Gastrointestinal- Phatology Flashcards
Sialolithiasis
Can occur in 3 major salivary glands. Single stone more common in submandibular gland (Wharton duct).
Presents as recurrent pre-/periprandial pain and
swelling in affected gland. Caused by dehydration or trauma.
Treat conservatively with NSAIDs, gland massage, warm compresses, sour candies
Sialadenitis
inflammation of salivary gland due
to obstruction, infection, or immune-mediated
mechanisms.
Salivary gland tumors
Most commonly benign and in parotid gland. Tumors in smaller glands more likely malignant.
Typically present as painless mass/swelling. Facial pain or paralysis suggests malignan involvement of CN VII.
Salivary gland tumors
- Pleomorphic adenoma (benign mixed tumor)
Most common salivary gland tumor.
Composed of chondromyxoid stroma and epithelium and recurs if incompletely excised or ruptured intraoperatively.
May undergo malignant transformation.
Salivary gland tumors
- Mucoepidermoid carcinoma
most common malignant tumor, has mucinous and squamous components.
Salivary gland tumors
- Warthin tumor (papillary cystadenoma lymphomatosum)
benign cystic tumor with germinal centers. Typically found in smokers. Bilateral in 10%; multifocal in 10%.
Achalasia
- Etiology
- Manometry findings
Failure of LES to relax due to loss of myenteric (Auerbach) plexus due to loss of postganglionic inhibitory neurons (which contain NO and VIP).
uncoordinated or absent peristalsis with high LES resting pressure progressive dysphagia to solids and
liquids. Barium swallow shows dilated esophagus with an area of distal stenosis (“bird’s beak”).
Secondary Achalasia
(pseudoachalasia) may arise from Chagas disease (T cruzi infection) or extraesophageal malignancies (mass effect or paraneoplastic).
Esophageal pathologies
- Boerhaave syndrome
Transmural, usually distal esophageal rupture with pneumomediastinum due to violent retching.
Subcutaneous emphysema may be due to dissecting air (crepitus may be felt in the neck region or chest wall). Surgical emergency.
Esophageal pathologies
- Eosinophilic esophagitis
Infiltration of eosinophils in the esophagus often in atopic patients. Food allergens dysphagia, food impaction.
Esophageal rings and linear furrows often seen on endoscopy. Typically unresponsive to GERD therapy.
Esophageal pathologies
- Esophageal strictures
Associated with caustic ingestion and acid reflux.
Esophageal pathologies
- Esophagitis
Associated with
- reflux,
- infection in immunocompromised (Candida: white pseudomembrane; HSV-1: punched-out ulcers; CMV: linear ulcers),
- caustic ingestion,
- pill esophagitis (eg, bisphosphonates, tetracycline, NSAIDs, iron, and potassium chloride).
Esophageal pathologies
- Gastroesophageal reflux disease
Commonly presents as heartburn, regurgitation, dysphagia. May also present as chronic cough,
hoarseness.
Associated with asthma. Transient decreases in LES tone.
Esophageal pathologies
- Mallory-Weiss syndrome
Partial-thickness mucosal lacerations at gastro esophageal junction due to severe vomiting.
Often presents with hematemesis. Usually found in alcoholics and bulimics.
Esophageal pathologies
- Plummer-Vinson syndrome
Triad of Dysphagia, Iron deficiency anemia, and Esophageal webs.
May be associated with glossitis. Increased risk of esophageal squamous cell carcinoma (“Plumbers DIE”)
Esophageal pathologies
- Sclerodermal esophageal dysmotility
Esophageal smooth muscle atrophy decrease LES pressure and dysmotility acid reflux and dysphagia
stricture, Barrett esophagus, and aspiration.
Part of CREST syndrome.
Barrett esophagus
Replacement of nonkeratinized stratified squamous
epithelium with intestinal epithelium.
Due to chronic gastroesophageal reflux disease (GERD). Associated with risk of esophageal adenocarcinoma.
Esophageal cancer
- clinical presentation
Typically presents with progressive dysphagia (first solids, then liquids) and weight loss; poor prognosis.
Esophageal cancer
- Squamous cell carcinoma
- Adenocarcinoma
Upper 2/3. Alcohol, hot liquids, caustic strictures, smoking, achalasia. More common worldwide
Lower 1/3. Chronic GERD, Barrett esophagus, obesity, smoking, achalasia. More common in America
Acute gastritis
- Etiology
NSAIDs, Burns (Curling ulcer), Burns (Curling ulcer).
Especially common among alcoholics and patients taking daily NSAIDs
Chronic gastritis
- Physiophatology
- Etiology
Mucosal inflammation, often leading to atrophy
(hypochlorhydria hypergastrinemia) and intestinal metaplasia (risk of gastric cancers).
H pylori (antrum first and spreads to body), Autoinmune (body/fundus of stomach).
Ménétrier disease
- Physiophatology
- Clinical presentation
Hyperplasia of gastric mucosa hypertrophied rugae. Causes excess mucus production with resultant protein loss and parietal cell atrophy with decrease acid production.
Precancerous.
Presents with epigastric pain, anorexia, weight loss, vomiting, edema (due to protein loss).
Gastric cancer
- Types
- Clinical presentation
- Association
Most commonly gastric adenocarcinoma; lymphoma, GI stromal tumor, carcinoid (rare).
Early aggressive local spread with node/liver metastases. Often presents late, with weight loss, abdominal pain, early satiety, and in some cases acanthosis nigricans or Leser-Trélat sign.
Associated with blood type A.
Gastric cancer
- Intestinal
- Diffuse
associated with H pylori, dietary nitrosamines (smoked foods), tobacco smoking, achlorhydria, chronic gastritis.
Commonly on lesser curvature; looks like ulcer with raised margins.
Not associated with H pylori; signet ring cells (mucin-filled cells with peripheral nuclei); stomach wall grossly thickened and leathery (linitis plastica).
Gastric cancer
- Virchow node
- Krukenberg tumor
- Sister Mary Joseph nodule
involvement of left supraclavicular node by metastasis from stomach.
bilateral metastases to ovaries. Abundant mucin-secreting, signet ring cells.
subcutaneous periumbilical metastasis.
Peptic ulcer disease
Pag. 374
Ulcer complications
Hemorrhage: Gastric, duodenal (posterior > anterior). Most common complication.
Obstruction: Pyloric channel, duodenal
Perforation: Duodenal (anterior > posterior). May see free air under diaphragm with referred pain to the shoulder via irritation of phrenic nerve.
Malabsorption syndromes
Can cause diarrhea, steatorrhea, weight loss, weakness, vitamin and mineral deficiencies. Screen for fecal fat (eg, Sudan stain).
Malabsorption syndromes
- Celiac disease (etiology, findings)
Autoimmune-mediated intolerance of gliadin malabsorption and steatorrhea.
Findings: IgA anti-tissue transglutaminase (IgA tTG), anti-endomysial, anti-deamidated gliadin peptide antibodies; villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis.
Malabsorption syndromes
- Celiac disease (associations, D-xylose tese)
Associated with HLA-DQ2, HLA-DQ8, northern
European descent, dermatitis herpetiformis, decrease bone density.
primarily affects distal duodenum and/or proximal jejunum.
d-xylose test: passively absorbed in proximal small intestine; blood and urine levels decrease with mucosa defects or bacterial overgrowth, normal in pancreatic insufficiency.
Malabsorption syndromes
- Lactose intolerance
Lactase deficiency. Normal-appearing villi. Osmotic diarrhea with low stool pH (colonic bacteria ferment lactose).
Lactose hydrogen breath test: ⊕ for lactose malabsorption if post-lactose breath hydrogen
value rises > 20 ppm compared with baseline
Malabsorption syndromes
- Pancreatic insufficiency
Causes malabsorption of fat and fat-soluble vitamins (A, D, E, K) as well as vitamin B12.
Low duodenal pH (bicarbonate) and fecal elastase.
Malabsorption syndromes
- Tropical sprue
Similar findings as celiac sprue (affects small bowel), but responds to antibiotics.
decrease mucosal absorption affecting duodenum and
jejunum but can involve ileum with time.
Associated with megaloblastic anemia due to folate deficiency and, later, B12 deficiency.
Malabsorption syndromes
- Whipple disease
Infection with Tropheryma whipplei (intracellular gram ⊕);
PAS ⊕ foamy macrophages in intestinal lamina propria, mesenteric nodes.
Cardiac symptoms, Arthralgias, and Neurologic symptoms are common. Diarrhea/steatorrhea occur later in disease course. Most common in older men.
Inflammatory bowel disease
Pag. 376
Irritable bowel syndrome
- Criteria
Recurrent abdominal pain associated with ≥ 2 of the following:
Related to defecation
Change in stool frequency
Change in form (consistency) of stool
Irritable bowel syndrome
- Characteristics and treatment
No structural abnormalities. Most common in middle-aged women. Chronic symptoms may be diarrhea-predominant, constipation-predominant, or mixed.
First-line treatment is lifestyle modification and dietary changes.
Appendicitis Diferential diagnosis
diverticulitis (elderly), ectopic pregnancy (use β-hCG to rule out), pseudoappendicitis.
Diverticulum
Blind pouch protruding from the alimentary tract that communicates with the lumen of the gut.
Most diverticula (esophagus, stomach, duodenum, colon) are acquired and are termed “false diverticula.”
Diverticulosis
Many false diverticula of the colon, commonly sigmoid. Common (in ~ 50% of people > 60 years). Associated with obesity and diets low in fiber, high in total fat/red meat.
Complications include diverticular bleeding (painless hematochezia), diverticulitis.
Diverticulitis
Inflammation of diverticula with wall thickening classically causing LLQ pain, fever, leukocytosis.
Complications: abscess, fistula, obstruction, perforation
Treat with antibiotics.
Zenker diverticulum
Pharyngoesophageal false diverticulum.
Elder MIKE has bad breath. Elderly Males Inferior pharyngeal constrictor Killian triangle Esophageal dysmotility Halitosis
Meckel diverticulum
- Physiophatolgy
- Clinical manifestations
- Diagnosis
True diverticulum. Persistence of the vitelline (omphalomesenteric) duct. May contain ectopic acid–secreting gastric mucosa and/or pancreatic tissue. Most common congenital anomaly of GI tract.
Can cause hematochezia/melena (less commonly), RLQ pain, intussusception, volvulus, or obstruction near
terminal ileum.
Diagnosis: pertechnetate study for uptake by heterotopic gastric mucosa.
Meckel diverticulum
- The rule of 2’s:
2 times as likely in males.
2 inches long.
2 feet from the ileocecal valve.
2% of population.
Commonly presents in first 2 years of life.
May have 2 types of epithelia (gastric/ pancreatic).
Hirschsprung disease
- Physiopatology
Congenital megacolon characterized by lack of ganglion cells/enteric nervous plexuses (Auerbach and Meissner plexuses) in distal segment of colon. Due to failure of neural crest cell migration. Associated with mutations in RET.
Hirschsprung disease
- Clinical presentation
- Diagnosis
- Treatment
Presents with bilious emesis, abdominal distention, and failure to pass meconium within 48 hours chronic constipation.
Risk with Down syndrome.
Explosive expulsion of feces (squirt sign) empty rectum on digital exam. Diagnosed by absence of ganglionic cells on rectal suction biopsy.
Treatment: resection
Malrotation
Anomaly of midgut rotation during fetal development improper positioning of bowel, formation of fibrous bands (Ladd bands). Can lead to volvulus, duodenal obstruction.
Volvulus
Twisting of portion of bowel around its mesentery; can lead to obstruction and infarction.
Midgut volvulus more common in infants and children. Sigmoid volvulus (coffee bean sign on x-ray) more common in elderly.
Intussusception
- Definition
- Clinical presentation
Telescoping of proximal bowel segment into a distal segment, commonly at ileocecal junction.
Compromised blood supply. intermittent abdominal pain often with “currant jelly” stools.
Intussusception
- Etiology
- Diagnosis
Often due to a lead point. Most common pathologic lead point is a Meckel diverticulum (children) or
intraluminal mass/tumor (adults).
May be associated with rotavirus vaccine, Henoch-Schönlein purpura, and recent viral infection
Exam may reveal sausageshaped mass. Ultrasound shows “target sign.”
