear as ____ and develop in the ____
• Patchy ____ macules and plaques
• Pyostomatitis vegetans
• Characteristic yellowish ____ found on the oral mucosa

Answer 18

granulomatosis
Crohn
lips
mucobuccal fold
linear
mucobuccal fold
erythematous
pustules

Question 19

• Polyps are abnormal growths of ____ tissue that develop on mucous membranes
• They can be ____ (with a stalk) or sessile (broad based without a stalk)
• Intestinal polyps can be classified as non-neoplastic or neoplastic
• The non-neoplastic polyps can be further classified as ____,
hamartomatous, or ____
• Neoplastic polyps can be classified as ____ or sessile ____ adenomas

Answer 19

epithelial
pedunculated
inflammatory
hyperplastic
adenomatous
serrated

Question 20

Hyperplastic polyps
• Benign epithelial proliferations that are the most commonly encountered polyp in the adult ____
• Grossly, hyperplastic polyps are dome-shaped nodules that rarely grow beyond ____ mm in diameter
• They are often multiple and found in the ____ colon and rectum
• Because they may be endoscopically similar in appearance to small adenomatous polyps (malignant potential), hyperplastic polyps are often ____ for pathologic analysis
• No significant ____ alterations

Answer 20

colorectum
5
sigmoid
removed
genetic

Question 21

Hamartomatous polyps
• Can occur ____ (non-neoplastic) or as a part of genetically determined or acquired syndrome, in which case they may be considered ____/pre-malignant
• Many hamartomatous polyp syndromes are caused by germline mutations in ____ genes or proto-oncogenes
• Some of these syndromes are associated with an increased ____ risk, either in the polyp, or in the extra-intestinal sites
• Hamartomatous polyposis syndromes
• ____ polyposis, Peutz-Jeghers syndrome, ____ syndrome

Answer 21

sporadically
neoplastic
tumor suppressor
cancer
juvenile
cowden

Question 22

Juvenile polyps
• Sporadic (benign) and syndromic forms of juvenile polyps are ____
• In sporadic form, polyps are ____
• In juvenile polyposis syndrome, there may be ____ polyps in the colon

• Majority sporadic polyps occur in children less than ____ years old, whereas patients with polyposis syndrome tend to be ____, with a mean age of 9.5 years
• Most common location is the ____, and presents as rectal bleeds
• Dysplasia is extremely ____ in sporadic polyps, in contrast, juvenile
polyposis syndrome is associated with ____
• 30 to 50% of patients with juvenile polyposis develop ____

Answer 22

indistinguishable
solitary
3-100
5
older
rectum
rare
dysplasia
colonic adenocarcinoma

Question 23

Juvenile polyposis syndrome
• Criteria for a diagnosis of syndromic juvenile polyposis
1. Greater than ____ juvenile polyps in the colon at one time
2. Presence of ____ juvenile polyps
3. Any number of juvenile polyps in a patient with a ____ of juvenile polyposis

• Autosomal dominant form
• No associated ____ abnormalities
• Nonfamilial form with associated congenital abnormalities
• ____disease, hydrocephalus, or intestinal ____

Answer 23

five
extracolonic
family history

congenital abnormalities
congenital heart
malrotation

Question 24

Peutz-jeghers syndrome
• Autosomally ____ inherited syndrome characterized by gastrointestinal ____ polyps and pigmented macules of mucous membranes and skin
• More than 95% of patients with Peutz-jeghers syndrome demonstrate pigmentation of the mucocutaneous membranes at ____, specifically around the nose, lips, buccal mucosa, hands and feet, genitalia, and perianal region
• Lifetime cancer risk for patients with Peutz-jegher is estimated to be ____%
• Gastrointestinal, lung, breast, pancreas, uterus, ovary, cervix, and Sertoli cells of the testis

Answer 24

dominant
hamartomatous
birth
93

Question 25

PJ Syndrome

• Harmartomatous polyps develop and involve the entire ____
• Polyps occur most commonly in the ____ followed by the colon, ____, duodenum, and ____ (in decreasing frequency)
• Jejunal and ileal hamartomatous polyps often produce ____, leading to partial or total bowel obstruction

Answer 25

GI tract
small bowel
stomach
appendix
intussusception

Question 26

Cowden syndrome
• Also known as multiple ____ (non-cancerous) syndrome is an autosomal ____ syndrome caused by a mutation in ____ gene, a tumor suppressor gene
• Characterized by extraintestinal hamartomas that frequently involve the face and oral cavity
• Facial ____, acral keratoses, ____ papules, and mucosal lesions are considered diagnostic criteria

• Vast majority of Cowden syndrome patients have polyps, but the lifetime risk of colorectal cancer is ____ compared with the development of other cancers
• Cowden syndrome is associated with increased risk of developing cancers of the ____ (85%), thyroid (35%), and the endometrium (28%)

Answer 26

hamartoma
dominant
PTEN
trichillemmomas
papillomatous
low
breast

Question 27

Adenomatous polyps
• Dysplastic neoplasm of intestinal epithelium with the potential for transformation to invasive ____, but important to note that most do not become ____
• Possibly associated with a ____-fat, ____-fiber diet
• High-risk patients are those that have a known ____ predisposition to colorectal carcinoma, a personal history of ____ adenomas or carcinoma, or a history of ____ disease
• Removal of adenomatous polyps has been shown to reduce mortality from colorectal cancer up to ____%

Answer 27

carcinoma
cancerous
high
low
inherited
colorectal
inflammatory bowel
85

Question 28

Familial adenomatous polyposis
• An autosomal ____ inherited syndrome characterized by the development of hundreds to thousands of adenomatous polyps throughout the colorectum
• Genetic testing for ____ mutations in the adenomatous polyposis coli gene (____ gene), a tumor suppressor gene, identifies 95% of patients with familial adenomatous polyposis
• ____ develops in 100% of untreated familial adenomatous patients
• ____ is the standard therapy for individuals carrying APC mutation

Answer 28

dominant
germline
APC
colorectal adenocarcinoma
prophylactic colectomy

Question 29

Extraintestinal manifestations

• Common in familial adenomatous polyposis, and includes ____, epidermoid cysts, fibromas, ____ teeth, odontomas, and congential hypertrophy of the ____ pigmented epithelium
• If eye care specialist notes findings, may recommend that patient see ____, or increase frequency of colon screening

• When extraintestinal manifestations are especially prominent in familial adenomatous polyposis, the condition is referred to as ____

Answer 29

osteomas
supernumerary
retinal
gastroenterologist
gardner syndrome

Question 30

Hereditary non-polyposis colorectal cancer (also known as Lynch syndrome)

• ____ disorder that increases risk of many types of cancer, particularly ____ cancer due to a germline mutation in genes that encode proteins that detect and ____ errors in DNA during replication, i.e. ____ pathway
• People with this disorder also have increased risk of cancers of the ____, small intestine, liver, ____ ducts, upper urinary tract, brain, and skin; women may have high risk of cancers of the ____ and endometrium

Answer 30

inherited
colorectal
repair
mismatch repair
stomach
gallbladder
ovaries

Question 31

Colorectal adenocarcinoma

• Adenocarcinoma of the colon is the most common ____ neoplasm of the gastrointestinal tract
• The small intestine, which accounts for 75% of the overall length of the gastrointestinal tract, is an ____ site for benign and malignant tumors
• High-risk populations include patients with positive ____ or history of ____
• Grossly, colon cancers can be ____, fungating, or ulcerated
• The vast majority of colorectal cancers are ____
• 5 year survival rate for colon cancer is ____ to 60%

Answer 31

malignant
uncommon
family history
inflammatory bowel disease
polypoid
adenocarcinomas
55

Question 32

Hirschsprung disease

• Congenital disorder where ____ cells are missing at the end of a child’s bowel
• There are no ____ motility patterns and the bowels remain ____

• It causes functional obstruction of the affected bowel and ____
dilation
• Stool moves through the bowel until it reaches the part lacking ____ cells; at that point, the stool moves slowly or stops

• The defect always begins at the ____ but extends proximally
• Approximately 80% of patients are ____; 10% have ____
• Diagnosis requires documenting the absence of ____ cells

Answer 32

nerve
propulsive
contracted
proximal
nerve
rectum
male
down syndrome
ganglion

Question 33

Diverticulosis

• Condition that occurs when small pouches form and push outward through weak spots in the wall of colon
• Most cases, however, are ____
• In diverticulitis, pouches in the wall of the colon become ____
• Diverticulitis most often causes abdominal ____
• Most cases are ____ and occur in patients over the age of ____ years
• Common in North America and Europe, but uncommon in ____ and Africa
• Protective factor seems to be a ____-fiber diet
• Treatment may be ____ fiber diets and stool ____

Answer 33

asymptomatic
inflamed
pain
acquired
40
asia
high
high
softeners

Question 34

Meckel’s diverticulum
• An outpouching in the ____ part of the ____
• Occurs as a result of failed involution of the ____ duct, i.e. leftover
of the umbilical cord
• Not often made of the same type of tissue as the small intestine, but is made of ____ tissue
• Tissue in Meckel’s diverticulum can produce ____ and create ulceration
• Peritonitis can result as a complication of ____ rupture

• Occurs approximately in 2% of the population

Answer 34

lower
small intestine
vitelline
gastric or pancreatic
acid
ulcer