Gastrointestinal Pathology Flashcards
Painful, superficial ulceration of oral mucosa characterized by grayish base surrounded by erythema; arises in relation to stress and resolves spontaneously, but often recurs
Apthous ulcer
Recurrent aphthous ulcers, genital ulcers, and uveitis due to immune complex vasculitis involving small vessels; can be seen after viral infection but etiology is unknown
Behcet syndrome
HSV-1 primary infection occurs in childhood. The lesions heal, but the virus remains dormant in ganglia of ______ nerve. Stress and sunlight cause reactivation of the virus, leading o vesicles that often arise on the lip
Trigeminal
SCC is a malignant neoplasm of squamous cells lining the oral mucosa. _____ and ______ are major risk factors, and the floor of the mouth is the most common location
Tobacco; alcohol
What are the 2 potential precursor lesions to SCC that are often biopsied to r/o carcinoma?
Leukoplakia
Erythroplakia (vascularized leukoplakia)
[note hairy leukoplakia at the lateral sides of the tongue in an immunocompromised state is a manifestation of EBV and represents hyperplasia of squamous mucosa — this is not dysplasia or a precursor to SCC]
Infection with mumps virus results in bilateral inflamed parotid glands. What are 3 other potential clinical manifestations with mumps infection?
Orchitis (carries risk of sterility in teens)
Pancreatitis
Aseptic meningitis
With mumps virus infection, serum _____ is increased due to salivary gland or pancreatic involvement
Amylase
Inflammation of the salivary gland is called _______. This is most commonly due to obstructing stone (sialolithiasis) leading to infection caused by ________. It is usually unilateral
Sialadenitis; S.aureus
Most common tumor of salivary gland; Benign tumor usually arising in parotid that is composed of stromal (e.g., cartilage) and epithelial tissue (e.g., glands). Described as mobile, painless, circumscribed mass at the angle of the jaw
Pleomorphic adenoma
Why is there a high rate of recurrence with pleomorphic adenoma of the salivary gland?
Extension of small islands of tumor through tumor capsule often results in incomplete resection
Rarely, a pleomorphic adenoma of the salivary gland may transform into carcinoma. This presents with signs of ________ damage
Facial n.
2nd most common tumor of salivary gland; benign cystic tumor with abundant lymphocytes and germinal centers that almost always arises in the parotid
Warthin tumor
Malignant tumor composed of mucinous and squamous cells, usually arises in parotid and commonly involves the facial nerve
Mucoepidermoid carcinoma
Tracheoesophageal fistula is a congenital defect resulting in connection between the esophagus and trachea. In the most common variant, there is atresia of the esophagus (resulting in a blind pouch), and the distal esophagus arises from the trachea. What are the 4 major clinical features associated with this defect?
Vomiting
Polyhydramnios
Abdominal distention (air going into stomach)
Aspiration (food going up into the lungs)
An esophageal web is a thin protrusion of esophageal mucosa, most often in the upper esophagus, that presents with dysphagia for poorly chewed food. These pts are at an increased risk for what malignancy?
Esophageal squamous cell carcinoma
[note this is protrusion of mucosa only!]
3 features of plummer vinson syndrome
Severe iron deficiency anemia
Esophageal web
Beefy red tongue due to atrophic glossitis
Outpouching of pharyngeal mucosa through ACQUIRED defect in the muscular wall arising above upper esophageal sphincter at junction of esophagus and pharynx. Presents with dysphagia, obstruction, and halitosis
Zenker diverticulum
[FALSE diverticulum]
Longitudinal laceration of mucosa at gastroesophageal junction caused by severe vomiting, usually due to alcoholism or bulimia; presents with PAINFUL hematemesis
Mallory-Weiss Syndrome
[at increased risk for Boerhaave syndrome — presents with subcutaneous emphysemia due to air in mediastinum]
Esophageal varices are dilated submucosal veins in lower esophagus that arise secondary to portal HTN. They are usually asymptomatic, but at risk of rupture (PAINLESS hematemesis). Backup of blood in what vein leads to this dilation?
Left gastric v.
Most common cause of death in cirrhosis
Esophageal variceal bleeding
Achalasia is disordered esophageal motility with inability to relax LES. It is caused by damaged ganglion cells in the _____ _______. Damage can be idiopathic or secondary to known insult (e.g., Chagas disease)
Myenteric plexus
[runs between inner circular and outer longitudinal layer of muscularis propria]
Clinical features of achalasia include dysphagia for solids AND liquids, putrid breath, high LES pressure on esophageal manometry, and bird-beak sign on barium swallow. These pts are at increased risk for what malignancy?
Esophageal SCC
Bowel sounds in the lower lung field indicates what?
Paraesophageal hernia
[these pts may also have lung hypoplasia if the hernia is congenital]
Risk factors for GERD include what type of hernia?
Sliding hiatal hernia
[other risk factors are alcohol, tobacco, obesity, fat-rich diet, caffeine, and hiatal hernia]
Barrett’s esophagus may result in the setting of GERD, and is characterized by a change in the normal __________ epithelium of the lower esophagus into a __________ epithelium with _____ cells
Non-keratinized squamous; non-ciliated columnar; goblet
Esophageal carcinoma is subclassified into adenocarcinoma or squamous cell carcinoma. Which one is the most common esophageal cancer worldwide and arises in upper or middle third of esphagus?
SCC
[adenocarcinoma is the most common in the West and arises in the lower 1/3]
Risk factors for esophageal SCC include alcohol, tobacco, very hot tea, achalasia, esophageal webs (e.g., plummer vinson syndrome), esophageal injury (e.g., lye ingestion). This type of cancer often presents late in the course with what types of signs/symptoms?
Progressive dysphagia, weight loss, pain, and hematemesis (similar to adenocarcinoma)
Additional findings of hoarse voice (recurrent laryngeal n. involvement), and cough (tracheal irritation)
Region of LN spread for esophageal carcinoma of the upper 1/3, middle 1/3, and lower 1/3
Upper 1/3 = Cervical nodes
Middle 1/3 = Mediastinal or tracheobronchial nodes
Lower 1/3 = Celiac and gastric nodes
Congenital malformation of abdominal wall leading to exposure of abdominal contents
Gastroschisis
Persistent herniation of bowel into umbilical cord due to failure of herniated intestines to return to body cavity during development
Omphalocele
Omphalocele contents are covered by ______ and _______ of umbilical cord
Peritoneum; amnion
Pyloric stenosis is congenital hypertrophy of pylorus presenting with projectile nonbilious vomiting, visible peristalsis, and an olive like mass in the abdomen. When does this condition classically present?
2 weeks after birth
[tx is myotomy]
Gastritis can be subclassified as acute or chronic. Acute gastritis is caused by acidic damage to the mucosa due to an imbalance between mucosal defenses and the acidic environment. Acidic damage results in superficial inflammation, erosion (loss of epithelium) and ulcer (loss of mucosal layer)
Risk factors for acute gastritis include severe burn (hypovolemia leading to _______ ulcer), NSAIDs (due to loss of ______ protection), heavy alcohol consumption, chemotherapy, increased intracranial pressure (_______ ulcer), and shock
Curling; prostaglandin; Cushing
How does increased intracranial pressure lead to acute gastritis?
Increased intracranial pressure results in increased vagal stimulation resulting in increased acetylcholine release, which binds parietal cell to increase acid production
Chronic gastritis can be divided into 2 types based on underlying etiology: autoimmune gastritis and H.pylori gastritis (most common). Chronic autoimmune gastritis involves autoimmune destruction of gastric parietal cells, which are predominantly present in the ___ and ____ of the stomach. This is associated with antibodies against _____ and/or ______ which are useful for dx
Body; fundus; parietal cells; intrinsic factor
What type of HSR is chronic autoimmune gastritis?
Type IV HSR — CD8+ mediated damage
Clinical features of chronic autoimmune gastritis include atrophy of mucosa, achlorhydria with increased ______ levels and antral _____ hyperplasia, and megaloblastic (pernicious) anemia due to lack of __________
Gastrin; G-cell; intrinsic factor
Chronic autoimmune gastritis induces intestinal _______, which leads to increased risk for gastric _______
Metaplasia; adenocarcinoma
[metaplasia is indicated by increased goblet cells]
H.pylori-induced acute and chronic inflammation results in chronic H.pylori gastritis. The ___ and ____ released by H.pylori along wtih inflammation lead to weakening of mucosal defenses. The _____ of the stomach is the most common site affected
Ureases; proteases; antrum
H.pylori infection presents wtih epigastric abdominal pain. These pts are at increased risk for ulceration and what 2 types of malignancy?
Gastric adenocarcinoma
MALT lymphoma
Treatment of H.pylori involves triple therapy, which resolves gastritis/ulcer and reverses intestinal metaplasia. What 2 tests confirm eradication of H.pylori?
Negative urea breath test
Lack of stool antigen
Peptic ulcer disease involves a solitary mucosal ulcer involving the _____ _____ (90% of cases) or the ____ ____ (10% of cases)
Proximal duodenum; distal stomach
A ______ ulcer is almost always due to H.pylori; rarely due to ZE syndrome. This type of ulcer presents with epigastric pain that ______ with meals. Diagnostic endoscopic biopsy showing ulcer with hypertrophy of ____glands
Duodenal; improves; Brunner
One of the complications of duodenal ulcer is rupture, which leads to bleeding from the _______ artery, or acute pancreatitis (both of these are complications of ________ ulcers)
Gastroduodenal a.; posterior
Gastric ulcers are usually due to H.pylori, but other causes include NSAIDs and bile reflux. They present with epigastric pain that _____ with meals. The ulcer is usually located on the ____ curvature of the antrum. Rupture carries the risk of bleeding from the ________ artery
Worsens; lesser; left gastric a.
Ddx of ulcers includes cancer. While _____ ulcers are almost never malignant, _____ ulcers can be caused by associated carcinoma
Duodenal; gastric
Gastric carcinoma is a malignant prolferation of surface columna epithelial cells (adenocarcinoma). Gastric carcinoma can be subclassified into what 2 types?
Intestinal type
Diffuse type
The ______ type of gastric adenocarcinoma presents as large, irregular ulcer with heaped up margins, most commonly involving lesser curvature of antrum. Risk factors include intestinal metaplasia, nitrosamines in smoked foods, and blood type A.
Intestinal
The _____ type of gastric adenocarcinoma involves signet ring cells that infiltrate the gastric wall. Desmoplasia results in thickening of the stomach wall in a condition called ____ _____. This is NOT associated with H.pylori, intestinal metaplasia, or nitrosamines
Diffuse; linitis plastica
[signet ring cell = cell with nucleus pushed to side by mucous]
Gastric carcinoma presents late, with weight loss, abdominal pain, anemia, and early satiety. Rarely, it may present with skin findings of ______ ______ or ______ _____ sign
Acanthosis nigricans; Leser-Trelat
Gastric adenocarcinoma often spreads to what unique lymph node?
LEFT supraclavicular node (Virchow node)
Distant metastasis of gastric adenocarcinoma most commonly involves what organ?
Liver
Distant metastasis of gastric adenocarcinoma most commonly involves the liver. Involvement of the periumbilical region is called the Sister Mary Joseph nodule, which is classically seen with the ____ type of gastric cancer.
Involvement of the bilateral ovaries (krukenberg tumor) is classically seen with the _____ type of gastric cancer
Intestinal
Diffuse
Infant presents with polyhydramnios, distension of stomach and blind loop of duodenum (‘double-bubble’ sign on xray), and bilious vomiting
Duodenal atresia
[congenital failure of the duodenum to canalize. Pts with Down syndrome are at increased risk]
Meckel diverticulum is outpouching of all 3 layers of bowel wall (true diverticulum); arises due to failure of _________ to involute
Vitelline duct
[normally involutes by 7th week gestation; most severe form causes fecal matter to drain from umbilicus]
Rule of 2s of meckels diverticulum
Seen in 2% of the population (most common congenital anomaly of GI tract)
2 inches long
Located in small bowel within 2 feet of ileocecal valve
Presents in first 2 years of life with bleeding, volvulus, intussusception (although most cases are asymptomatic)
Why do meckel’s diverticula sometimes bleed?
May contain heterotopic gastric tissue which secretes acid, damaging bowel wall and leading to bleeds
A volvulus is a twisting of bowel along its mesentery, resulting in obstruction and disruption of blood supply (infarction). What is the most common location in elderly vs. young adults?
Elderly = sigmoid colon
Young adults = cecum
Intussusception is telescoping of the proximal segment of bowel into the distal segment resulting in infarction or obstruction, which may present with current jelly stools. The primary risk factor is a leading edge, and in children the most common cause is ________ _______, while in adults, the most common cause is _______
Lymphoid hyperplasia (terminal ileum dragged into cecum); tumor
Small bowel is highly susceptible to ischemic injury. A transmural infarction occurs with embolism/thrombosis of the ______ artery or thrombosis of the ______ vein.
A ______ infarction (as opposed to transmural) occurs with marked hypotension
Superior mesenteric a.; mesenteric
Mucosal
[causes of transmural infarction include atrial fibrillation, vasculitis, lupus anticoagulant, etc.]
Clinical features of intestinal infarct are abdominal pain, bloody diarrhea, and ______ bowel sounds
Decreased
Lactose intolerance is due to decreased function of the lactase enzyme found in brush border of enterocytes. Clinical presentation is abdominal distension and diarrhea on consumption of milk products. Deficiency may be congenital or acquired. What are 2 ways in which deficiency is acquired?
Acquired with age
Following infection that damages enterocytes (lactase function returns upon healing)
Celiac disease is immune-mediated damage of small bowel villi due to gluten exposure. What are the 2 HLA associations?
HLA-DQ2 and DQ8
More on pathogenesis of celiac disease: Gluten is present in wheat and grains. The most pathogenic component is gliadin. Gliadin is ________ by tissue transglutaminase, the product of this reaction is then presented by APCs via _______ and _______ T cells mediate tissue damage. Presents clinically in children with abdominal distension, diarrhea, and failure to thrive, and in adults with chronic diarrhea and bloating
Deamidated; MHC II; helper (CD4)
What is the pathogenesis of dermatitis herpetiformis, the skin manifestation of celiac disease?
IgA deposition at tips of dermal papillae
Lab findings of celiac disease include IgA antibodies against ______, ______, or _______.
In the case of IgA deficiency, _____ antibodies are useful for diagnosis
Endomysium, tTG, or gliadin
IgG
Duodenal biopsy in a celiac disease patient would show flattening of villi, ______ of crypts, and increased intraepithelial lymphocytes.
Damage is most prominent in the _______, while the _____ and _____are less involved
Hyperplasia
Duodenum; jejunum; ileum
Symptoms of celiac disease resolve with a gluten-free diet. If a patient presents with refractory disease despite good dietary control, what should you check them for?
Small bowel carcinoma
T-cell lymphoma (enteropathy-associated T cell lymphoma aka EATL)
[note that T cell lymphoma is a rare occurence but this is one case where you may see it]
______ ______ = damage to small bowel villi due to unknown organism, resulting in malabsorption. Occurs in tropical regions (e.g., Caribbean), arises after infectious diarrhea, and responds to antibiotics
Tropical sprue
What is the primary difference between celiac disease and tropical sprue regarding site of most prominent damage?
Celiac = damage most prominent in duodenum
Tropical sprue = damage most prominent in jejunum and ileum
Whipple disease = systemic tissue damage characterized by ______ loaded with Tropheryma whippelii organisms. Partially destroyed organisms are present in the _______ of these cells, which stain positive for ____
Macrophages; lysosomes; PAS