GIT Flashcards
A: normal gastroesophageal junction
B: Barrett esophagus; note the small islands of paler squamous mucosa within the Barrett mucosa
describe the image
C: histologic appearance of the gastroesophageal junction in Barrett esophagus; note the transition between esophageal squamous mucosa (left) and metaplastic mucosa containing goblet cells (right)
describe the etiology of the condition seen in the image
- long-standing acid reflux esophagitis → GERD
- more common in males
- more common in whites
- GERD is caused by:
- obesity
- limited scleroderma (CREST)
- E = esophageal dysmotility → GERD
- anti-centromere positive, hiatal hernia
describe the pathogenesis of the condition seen in the image
- decreased tone in LES → genetic reprogramming of stem cells in the lower 1/3 of the esophagus
- proliferation of progenitor cells for healing which then differentiate into columnar cells → more resistant to peptic acid injury
describe the presentation of the condition seen in the image
- presentation is similar to reflux
- heart burn → worse when lying down
- dyspepsia
- waterbrush (bad metallic taste of acid in mouth)
- epigastric pain
- substernal discomfort relieved by antacids
definitive diagnosis of the condition seen in the image is accomplished by ____
definitive diagnosis of the condition seen in the image is accomplished by upper GI endoscopy and biopsy
- endoscopy: normal pearly white esophageal squamous mucosa → velvety pink columnar mucosa
describe complications of the condition seen in the image
- # 1 risk factor for dysplasia → adenocarcinoma of the esophagus
- ALWAYS d/t Barrett’s
- progressive dysphagia and odynophagia
- melena → iron deficiency anemia
describe the etiology of the condition seen in the image
- more common in US
- precursor lesion = GERD, Barrett esophagus (dysplasia)
- lower 1/3 of esophagus
_____ is the precursor lesion to the condition seen in the image
GERD → Barrett esophagus is the precursor lesion to the condition seen in the image
describe the risk factors for the condition seen in the image
- white men, smokers, obese, previous radiation therapy
describe the presentation of the condition seen in the image
- presentation:
- signs and symptoms similar to SCC
- dysphagia, initially to solid then to liquid
- odynophagia
- weight loss → cachexia
- chest pain
- vomiting
describe the complications of the condition seen in the image
- complications:
- melena → iron deficency anemia
- TEF → aspiration pneumonia → lung abscess
- invade heart → pericarditis → percardial effusion
describe the image
squamous cell carcinoma composed of nests of malignant cells that partially recapitulate the stratified organization of squamous epithelium
describe risk factors of the condition seen in the image
- etiology:
- fungal contamination
- nitrites (smoked food)
- alcohol
- tobacco use
- GERD
- achalasia
- Tylosis: oral leukoplakia, SCCE, hyperkeratosis of palms and soles
- Plummer-Vinson
- characterized by difficulty in swallowing, iron-deficiency anemia, glossitis, cheilosis and esophageal webs
- Celiac disease
describe the pathogenesis of the condition seen in the image
- usually in upper 2/3 of esophagus (middle 1/3 = more likely)
- begins as in-situ lesion in the form of squamous dysplasia
- growth pattern; exophytic, excavated (ulcerative), infiltrative
describe the presentation of the condition seen in the image
- presentation:
- progressive dysphagia (to solids then to liquids)
- odynophagia
- cachexia
- fatigue (d/t melena → iron deficiency anemia)
- hematemesis
- hoarse voice and cough
describe investigations for the condition seen in the image
- investigations:
- GI endoscopy w/ biopsy: malignant squamous cells invading into the submucosa & muscularis propria
- barium swalllow: shows obstruction of lumen
describe complications of the condition seen in the image
- complications:
- can obstruct
- bleed (melena) → IDA
- perforate → mediastinitis
- form a TEF (food can get into lungs → aspiration pneumonia → lung abscess)
- can spread to cervical, mediastinal, paratracheal, tracheobronchial, gastric and celiac nodes depending on site of tumor
- direct metastasis to adjacent mediastinal structures including trachea and heart
describe the image
lymphoid aggregates with germinal centers and abundant subepithelial plasma cells within the superficial lamina propria are characteristic of H. pylori gastritis
describe the image
spiral-shaped H. pylori bacilli are highlighted with Warthin-Starry silver stain. Organisms are abundant within surface mucus
the condition seen in the image is caused by chronic infection with ___ at the ____ region of lesser curvature
the condition seen in the image is caused by chronic infection with H. pylori at the antro-pyloric region of lesser curvature
describe the histology of the condition seen in the image
- histology:
- reactive lymphoid aggregates
- chronic inflammatory infiltrate (lymphocytes, plasma cells) in lamina propria
- H. pylori is G-ve and not invasive
- therefore always seen on luminal surface
- addition of neutrophils = chronic ACTIVE gastritis
describe the pathogenesis of the condition seen in the image
- produces urease (urea → ammonia to neutralize acid) and phospholipase (destroys phospholipid bilayer in mucosa of stomach) → diffuse effacement of the mucosa by lymphocytes → chronic gastritis/peptic ulcers
- cytotoxin-associated gene A → increases risk for peptic ulcer disease and adenocarcinoma
- flagella → motility in mucoid environment
describe investigations of the condition seen in the image
- upper GI endoscopy + biopsy with Steiner Silver Stain
- black = organism
- microscopy:
- reactive lymphoid aggregates found just below epithelial lining (**hallmark of H. pylori**)
- inflammatory infiltrate in lamina propria
- PMNs in surface epithelium and glandular lumen
- intestinal metaplasia and glandular atrophy +/- dysplasia
in the condition seen in the image, ____ are found just below the epithelial lining which is a hallmark of _____
in the condition seen in the image, reactive lymphoid aggregates are found just below the epithelial lining which is a hallmark of H. pylori
in the condition seen in the image, confirmation of the etiologic agent would be supported by _____
in the condition seen in the image, confirmation of the etiologic agent would be supported by regression of tumor with antibiotics
describe the complications of the condition seen in the image
- chronic inflammation → intestinal metaplasia → dysplasia → intestinal gastric adenocarcinoma
- lymphoid aggregates → uncontrolled prolif. of B cells → MALToma (gastric lymphoma)
- peptic ulcer disease
describe the image
diffuse gastric cancers display an infiltrative growth pattern and are composed of discohesive cells with large mucin vacuoles that expand the cytoplasm and push the nucleus to the periphery, creating a signet ring cell morphology
describe the etiology of the diffuse form of the condition seen in the image
- etiology:
- mutation = E-cadherin (CDH1) → signet ring cells that contain mucin
- no intestinal metaplasia
describe the morphology of the diffuse form of the condition seen in the image
- morphology:
- “leather bottle stomach”/linitisplastica becuase signet ring cell infiltrates the stomach wall
- no gland formation: single cells, sheets, clusters
describe the complications of the diffuse form of the condition seen in the image
- complications:
-
ovarian metastasis → Krukenberg tumor → bilateral (only with diffuse type)
- Krukenberg: from diffuse gastric adenocarcinoma, invasive lobular carcinoma of breast, and colon cancer
-
ovarian metastasis → Krukenberg tumor → bilateral (only with diffuse type)
describe the etiology of the intestinal form of the condition seen in the image
- etiology:
- H. pylori = most common
- autoimmune
- smoked foods (nitrosamines)
describe the morphology of the intestinal form of the condition seen in the image
- morphology:
- neoplastic cells form glands
- histology: malignant glands that make mucin → invading into the submucosa & muscularis propria
describe complications of the intestinal form of the condition seen in the image
- complications:
- bleed → IDA
-
left supraclavicular/Virchow’s LN metastasis
- one of the nodes that drains the stomach
- periumbilical metastasis (intestinal) → Sister Mary Joseph nodule
____ is a prognostic indicator of the intestinal form of the condition seen in the image
depth of invasion and nodal status is a prognostic indicator of the intestinal form of the condition seen in the image
___ is the tumor marker for the condition seen in the image
CEA is the tumor marker for the condition seen in the image
GIST tumors are derived from ____
GIST tumors are derived from interstitial cells of Cajal
a majority of GIST tumors express ____ and have mutations in ____
a majority of GIST tumors express CD117 and have mutations in c-Kit
describe the histology of cells seen in GIST
spindle-shaped tumor cells
GIST is treated with ____
GIST is treated with TKI (Imatinic/Gleevec)
same treatment as CML (9,22 translocation)
describe predisposing factors for the condition seen in the image
- predisposing factors:
- tobacco chewing (most common)
- alcohol
- HPV 16 & 18
- jagged teeth
- ill-fitting dentures
describe what is seen on biopsy of the condition seen in the image
- investigations:
- biopsy = malignant squamous cells w/ keratin pearls
describe complications of the condition seen in the image
- complications:
- spreads via lymphatics → anterior cervical lymph nodes
describe the image seen
celiac sprue/disease
complete loss of villi or total villous atrophy
dense plasma cell infiltrates in the lamina propria
describe the etiology of the condition seen in the image
- etiology = gluten (wheat, barley, oats, rye)
- specifically gliadin protein
- associated with HLA-DQ2 (more common) & HLA-DQ8
describe the morphology seen in the condition in the image
- morphology:
- increased intraepithelial lymphocytes (CD8 T cells) in lamina propria
- elongated and hyperplastic crypts
- marked atrophy (flattening) and loss of villi → decreased SA for absorption
describe the pathogenesis of the condition seen in the image
- pathogenesis:
- inappropriate immune cell mediated Type IV HS response to gliadin in the proximal small intestine (duodenum) →
- gluten is deamidated to form gliadin by tissue transglutaminase (tTG) → phagocytosed by APC with HLA DQ2/DQ8 → presentation to CD4 T cells in lamina propria → cytokine production → destruction of villi
describe the pathogenesis of the condition seen in the image
- presentation:
- malabsorption → steatorrhea (foul-smelling, pale bulky stools)
- weight loss
- flatulence
the condition in the image mainly affects the ____
the condition in the image mainly affects the duodenum
describe complications of the condition seen in the image
-
T-cell lymphoma (EATL = enteropathy-associated T-cell lymphoma)
- classic scenario = patient adherent to gluten-free diet with worsening symptoms
- increased risk for small bowel carcinoma
in the condition seen in the image, too much IgA causes _____
in the condition seen in the image, too much IgA causes dermatitis herpetiformis (deposition of IgA in the dermal papillae)
describe the image
villi are stout and packed with foamy macrophages
lipid particles –> dilated lacteals
PAS stain –> foamy particles in LP
describe the etiology of the condition seen in the image
G+ve sickle-shaped actinomycete Trophyeryma whippeli (PAS +)
describe the pathogenesis of the condition seen in the image
phagocytosis and incomplete degradation G+ve Trophyerma whipplei, which accumulate inside lysosomes of the macrophages (foamy-looking) → mechanical lymphatic (lacteal obstruction) → distended/flattened villi → malabsorption
list the extra-intestinal manifestations of condition seen in the image
- brain: dementia/seizures
- skin: hyperpigmentation
- lymphadenopathy: intestinal/mesenteric & peripheral
- joints: migratory polyarthritis
- heart: infective endocarditis and aortic valve regurg.
- eyes: uveitis → blindness
describe the investigations of the condition seen in the image
- investigations:
- small bowel biopsy:
- distended PAS positive (red) foamy macrophages in lamina propria (mucosa)
- EM → rod-shaped bacilli
- small bowel biopsy:
describe the etiology of the condition seen in the image in adults vs. children
- adult: fecolith obstruction (obstruction of lumen)
- children: d/t lymphoid hyperplasia in the lymphoid follicles of the appendix (follicles are aggregations of lymphoid cells)
describe the pathogenesis of the condition seen in the image
- pathogenesis:
- obstruction → continued secretion of mucinous fluid → increased intraluminal pressure → collapse of draining veins → ischemic injury → bacterial proliferation → inflammation and edema
describe the investigations of the condition seen in the image
- investigation:
- CBC: increased neutrophils and increased band cells
- biopsy: presence of neutrophils all the way to muscularis propria
- positive for Rovsing, Psoas and Obturator signs
describe complications of the condition seen in the image
- complications:
- perforation → peritonitis → septicemia
- peri-appendiceal abscess → liver abscess, bacteremia
on biopsy of the condition seen in the image, there are ____ all the way to the _____
on biopsy of the condition seen in the image, there are neutrophils all the way to the muscularis propria
describe the image
diverticulosis
sigmoid diverticulum showing protrusion of the mucosa and submucosa through the muscularis propria
in the condition in the image, there is herniated of the ___ and ___ which makes it a ____
in the condition in the image, there is herniated of the mucosa and submucosa which makes it a false diverticulum (pseudodiverticulum)
describe where the condition in the image are located (anatomical weakness)
diverticula are located on the mesenteric border where the vasa recta penetrate the muscle wall (anatomic weakness site)
describe the morphology of the condition seen in the image
- morphology:
- acquired pseudo-diverticulum (involves mucosa & a little submucosa – NOT the entire wall)
- most commonly seen as flask-like structure in the sigmoid colon
describe the predisposing factors of the condition seen in the image
- predisposing factors:
- elderly on a low-fiber diet
- long-standing history of constipation
describe the pathogenesis of the condition seen in the image
- pathogenesis:
- decreased dietary fiber → sustained bowel contractions and increased intraluminal pressure → herniation of colonic wall at sites of focal defects
describe the presentation of the condition seen in the image
- presentation:
- asymptomatic, incidental finding on colonoscopy, can cause painless bleeding
list complications of the condition seen in the image
- complications:
- lower GI bleed → hematochezia
- perforate → sepsis
- acute diverticulitis (mimics appendicitis) → inflammation of diverticulum
- enterovesical (colovesical) fistula → fistula with bladder due to perforation
- chronic diverticulitis → strictures from narrowing of lumen from fibrosis → perforate → septic shock and DIC
- NO malignant potential
describe the image
ulcerative colitis
total colectomy with pancolitis showing active disease, with red, granular mucosa in the cecum (left) and smooth, atrophic mucosa distally (right)
describe the image
ulcerative colitis
the disease is limited to the mucosa + submucosa
the condition seen in the image is associated with HLA-___ as well as _____
the condition seen in the image is associated with HLA-DRB1 as well as primary sclerosing cholangitis (p-ANCA)
describe the classic features seen in the condition in the image
- classic features:
- always starts the rectum & moves proximally; continuous
- no skipped lesions → curable by surgery
describe the histology of the condition see in the image
- histology:
- mucosal and submucosal involvement
- architectural distortion
- dense chronic inflammation with basal plasmacytosis
- basal plasmacytosis = presence of plasma cells between the base of the crypts and the muscularis mucosae
- crypt abscesses (PMNs in the lumen of crypts)
- no granulomas
describe the gross appearance of the condition seen in the image
- gross:
- mucosa red, granular and friable
- broad-based ulcers
- isolated islands of intervening regenerating mucosa bulge creating pseudopolyps
during a barium enema while investigating the condition in the image, a ____ appearance is seen due to ____
during a barium enema while investigating the condition in the image, a lead-pipe appearance is seen due to loss of haustra
flare-ups of the condition seen in the image is associated with ____
flare-ups of the condition seen in the image is associated with physical and mental stress
in the condition in the image, in severe cases of pancolitis, the ____ can be affected as well, which is called _____
in the condition in the image, in severe cases of pancolitis, the ileum can be affected as well, which is called backwash ileitis
the condition in the image leads to a higher risk of ____
the condition in the image leads to a higher risk of colon cancer
describe the image
Crohn’s disease
linear mucosal ulcers and thickened intestinal wall
describe the image
Crohn’s disease
haphazard crypt organization results from repeated injury and regeneration
describe the image
Crohns disease
transmural Crohn disease with submucosal and serosal non-caseating granulomas
the condition in the image is associated with HLA- ____
the condition in the image is associated with HLA-DR7 and HLA-DQ4
describe the histology of the condition in the image
cobblestone appearance
- sharply delimited & transmural involvement
- non-caseating granulomas
- mucosal fissuring with involvement of fistulas
- skipped lesions that spare the rectum
describe the gross appearance of the condition
- gross:
- linear (deep) ulcers & creeping mesenteric fat due to fibrosis
- thick wall due to edema, hypertrophy, fibrosis and inflammation
- long narrow thickened segments of small intestine
- string sign on radiography
the most common location of the condition in the image is ____
the most common location of the condition in the image is the terminal ileum
- malabsorption: vit. B12 deficiency, malabsorption of bile salts
- may have non-bloody diarrhea due to malabsorption
on barium enema in the condition in the image, _____ is seen due to _____
on barium enema in the condition in the image, string-sign is seen due to narrowing of lumen from fibrosis (aka strictures)
on biopsy of the condition seen in the image, there is ____ involvement with ____ and inflammatory infiltrate
on biopsy of the condition seen in the image, there is transmural involvement with non-caseating granulomas and inflammatory infiltrate
describe the extra-intestinal features of the condition seen in the image
- migratory polyarthriris = most common
- erythema nodosum = inflammation of fat under skin (usually shin)
- gallstones: malabsorption of bile acids → decreased bile solubility → cholecystitis
- kidney stones
- ankylosing spondylitis
- uveitis
describe complications of the condition seen in the image
smoking can trigger a flare (unlike UC where it is protective)
- intestinal obstruction due to fibrosis → perforation → peritonitis
- malabsorption if small bowel is affected
- strictures, fissures (deep ulcers)
-
fistulas:
- perianal
- abdominal
- bladder → enterovesical
- colon cancer ONLY when colon is involved
describe the image
pseudomembranous colitis
typical pattern of neutrophils emanating from a crypt is reminiscent of a volcanic eruption
describe the etiology of the condition seen in the image
- hospitalized patients on broad-spectrum antibiotics (clindamycin; disruption of normal flora) → C. difficile exotoxin mediated damage
describe the morphology of the condition seen in the image
- yellow plaques covering mucosal surface (mucosal itself is not eroded)
-
pseudomembrane
- fibrinopurulent-necrotic debris, inflammatory cells (mainly neutrophil), necrotic epithelium & mucus
- congested vessels
describe the pathogenesis of the condition seen in the image
- exotoxin mediated → denuded surface epithelium & superficially damaged crypts distended by mucopurulent exudate erupt to form a mushrooming cloud → coalescence of clouds to produce pseudomembrane → consists of inflammatory cells, necrotic debris and fibrin
- most common location = rectosigmoid
describe the presentation of the condition seen in the image
- fever, lower abdominal pain, cramps, massive bloody & mucoid diarrhea (dysentery)
describe investigations for the condition seen in the image
assay stool for exotoxin
list complications for the condition seen in the image
- perforate → peritonitis → E. coli sepsis → septic shock
- mucoid diarrhea → hypovolemic shock, hypokalemia & peripheral edema
- hypokalemia → arrhythmias
- toxic megacolon (but hallmark complication of UC)
describe the right vs. left sided presentation of the condition in the image
-
right sided = proximal/ascending colon due to microsatellite instability
- iron deficiency anemia
- weight loss
- exophytic tumors polypoidal lesion → obstruction is uncommon
-
left sided = distal/descending → adenoma-carcinoma seq.
- LLQ pain
- blood streaked stool w/ a change in stool caliber
- circumferential lesions → annular, encircling napkin ring constrictions → obstruction and altered bowel movements
describe the etiology of the condition in the image
- gene = APC (tumor suppressor gene) which requires 2 hits → inherit 1 bad hit and get 2nd hit later in life → form polyps → mutations in KRAS → mutation in p53 → adenocarcinoma
describe the gross morphology of the condition in the image
-
pedunculated morphology → tubular adenoma
- numerous benign polyps on left side of colon (sigmoid, descending)
- benign tumor with dysplastic cells and therefore can become cancer
describe the presentation of the condition in the image
- asymptomatic in early stages
- later stages: bright red bloody & mucoid diarrhea, intestinal obstruction and LLQ pain
- screen with sigmoidoscopy (screen at age 12) and offer prophylactic colectomy
describe the complication of the condition in the image
- diameter of left colon is smaller → napkin ring constriction → intestinal obstruction
explain the variants of the condition seen in the image
-
Gardner’s syndrome = polyposis of colon + extra-intestinal signs and symptoms
- multiple osteomas (especially mandible)
- skin cysts: epidermal cysts, fibromas, lipomas
- CT growth → desmoid tumors
- hypertrophy of retinal pigment
- supernumerary teeth
- papillary thyroid cancer
- Turcot’s syndrome = FAP + CNS gliomas and medulloblastomas
describe the image
carcinoid tumor
carcinoid tumors often form a submucosal nodule composed of tumor cells embedded in dense fibrous tissue
describe the image
carcinoid tumor
bland cytology that typifies neuroendocrine tumors
the chromatin texture, with fine and coarse clumps, frequently assumes a “salt-and-pepper” pattern
the condition in the image is most commonly found in the ____ (layer) of the ____ and ____
the condition in the image is most commonly found in the submucosa of the SI and appendix
describe the origin of the condition seen in the image
origin = enterochromaffin/Kulchitsky/neuroendocrine cells
describe type I of the condition seen in the image
- type I: gastric atrophy and achlorydia
- autoimmune chronic gastritis
- hypergastrinemia → ECL cell hyperplasia
- may be multiple, but usually benign
describe type II of the condition seen in the image
- type II: gastrinoma/Zollinger-Ellison syndrome (gastrinoma of the pancreas)
- usually in MEN-1 syndrome
- ZE: hypergastrinemia → increased acid but no negative feedback → multiple, large duodenal ulcers
describe type III of the condition seen in the image
- type III: sporadic
- malignant → very aggressive, sporadic
describe the the condition in the image when it affects the small intestine and appendix
- small, occult primary tumors can metastasize widely leading to carcinoid syndrome if serotonin bypasses the liver, avoiding degradation to 5-HIAA by MAO
- serotonin leaks out hepatic tributaries and can lead to carcinoid heart disease → R-sided valvular fibrosis (tricuspid regurg. &pulm. valve stenosis)
- L-side of heart unaffected since lungs contain MAO and COMT
- serotonin leaks out hepatic tributaries and can lead to carcinoid heart disease → R-sided valvular fibrosis (tricuspid regurg. &pulm. valve stenosis)
describe what is seen on biopsy of the condition seen in the image
- biopsy: uniform cells with stippled oval nuclei & salt and pepper appearance in the submucosa
____ is increased in the urine in the condition seen in the image
5-HIAA
list the tumor markers for the condition seen in the image
synaptophysin, chromogranin, CD56 (origin of cells)
describe the image
cirrhosis
thick bands of collagen separate rounded cirrhotic nodules
describe the hepatic diseases that can lead to the condition seen in the image
- etiology: irreversible diffuse fibrosis of the liver with formation of regenerative nodules
- hepatic diseases
- viral hepatitis → B & C
- auto-immune hepatitis → ANA, anti-smooth muscle Ab
- steatohepatitis: alcohol
- see Mallory bodies (intermediate filaments as eosinophilic cytoplasmic inclusions)
- hepatic diseases
describe the biliary diseases that can lead to the condition seen in the image
- biliary diseases
- primary biliary cirrhosis = anti-mt Ab
-
primary sclerosing cholangitis = causes strictures; beaded appearance; p-ANCA positive
- can be caused by UC
describe the metabolic diseases that can lead to the condition seen in the image
- metabolic diseases:
-
hemochromatosis: increased iron; increased ferritin; decreased TIBC (total iron binding capacity)
- diabetes mellitus
- increased skin pigmentation
- cardiomyopathy
- Wilson’s disease: decreased serum ceruloplasmin, increased hepatic Cu, increased urinary Cu excretion and KF rings
- A1AT deficiency caused by PiZZ
-
hemochromatosis: increased iron; increased ferritin; decreased TIBC (total iron binding capacity)
describe the pathogenesis of the condition in the image
- activate ito/stellate cells (store vit. A) to deposit type III collagen and type I collagen in space of Disse
- loss of fenestrations in endothelial cells → impaired secretion of proteins (albumin, clotting factors)
- new vascular channels in fibrous septae → shunting of blood
- obstruction of biliary channels → jaundice
describe the presentation of the condition seen in the image
- estrogen metabolism impairment:
- palmar erythema
- spider nevi/angioma
- testicular atrophy
- gynecomastia
- finger clubbing, jaundice, leukonychia (white nails due to low albumin), Dupuytren contracture, xanthomas
describe the investigations of the condition seen in the image
- biopsy with trichrome stain (stains collagen blue)
- increased AST, increased bilirubin, decreased clotting factors, decreased albumin
list complications of the condition seen in the image
- hepatic failure
- synthetic function abnormalities (albumin, clotting factors)
- portal HTN → ascites, varices, splenomegaly, hepatic encephalopathy
- hepatic encephalopathy because of defective urea cycle → build-up of ammonia in the brain
- asterixis (hand flapping tremor) due to increased ammonia
- hepatic encephalopathy because of defective urea cycle → build-up of ammonia in the brain
- HCC
- increased bleeding
- loss of coagulation cascade proteins and vit. K
describe the etiology of the condition seen in the image
- global distribution strongly related to the prevalence of HBV
- cirrhosis of any etiology
- most common = alcohol and HBV
- Aspergillus flavus (aflatoxin → cirrhosis)
- A1AT def.
- NAFLD/NASH
describe the histological morphology of the condition seen in the image
- histology:
- trabecular, sinusoidal, or pseudoacinar pattern
- hallmark: bile production by tumor cells → increased bile output → seen as cytoplasmic inclusion (increased globules of bile in cytoplasm)
describe the investigations of the condition seen in the image
- increased AFP as well as a sudden increase in ALP and GGT
describe the complications of the condition seen in the image
- spreads to:
- lungs
- bone (via blood)
- increased risk of Budd-Chiari
describe the trabecular type of the condition seen in the image
nests and cords of hepatocytes
describe the fibrolamellar type of the condition seen in the image
- fibrolamellar type
- no association with viral hepatitis or cirrhosis = idiopathic
- well differentiated polygonal cells in cords or nests separated by fibrous septa
- best prognosis of all types
describe the risk factors for the condition seen in the image
- RF:
- 6 F’s: female, fat, forty, fertile (oral contraceptives), fair skin, family history
- reduced bile salts due to poor absorption or underproduction:
- Crohns = inflammation of ileum → malabsorption of bile salts
- cirrhosis = decreased bile salt synthesis
describe the etiology of the condition seen in the image
- etiology:
- gallbladder stasis
- inborn error of bile salt metabolism
- hyperlipidemia syndromes
the condition in the image is ___ and is therefore not seen on ____
the condition in the image is radiolucent and is therefore not seen on x-ray
describe the etiology of the condition seen in the image
pigment stones = bilirubin calcium salts
- etiology:
-
chronic hemolytic anemia
- HS, B-thalassemia, SCD
- biliary infections → bacteria have glucorinidases that convert bilirubin → unconjugated
- liver cirrhosis or chronic liver disease → lack of conjugation of bilirubin
-
chronic hemolytic anemia
describe the pathogenesis of the condition seen in the image
- pathogenesis:
- bile is supersaturated with cholesterol → bile hypomotility promotes nucleation (precipitation of cholesterol from bile into vesicles)
- mucous hypersecretion traps the crystal permitting aggregation into stones → acts like glue
list complications of the condition seen in the image
- complications:
- empyema
- acute cholecystitis
-
chronic cholecystitis
- porcelain gallbladder = extensive dystrophic calcification → gallbladder cancer
- gallstone ileus → fistula with small bowel → gallstone obstructs the ileocecal valve
- acute pancreatitis → obstruction of the common bile duct (biliary tree)
- acute cholangitis → obstruction of the common bile duct (biliary tree)
-
gallbladder adenocarcinoma
- most common predisposing factor
describe the risk factors for the condition seen in the image
all RFs for cholangiocarcinoma cause chronic inflammation and cholestasis
- primary sclerosing cholangitis
- parasitic infections
- Clonorchis sinensis, Opisthorchis viverini
- cystic dilatations of biliary system → Caroli’s disease
- gallstones
- chemicals
- benidene
- nitrosamines
describe the presentation of the condition seen in the image
- presentation:
- patients typically have non-cirrhotic livers & present with obstructive symptoms
- malaise, weight loss, jaundice
- ascending cholangitis
- Charcot’s triad: jaundice, fever, chills
-
Raynaud pentad: Charcot triad + hypothension and mental status changes
- poor prognosis
- more likely to spread beyond liver than HCC
- patients typically have non-cirrhotic livers & present with obstructive symptoms
primary biliary cholangitis is a non-____, ____ destruction of ____-sized bile ducts
primary biliary cholangitis is a non-suppurative, granulomatous destruction of medium-sized bile ducts
describe the pathogenesis of PBC and name a differential
chronic non-suppurative (non-caseating granulomatous) granulomatous inflammation caused by autoimmune CD4 T cell-mediated destruction of the intrahepatic bile ducts
PSC = intrahepatic AND extrahepatic bile ducts
describe the presentation of PBC
- pruritus (itching) caused by bile salts
- increased bile acids deposited in skin
- steatorrhea
- liver tries to compensate by making cholesterol → xanthomas, xanthelasma
PBC is associated with anti-_____
PBC is associated with anti-mitochondrial antibodies
list complications of PBC
- ductopenia
- malabsorption of fat and fat-soluble vitamins
- hypercholesterolemia → xanthomas
describe the hallmarks of primary sclerosing cholangitis
- inflammation, fibrosis, strictures and dilatations of intra- AND extrahepatic ducts
- associated with UC and is p-ANCA positive
on ERCP of suspected PSC, there is ___ of the biliary tree
on ERCP of suspected PSC, there is beading of the biliary tree
describe the histology in PSC
periductal fibrosis → onion-skin fibrosis → obliterating of bile ducts
describe the etiology of the condition seen in the image
- MCC = alcohol and gallstones
- I GET SMASHED
- Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps/Malignancy, Autoimmune, Scorpion sting, Hypercalcemia, ERCP, Drugs (diuretics, estrogen)
- I GET SMASHED
describe the morphology of the condition seen in the image
- focal fat necrosis in pancreas and peripancreatic tissue and abdominal cavity
- calcium deposition in these areas → appear radiopaque on radiographs
- pancreatic injury → release of amylase & lipase → breaks down lipids to release FAs which combine with Ca2+ → saponification
- liquefactive necrosis of the exocrine pancreas
describe the pathogenesis of the condition seen in the image
- acinar cell injury → enzymatic auto-digestion of pancreas → trypsin → constant activation of all other enzymes
describe the investigations of the condition seen in the image
- 24-48 hours: measure amylase (highly sensitive, not specific)
- 72-96 hours: measure lipase (specific, not sensitive)
describe the complications of the condition seen in the image
- ARDS
- hemolysis with peripheral vascular collapse
- hypovolemic shock → acute tubular necrosis → acute renal failure
- secondary infection by bacteria → sepsis → DIC
- hypocalcemia → tetany and heart murmurs
- pancreatic abscess = infection of pancreatic pseudocyst most commonly by intestinal bacterial (like E. coli)
describe the image
acute pancreatitis
microscopy shows a region of fat necrosis (right) and focal pancreatic parenchymal necrosis (center)
in the condition seen in the image, there is ___ of parenchyma due to repeated ____
in the condition seen in the image, there is fibrosis of parenchyma due to repeated bouts of acute pancreatitis
describe the etiology of the condition seen in the image
- adults: most common cause = chronic alcoholism
- children: CF, pancreatic divisum, mumps
describe the presentation of the condition seen in the image
- repeated attacks or persistence of moderately severe abdominal pain and back pain
- possible progression to pancreatic insufficiency and diabetes
- malabsorption (b/c no amylase or lipase) & steatorrhea & jaundice
- malabsorption corrected by pancreatic enzyme supplements
- intraluminal hydrolysis of fats, proteins, carbs by enzymes is defective → malabsorption
describe what would be seen on CT/x-ray of the condition in the image
fibrotic pancreas w/ dystrophic calcification of pancreas
the most important prognostic indicator of the condition seen in the image is ____
the most important prognostic indicator of the condition seen in the image is hypocalcemia due to malabsorption of vit. D → cardiac arrhythmias
describe the complications of the condition seen in the image
- pancreatic pseudocyst: fluid-filled cavity NOT lined by epithelium; fibrous scar
- pancreatic insufficiency: diabetes (if islets are damaged), fat malabsorption, steatorrhea, fat-soluble vit. deficiencies
- pancreatic carcinoma → esp. with alcohol
the most common location for the condition seen in the image is ____
what can this affect?
the most common location for the condition seen in the image is the head of the pancreas
- adenocarcinoma of the head of the pancreas/ampulla obstructs bile flow
- jaundice → increase ALP, light colored stools, palpable gallbladder (Courvoisier sign)
list the predisposing factors for the condition seen in the image
- smoking (most common)
- familial relapsing chronic pancreatitis
- KRAS mutation
describe the presentation of the condition seen in the image
-
majority are silent until late
- therefore classically called “painless jaundice”
- the first symptom is pain due to invasion of the posterior abdominal wall and nerves (perineural)
in the condition seen in the image, the first symptom is ____ due to ___
the first symptom is pain due to invasion of the posterior abdominal wall and nerves (perineural)
describe the histology of the condition seen in the image
- majority ductal type adenocarcinomas
- dense stromal fibrosis → desmoplasia
- propensity for perineural invasion
there is no single specific marker for the condition seen in the image, but ___ is raised sometimes
there is no single specific marker for the condition seen in the image, but CA 19-9 is raised sometimes
describe the complications of the condition seen in the image
- Trousseau’s sign: recurrent migratory thrombophlebitis
- due to release of platelet factors and procoagulants from tumor
- renal vein thrombosis
- diabetes (if islets are destroyed)
- perineural invasion
- metastasis to the mesenteric lymph nodes and liver
