GIT

Question 1

there is no single specific marker for the condition seen in the image, but ___ is raised sometimes

Answer 1

there is no single specific marker for the condition seen in the image, but CA 19-9 is raised sometimes

Question 2

describe the complication of the condition in the image

Answer 2

• diameter of left colon is smaller → napkin ring constriction → intestinal obstruction

Question 3

describe the histology of cells seen in GIST

Answer 3

spindle-shaped tumor cells

Question 4

describe the etiology of the condition seen in the image

Answer 4

• MCC = alcohol and gallstones
  
  • I GET SMASHED
    
    • Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps/Malignancy, Autoimmune, Scorpion sting, Hypercalcemia, ERCP, Drugs (diuretics, estrogen)

Question 5

describe complications of the condition seen in the image

Answer 5

• 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

Question 6

describe the etiology of the condition seen in the image in adults vs. children

Answer 6

• adult: fecolith obstruction (obstruction of lumen)
• children: d/t lymphoid hyperplasia in the lymphoid follicles of the appendix (follicles are aggregations of lymphoid cells)

Question 7

describe the investigations of the condition seen in the image

Answer 7

• investigations:
  
  • small bowel biopsy:
    
    • distended PAS positive (red) foamy macrophages in lamina propria (mucosa)
  • EM → rod-shaped bacilli

Question 8

describe the presentation of the condition in the image

Answer 8

• 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

Question 9

describe type II of the condition seen in the image

Answer 9

• 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

Question 10

GIST tumors are derived from ____

Answer 10

GIST tumors are derived from interstitial cells of Cajal

Question 11

describe the histology of the condition see in the image

Answer 11

• 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

Question 12

describe the morphology of the condition seen in the image

Answer 12

• yellow plaques covering mucosal surface (mucosal itself is not eroded)
• pseudomembrane
  
  • fibrinopurulent-necrotic debris, inflammatory cells (mainly neutrophil), necrotic epithelium & mucus
  • congested vessels

Question 13

____ is increased in the urine in the condition seen in the image

Answer 13

5-HIAA

Question 14

describe what is seen on biopsy of the condition seen in the image

Answer 14

• investigations:
  
  • biopsy = malignant squamous cells w/ keratin pearls

Question 15

describe the extra-intestinal features of the condition seen in the image

Answer 15

• 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

Question 16

describe the gross appearance of the condition seen in the image

Answer 16

• gross:
  
  • mucosa red, granular and friable
  • broad-based ulcers
  • isolated islands of intervening regenerating mucosa bulge creating pseudopolyps

Question 17

describe the pathogenesis of the condition seen in the image

Answer 17

• pathogenesis:
  
  • obstruction → continued secretion of mucinous fluid → increased intraluminal pressure → collapse of draining veins → ischemic injury → bacterial proliferation → inflammation and edema

Question 18

describe the etiology of the condition seen in the image

Answer 18

• etiology:
  
  • gallbladder stasis
  • inborn error of bile salt metabolism
  • hyperlipidemia syndromes

Question 19

describe complications of the intestinal form of the condition seen in the image

Answer 19

• complications:
  
  • bleed → IDA
  • left supraclavicular/Virchow’s LN metastasis
    
    • one of the nodes that drains the stomach
  • periumbilical metastasis (intestinal) → Sister Mary Joseph nodule

Question 20

describe the pathogenesis of the condition seen in the image

Answer 20

• acinar cell injury → enzymatic auto-digestion of pancreas → trypsin → constant activation of all other enzymes

Question 21

on barium enema in the condition in the image, _____ is seen due to _____

Answer 21

on barium enema in the condition in the image, string-sign is seen due to narrowing of lumen from fibrosis (aka strictures)

Question 22

describe the risk factors for the condition seen in the image

Answer 22

• white men, smokers, obese, previous radiation therapy

Question 23

the condition seen in the image is caused by chronic infection with ___ at the ____ region of lesser curvature

Answer 23

the condition seen in the image is caused by chronic infection with H. pylori at the antro-pyloric region of lesser curvature

Question 24

describe the risk factors for the condition seen in the image

Answer 24

• 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

Question 25

in the condition in the image, there is herniated of the ___ and ___ which makes it a \_\_\_\_

Answer 25

in the condition in the image, there is herniated of the **mucosa** and **submucosa** which makes it a **false diverticulum (pseudodiverticulum)**

Question 26

list the predisposing factors for the condition seen in the image

Answer 26

1. smoking (most common) * familial relapsing chronic pancreatitis * KRAS mutation

Question 27

describe the complications of the condition seen in the image

Answer 27

* 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

Question 28

describe the image

Answer 28

**pseudomembranous colitis** typical pattern of neutrophils emanating from a crypt is reminiscent of a volcanic eruption

Question 29

describe the presentation of the condition seen in the image

Answer 29

* presentation: * asymptomatic, incidental finding on colonoscopy, can cause painless bleeding

Question 30

describe the pathogenesis of the condition seen in the image

Answer 30

* pathogenesis: * decreased dietary fiber → **sustained bowel contractions** and **increased intraluminal pressure** → herniation of colonic wall at sites of focal defects

Question 31

the condition in the image is ___ and is therefore not seen on \_\_\_\_

Answer 31

the condition in the image is **radiolucent** and is therefore not seen on **x-ray**

Question 32

describe the morphology seen in the condition in the image

Answer 32

* 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

Question 33

describe the presentation of the condition seen in the image

Answer 33

* estrogen metabolism impairment: * palmar erythema * spider nevi/angioma * testicular atrophy * gynecomastia * finger clubbing, jaundice, leukonychia (white nails due to low albumin), Dupuytren contracture, xanthomas

Question 34

describe the risk factors for the condition seen in the image

Answer 34

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

Question 35

describe the predisposing factors of the condition seen in the image

Answer 35

* predisposing factors: * elderly on a **low-fiber diet** * long-standing history of constipation

Question 36

the condition in the image leads to a higher risk of \_\_\_\_

Answer 36

the condition in the image leads to a higher risk of **colon cancer**

Question 37

describe the pathogenesis of the condition seen in the image

Answer 37

* 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

Question 38

describe the presentation of PBC

Answer 38

* pruritus (itching) caused by bile salts * increased bile acids deposited in skin * steatorrhea * liver tries to compensate by making cholesterol → **xanthomas**, xanthelasma

Question 39

describe the image

Answer 39

Crohns disease transmural Crohn disease with submucosal and serosal non-caseating granulomas

Question 40

describe the morphology of the condition seen in the image

Answer 40

* morphology: * acquired **pseudo-diverticulum** (involves mucosa & a little submucosa -- NOT the entire wall) * most commonly seen as **flask-like structure in the sigmoid colon**

Question 41

describe investigations of the condition seen in the image

Answer 41

* 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

Question 42

describe the image

Answer 42

lymphoid aggregates with germinal centers and abundant subepithelial plasma cells within the superficial lamina propria are characteristic of H. pylori gastritis

Question 43

list the extra-intestinal manifestations of condition seen in the image

Answer 43

* brain: dementia/seizures * skin: hyperpigmentation * lymphadenopathy: intestinal/mesenteric & peripheral * joints: migratory polyarthritis * heart: infective endocarditis and aortic valve regurg. * eyes: uveitis → blindness

Question 44

\_\_\_\_ is a prognostic indicator of the **intestinal** form of the condition seen in the image

Answer 44

**depth of invasion and nodal status** is a prognostic indicator of the **intestinal** form of the condition seen in the image

Question 45

in the condition seen in the image, there is ___ of parenchyma due to repeated \_\_\_\_

Answer 45

in the condition seen in the image, there is **fibrosis** of parenchyma due to repeated **bouts of acute pancreatitis**

Question 46

describe the image

Answer 46

Crohn's disease linear mucosal ulcers and thickened intestinal wall

Question 47

describe the hepatic diseases that can lead to the condition seen in the image

Answer 47

* 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)

Question 48

list complications for the condition seen in the image

Answer 48

* perforate → peritonitis → E. coli sepsis → septic shock * mucoid diarrhea → hypovolemic shock, hypokalemia & peripheral edema * hypokalemia → arrhythmias * toxic megacolon (but hallmark complication of UC)

Question 49

in the condition seen in the image, ____ are found just below the epithelial lining which is a hallmark of \_\_\_\_\_

Answer 49

in the condition seen in the image, **reactive lymphoid aggregates** are found just below the epithelial lining which is a hallmark of **H. pylori**

Question 50

describe the etiology of the diffuse form of the condition seen in the image

Answer 50

* etiology: * mutation = **E-cadherin (CDH1)** → signet ring cells that contain mucin * no intestinal metaplasia

Question 51

describe risk factors of the condition seen in the image

Answer 51

* 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

Question 52

describe the image

Answer 52

ulcerative colitis total colectomy with pancolitis showing active disease, with red, granular mucosa in the cecum (left) and smooth, atrophic mucosa distally (right)

Question 53

describe the etiology of the condition seen in the image

Answer 53

* more common in US * precursor lesion = GERD, Barrett esophagus (dysplasia) * lower 1/3 of esophagus

Question 54

describe the presentation of the condition seen in the image

Answer 54

* fever, lower abdominal pain, cramps, massive bloody & mucoid diarrhea (dysentery)

Question 55

describe complications of the condition seen in the image

Answer 55

* complications: * perforation → peritonitis → septicemia * peri-appendiceal abscess → liver abscess, bacteremia

Question 56

describe the pathogenesis of the condition seen in the image

Answer 56

* 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

Question 57

list the tumor markers for the condition seen in the image

Answer 57

synaptophysin, chromogranin, CD56 (origin of cells)

Question 58

describe what would be seen on CT/x-ray of the condition in the image

Answer 58

**fibrotic pancreas** w/ **dystrophic calcification** of pancreas

Question 59

describe the etiology of the condition seen in the image

Answer 59

* hospitalized patients on **broad-spectrum antibiotics** (clindamycin; disruption of normal flora) → **C. difficile** exotoxin mediated damage

Question 60

describe the investigations of the condition seen in the image

Answer 60

* increased AFP as well as a sudden increase in ALP and GGT

Question 61

describe predisposing factors for the condition seen in the image

Answer 61

* predisposing factors: * tobacco chewing (most common) * alcohol * HPV 16 & 18 * jagged teeth * ill-fitting dentures

Question 62

describe the image

Answer 62

villi are stout and packed with foamy macrophages lipid particles --\> dilated lacteals PAS stain --\> foamy particles in LP

Question 63

describe the etiology of the condition seen in the image

Answer 63

* adults: **most common cause = chronic alcoholism** * children: **CF**, pancreatic divisum, mumps

Question 64

on biopsy of the condition seen in the image, there are ____ all the way to the \_\_\_\_\_

Answer 64

on biopsy of the condition seen in the image, there are **neutrophils** all the way to the **muscularis propria**

Question 65

describe the pathogenesis of the condition seen in the image

Answer 65

* 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

Question 66

describe the image

Answer 66

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)**

Question 67

describe the histology of the condition seen in the image

Answer 67

* 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

Question 68

describe the image

Answer 68

**cirrhosis** thick bands of collagen separate rounded cirrhotic nodules

Question 69

describe complications of the condition seen in the image

Answer 69

* complications: * spreads via lymphatics → **anterior cervical lymph​ nodes**

Question 70

describe the pathogenesis of the condition in the image

Answer 70

* 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

Question 71

the condition seen in the image is associated with HLA-\_\_\_ as well as \_\_\_\_\_

Answer 71

the condition seen in the image is associated with HLA-**DRB1** as well as **primary sclerosing cholangitis (p-ANCA)**

Question 72

a majority of GIST tumors express ____ and have mutations in \_\_\_\_

Answer 72

a majority of GIST tumors express **CD117** and have mutations in **c-Kit**

Question 73

describe complications of the condition seen in the image

Answer 73

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

Question 74

describe the **metabolic** diseases that can lead to the condition seen in the image

Answer 74

* 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

Question 75

describe the complications of the condition seen in the image

Answer 75

* **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

Question 76

the most common location of the condition in the image is \_\_\_\_

Answer 76

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

Question 77

list complications of PBC

Answer 77

* **ductopenia** * malabsorption of fat and fat-soluble vitamins * **hypercholesterolemia → xanthomas**

Question 78

primary biliary cholangitis is a non-\_\_\_\_, ____ destruction of \_\_\_\_-sized bile ducts

Answer 78

primary biliary cholangitis is a non-**suppurative**, **granulomatous** destruction of **medium**-sized bile ducts

Question 79

describe the complications of the condition seen in the image

Answer 79

* spreads to: 1. lungs 2. bone (via blood) * increased risk of Budd-Chiari

Question 80

describe investigations for the condition seen in the image

Answer 80

* investigations: * GI endoscopy w/ biopsy: malignant squamous cells **invading into the submucosa &** **muscularis** **propria** * barium swalllow: shows obstruction of lumen

Question 81

on biopsy of the condition seen in the image, there is ____ involvement with ____ and inflammatory infiltrate

Answer 81

on biopsy of the condition seen in the image, there is **transmural** involvement with **non-caseating granulomas** and inflammatory infiltrate

Question 82

describe complications of the condition seen in the image

Answer 82

* #1 risk factor for **dysplasia → adenocarcinoma** of the esophagus * ALWAYS d/t Barrett's * progressive dysphagia and odynophagia * melena → iron deficiency anemia

Question 83

describe the morphology of the condition seen in the image

Answer 83

* 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

Question 84

describe the investigations of the condition seen in the image

Answer 84

* _24-48 hours_: measure **amylase** (highly sensitive, not specific) * _72-96 hours_: measure **lipase** (specific, not sensitive)

Question 85

explain the variants of the condition seen in the image

Answer 85

* **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

Question 86

\_\_\_ is the tumor marker for the condition seen in the image

Answer 86

**CEA** is the tumor marker for the condition seen in the image

Question 87

describe the presentation of the condition seen in the image

Answer 87

* 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

Question 88

describe the image

Answer 88

ulcerative colitis the disease is limited to the **mucosa + submucosa**

Question 89

describe the fibrolamellar type of the condition seen in the image

Answer 89

* 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

Question 90

describe the image

Answer 90

squamous cell carcinoma composed of nests of malignant cells that partially recapitulate the stratified organization of squamous epithelium

Question 91

describe the investigations of the condition seen in the image

Answer 91

* biopsy with trichrome stain (stains collagen blue) * increased AST, increased bilirubin, decreased clotting factors, decreased albumin

Question 92

describe the etiology of the condition seen in the image

Answer 92

* etiology = **gluten** (wheat, barley, oats, rye) * specifically **gliadin** protein * associated with **HLA-DQ2** (more common) & **HLA-DQ8**

Question 93

describe the gross appearance of the condition

Answer 93

* 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

Question 94

describe the image

Answer 94

Crohn's disease haphazard crypt organization results from repeated injury and regeneration

Question 95

list complications of the condition seen in the image

Answer 95

* 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

Question 96

describe investigations for the condition seen in the image

Answer 96

**assay stool for exotoxin**

Question 97

describe the biliary diseases that can lead to the condition seen in the image

Answer 97

* biliary diseases * **primary biliary cirrhosis = anti-mt Ab** * **primary sclerosing cholangitis** = causes strictures; beaded appearance; p-ANCA positive * can be caused by UC

Question 98

describe the complications of the condition seen in the image

Answer 98

* chronic inflammation → intestinal metaplasia → dysplasia → **intestinal gastric adenocarcinoma** * lymphoid aggregates → uncontrolled prolif. of B cells → **MALToma** (gastric lymphoma) * peptic ulcer disease

Question 99

describe the complications of the condition seen in the image

Answer 99

* **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)

Question 100

describe the hallmarks of primary sclerosing cholangitis

Answer 100

* inflammation, fibrosis, strictures and dilatations of intra- AND extrahepatic ducts * associated with UC and is p-ANCA positive

Question 101

describe the image

Answer 101

spiral-shaped H. pylori bacilli are highlighted with Warthin-Starry silver stain. Organisms are abundant within surface mucus

Question 102

in the condition seen in the image, confirmation of the etiologic agent would be supported by \_\_\_\_\_

Answer 102

in the condition seen in the image, confirmation of the etiologic agent would be supported by **regression of tumor with antibiotics**

Question 103

describe the etiology of the condition seen in the image

Answer 103

* 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

Question 104

describe the the condition in the image when it affects the small intestine and appendix

Answer 104

* 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

Question 105

describe the image

Answer 105

**diverticulosis** sigmoid diverticulum showing **protrusion of the mucosa and submucosa** through the muscularis propria

Question 106

the condition in the image is most commonly found in the ____ (layer) of the ____ and \_\_\_\_

Answer 106

the condition in the image is most commonly found in the **submucosa** of the **SI** and **appendix**

Question 107

describe the presentation of the condition seen in the image

Answer 107

* 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

Question 108

list complications of the condition seen in the image

Answer 108

* 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 * HCC * increased bleeding * loss of coagulation cascade proteins and vit. K

Question 109

in the condition seen in the image, the first symptom is ____ due to \_\_\_

Answer 109

the first symptom is **pain** due to **invasion** **of the posterior abdominal wall and nerves (perineural)**

Question 110

describe the presentation of the condition seen in the image

Answer 110

* 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

Question 111

describe the image

Answer 111

**acute pancreatitis** microscopy shows a region of fat necrosis (right) and focal pancreatic parenchymal necrosis (center)

Question 112

describe the histology of the condition in the image

Answer 112

cobblestone appearance * sharply delimited & transmural involvement * non-caseating granulomas * mucosal fissuring with involvement of fistulas * skipped lesions that spare the rectum

Question 113

flare-ups of the condition seen in the image is associated with \_\_\_\_

Answer 113

flare-ups of the condition seen in the image is associated with **physical and mental stress**

Question 114

describe where the condition in the image are located (anatomical weakness)

Answer 114

diverticula are located on the **mesenteric border where the vasa recta penetrate the muscle wall** (anatomic weakness site)

Question 115

describe the morphology of the **intestinal** form of the condition seen in the image

Answer 115

* morphology: * neoplastic cells form glands * histology: malignant glands that make mucin → invading into the submucosa & muscularis propria

Question 116

definitive diagnosis of the condition seen in the image is accomplished by \_\_\_\_

Answer 116

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**

Question 117

describe the right vs. left sided presentation of the condition in the image

Answer 117

* _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**

Question 118

describe the etiology of the condition seen in the image

Answer 118

* 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

Question 119

describe the pathogenesis of PBC and name a differential

Answer 119

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

Question 120

in the condition seen in the image, too much IgA causes \_\_\_\_\_

Answer 120

in the condition seen in the image, too much IgA causes **dermatitis herpetiformis (deposition of IgA in the dermal papillae)**

Question 121

the most important prognostic indicator of the condition seen in the image is \_\_\_\_

Answer 121

the most important prognostic indicator of the condition seen in the image is **hypocalcemia due to malabsorption of vit. D** →​ ***cardiac arrhythmias***

Question 122

describe the complications of the condition seen in the image

Answer 122

* complications: * melena → iron deficency anemia * TEF → aspiration pneumonia → lung abscess * invade heart → pericarditis → percardial effusion

Question 123

describe the morphology of the **diffuse** form of the condition seen in the image

Answer 123

* morphology: * **"leather bottle stomach"/****linitis****plastica** becuase signet ring cell infiltrates the stomach wall * no gland formation: single cells, sheets, clusters

Question 124

describe the etiology of the condition seen in the image

Answer 124

**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

Question 125

describe the image

Answer 125

**carcinoid tumor** bland cytology that typifies neuroendocrine tumors the chromatin texture, with fine and coarse clumps, frequently assumes a **"salt-and-pepper" pattern**

Question 126

describe the etiology of the **intestinal** form of the condition seen in the image

Answer 126

* etiology: * H. pylori = most common * autoimmune * smoked foods (nitrosamines)

Question 127

describe type I of the condition seen in the image

Answer 127

* type I: gastric atrophy and achlorydia * **autoimmune chronic gastritis** * hypergastrinemia → ECL cell hyperplasia * may be multiple, but usually benign

Question 128

describe the complications of the **diffuse** form of the condition seen in the image

Answer 128

* complications: * **ovarian metastasis → Krukenberg tumor → bilateral (only with diffuse type)** * Krukenberg: from diffuse gastric adenocarcinoma, invasive lobular carcinoma of breast, and colon cancer

Question 129

GIST is treated with \_\_\_\_

Answer 129

GIST is treated with **TKI (Imatinic/Gleevec)** ## Footnote **same treatment as CML (9,22 translocation)**

Question 130

describe the classic features seen in the condition in the image

Answer 130

* classic features: * **always starts the rectum** & moves proximally; continuous * **no skipped lesions** → curable by surgery

Question 131

describe the pathogenesis of the condition seen in the image

Answer 131

* 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

Question 132

describe the gross morphology of the condition in the image

Answer 132

* **pedunculated morphology** → tubular adenoma * numerous benign polyps on **left** **side of** **colon** (sigmoid, descending) * **benign tumor with dysplastic cells** and therefore can become cancer

Question 133

describe type III of the condition seen in the image

Answer 133

* type III: sporadic * malignant → very aggressive, sporadic

Question 134

describe what is seen on biopsy of the condition seen in the image

Answer 134

* biopsy: uniform cells with **stippled oval nuclei** & **salt and pepper** appearance in the **submucosa**

Question 135

describe the etiology of the condition in the image

Answer 135

* 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

Question 136

the most common location for the condition seen in the image is \_\_\_\_ what can this affect?

Answer 136

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)

Question 137

describe the trabecular type of the condition seen in the image

Answer 137

**nests and cords of hepatocytes**

Question 138

describe the histological morphology of the condition seen in the image

Answer 138

* 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)

Question 139

describe the histology of the condition seen in the image

Answer 139

* majority ductal type adenocarcinomas * dense stromal fibrosis → **desmoplasia** * propensity for perineural invasion

Question 140

the condition in the image mainly affects the \_\_\_\_

Answer 140

the condition in the image mainly affects the **duodenum**

Question 141

Answer 141

A: normal gastroesophageal junction B: Barrett esophagus; note the small islands of paler squamous mucosa within the Barrett mucosa

Question 142

PBC is associated with anti-\_\_\_\_\_

Answer 142

PBC is associated with anti-**mitochondrial antibodies**

Question 143

list complications of the condition seen in the image

Answer 143

* 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

Question 144

describe the image seen

Answer 144

**celiac sprue/disease** complete loss of villi or total villous atrophy dense plasma cell infiltrates in the lamina propria

Question 145

on ERCP of suspected PSC, there is ___ of the biliary tree

Answer 145

on ERCP of suspected PSC, there is **beading** of the biliary tree

Question 146

\_\_\_\_\_ is the precursor lesion to the condition seen in the image

Answer 146

**GERD → Barrett esophagus** is the precursor lesion to the condition seen in the image

Question 147

describe the image

Answer 147

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

Question 148

describe the presentation of the condition seen in the image

Answer 148

* presentation: * progressive dysphagia (to solids then to liquids) * odynophagia * cachexia * fatigue (d/t melena → iron deficiency anemia) * hematemesis * hoarse voice and cough

Question 149

describe the etiology of the condition seen in the image

Answer 149

G+ve sickle-shaped actinomycete **Trophyeryma whippeli** (PAS +)

Question 150

describe the pathogenesis of the condition seen in the image

Answer 150

* 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

Question 151

describe the pathogenesis of the condition seen in the image

Answer 151

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

Question 152

describe complications of the condition seen in the image

Answer 152

* **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

Question 153

describe the presentation of the condition seen in the image

Answer 153

* presentation: * signs and symptoms similar to SCC * dysphagia, initially to solid then to liquid * odynophagia * weight loss → cachexia * chest pain * vomiting

Question 154

the condition in the image is associated with HLA- \_\_\_\_

Answer 154

the condition in the image is associated with **HLA-DR7 and HLA-DQ4**

Question 155

during a barium enema while investigating the condition in the image, a ____ appearance is seen due to \_\_\_\_

Answer 155

during a barium enema while investigating the condition in the image, a **lead-pipe** appearance is seen due to **loss of haustra**

Question 156

describe the image

Answer 156

**carcinoid tumor** carcinoid tumors often form a **submucosal nodule composed of tumor cells embedded in dense fibrous tissue**

Question 157

describe the presentation of the condition seen in the image

Answer 157

* **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)

Question 158

in the condition in the image, in severe cases of pancolitis, the ____ can be affected as well, which is called \_\_\_\_\_

Answer 158

in the condition in the image, in severe cases of pancolitis, the **ileum** can be affected as well, which is called **backwash ileitis**

Question 159

describe the investigations of the condition seen in the image

Answer 159

* 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

Question 160

describe the origin of the condition seen in the image

Answer 160

origin **= enterochromaffin/Kulchitsky/neuroendocrine cells**

Question 161

describe the pathogenesis of the condition seen in the image

Answer 161

* 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**

Question 162

describe the pathogenesis of the condition seen in the image

Answer 162

* presentation: * malabsorption → steatorrhea (foul-smelling, pale bulky stools) * weight loss * flatulence

Question 163

describe the histology in PSC

Answer 163

periductal fibrosis → onion-skin fibrosis → obliterating of bile ducts