Bowel Pathology Flashcards by LL Cool G

A patient has diarrhea, steatorrhea, weight loss, weakness, and vitamin/mineral deficiencies; she likely suffers from what type of illness? 

A malabsorption syndrome 

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A child develops greasy stools and failure to thrive after the addition of wheat to her diet. She has autoantibodies to what substance? 

Gluten (gliadin), suggesting celiac disease 

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Celiac disease primarily affects what part(s) of the bowel? 

Distal duodenum and/or proximal jejunum 

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Unlike a patient with celiac disease, a patient with tropical sprue can be treated with which class of drugs? 

Antibiotics 

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A patient with tropical sprue has a colonoscopy with biopsy. Which sections of the GI tract are likely to be affected? 

The entire small bowel 

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An 80-year-old man presents with Whipple disease. A Gram stain of the causative organism would show what? 

Gram-positive rods (Tropheryma whipplei) 

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A patient with suspected Whipple disease has a biopsy with PAS staining. Where would you look to confirm foamy macrophages? 

Intestinal lamina propria, mesenteric lymph nodes 

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A woman is diagnosed with Whipple disease and wants to know about potential complications. What non-GI symptoms might also occur? 

Cardiac symptoms, Arthralgias, Neurologic symptoms (these symptoms occur mostly in older men)—think foamy whipped cream in a CAN 

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A 15-year-old boy with chronic respiratory infections due to Pseudomonas has fatty stools. What is the most likely pathophysiology? 

Pancreatic insufficiency due to sludging of pancreatic secretions, as a result of cystic fibrosis 

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A chronic alcoholic refuses to stop drinking. He is finally diagnosed with chronic pancreatitis. What do you expect to see on stool studies? 

Neutral fat in stool (chronic pancreatitis leads to pancreatic insufficiency, fat malabsorption, steatorrhea, and findings of fat in stool) 

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A patient is diagnosed with ampullary cancer. What do you expect to see on stool studies?  

Steatorrhea (obstructive cancers of the pancreatic head lead to pancreatic insufficiency, causing increased neutral fat in the stool)  

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Pancreatic insufficiency causes the malabsorption of which macronutrient(s)? 

Fat, the fat-soluble vitamins (A, D, E, K), sometimes vitamin B12 

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An 70-year-old man with arthralgias, cardiac and neurologic symptoms gets a duodenal biopsy. What is likely to be found with PAS stain?  

Foamy macrophages (this is Whipple disease—remember foamy whipped cream)  

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A patient is said to have autoimmune damage to the small bowel caused by gluten sensitivity. What illness is described? 

Celiac disease 

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A child has diarrhea and a rash on the extensor surfaces that resolves with dietary modification. It is associated with which GI pathology?  

Associated with celiac disease (this is dermatitis herpetiformis)  

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A patient with diarrhea that occurs on a wheat-containing diet undergoes colonoscopy. What histologic findings are expected? 

Blunting of villi and the presence of lymphocytes in the lamina propria (this is celiac disease) 

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What serum test is used to screen for celiac disease?  

Serum levels of anti-tissue transglutaminase antibodies are used for screening  

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A patient is found to have gluten insensitivity. What is the pathophysiology of his disease? 

Antibodies destroy villi (primarily in the distal duodenum and proximal jejunum), thereby decreasing mucosal absorption and causing diarrhea 

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A patient has anti-endomysial, anti-tissue transglutaminase, and anti-gliadin antibodies. What serotypes are associated with this syndrome? 

HLA-DQ2, HLA-DQ8 

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A man returns from the Bahamas with complaints of diarrhea and decreased mucosal absorption. Will this patient respond to antibiotics?  

The patient has tropical sprue and will respond to antibiotics  

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A patient presents with extremely itchy rashes on her knees and elbows. IF shows IgA deposits at dermal papillae. How do you treat her?  

A gluten-free diet will resolve the skin lesions. (this is dermatitis herpetiformis, which is a finding in celiac disease)

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What is generally accepted as the etiology of Crohn disease? 

Disordered immune responses to intestinal bacteria 

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A man with ulcerative colitis asks if his condition was caused by a bacteria or virus. You explain that his disease a type of what process? 

It is an autoimmune condition, possibly a disordered response to bacteria, but not directly caused by said bacteria 

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A 20-year-old patient has recurrent diarrhea that is sometimes bloody, weight loss, oral ulcers, and perianal fistulas. Likely diagnosis? 

Crohn disease 

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What type of inflammatory bowel disease tends to show skip lesions (noncontiguous areas of mucosal involvement)? 

Crohn disease 

A patient has a continuous segment of friable colonic mucosa that abruptly stops in the mid-transverse colon. First-line treatment is what? 

Aminosalicylates (this is ulcerative colitis, which typically has colonic inflammation always involving the rectum) 

A man has transmural colonic inflammation with noncaseating granulomas and lymphoid aggregates. What cell type mediates this pathology? 

Th1 cells (this is Crohn disease) 

Is perianal disease mainly a complication of Crohn disease, ulcerative colitis, or both? 

Crohn disease 

A young woman diagnosed with ulcerative colitis asks if she will have issues with malabsorption. How do you respond? 

Malabsorption is unlikely with ulcerative colitis, since it is often limited to the colon (unlike Crohn disease) 

Is toxic megacolon mainly a complication of Crohn disease, ulcerative colitis, or both? 

Ulcerative colitis 

A 26-year-old man with abdominal pain and mucous in the stool has transmural inflammation of the ileum. What complications may occur? 

Migratory polyarthritis, erythema nodosum, pyoderma gangrenosum, ankylosing spondylitis, aphthous ulcers, uveitis (this is Crohn disease) 

A patient suffering from primary sclerosing cholangitis is likely to also carry a diagnosis of which inflammatory bowel disease? 

Ulcerative colitis 

How does mucosal and submucosal inflammation with pseudopolyps and freely hanging mesentery in ulcerative colitis appear on imaging? 

Lead-pipe appearance (the loss of haustra, giving the colon its segmented appearance, leads to this appearance) 

Describe the gross morphology typically found in Crohn disease. 

Cobblestone mucosa, creeping fat, bowel wall thickening (string sign on X-ray), linear ulcers, fissures, fistulas, transmural inflammation 

Describe the gross morphology typically found in ulcerative colitis. 

Mucosal and submucosal inflammation. friable mucosa with freely hanging mesentery (loss of haustra causes lead-pipe appearance on imaging) 

Name at least two complications of ulcerative colitis. 

Malnutrition, primary sclerosing cholangitis, toxic megacolon, colorectal carcinoma (worse with right-sided colitis or pancolitis) 

Name at least two extraintestinal manifestations of ulcerative colitis. 

Pyoderma gangrenosum, erythema nodosum, primary sclerosing cholangitis, ankylosing spondylitis, aphthous ulcers, uveitis 

What mnemonic can help you to remember the basics of Crohn disease? 

For Crohn, think of a fat granny and an old crone skipping down a cobblestone road away from the wreck (rectal bleeding) 

Irritable bowel syndrome is diagnosed if at least two of what three criteria are met? 

Recurrent abdominal pain that improves after defecation, change in stool frequency, and change in the appearance of stool 

A 40-y/o woman has irregular bowel movements and pain that subsides after defecation. She asks if these symptoms are likely to be chronic. 

Yes (the patient likely has irritable bowel syndrome, which has chronic symptoms) 

What is the treatment for irritable bowel syndrome? 

Since the symptoms fluctuate, it is important to reassess the patient's chief complaint and treat the current symptoms

A 13-year-old boy has sharp pain that started at the umbilicus and then migrated toward the right. What test can confirm the diagnosis? 

Ultrasound can confirm appendicitis, but cannot not rule it out if clinical suspicion is high (the painful spot is the McBurney point) 

A boy has 2 days of fever, vomiting, and severe abdominal pain. On work-up, the RLQ is tender and WBC count elevated. What is the treatment? 

Surgery (appendectomy for appendicitis) 

In elderly patients, what condition must be included in the differential diagnosis of acute abdominal pain (in addition to appendicitis)? 

Diverticulitis 

A 7-year-old boy is transferred to your ED for suspected appendicitis. What signs would you check for on your physical exam? 

Psoas, obturator, and Rovsing signs, & may see pain at the McBurney point, guarding, and rebound tenderness 

In children, what causes appendicitis? 

Obstruction by lymphoid hyperplasia (as opposed to fecaliths in adults)

An infant has twisting of a portion of the bowels around its mesentery. Where is this twisting likely to occur?

Midgut (this is volvulus)

A 3-year-old presents with loose stools and severe but intermittent lower abdominal pain. What section of the GI tract is likely affected? 

The ileocecal junction (this is intussusception, which often presents with classic "currant jelly" stools) 

Is intussusception found more commonly in adults or infants? 

Infants 

An adult with telescoping bowel on imaging should receive a colonoscopy for what associated condition? 

Colon cancer (this is intussusception, which may be a presenting sign of colon cancer in adults) 

A young child presents with abdominal pain. Abdominal ultrasound shows a "bull's eye" appearance to a loop of bowel. Do you call surgery? 

Yes, as this finding is classically associated with intussusception, which is an abdominal emergency

In a patient with Hirschsprung disease, where is the dilated segment of the colon relative to the aganglionic segment? 

Proximal 

What would the biopsy of a patient with Hirschsprung disease likely demonstrate? 

Lack of ganglionic cells (Auerbach and Meissner plexuses) that allow relaxation of the affected bowel 

At birth, a baby presents with an aganglionic segment of the colon, causing him to not pass meconium. Could genetic screening be of value? 

Yes, as this is Hirschsprung disease, which is associated with RET gene mutations (risk is also increased in patients with Down syndrome) 

Hirschsprung disease results from the failure of what process? 

Neural crest cell migration 

A woman who heard about a condition called Hirschsprung disease wonders if her baby may have it. What symptoms would you ask about? 

Inability to pass meconium after birth or chronic constipation in a child, bilious emesis, abdominal distention 

A newborn has bilious emesis and fails to pass meconium after 48 hours. What is the treatment for this disease? How is it diagnosed? 

Treated with resection; diagnosed by rectal suction biopsy (this is Hirschsprung disease) 

Colonoscopy is performed on a newborn with Hirschsprung disease. What will be found proximal to the diseased segment of bowel? 

A transition zone (dilated portion of bowel) proximal to the diseased (aganglionic) segment 

Does Hirschsprung disease involve the rectum? 

Yes 

Which patients are most at risk for necrotizing enterocolitis? 

Premature neonates because of their decreased immunity, & formula feeding also increases risk 

Where does ischemic colitis commonly occur? 

The splenic flexure and distal colon (watershed areas between arterial territories that therefore have tenuous blood flow) 

An 80-year-old man with CAD presents has 6 months of weight loss due to pain after eating. Where do you suspect the pain is occurring? 

The splenic flexure (LUQ) or distal colon (LLQ) (this is ischemic colitis, which affects watershed areas) 

What is a common complaint of patients with ischemic colitis? 

Pain after eating (increased metabolic demand in intestines and inability to appropriately increase blood flow leads to an ischemic state) 

An elderly patient has painless hematochezia. After colonoscopy fails to detect any neoplasms, what test can confirm the most likely cause? 

Angiography, as the most likely cause of the painless bleeding is angiodysplasia 

Where is angiodysplasia typically found in the gastrointestinal tract? 

Cecum, terminal ileum, ascending colon 

A 70-year-old man complains of bright-red blood per rectum. Angiography shows tortuous dilation of vessels at the bleeding site. Diagnosis? 

Angiodysplasia 

A patient with angiodysplasia will typically complain of what symptoms? 

Hematochezia, due to bleeding from tortuous dilation of vessels 

Is angiodysplasia more common in children, young adults, or the elderly? 

The elderly 

A 48-y/o man with many past abdominal surgeries has a distended abdomen with decreased bowel sounds. What does this patient likely have? 

Ileus, or intestinal hypomotility without obstruction 

An opiate abuser complains of increased constipation and decreased flatus. On CT, no obstructions are noted. What does he have? 

Ileus (intestinal hypomotility without obstruction) 

A recent abdominal surgery patient has stomach pain and vomiting. Laparotomy is performed and adhesions are seen. What do you see grossly? 

Adhesions that are symptomatic may demonstrate well-demarcated necrotic zones 

A man with a history of heart disease has abdominal pain and red “currant jelly” stools. Do you limit your differential to intussusception? 

No, as acute mesenteric ischemia may also present with red “currant jelly” stools 

A patient with sepsis is diagnosed with intestinal hypomotility without obstruction. What treatment options may be of use for this patient? 

Treat with bowel rest, electrolyte correction, and cholinergic drugs to stimulate intestinal motility (this is ileus) 