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Clinical Pathology > GI Tract 2 (Lower) > Flashcards

GI Tract 2 (Lower) Flashcards

1
Q

What is a ‘true’ diverticulum?

A

Congenital

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2
Q

What is a ‘false’ or ‘pseudo’ diverticulum?

A

Acquired

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3
Q

Is sigmoid diverticulosis congenital or acquired?

A

Acquired

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4
Q

Is diverticulosis of the right colon acquired or congenital?

A

Can be either?

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5
Q

What is diverticulosis of the colon?

A

Protrusions of mucosa and submucosa through the bowel wall

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6
Q

Where does diverticulosis of the colon most commonly occur?

A

Sigmoid colon.

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7
Q

Where in the bowel wall are diverticula located?

A

Located between mesenteric and anti-mesenteric taenia coli ( also between anti-mesenteric t.coli in 50 % cases )

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8
Q

What percentage of diverticula are found in the caecum?

A

15%

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9
Q

What is the epidemiology of diverticulosis?

A
  • Common in developed ( western ) world
  • Rare in Africa , Asia , S. America
  • Common in urban cf. rural areas
  • Changing prevalence in migrant populations
  • Relationship with fibre content of diet
  • Increases with age
  • Male = female
  • Less common in vegetarians
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10
Q

What is the pathology of diverticulosis?

A
  • Increased intra-luminal pressure
  • Irregular, uncoordinated peristalsis
  • Thickening of muscularis propria ( earliest change – “prediverticular disease” )
  • Elastosis of taeniae coli ( leading to shortening of colon )
  • Redundant mucosal folds and ridges
  • Sacculation and diverticula
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11
Q

What are the clinical features of diverticular disease?

A
  • Asymptomatic ( 90 – 99 % )
  • Cramping abdominal pain
  • Alternating constipation and diarrhoea
  • Acute and chronic complications ( 10 – 30 %)
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12
Q

What are the acute complications of diverticulosis?

A
  • Diverticulitis / peridiverticular abscess ( 20 – 25 % )
  • Perforation
  • Haemorrhage ( 5 % )
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13
Q

What are the chronic complications of diverticulosis?

A
  • Intestinal obstruction ( strictures : 5 – 10 % )
  • Fistula ( urinary bladder, vagina )
  • Diverticular colitis ( segmental and granulomatous )
  • Polypoid prolapsing mucosal folds
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14
Q

How is colitis classified into acute and chronic?

A

Acute - days to few weeks

Chronic - months to years

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15
Q

What disease is associated with transmural colitis?

A

Crohn’s disease

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16
Q

What disease is predominantly associated with submucosal/muscular colitis?

A

Eosinophilic colitis

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17
Q

Which types of colitis are acute?

A
  • Acute infective colitis eg. campylobacter, salmonella, CMV
  • Antibiotic associated colitis (including PMC)
  • Drug induced colitis
  • Acute ischaemic colitis ( transient or gangrenous )
  • Acute radiation colitis
  • Neutropenic colitis
  • Phlegmonous colitis
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18
Q

Which types of colitis are chronic?

A
  • Chronic idiopathic inflammatory bowel disease
  • Microscopic colitis ( collagenous & lymphocytic )
  • Ischaemic colitis
  • Diverticular colitis
  • Chronic infective colitis eg. amoebic colitis & TB
  • Diversion colitis
  • Eosinophilic colitis
  • Chronic radiation colitis
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19
Q

Which three diseases fall under the ‘idiopathic inflammatory bowel disease’ umbrella?

A

Ulcerative colitis
Crohn’s disease
Indeterminate colitis (10-15%)

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20
Q

What is the epidemiology of IBD?

A
  • UC 5 – 15 cases per 100,000 p.a.
  • CD 5 – 10 cases per 100,000 p.a.
  • Incidence highest in Scandinavia, UK, Northern Europe, USA
  • Lower in Japan, Southern Europe, Africa
  • Peak age incidence 20 – 40 years of age
  • CD more common in females 1.3 : 1
  • UC equally common in males and females
  • Incidence of UC is increased in urban areas
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21
Q

For which IBD condition is smoking a risk factor and for which does it have a protective effect?

A

UC - protective

CD - risk factor

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22
Q

Give some other risk factors for IBD.

A 
Oral Contraceptive
MMR
Childhood infections
Domestic hygeine
Appendicectomy
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23
Q

What is the risk of UC in the 1st degree relative of someone with UC?

A

x8

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24
Q

What is the risk of CD in the 1st degree relative of someone with UC?

A

x1.7

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25
Q

What is the risk of UC in the first degree relative of someone with CD?

A

x3.8

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26
Q

What is the risk of CD in the first degree relative of someone with CD?

A

x8

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27
Q

What is the clinical presentation of UC?

A
  • Diarrhoea ( > 66 % ) with urgency/tenesmus
  • Constipation ( 2 % )
  • Rectal bleeding ( > 90 % )
  • Abdominal pain ( 30 – 60 % )
  • Anorexia
  • Weight loss ( 15 – 40 % )
  • Anaemia
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28
Q

What are the possible complications of UC?

A
  • Toxic megacolon
  • Haemmorhage
  • Stricture (rare)
  • Adenocarcinoma
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29
Q

What are the clinical features of CD?

A
  • Chronic relapsing disease
  • Affects all levels of GIT from mouth to anus
  • Diarrhoea ( may be bloody )
  • Colicky abdominal pain
  • Palpable abdominal mass
  • Weight loss / failure to thrive
  • Anorexia
  • Fever
  • Oral ulcers
  • Peri – anal disease
  • Anaemia
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30
Q

What is the distribution of CD across the GI tract epidemiologically speaking?

A

Ileocolic 30 – 55 %
Small bowel 25 – 35 %
Colonic 15 – 25 %
Peri-anal / ano-rectal 2 – 3 %
Gastro – duodenal 1 – 2 %

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31
Q

What are the possible complications of CD?

A
  • Toxic megacolon
  • Perforation
  • Fistula
  • Stricture ( common )
  • Haemorrhage
  • Carcinoma
  • Short bowel syndrome (repeated resection)
32
Q

What is the difference in how CD and UC affect the GI tract?

A

UC - affects colon, appendix and terminal ileum

CD - affects all parts of the digestive tract

33
Q

How do UC and CD lesions differ?

A

UC - continuous disease

CD - skip lesions

34
Q

What is the difference in rectum involvement between UC and CD?

A

UC - rectum always involved

CD - rectum normal in 50%

35
Q

What is the difference in terminal ileum involvement between CD and UC?

A

UC - terminal ileum involved in 10%

CD - terminal ileum involved in 30%

36
Q

What is the difference in macroscopic appearance between UC and CD?

A

UC - granular red mucosa with flat, undermining ulcers

CD - cobblestone appearance with apthoid and fissuring ulcers

37
Q

What is the difference in the effect on the serosa in UC and CD?

A

UC - normal serosa

CD - Serositis (fat wrapping)

38
Q

How common are strictures in CD and UC?

A

UC - strictures rare

CD - strictures common

39
Q

What is the difference in the incidence on spontaneous fistulae in UC and CD?

A

UC - no spontaneous fistulae

CD - fistulae in > 10%

40
Q

How common are anal lesions in UC and CD?

A

UC - anal lesions in 25%

CD - anal lesions in 75%

41
Q

What is the difference in inflammation between UC and CD?

A

UC - mainly mucosal inflammation

CD - transmural

42
Q

How common are crypt abscesses in UC and CD?

A

UC - common

CD - less common

43
Q

How severe is crypt distortion in UC vs CD?

A

UC - crypt distortion severe

CD - crypt distortion less severe?

44
Q

Are granulomas present in UC or CD?

A

Only present in CD - sarcoid- like granulomas present in around 60%.

45
Q

How common are inflammatory polyps in UC vs CD?

A

UC - inflammatory polyps common

CD - inflammatory polyps less common

46
Q

What are the hepatic manifestations of IBD?

A
  • Fatty change
  • Granulomas
  • PSC
  • Bile duct carcinoma
47
Q

What are the skeletal manifestations of IBD?

A
  • Polyarthritis
  • Sacro-ileitis
  • Ankylosing spondylitis
48
Q

What are the muco-cutaneous manifestations of IBD?

A
  • Oral apthoid ulcers
  • Pyoderma gangrenosum
  • Erythema nodosum
49
Q

What are the ocular manifestations of IBD?

A
  • Iritis/uveitis
  • Episcleritis
  • retinitis
50
Q

What are the renal manifestations of IBD?

A
  • Kidney and bladder stones
51
Q

What are the haematological manifestations of IBD?

A
  • Anaemia
  • Leucocytosis
  • Thrombocytosis
  • Thrombo-embolic disease
52
Q

What are the systemic manifestations of IBD?

A
  • Amyloid

- Vasculitis

53
Q

What is the overall prevalence of colorectal cancer (CRC) in UC?

A 
Overall - 3.7%
In pancolitis - 5.4%
At 10 years - 2%
At 20 years - 8%
At 30 years 18%
54
Q

What are the risk factors for CRC in UC?

A
  • Early age of onset
  • Duration of disease > 8-10 years
  • Total or extensive colitis
  • PSC
  • Family History of CRC
  • ? Severity of inflammation ( pseudopolyps )
  • Presence of dysplasia
55
Q

What is a colorectal polyp?

A
  • A “mucosal protrusion”
  • Solitary or multiple ( polyposis )
  • Pedunculated , sessile or “flat”
  • Small or large
  • Due to mucosal or submucosal pathology or a lesion deeper in the bowel wall
56
Q

What are the different types of polyps?

A
  • neoplastic
  • hamartomatous
  • inflammatory
  • reactive
57
Q

What are the different types of non-neoplastic polyps that can be found in the colorectum?

A
  • Hyperplastic polyps (? Reactive ? Neoplastic)
  • Hamartomatous polyps (Peutz-jeghers polyps, Juvenile polyps)
  • Polyps related to mucosal prolapse (inflammatory cloacogenic polyp, inflammatory cap polyp & inflammatory myoglandular polyp)
  • Post-inflammatory polyps (“pseudopolyps”)
  • Inflammatory fibroid polyp
  • Benign lymphoid polyp
58
Q

What are hyperplastic polyps?

A
  • Common
  • 1 – 5 mm in size
  • often multiple
  • located in rectum and sigmoid colon
  • small distal HPs have NO malignant potential
59
Q

What kind of cancer might large, right-sided “hyperplastic polyps” give rise to?

A

Microsatellite unstable carcinoma (10% - 15% all colorectal cancer)

60
Q

What is a juvenile polyp?

A
  • often spherical and pedunculated
  • 10 – 30 mm
  • commonest type of polyp in children
  • typically occur in rectum & distal colon
  • sporadic polyps have no malignant potential
61
Q

What is juvenile polyposis a risk factor for?

A

Colorectal and gastric cancer

62
Q

What is Peutz- Jeghers Syndrome?

A
  • Autosomal dominant condition ( mutation in STK11 gene on chromosome 19 )
  • Prevalence : 1 in 50,000 – 1 in 120,000 births
  • Present clinically in teens or 20s with abdominal pain (intussusception), gastro-intestinal bleeding & anaemia
  • Multiple gastro-intestinal tract polyps (predominantly small bowel)
  • Muco-cutaneous pigmentation (1 – 5mm macules peri-oral , lips , buccal mucosa , fingers and toes)
63
Q

What are the benign neoplastic polyps?

A
  • Adenoma
  • Lipoma
  • Leiomyoma
  • Haemangioma
  • Neurofibroma
64
Q

What are the malignant neoplastic polyps?

A
  • Carcinoma
  • Carcinoid
  • Leiomyosarcoma
  • GIST
  • Lymphoma
  • Metastatic tumour
65
Q

What are adenomas?

A
  • Benign epithelial tumours
  • Commonly polypoid but may be “flat”
  • Precursor of colorectal cancer (at least 80%)
  • Present 25% - 35% population > 50 years
  • Multiple in 20 – 30 % patients
  • Evenly distributed around colon BUT larger in recto-sigmoid and caecum
66
Q

What are the risk factors for colorectal cancer?

A
  • Diet - (Dietary fibre, fat, red meat, folate, calcium)
  • Obesity / Physical Activity
  • Alcohol
  • NSAIDs
  • HRT and oral contraceptives
  • Schistosomiasis
  • Pelvic radiation
  • Ulcerative colitis and Crohns disease
67
Q

What is familial adenomatous polyposis?

A
  • Associated with multiple benign adenomatous polyps in the colon
  • Due to a mutation in the APC tumour suppressor gene
68
Q

What is hereditary non-polyposis colorectal cancer?

A
  • Increased risk of endometrial, ovarian, gastric, small bowel, urinary tract and biliary tract cancer
  • Due to mutations in DNA mismatch repair genes
  • 1 – 2 % all colorectal cancer
  • Autosomal dominant
  • 50 - 70 % lifetime risk of large bowel cancer
69
Q

What are the different types of colorectal cancer?

A
  • Adenocarcinoma ( > 95 % ) - (Mucinous adenocarcinoma ( 10 – 20 % ))
  • Adenosquamous carcinoma
  • Squamous cell carcinoma
  • Neuroendocrine carcinoma & MANEC (small cell anaplastic ca ; well diffn EC ca)
  • Undifferentiated ( large cell ) carcinoma
  • Medullary carcinoma
70
Q

What is the typical spread of colorectal cancer?

A
  • Direct invasion of adjacent tissues
  • Lymphatic metastasis (lymph nodes)
  • Haematogenous metastasis (liver & lung)
  • Transcoelomic (peritoneal) metastasis
  • Iatrogenic spread (eg. needle track recurrence port site recurrence)
71
Q

What are the two ways of staging colorectal cancer?

A
  • Dukes

- TNM

72
Q

What does the T from TNM stand for?

A

T: size or direct extent of the primary tumor

  • Tx: tumor cannot be evaluated
  • T is: carcinoma in situ
  • T0: no signs of tumor
  • T1, T2, T3, T4: size and/or extension of the primary tumor
73
Q

What does the N from TNM stand from?

A

N: degree of spread to regional lymph nodes

  • Nx: lymph nodes cannot be evaluated
  • N0: tumor cells absent from regional lymph nodes
  • N1: regional lymph node metastasis present; (at some sites: tumor spread to closest or small number of regional lymph nodes)
  • N2: tumor spread to an extent between N1 and N3 (N2 is not used at all sites)
  • N3: tumor spread to more distant or numerous regional lymph nodes (N3 is not used at all sites)
74
Q

What does the M from TNM stand for?

A

M: presence of distant metastasis

  • M0: no distant metastasis
  • M1: metastasis to distant organs (beyond regional lymph nodes)
75
Q

What is Dukes staging?

A
  • Stage A : adenocarcinoma confined to the bowel wall with no lymph node metastasis
  • Stage B : adenocarcinoma invading through the bowel wall with no lymph node metastasis
  • Stage C : adenocarcinoma with regional lymph node metastasis regardless of depth of invasion
  • Stage D : distant metastasis present

Clinical Pathology (65 decks)

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