Anus/Peritoneum/Gallbladder/Pancreas Path Flashcards
Hemorrhoid Risk Factors (3)
Straining from constipation
Venous stasis from pregnancy or Portal HTN
Anal Cancer - Normal Epithelium and Cancer Type
Upper, Middle and Lower Anal Canal
Upper
Columnar epithelium - Adenocarcinoma
Middle
Transitional epithelium - Cloacogenic carcinoma
Lower
Squamous epithelium - Squamous cell carcinoma
Associated with HPV
Acute Appendicitis Clinical Features (4), Complication (2)
Periumbilical pain radiating to RLQ
Mild Fever
Leukocytosis
Tenderness at McBurney’s Point
Acute gangrenous appendicitis causing perforation
(suppurative necrosis leading to peritonitis)
Tumors of the Appendix
Examples with Descriptions (2)
Carcinoid Tumor (most common, benign) Symptoms mimic acute appendicitis due to mass obstruction
Pseudomyxoma peritonei
Malignant mucinous cystadenoma
Peritonitis
Etiologies with Examples (3)
Bacterial infection
Spontaneous more common in cirrhosis/ascites
Chemical irritation
Foreign bodies introduced during surgery
Perforation of visceral structures
Pancreatitis, Endometriosis, Ruptured Dermoid cysts
Sclerosing Retroperitonitis
Description and Complication
Idiopathic dense fibrosis that extends into the mesentery
Ureter compression
Peritoneal Tumors
Prognosis
Primary Examples and Characteristics (3)
Secondary Sequela
Malignant tumors with poor prognoses
Primary:
Mesothelioma and Desmoplastic round cell tumors
Associated with EWS-WT1 fusion gene from t(11;22)(p13;q12) tranlocation
Secondary:
Causes peritoneal carcinomatosis
Most common Gallbladder congenital anomaly
Phrygian cup: inward folded fundus
Cholesterol Cholelithiasis
Morphology (3) and Pathogenesis (5)
Form in gallbladder only
Yellow with finely granular surface
Radiolucent
Form when cholesterol precipitates out of the bile:
Bile supersaturation with cholesterol (western diet)
Gallbladder hypomotility
Acceleration of crystal nucleation
Mucus hypersecretion
Pigmented Cholelithiasis
Morphology (4) and Pathogenesis
Black and radiopaque if in sterile duct
Brown and radiolucent if in infected duct
Form when levels of unconjugated bile increase:
Hemolytic anemia
Ileal dysfunction/bypass
Infection of biliary tract
Cholelithiasis Clinical Features (2) and Complications (2)
RUQ pain that radiates to right shoulder/scapula Small stones (gravel) are more dangerous
Stones associated with 90% of acute and chronic cholecystitis
Acute Cholecystitis
Presentation (4), Morphology (3) and Complication
Progressive RUQ lasting > 6 hours
Increased serum bilirubin and alkaline phosphatase
Acalculous cholecystitis causes gangrene/perforation
Enlarged, tense GB covered in fibrous exudate and filled with fibrinous material
Gallbladder empyema can cause necrosis
Chronic Cholecystitis
Presentation (2), Morphology (5) and Complications (5)
Fatty food intolerance
Recurrent RUQ/epigastric pain attacks
Subserosal fibrosis Rokitansky-Aschoff Sinuses (diverticula) Porcelain Gallbladder (calcification) Xanthogranulomatous Gallbladder (foam cells) Hydrops of Gallbladder (atrophy)
Increased risk of infection, peritonitis, cholecystenteric fistula and obstruction
Porcelain GB risks Cholangiocarcinoma
Gallbladder Carcinoma
Pathogenesis (2) Morphology (2) Symptoms (4) and Clinical Features (4)
Chronic inflammation via gall stone obstruction
Infiltrating: poorly defined mural thickening and induration
Exophytic: Grows into lumen and invades underlying wall
Abdominal pain, Jaundice, Anorexia, N/V
Mostly found in surgery to remove gall stones
Infiltrating more common and worse prognosis
Poor prognosis when symptomatic
Associated with ERBB2 oncoprotein
Pancreatic Congenital Anomaly Descriptions
Divisum (3) and Annular (2)
Divisum
Most common anomaly
Failed fusion of ventral/dorsal ductal systems
Increased risk of chronic pancreatitis
Annular
Ring of pancreatic tissue surround 2nd part of duodenum
Causes duodenal obstruction
Acute Pancreatitis
Description, Pathogenesis (5) and Etiologies (2)
Reversible parenchymal injury via auto-digestion
Duct obstruction leading to primary acinar injury that causes defective proenzyme transport
Inappropriate trypsinogen release/activation
Active lipase secreted causing fat necrosis
Males: alcohol acts as direct acinar cell toxin
Females: increased risk of cholelithiasis obstruction
Acute Pancreatitis
Presentation (4) and Morphology (4)
Epigastric pain radiating to back
Increased serum lipase and amylase (lipase diagnostic)
Hypocalcemia
Shock via systemic inflammatory response system
Fat necrosis
Microvascular damage and leakage (edema)
Parenchymal proteolytic destruction
Interstitial hemorrhage
Congenital Pancreatitis
General Etiology and Specific Genetic Assocations (6)
Defects that increase trypsin activity
PRSS1 SPINK1 CFTR CASR CTRC CPA1
Chronic Pancreatitis
Etiology, Description (2) and Pathogenesis (5)
Mostly from chronic alcohol abuse
Irreversible destruction of exocrine and endocrine parenchyma
Repeated bouts of acute pancreatitis causing:
Perilobular fibrosis, Duct Distortion and Altered secretions
Associated with increased PDGF and TGF-beta
Chronic Pancreatitis
Morphology (4) and Clinical Features (4)
Acinar atrophy
Variable duct dilation
Focal calcification (diagnostic)
Islet sparing
Recurrent attacks of epigastric pain and jaundice
Triggers are alcohol and overeating
Mostly seen in middle aged males
Not usually life threatening (but 50% die in 20-25 years)
Pancreatic Cyst Descriptions
Congenital (3) and Pseudocysts (3)
Congenital:
Anomalous duct formation with a thin capsule containing serous fluid
Associated with VHL syndrome and APCKD
Pseudocysts (most common)
Lack epithelial lining
Collections of necrotic and hemorrhagic materials rich in enzymes
Seen after fat necrosis (acute pancreatitis)
Pancreatic Carcinoma
Epidemiology (2), Risk Factors (6) Clinical Features (6) Cancer Marker Use (3)
4th leading cause of death related to cancer in US
One of the most aggressive cancers with a high mortality rate
2x increased risk with cigarette smoking
FH, high fat diet, Diabetes, Chronic pancreatitis and Ashkenazi Jews also increase risk
Epigastric pain, obstructive jaundice and W/L are main symptoms
Mostly seen in older adults as advanced disease
Causes migratory thrombophlebitis
Metastasizes to lungs and liver
CA19-9 levels used to diagnose and track treatment response
CA19-9 not sensitive enough for screening purposes
Pancreatic Carcinoma
Locations with Significance (2)
Morphology (3) and Genetic Pathogenesis (5)
Most lesions in head: extrahepatic biliary obstruction which increases direct bilirubin causing painless jaundice
Clinically silent if found in tail/body
Glands with pleomorphic cuboidal-columnar epithelium
Dense stromal fibrosis (desmoplastic response)
Precursor lesion in Pancreatic Intraepithelial Neoplasia (PanIN)
KRAS in main oncogene
Hypermethylated CDKN2A is main inactivated tumor suppressor
SMAD4/TP53 inactivation and BRCA2 mutations also common
