Chapter 17-Stomach Flashcards
What is the terminology used when there are neutrophils present at the lesion in gastritis
Acute gastritis
What is the terminology used when there are no inflammatory cells present in the gastritis lesion
Gastropathy
What are the diseases that fall under the category of hypertrophic gastropathy
- Menetrier disease
- Zollinger Ellison Syndrome
What is the mechanism that NSAIDs can cause gastritis or gastropathy
- NSAIDs inhibit COX
- COX stimulate prostaglandin synthesis
- Prostaglandins stimulate production all of the products protecting the stomach lining from harsh conditions
What stomach condition are people at higher altitudes at risk of developing
Decreased oxygen leads to acute gastritis
Patients with NSAID induced gastritis will respond to which treatments
PPI
Antacids
What are the stree related mucosal diseases
- Stress ulcers
- Severe burns or Ulcers (Curling ulcers)
- Intracranial disease (Cushing disease)
When are stress ulcers commonly seen in patients
Individuals with shock, sepsis or severe trauma
When are Curling ulcers commonly seen
Severe burns or trauma leading to ulcers in the proximal duodenum
When are Cushing ulcers commonly seen
Gastric, duodenal or esophageal ulcers in patients with increased intracranial disease
What are cushing ulcers commonly resulting in
Perforation
What is the common cause of stress related gastric mucosal injury
Local ischemia due to systemic hypotension of reduced bloody flow due to splanchnic vasoconstriction
Upregulation of what in the stomach that can cause ischemic gastric mucosal injury
iNOsynthase and release of endothelin 1 (causes vasoconstriction)
Upregulation of what in the stomach that can protect against ischemic gastric mucosal injury
COX2
How does increased intracranial pressure cause Cushing ulcers
Intracranial injury causes direct stimulation of vagal nuclei, causing hyposecretion of gastric acid
What is the location of acute stress ulcers and what are the number that they normally occur in
Anywhere in the stomach, and there are normally multiple lesions
What is the morphology of the stress ulcers
-Ulcer base is stained brown/black by digestion of extravasated blood
What is absent in acute stress ulcers that differentiate it from peptic ulcers
Scarring and blood vessel thickening
Most critically ill patients admitted to the ICU show signs of which condition
Histological evidence of gastric mucosal damage
What is the most important determination of clinical outcome of gastric mucosal damage
Correction of the underlying condition
What are the nonstress related caused of gastric bleeding
GAVE Disease
Dieulafoy lesion
What is the Dieulafoy lesion caused by
Submucosa artery does not branch within the wall of the stomach, leading to an enlarged mucosal artery
Where are Dieulafoy lesions commonly found
Along the lesser curvature, near the gastroesophageal junction
What is the result of the Dieulafoy lesion
Erosion of the overlying epithelium causes gastric bleeding
What exacerbates the bleeding from a Dieulafoy lesion
NSAID use
What is the characteristic endoscopic finding in GAVE disease
Longitudinal stripes of edematous erythematous mucosa alternating with less injured pale mucosa aka watermelon stomach
What are the longitudinal erythematous stripes in GAVE caused by
Ecstatic mucosal vessels
What are the histological findings of GAVE
Natural mucosa shows reactive gastropathy with dilated capillaries containing fibrin thrombi
What are the conditions associated with GAVE
Cirrhosis and systemic sclerosis
What is the most common cause of chronic gastritis
Infection with H. Pylori
What is the most common cause of diffuse atrophic gastritis, and the most common second to H. Pylori with chronic gastritis
Autoimmune gastric
If you were to take a gastric biopsy of the duodenal ulcer, what most likely will be present
H. Pylori
What percentage of patients with chronic gastritis are infected with H. Pylori
90%
What are the common cases where H.pylori is more prevalent
- Poverty
- Crowded housing
- Black of Mexican
- Rural housing
- Birth outside US
What are the levels of gastrin in an infection with H. Pylori
- Locally elevated
- Serum normal
What is the result when the inflammation from H.pylori is limited to the antrum of the stomach
Increased acid production causes increased risk of duodenal peptic ulcer
What is the result when the inflammation of the H. Pylori infection is in the fundus and body of the stomach
Multifocal atrophic gastritis
What is multifocal atrophic gastritis associated with
- Patchy mucosa
- Reduced parietal cell mass and acid secretion
- intestinal metaplasia
- increased risk of gastric adenocarcinoma
What is the relationship between duodenal ulcers and adenocarcinoma
They are inversely related, as the increased pattern causing adenocarcinoma will decrease the chance of duodenal ulcers
What are the four things that are associated with the virulence of the H. Pylori infections
- Flagella
- Urease
- Adhesins
- Toxins
What is the gene/toxin present in 90% of patients with elevated gastric cancer risk
CagA toxin from H pylori
Deficiency of which vitamin is associated with an increased risk of H.pylori associated gastric cancer
Iron
What is the locations commonly associated with H. Pylori
Gastric epithelium, not found in intestinal metaplasia or duodenal epithelium
What are characteristic of H. Pylori gastritis
Intraepithelial neutrophil and subepithelial plasma cells
When the inflammation due to H. Pylori is intense, which condition can it mimic
Thicken fugal folds that can mimic appearance of early cancers
How can H. Pylori gastritis be differentiated from autoimmune gastritis
H. Pylori causes mucosa to atrophy and result in loss of parietal and chief cells, taking on the appearance ECF antral mucosa. As opposed to autoimmune gastritis which takes on the form of patchiness, with intact oxytynic glands
The development of atrophy in the stomach is associated with which conditions
Intestinal metaplasia and gastric adenocarcinoma
What is the stain that is used to highlight H. Pylori in stains histologically
Warthin-Starry silver stain
What is autoimmune gastritis associated and defined by
- Abs against parietal cells and intrinsic factor
- reduced serum pepsinogen 1 levels
- Endocrine cell hyperplasia
- B12 deficiency
- Defective gastric acid secretion
What is the cause of the increased gastrin release associated with autoimmune gastritis
Loss of parietal cells and acid secretion causes the increased levels of gastrin secretion
What is the principal cell of injury and the target in autoimmune gastritis
CD4 T cells targeting parietal cells
What is morphologically characteristic of autoimmune gastritis
Diffuse mucosal damage to the oxyntic (acid production) mucosa within the body and fundus with atrophy and loss of rural folds
Which stain can be used to see hyperplasia associated with autoimmune gastritis
Immunostaining for proteins such as chromogrannin A (parallels mucosal atrophy)
What is the median age of diagnosis for autoimmune gastritis
60
Which conditions are commonly associated with autoimmune gastritis
Other autoimmune diseases such as Hashimotos, DM, Addison’s, Graves, myasthenia gravis etc
What is a potential response to the anemia caused by the lack of B12 in autoimmune gastritis
Atropic glossitis, which is a smooth and beefy red tongue, megaloblastosis, spinal cord lesions, and cerebral dysfunction. Usually presents with numbness and parenthesis
What are the defining features of subacute combined degeneration of the cord
- Loss of vibration and positional sense
- Sensory ataxia with Romberg sign
- limb weakness
- extensor plantar response
What is eosinophilia gastritis
Gastritis with tissue damage associated with dense infiltrates of eosinophils in the mucosa and muscularis part of the antral and pyloric region
What is a common cause of allergens in children that lead to eosinophilia gastritis
Soy protein and cow’s milk
Which conditions are commonly associated with eosinophilia gastritis
Immune disorders:
- systemic sclerosis
- polymyositis
- Parastic infections
- H.pyloir infections
Which gender is more commonly to develop lymphocytic gastritis
Women
Which condition is commonly presented with lymphocytic gastritis
Celiac disease
What is the histological finding with lymphocytic gastritis
Intraepithelial T lymphocytes
What are the morphological findings associated with lymphocytic gastritis
Thickened folds covered by small nodules with central aphthous ulcerations
What is another name for lymphocytic gastritis
Varioliform gastritis
What is the characteristic feature of granulomatous gastritis
Well formed granulomas or aggregates of macrophages
What is the most common cause of granulomatous gastritis, and what are the second and third
First: crohns
Second: sarcoidosis
Third: Infections
What is the location that is affected with peptic ulcer disease
Duodenum and stomach
What three things are accounted for in almost all cases of peptic ulcer diseases
- H. Pylori
- NSAIDs
- Cigarette smoke
What is the most common peptic ulcer diseases associated with
H pylori leading to PUD affecting the gastric antrum and duodenum
What is peptic ulcer disease of the antral portion of the stomach characterized by
Increased gastric acid secretion and decreased duodenal bicarbonate secretion
What is peptic ulcer disease of the gastric body or fundus associated with
Less acid secretions as a result of mucosal atrophy, and although it is more than normal, not enough to overcome the protected membranes
Why is peptic ulcer disease increasing in those over the age of 60
Use of baby aspirin (NSAID)
What is the most common location for peptic ulcer disease
Proximal duodenum
Which portion of the duodenum wall do peptic ulcers affect
Anterior wall
Which portion of the stomac is affected in gastric peptic ulcers
Lesser curvature of the stomach
What is the general morphology of a peptic ulcer
Solitary, with a round ulcer that sharply “punched out defect”
How do you differentiate between peptic ulcers and cancer
Ulcers are punched out, while cancers will be raised
How common is malignant transformation of the peptic ulcers
Very rarely
Which complications are commonly reported with peptic ulcers
-Iron deficiency anemia, hemorrhage and perforation
What does pain tend to occur with peptic ulcers
- 1 to 3 hours after meals
- worse at night
- relieved by food or antacids
Wheat is the first indication of an ulcer
Bleeding
What is the percentage of patients that bleeding as a result of an ulcer may occur and what percentage of deaths
15-20% and accounts for 25% of deaths
What accounts for the majority of deaths in patients with pueptic ulcers
Perforation
What is the characteristic of the condition gastric cystica
Epithelial proliferation associated with entrapment of the epithelial lined cysts
What are the characteristics of hypertropic gastropathies
-Uncommon diseases that have giant cerebriform enlargement of the rural folds (due to epithelial hyperplasia) without inflammation
What are the two examples of hypergastric gastropathies
- Menetrier Disease
- ZE
What is the mechanism of disease of Menetrier disease
-excess TGF resulting in diffuse hyperplasia of the foveolar epithelium of the body and fundus and hyperproteinemia
Patients with Menetrier disease are at an increase of which condition
Adenocarcinoma
What are the morphological changes seen in Menetrier disease
-Rural fold enlargement in the bonds and fundus, but the antrum is spared
What are the histological findings of Menetrier disease
-Hyperplasia of the fovealar cells, where the glands are elongated with a corkscrew like appearance and cystic dilation
What are the treatments of Menetrier disease
Intravenous albumin, parenteral supplementation and anti TGF
What are the characteristics of the Zollinger Ellison syndrome
Gastrin secreting tumors, presenting with duodenal or chronic diarrhea
Where are gastromas commonly found
Small intestine and pancreas
What are the features of Zollinger Ellison syndrome
-Doubling of the oxyntic mucosal thickening due to the increase in the number of parietal cels
The increase in gastrin from Zollinger Ellison syndome result in hyperplasia of which areas
- mucous neck cells
- Mucin hyperproduction
- proliferation of endocrine cells of oxyntic mucosa
What is the main concern of treatment for Zollinger Ellison syndome
Treatment focused on the gastroma, because it is the main determinative of long term survival
What percent of the Zollinger Ellison gastromas are milignant
60-90%
Where condition/ neoplasias are associated with Zollinger Ellison
MEN1
What is the treatment for patients with Zollinger Ellison and MEN1
Somatostatin analogues
Fundic gland polyps occur in individuals with which condition
Familial adenomatous polyposis (FAP)
What is the risk of fundic gland polyps that carry a large risk
Those that are familial with FAP, as sporadic carries no risk of cancer
Which gender is more commonly affected by gastric adenomas
Males
The risk of adenocarcinoma from gastric adenomas are correlated to what
Related to the size of the lesion
What is the most common malignancy of the stomach and by which percentage
Adenocarcinoma and 90% of all cancers of the stomach
What are the common sites involved in metastasis of gastric adenocarcinomas
Virchow nodes (supraclavicular) Sister Mary Joseph (Periumbicular) Irish (left axillary node) Krukenburg tumor (ovarian) Blume shelf (punch of Douglas aka retouterine pouch)
Which mutation is strongly associated with familial gastric adenocarcinomas
CDH1, which is for E cadherin
Individuals with which mutation are at a higher risk of developing diffuse gastric cancer
BRCA2
Which mutation is strongly assocaited with sporadic intestinal type gastric cancers
Wnt pathway (beta catenin and APC)
Gastric tumors of diffuse infiltrate growth are commonly composed of which cells
Signet ring cells
Which condition commonly demonstrates linitis plastica and what is that syndome
Gastric adenocarcinomas, with thickened gastric wall with thicker regal folds aka leather bottle appearance
Which condition starts a desmoplastic reaction
Adenocarcinoma
What is the most diagnostic feature of gastric cancer
- Extent of nodal metastasis
- Depth of invasion
What patient group and location is most common for EBV be cell lymphoproliferations
Allogenic hematopoietic stem cell and organ transplant patients, the bowel is the most common location
Which translocation is most commonly associated with MALTomas and which is the gene product
(11;18)(q21;q21)
-apoptosis inhibitor protein 2 (API2)
What is the histological characteristic feature of MALTomas
Lyzphoepithlelial lesion with neoplastic lymphocytes surrounding and infiltrating gastric glands
Carcinoid syndrome is commonly assocaited with which metastatic disease
Liver metastatic disease
What is the most common location of a GI carcinoid tumor
Midgut, aka jejunum and illeum
What is the prognosis of forgut carcinoid tumor
Good, as they rarely metastasis and cured with resection
What is the prognosis of midgut carcinoid tumors
Not great, since they tend to be aggressive
What characteristics of the midgut carcinoid tumors are associated with worse outcomes
Greater depth
Increased size
Necrosis and mitosis
What is the prognosis of hindgut carcinoid
Good, as most are benign
What is the most common mesenchymal tumor of the abdomen, and which location is most common
GI stromal tumor (GIST) in the stomach
What is the origin of the GI stromal tumors
Cells of Cajal
Which condition is described as having a salt and pepper histological description
GI carcinoid tumor
Which conditions of GIST
- NF1
- Carney triad (GIST, paraganglioma, and pulmonary chondroma)
Most GIST contain which mutation
Tyrosine kinase KIT
