GI III Flashcards by Elyaa Saleh

Clinical features of IBS

1) Abdominal pain or discomfort (at least 3 days per month over 3 months)
2) Improvement with defecation
3) Change in stool frequency or form
4) Other Manifestations: Fibromyalgia, visceral hyper-sensitivity, backache, headache, urinary symptoms, dyspareunia, lethargy, and depression

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DD of IBS

Diarrhoeic IBS cases:
Microscopic colitis, coeliac disease, giardiasis,
lactose intolerance, small bowel bacterial
overgrowth, bile salt malabsorption, colon
cancer, and inflammatory bowel disease

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Treatment of IBS

 Psychotherapy
 Dietary fiber supplementation
 Tricyclic antidepressants
 Selective Serotonin Reuptake Inhibitors
(SSRIs)
 Probiotics
 Antibiotics
 Chloride channel agonist (cases with
constipation)

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cause of Crohn’s disease

Idiopathic however it is associated with the following genes:
1) NOD2 mutation
2) ATG16L1 and IRGM
3) Some polymorphisms of the IL-23 receptor gene

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loc. of Chron’s disease

loc. Ileum/colon

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Loc. of Ulcerative Colitis

loc. Colon only

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The 2 types of inflammatory bowel diseases

1) Crohn disease
2) Ulcerative Colitis

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Macroscopic feature:
A. Stricture
B. Linear mucosal ulcers –> deep, knife-like
C. Perforation –> Serositis
D. “Creeping” fat (casued by Transmural inflammation)
E. Sparing of interspersed mucosa –> Coarsely
textured, “cobblestone appearance”

Are the features of what infalmmatory disroder?

Chron’s disease

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Microscopic features:
- Transmural inflammation
- Moderate Pseudo-polys
- Marked Fibrosis
- Garnulomas
- Fistula/sinusis
- Deep, Knife-like ulcers
- Mareked lymphoid reactions

Are the microscopic features of what Inflammatory disorder?

Chron’s disease

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Clinical manifesations of Crohn’s disease

1) Perianal fistula –> in colonic disease
2) Fat/Vitamine malabsorption
3) Malignant potential w/ colonic involvement
4) Common recurrence after surgery

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Extra-Intestinal Manifestations of Crohn’s disease

1) Uveitis
2) Migratory polyarthritis
3) Sacroiliitis
4) Ankylosing spondylitis
5) Erythema nodosum
6) Clubbing of the fingertips
7) Pericholangitis and Primary Sclerosing
Cholangitis
8) Increased risk of Colonic Adenocarcinoma

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Extra-Intestinal clinical features of Ulcerative Colitis

1) Uveitis
2) Migratory Polyarthritis
3) Sacroiliitis
4) Ankylosing Spondylitis
5) Skin lesions (e.g. Pyoderma Gangrenosum,
Erythema Nodosum)
6) Sclerosing Cholangitis w/ an Increased
risk for development of Cholangiocarcinoma

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complications of Ulcerative colitis?

TOXIC MEGACOLON

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maco/micro features:
- invloves many parts of the colon
- Diffuse Mucosal inflammation: slightly red and granular or have extensive, superficial broad-based ulcers
- Marked Pseudo-polyps
- moderate Lymphoid reactions
- NO GRANULOMAS

Are the features of what inflalmmatory bowel syndrom?

Ulcerative colitis

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Location of Ulcerative ulcers

Colon only

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Complications of Long-standing ulcerative colitis

1) Development of inflammatory polyps (“PseudoPolyps”)
–> composed of Inflammatory tissue
–> No Dysplastic features (= No premalignant)
2) ↑ risk of Colorectal Adenocarcinoma (develops through dysplasia)

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Histopathological calssifications of IBD-associated with?
1) Decreased intracellular mucin
2) Nuclear enlargement
3) Nuclear crowding
4) Nuclear hyperchromasia
5) Maintenance of the basilar orientation of the nuclei

Low Grade Dysplasia

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Histological calssification of IBD-associated with?

1) Irregular nuclear crowding
2) Pleomorphic nuclei
3) Variable nuclear hyperchromasia
4) Markedly irregular external nuclear contours
5) Increased nuclear stratification (many nuclei located in the luminal half of the cell)

High Grade Dysplasia

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Management of Ulcerative colitis

Colectomy

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causative agent of infectious Ulcerative Colitis

Clostridium difficile

other causes –> Collagenous Colitis

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causative agents of Infectious Crohn’s Disease

1) Salmonella,
2) Shigella,
3) Yersinia,
4) Campylobacter,
5) E. Coli
other causes –> Colonic Lymphoma

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Causatice agent of Behcet’s disease

1) Cytomegalovirus, Rotavirus
2) Entamoeba
3) Aspergillosis
4) Cryptosporidium

other casuses :Kaposi’s Sarcoma, Chemotherapy

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clinical findings of Toxic Megacolon

1) Signs of systemic toxicity
2) Abdominal tenderness
3) Reduced bowel sounds
4) Signs of Peritonitis –> Indicative of colon perforation
5) Fever
6)Tachycardia

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Labratory fidnings of Toxic Megacolon

1) Anaemia and Leukocytosis
2) Increased ESR and Elevated CRP
3) Hypokalaemia and Hypoalbuminaemia
4) Toxin detection –> ** C. difficile infection**

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Management of Toxic Megacolon

1) Medical therapy: - High-dose **intravenous steroids** --> Patients with Ulcerative Colitis - Metronidazole or **Vancomycin** - Gancyclovir (CMV cases) 2) Surgery

location of Diverticular disease

Mainly in the sigmoid colon

Macroscopic Features:  Small, **flask-like out-pouchings**(0.5-1.0 cm)  **Regular distribution** in between the taeniae coli of the **Sigmoid Colon** Are the features of what Gastric condition?

Diverticular disease

Microscopic Findings: **Thin wall**, composed of: - Flattened or **atrophic mucosa** - Compressed submucosa - Attenuated (or absent) muscularis propria - **Hypertrophy of the circular layer of the muscularis propria** Are the features of what condition?

Diverticulum disease

clinical featurs of Diverticulosis

Asymptomatic in 70-90% of patients

Clinical features of Acute Diverticulitis

1) Abdominal pain in the left iliac fossa, 2) malaise, 3) fever and 4) localised tenderness

compliactions of Diverticular disease

1) **Fistuala --> Faecaluria** (caused by inflammation btw Sigmoid colon and urinary bladder or vagina) 2) **Stricture --> Bowel obstruction** (Caused by low fiber diet --> SM hypertrophy and hyperplasia) 3) **lower GI tract bleeding** --> small amount of bleeding

loc. of Meckel diverticulum

~ 20 cm from the **ileocaecal valve**

Epi of Meckel diverticulum

Most common intestinal congenital anomaly

Clinical manifesations of Meckel Diverticulum

1) Intestinal obstruction, 2) ulcer with haemorrhage, 3) perforation, or 4) diverticulitis

Microscopic findings: - Small intestinal mucosa, in 50% to 70% of cases - **Ectopic gastric or pancreatic tissues**; the rest are the features of what condition?

Meckel diverticulum

**Perforation** of a pericolic abscess into the abdominal cavity results in ---> -----------

**Peritonitis**

Extension of acute inflammatory infiltrate beyond the Diverticulum in the surrounding subserosal tissue ---> ---------------------

**Pericolic abscess**

Puss Content of a Pericolic Abscess

Neutrophils, cellular debris, fibrin and oedema fluid

Cause of **Hirschsprung disease** aka Congenital Aganglionic Megacolon

Heterozygous **loss of function mutations in receptor tyrosine kinase RET** Congenital defect in colonic innervation

Epi of Hirschsprung disease aka Congenital Aganglionis Megacolon

M > F * more sever in females

patho of Hirschsprung disease

**Disrupted neural crest cells migration from Caecum to Rectum** --> Distal intestinal segment without both Meissner submucosal plexus and Auerbach myenteric plexus --> **Absent coordinated peristalsis** -- >**Functional obstruction** --> Dilatation proximal to the affected segment

Macroscopic features: - Aganglionic region: Normal or contracted appearance - Normal innervated proximal colon --> Progressive dilatation, due to distal obstruction Micro: - **Absence of ganglion cells** in the affected segment Are the feature of what disease?

Hirschsprung disease

Complications of Hirschprung disease

**Necrotising Enterocolitis**

clinical manifestations of Necrotising Entercolitis

1) Abdominal distention 2) Disappearance of bowel sounds 3) Passage of small amounts of blood-stained stool

Epi of Necrotising Entercolitis

Condition primarily affecting **infants** who either are **premature** or have had **exchange transfusions**

loc. of Necrotizing Entercolitis

Terminal Ileum and Ascending Colon

Microscopic findings:  **Necrotic mucosa** that may partially slough off  Small submucosal **gas-filled cysts** Are the features of what type of disease?

Necrotizing Entercolitis

Diagnostic sign of Necrotizing Entercolitis

submucosal GAS cysts

Epi of Acute Appendicitis

Most common in adolescents and young adults

patho of Acute Appendicitis

1) Progressive **increases in intraluminal pressure --> Impairment of venous outflow** 2) 50-80% of cases: **Luminal obstruction** (by faecalith, gallstone, tumour, mass of worms) 3) **Ischaemic injury and stasis of luminal contents** 4) **Bacterial proliferation --> Inflammatory response**(tissue oedema, neutrophilic infiltration of the lumen, muscular wall and peri-appendiceal soft tissues)

Macroscopic Features: 1) **Dull, granular-appearing, erythematous surface** Microscopic Findings: - Congested sub-serosal vessels - Transmural, modest, perivasc. neutroph. infiltrate - **Massive Neutrophilic infiltration of the muscularis propria** (key-point for the diagnosis) - Formation of focal abscesses within the wall --> Acute suppurative appendicitis - **Haemorrhagic ulceration** and gangrenous necrosis, extending to serosa --> Acute gangrenous appendicitis --> Rupture and suppurative peritonitis Are the features of what disease?

Acute Appendicitis

clincial features of Acute Appendicitis

1) Pain in Peri-umbilical region --> Right lower quadrant 2) Nausea and Vomiting 3) Low-grade Fever 4) Mild elevation of WBC 5) Characteristic McBurney’s sign (deep tenderness at a point located two thirds of the distance from the umbilicus to the right anterior superior iliac spine)

DD of Acute Appendicitis

1) Mesenteric lymphadenitis, 2) acute salpingitis, 3) ectopic pregnancy, 4) Meckel diverticulitis

cause/patho of Inflammatory polyps

**Impaired relaxation of the anorectal sphincter** -->Sharp angle at the anterior rectal shelf --> Recurrent **abrasion and ulceration** of the overlying **rectal mucosa** --> Chronic process of **injury and repair** --> Inflammatory polyp

characteristic Clinical Triad of Inflammatory polyps

1. Rectal bleeding 2. Mucus discharge 3. Inflammatory lesion of the anterior rectal wall

epi of Juvenile polyps

Children ≤ 5years

loc of Juvenile polyps

Rectum

Clinical manifestations of Juvenile polyps

1) Rectal bleeding 2) Rectal prolapse with polyp’s protrusion through the anal sphincter

Management of Juenile Polyps

Colectomy; to limit haemorrhage associated with polyp ulceration

casue of PEUTZ-JEGHERS SYNDROME

Germline heterozygous mutations in LKB1/STK11 gene

PEUTZ-JEGHERS SYNDROME is characterside by?

- Multiple gastro-intestinal hamartomatous polyps and - Muco-cutaneous hyperpigmentation

Location of Peutz-Jeghers Syndrome

Small intestine, stomach, colon; rarely in bladder and lungs

Macroscopic features:  Large and **pedunculated lesions**  **Lobulated** contour (outline) Microscopic findings:  **Characteristic arborising network of connective tissue, smooth muscle, lamina propria, and glands with normal intestinalepithelium lining** Are the features of what type of gastric polyp?

PEUTZ-JEGHERS SYNDROME

Pathogenetic mechanism of Hyperplastic polyps

- Decreased epithelial cell turnover - Delayed shedding of surface epithelial cells --> **“Pileup” of goblet cells**

loc. of Hyperplastic Polyps

left colon

Macroscopic features: - Smooth nodular protrusions of the mucosa (on crests of mucosal folds) Microscopic Findings: - **Mature goblet and absorptive cells** - Irregular tufting (due to overcrowding) of epithelial cells --> **Serrated architecture in cross-section** Are the features of what type of gastric polyp?

Hyperplastic polyps

prognosis of hyperplastic polyps

Benign lesions without malignant potential

DD of Hyperplastic polyps

Sessile serrated adenomas (with malignant potential)

Macroscopic features:  **Pedunculated or sessile lesions**; 0.3-10cm  Surface: **Velvet- or raspberry-like texture** Microscopic findings: - Characteristics of epithelial **Dysplasia**:  Nuclear hyperchromasia  Cellular elongation  Stratification Are the features of what type of Gastric neoplasm?

COLONIC ADENOMAS

risk factors of Colonic Adenoma

(for progression of an Adenoma to Adeno-Ca): 1) Increasing size 2) High grade of Dysplasia 3) Histological type (Villous > Tubular)

micro: Small, pedunculated polyps with small, rounded or tubular glands what type of Colonic Adenoma has the following features?

Tubular Adenoma

micro: Large and sessile, covered by slender villi (invasive growth more frequent than in tubular adenoma) what type of Colonic Adenoma tumour has the following features?

Villous Adenoma

micro: Mixture of tubular and villous elements type of Colonic Adenoma?

Tubulo-Villous

micro: : Serrated architecture throughout gland’s length (including crypt base) Type of Colonic Adenoma?

Sessile serrated adenomas vs. Hyperplastic polyps

Microscopic features: - **Serrated epithelium** at the surface and deep in the crypts  **Saw-tooth appearance**, epithelium has jagged appearing edge  Crypt dilation at base with serrations  **"Boot"-shape or "L"-shaped glands**  Shape may be similar to a **hockey stick**  Horizontal crypts = Crypt long axis parallel to the muscularis mucosae  Crypt branching Are the features of what type of Gastric Adneoma?

SESSILE SERRATED ADENOMAS

cause of Fmilial Adenomastous Polyposis (FAP)

Mutations in Adenomatous Polyposis Coli (APC) gene

Diagnosis of Familial Adenomatous Polyposis

> 100 polyps (necessary for classic FAP)

Tx for Familial Adenomatous Polyposis

**Prophylactic colectomy** if left untreated--> Colorectal Adeno-CA

epi of colon Adenocarnicoma

Most common malignancy of GI tract

Dietary factors responsible for the development of colorectal cancer

i. Low intake of unabsorbable vegetable fiber and ii. High intake of refined carbohydrates and fat

the **2 Genetic pathways** invloved in Colon Adenocarcinoma

**1. APC β-Catenin/WNT signaling pathway** **2. Microsatellite instability pathway**

Macroscopic Features:  Proximal Colon (Caecum & Ascending Colon): Polypoid, exophytic lesions; Rarely lumen obstruction  Distal Colon: **Annular lesions (“napkin ring”)** --> Constrictions and luminal narrowing Are the features of what type of Gastric Malignancy?

Colon Adeno-CA

Microscopic findings:  **Tall columnar cells**  Invasive growth with **intense desmoplastic reaction**  Amount and morphology of glandular structures, depending on grade of differentiation (Grade I-III)  Some tumours characterised by **abundant mucin production** --> Mucinous Adeno-CAs  Others with presence of **“signet ring” cells** Are the features of what type of Gastric Carcinoma?

COLON ADENOCARCINOMA

Clinical features of Colon Adeno-Ca

- Right-sided colon cancers: --> Fatigue and weakness (iron-deficiency anaemia) - Left-sided colorectal Adeno-CAs: 1) Occult bleeding 2) Changes in bowel habits 3) Cramping

causes of Haemorrhoids

1) Constipation --> Straining during defecation --> Increase in intra-abdominal and venous pressures 2) Venous stasis of pregnancy 3) Portal hypertension

Clinical Features of Harmorrohoids

Pain and Rectal bleeding (bright red blood)

Management of Haemorrhoids

1) Sclerotherapy 2) Rubber band ligation 3) Infrared coagulation 4) Haemorrhoidectomy