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GI2 E1 > anus, perotineum, GB, appendix > Flashcards

anus, perotineum, GB, appendix Flashcards

robbins

1
Q

a normal true diverticulum of the colon

A

appendix

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2
Q

in what population is acute appendicitis most common

A

young adults and adolescents,

males

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3
Q

pathogenesis of acute appendicitis

A

= a progressive increase in intraluminal pressure that compromise venous outflow

overt luminal obstruction with a mass of stool, tumor, mass of worms–> stasis –> bacterial proliferation–> ischemia and inflammation–> edema and neutrophil infiltration into lumen, muscle, and surrounding soft tissue

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4
Q

dull granular erythematous surface of the appendix

A

acute appendicitis

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5
Q

a dx of acute appendicitis requires ____

A

neutrophilic infiltration of the muscularis propria

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6
Q

pathogenesis of acute gangrenous appendicitis

A

compromise of the appendiceal vessels to the extent of large hemorrhaging ulceration and gangrenous necrosis that extends to the serosa

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7
Q

clinical presentation of acute appendicitis

A

first, periumbilical pain localized to RLQ
then, nausea, vomiting, low grade fever, mild WBC elevation
McBurney sign= tendy 2/3 between umbilicus to ASIS

but often classical signs are not present

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8
Q

complications and prognosis of untreated appendicitis

A

sign morbidity

perforation
pyelophlebitis
portal V thrombosis
liver abscess
bacteremia
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9
Q

most common tumor of the appendix

A

well differentiated neuroendocrine tumor aka carcinoid tumor

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10
Q

prognosis of a carcinoid tumor of the appendix

A

usually found incidentally during surgery

almost always benign, can reach up to 2-3 cm

huge bulge at end of appendix but met is rare

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11
Q

_______ may cause obstruction of the appendix and enlargement that mimics acute appendicitis

A

adenocarcinoma of the appendix

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12
Q

a dilated appendix filled with mucin, _____, can be secondary to an obstruction caused by ____ or a ____/_____

A

mucocele

inspissated mucin or a cystadenoma/ mucinous cystadenocarcinoma

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13
Q

what is the prognosis of a mucinous cystadenocarcinoma of the appendix

A

can invade through the appendiceal wall and lead to intraperotineal seeding and swelling

–> pseudomyxoma peritonei = the abdomen fills with tenacious, semisolid mucin –> ultimately fatal

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14
Q

histology breakdown of the anus

A

top 1/3= columnar rectal epithelium

middle 1/3= transitional epithelium

lower 1/3= stratified squamous epithelium

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15
Q

______ of the anal canal may have typical glandular (~__ 1/3) or squamous (~__ 1/3) patterns of differentiation

A

carcinomas
upper
lower

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16
Q

in ________ of the anal canal can have the following histological patterns

______ = a differentiation pattern of tumors of the anal canal = populated by immature cells derived from the basal layer of transitional epithelium

or mixed with squamous or mucinous differentiation

A

anal cell carcinoma

basaloid pattern

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17
Q

pure squamous cell carcinoma of the anal canal is frequently associated with _____, which also causes precursor lesions like ____

A

HPV

condyloma acuminatum

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18
Q

_______ develop secondary to persistently elevated venous pressure within the hemorrhoid plexus

A

hemorhoids

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19
Q

most frequent predisposing influences for hemorrhoids

A

straining at defecation bc of constipation
venous stasis of pregnancy
portal HTN

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20
Q

pathogenesis of hemorrhoids

A

portal HTN in the rectum,

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21
Q

why are anal varices both less common and less serious than hemorrhoids

A

because the variceal dilations of the anal and perianal venous plexus form collaterals that connect portal and caval system

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22
Q

differentiate between external and internal hemorrhoids

A

external: within inferior hemorrhoidal plexus and below the anorectal line

internal= dilation of superior hemorrhoidal plexus and are within the distal rectum

internal no hurt, external hurt

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23
Q

clinical presentation of hemorrhoids

A

pain and rectal bleeding with bright red blood on tissue

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24
Q

population associated with hemorrhoids

A

older than 30 and prego

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25
Q

trx for hemorrhoids

A

not an emergency
sclerotherapy, rubber band ligation, or infrared coag

severe/external can be removed via hemorrhoidectomy

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26
Q

although ____ of the peritoneal cavity are less common than inflammation and infection, they carry a grave prognosis

A

tumors

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27
Q

most common causes of peritonitis

A

leakage of bile or pancreatic enzymes

perforation/rupture of biliary system

acute hemorrhagic pancreatitis

fb= surgery, granulomas, fibrous scarring

endometriosis

ruptured dermoid cyst–> release keratins and induce an intense gramulomatous rxn

perforation of abd viscera

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28
Q

leakage of bile or pancreatic enzymes into peritoneal cavity –> ____

A

sterile peritonitis

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29
Q

perforation/rupture of biliary system –> a highly ____ peritonitis, usually complicated by ______

A

irritating

bacterial super-infection

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30
Q

link acute hemorrhagic pancreatitis to peritonitis

A

=leakage of pancreatic enzymes and fat necrosis

can lead to damaged bowel–> bacterial spread

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31
Q

link endometriosis to peritonitis

A

causes hemorrhage into the cavity, acts as an irritant

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32
Q

most common agents of bacterial peritonitis

A

E. Coli
S. aureus
enterococci
C. perfringens

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33
Q

spontaneous bacterial peritonitis is seen most often in what population

A

those with cirrhosis, ascites

also, but less frequently, children with nephrotic syndrome

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34
Q

cellular inflammatory response in peritonitis is composed of what

–> ?

A

dense collection of neutrophils and fibinopuruent debris that coat the viscera and abd walls
usually superficial

becomes suppurative–> subhepatic and subdiaphragmatic abscesses

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35
Q

dense fibrosis that may extend to involve the mesentry

A

sclerosing retroperitonitis

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36
Q

etiology of sclerosing retroperitonitis

A

igG4 related autoimmune ds–> lead to fibrosis of many tissues, OFTEN the ureters

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37
Q

primary malignant tumors arising from peritoneal lining are _____ that are similar to tumors of the ___ and ____

A

mesothelioma

pleura & pericardium

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38
Q

peritoneal mesothelioma is almost always associated with sign _____

A

asbestos exposure

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39
Q

while primary tumors of the peritoneum are ____, the most common is _____

A

rare

desmoplastic small round cell tumor

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40
Q

desmoplastic small round cell tumor- prognosis + population

A

v aggressive

children and YA

41
Q

desmoplastic small round cell tumor- etiology

A

reciprocal translocation of t(11,22) (p13;q12) –> fursion of EWS and WT1 genes

42
Q

secondary tumors of the peritoneum may involve the peritoneum by spreading/seeing, resulting in __________

A

peritoneal carcinomatosis.

43
Q

more than 95% of biliary tract ds is attributable to

A

cholelithiasis aka gallstones

44
Q

aberrant location of the gallbladder is most commonly located where

A

partial/complete embedding in th eliver

45
Q

most common congenital anomaly of the gall bladder

A

phrygian cap= a folded fundus

46
Q

define true biliary atresia

A

agenesis of all or any portion of the hepatic or common bile ducts and hypoplastic narrowing of the biliary channels

47
Q

clinical presentation of gallstones

A

cast majority are silent and most individuals remain pain free for decades

48
Q

most common types of gall stones

A

crystalline cholesterol monohydrate

and pigment stones (bilirubin calcium salts)

49
Q

populations at higher risk for gallstones

A

US+Western Europe have 90% of stones

75% of Pima Natives, Hopi, and Navajo.

in non-Western= setting of bacterial infections of biliary tree and parasitic infections

50
Q

most common type of gallstone in the non-western populations specifically

A

pigment stones

51
Q

major risk factors for developing gallstones

A 
middle age or older
females
caucasians for chol, asians for pigment
hypersecretion of biliary chol
metabolic syndrome and obesity
estrogen exposure via OTC/pregnancy
rapid weight loss
hyperlipidemia

acquired gallbladder stasis

mutations in ABC transporters of biliary lipids in hepatocytes

52
Q

connect increased estrogen levels to gallstones

A

increased estrogen–> increased expression of hepatic lipoprotein receptors + HMG-CoA reductase activity–> increased chol uptake and biosynthesis–> increased biliary secretion of chol

53
Q

x ABCG8 gene –>

A

higher risk of cholesterol gallstones

54
Q

etiology of cholesterol gallstones

A

when [chol] exceeds solubility capacity of bile, chol can no longer remain dispersed and nucleates into solid chol monohydrate crystals

accelerated chol crystal nucleation

hypersecretion of mucus in gall bladder (traps nucleated crystals)

55
Q

etiology of pigment gallstones

A

elevated levels of unconjugated bilirubin in bile = chronic hemolytic anemia, severe ileal dysfunction or bypass, bacterial contamination of biliary tree,

infection with E Coli, Ascaris lumbricoides, C sinensis–> increased microbial B-glucoronidase–> increased risk

secondary to Gi ds like ileal ds, ileal resection/bypass/CF w pancreatic insufficiency

56
Q

what is a pigment gallstone made of

A

mix of insoluble Ca salts of unconjugated bilirubin + inorganic Ca salts

57
Q

cholesterol stones exclusively arise where

A

within the gallbladder

58
Q

differentiate between appearance of chol and pigment gallstones

A

chol= pale yellow, round-ovoid, fine granular, hard external surface with glistening radiating crystalline palisade inside

with increased chol can become grey-white to black and are radioluscent

pigment= brown-black. brown in sterile bile and brown in infected bile. made of unconj bilirunin, CaCarbonate, CaPO4, mucin glycoprotein and some chol crystals. speculated contour

59
Q

clinical presentation of the 4% of gallstones that actually become symptomatic

A

biliary colic= excruciating, constant pain following a fatty meal. localized to RUQ or epigastrium that may radiate to the R shoulder or back.

pain with cholecystitis secondary to cholelithiasis

severe complications= empyema, perforation, fistulas, cholangitis, obstructive cholestasis, pancreatitis

60
Q

(GB) the larger the calculi, the less likely they are to _____, and so they are less ____ though occasionally a large stone might cause ____ obstruction

A

enter the cystic or common ducts to produce obstruction

dangerous

intestinal by eroding directly into the adjacent loop of SB

61
Q

90% of acute calculous cholecystitis is precipitated by

A

obstruction of the neck or cystic duct by a stone

62
Q

most common reason for emergency cholecystectomy

A

acute cholecystitis

63
Q

cholecystitis without gallstones may occur in ______

A

severely ill patients

64
Q

etiology of acute cholecystitis

A

result from chemical irritation and inflammation of gallbadder post obstruction of stones

mucosal phospholipases hydrolyze luminal lecithin to toxic lysolecithins–> glycoprotein mucus layer is disrupted, exposing the mucosal epithelium to the direct detergent action of bile salts

prostglandins released from the wall contribute to inflammation, distention and increased intraluminal P–> x blood flow to the mucosa

only later will bacterial contamination develop

65
Q

acute calculous cholecystitis frequently develops in ______ who have symptomatic gallstones

A

diabetic pts

66
Q

acute Acalculous cholecystitis is thought to result from

A

ischemia
cystic A is an end artery

also other things obstructing the cystic duct that aren’t stones

67
Q

risk factors for acute Acalculous cholecystitis

A
  1. sepsis with hypotension and multi-system organ failure
  2. immunosupression
  3. major trauma and burns
  4. DM
  5. infections
68
Q

gall bladder is enlarged, tense, bright red or blotchy, violet to green-black discoloration, imparted by subserosal hemorrhages: covered by fibrinous exudate

A

acute cholecystitis

69
Q

calculous cholecystitis, usually present where

A

neck of the gallbladder or cystic duct

70
Q

define gallbladder empyema

A

when the exudate found within the gallbladder lumen is virtually pure pus, as opposed to fibrin+pus+hemorrhage

71
Q

green-black necrotic gallbladder with perforations

A

gangrenous cholecystitis

72
Q

gallbladder invasion by clostridia and coliforms=

A

acute “emphysematous cholecystitis”

73
Q

clinical presentation of acute calculous cholecystitis

A

usually have had episodes of pain before

an episode beings with progressive RUQ/epigastric pain lasting more than 6 hours

associated with fever, anorexia, tachy, sweating, nausea, and vomiting

hyperbilirubinemia, leukocytosis with mild elevations of serum alkaline phosphate values

can be super mild and resolve on its own or might be a surgical emergency

74
Q

clinical presentations of acute Acalculous cholecystitis

A

insidious, since sx are obstructed by the underlying conditions precipitating the attacks

75
Q

in the case of severely ill patients, early recognition of acute Acalculous cholecystitis is crucial or else…

A

almost ensured a fatal outcome

76
Q

incidence of ____ and ____ are a lot higher in Acalculous than calculous cholecystitis

A

gangrene and perforation

77
Q

what agents can, albeit rarely, give rise to acute Acalculous cholecystitis

A

salmonella typhi

staphylococci

78
Q

a more indolent form of acute acalculous cholecystitis can occur in what patient populations + settings

A

systemic vasculitis
severe atherosclerotic ischemic ds in the elderly
AIDS
biliary tract infections

79
Q

chronic cholecystitis can be a sequel to __________, but in many instances it develops in apparent absence of ________

A

repeated bouts of mild to severe acute cholecystitis

antecedent attacks

80
Q

chronic cholecystitis is associated with ____ 90% of the time

A

cholelithiasis

81
Q

organisms associated with chronic cholecystitis

A

E. Coli

enterococci

82
Q

morphological changes with cholecystitis

A

subserosal fibrosis, wall thickness, inflammation to variable amounts

Rokitansky-Aschoff sinuses= buried crypts of epithelium within the gallbladder wall

porcelain gallbladder= extensive dystrophic calcification of the GB wall

83
Q

what is xanthogranulomatous cholecystitis

A

GB is chronically inflamed with foci of necrosis and hemorrhage

triggered by rupture of Rokitansky-Aschoff sinuses into the wall of the gall bladder followed by an accumulation of Mø that have ingested biliary phospholipids

84
Q

define hydrops of the gallbladder

A

atrophic, chronically obstructed GB that is often dilated, and can contain clear secretions

85
Q

clinical presentation of chronic cholecystitis

A

recurrent attacks of steady epigastric/RUQ pain

N/V, intolerance of fatty foods

86
Q

complications of acute/chronic cholecystitis

A
  • bacterial super-infection–> cholangitis/sepsis
  • GB perforation and local abscess formation
  • GB rupture with diffuse peritonitis
  • biliary enteric fistula, w drainage of bile into adjacent organs, entry of air and bacteria into the biliary tree, and potentially gallstone-induced ileus
  • aggravation of comorbid ds
  • porcelain gallbladder
87
Q

_____ is the most common malignancy of the extrahepatic biliary tract

A

carcinoma of the gallbladder

88
Q

what populations have the highest rates of carcinoma of the gallbladder

A

chile, bolivia, north indians, Natives/Hispanics in the southwest US

women

89
Q

prognosis of carcinoma of the gallbladder

A

less than 10% 5 year survival

most are diagnosed at an advanced stage,

90
Q

most important risk factors for carcinoma of the gallbladder

A

gender
ethnicity
presence of gallstones –> chronic inflammation

91
Q

genetic mutations associated with carcinoma of the gallbladder

A

oncoprotein ERBB2 (Her-2/neu) overexpression

chromatin remodelling, PBRM1 and MLL3

92
Q

carcinoma of the gallbladder- 2 growth patterns

A

infiltrating = most common
-poorly defined area of diffuse mural thickening and induration, firm and scirrhous, can ulcerate into liver/other surrounding viscera

exophytic= irregular, cauliflower mass
-invades the underlying wall

93
Q

most carcinomas of the gallbladder are

A

adenocarcinomas

94
Q

papillary tumors of the GB have a ____ prognosis than other tumors of the GB

A

better

95
Q

prognosis of GB carcinoma

A

by the time they are discovered, most have invaded the liver, and many have extended to the cystic duct/adj bile ducts/portal-hepatic LNs

96
Q

common sites of GB carcinoma seeding

A

peritoneum
GI tract
lungs

97
Q

lesions in the epithelium in a gallbladder with long-standing cholelithiasis, nearly always flat with varying grades of cellular atypia

A

preneoplastic lesions, often carcinoma-in-situ

uncommon to find

98
Q

clinical presentation of carcinoma of the gallbladder

A

usually insidious, uncommon to diagnose pre-op

present with abd pain, jaundice, anorexia, N/V

early detect in pts with a palpable GB and acute cholecystitis

99
Q

trx for carcinoma of the gallbladder

A

surgical resection, chemo

GI2 E1 (19 decks)

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