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YEAR 5: Histopathology > Histo: Lower GI Disease > Flashcards

Histo: Lower GI Disease Flashcards

1
Q

What are the general effects of bowel pathology?

A
  • Disturbance of of normal function
  • Bleeding
  • Perforation / Fistula
  • Obstruction
  • Systemic illness
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2
Q

List some congenital disorders of the GI tract.

A
  • Atresia/stenosis
  • Duplication
  • Imperforate anus
  • Hirschsprung disease (MOST COMMON)
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3
Q

What is atresia?

A

Lack of connection between two parts of bowel

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4
Q

What is Hirschsprung disease?
How does it present?

A

The absence of ganglion cells of the myenteric plexus resulting in failure of dilatation of the distal colon

Presents with:

  • Delayed passage of meconium
  • Constipation
  • Abdominal distension
  • Vomiting
  • Overflow diarrhoea
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5
Q

List some genetic associations of Hirschsprung disease.

A
  • Down syndrome (2%)
  • RET proto-oncogene mutation (chr 10)
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6
Q

How is Hirschsprung disease diagnosed?

A

Clinical impression from history and examination

Full thickness rectal biopsy (gold standard)

  • Shows hypertrophied nerve fibres but no ganglia
  • if ganglion cells seen = not Hirschprungs
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7
Q

How is Hirschsprung disease treated?

A

Resection of affected (constricted) segment (anorectal pull-through precedure)

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8
Q

Causes of Mechanical obstruction

A
  • Adhesion
  • Herniation
  • Cancer
  • Volvulus
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9
Q

What is a volvulus? What complications does it cause

A

Twisting of a loop of bowel at the mesenteric base around a vascular pedicle

Causes bowel obtruction +/- infarction

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10
Q

Which part of the intestines tend to be affected by volvulus in infants and the elderly?

A

Infant - small bowel

Elderly - sigmoid colon

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11
Q

Describe the pathophysiology of diverticular disease
Which part of bowel is most commonly affected?
What is a risk factor for developing diverticular disease?

A
  • High intraluminal pressure leads to herniation of the bowel mucosa through weak points in the bowel wall (usually sites of entry of nutrient vessels)
  • 90% in left colon (specifically sigmoid)
  • Associated with low-fibre diet
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12
Q

What are some complications of diverticular disease?

A
  • Pain
  • Diverticulitis
  • Perforation
  • Fistula
  • Obstruction
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13
Q

List some causes of acute colitis.

A
  • Infection
  • Drugs/toxins (especially antibiotics)
  • Chemotherapy
  • Radiation
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14
Q

List some causes of chronic colitis

A
  • Crohn’s
  • Ulcerative colitis
  • TB
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15
Q

List some infectious causes of colitis

A
  • Viral e.g. CMV
  • Bacterial e.g. Salmonella
  • Protozoal e.g. Entamoeba histolytica
  • Fungal e.g. Candida
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16
Q

List the effects of infection on the colon.

A
  • Secretory diarrhoea (due to toxin)
  • Exudative diarrhoea (due to invasion and mucosal damage)
  • Severe tissue damage and perforation
  • Systemic illness
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17
Q

What is pseudomembranous colitis?

A

Antibiotic-associated colitis characterised by acute colitis with pseudomembrane formation

Caused by C. difficile exotoxins

pseudomembrane = membrane formed by inflammatory tissue

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18
Q

How can C. difficile colitis be diagnosed?

A
  • Lab - toxin stool assay
  • Histology - characteristic features on biopsy

Always considered in hospital - precipitated by ABx
(Clindamycin, Cephalosporins)

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19
Q

How is pseudomembranous colitis treated?

A

Vancomycin

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20
Q

What can causes both acute and chronic colitis?

A

Ischaemia
IBD

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21
Q

Where in the intestines does ischaemic colitis tend to occur? Give 2 examples.

A

Watershed zones - areas that receive dual blood supply from the most distal branches of two large arteries
- Splenic flexure - SMA and IMA
- Rectosigmoid - IMA and internal iliac

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22
Q

How can ischaemic colitis be classified?

A
  • Mucosal
  • Mural
  • Transmural (perforation)
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23
Q

List the potential causes of ischaemic colitis.

A
  • Arterial occlusion - atheroma, embolism
  • Venous occlusion - thrombus
  • Small vessel disease - diabetes mellitus, vasculitis
  • Low flow states - CHF, shock, haemorrhage
  • Obstruction - hernia, intussusception, volvulus, adhesions
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24
Q

What are some clinical features of IBD?

A
  • Diarrhoea (bloody in UC)
  • Fever
  • Abdominal pain
  • Anaemia
  • Weight loss
  • Perforation
  • Extra-intestinal manifestations
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25
Describe the epidemiology of Crohn's
- Mainly affects white people - Onset typically late teens - 20s
26
List some characteristic features of Crohn's disease.
* Can affect whole GI tract (mouth to anus) * Skip lesions with cobblestone mucosa * Transmural inflammation * Non-caseating granulomas * Fissure/sinus/fistula formation * Bowel wall is thickened * Mostly affects large bowel and terminal ileum
27
List some extra-intestinal features of Crohn's.
* Arthritis * Uveitis * Stomatitis/cheilitis * Skin lesions - pyoderma gangrenosum, erythema multiforme, erythema nodosum
28
Describe the epidemiology of UC
- Slightly more common that Crohn's - Mainly affects white people - Onset typically 20-25 years
29
List some characteristic features of ulcerative colitis.
* Involves rectum and colon in a continuous fashion (**starts at rectum**) * May see backwash ileitis (involvement of the terminal ileum) * Inflammation is confined to the mucosa * Shallow ulceration * Bowel wall is normal thickness
30
List some complications of ulcerative colitis.
* Severe haemorrhage * Toxic megacolon * Adenocarcinoma (20-30x increased risk)
31
List some extra-intestinal manifestation of UC
- Arthritis - Myositis - Uveitis/iritis - Skin lesion - erythema nodosum, pyoderma gangrenosum - **Primary sclerosing cholangitis**
32
Which hepatobiliary condition is associated with UC?
Primary sclerosing cholangitis ## Footnote NOTE: PSC is big risk factor for cholangiocarcinoma
33
List some types of tumour affecting the of colon and rectum
Non-neoplastic polyps Neoplastic Epithelial Tumours - Adenoma - Adenocarcinoma - Neuro-endocrine tumours - carcinoid (mainly affects small bowel) Mesenchymal lesions - Lipoma - Leiomyoma Lymphoma
34
What is a polyp?
A growth that protrudes into the lumen of an organ
35
List some non-neoplastic and neoplastic polyps of the colon and rectum
Non-neoplastic - Hyperplastic and sessile serrated lesions - Inflammatory pseudopolyps seen in UC - Hamartomatous polyps (Peutz-Jeghers) Neoplastic - Adenoma - Adenocarcinoma
36
What are sessile serrated lesions?
Type of hyperplastic polyp with architectual abnormalitis that may be premalignant and show dyplasia
37
What are adenomas? What are the types of adenoma?
Benign tumours that characterised by excessive epithelial proliferation and may be dysplastic - Tubular - Tubulovillous - Villous (highest risk of carcinoma)
38
What are the risk factors for cancer in an individual adenoma polyp?
- Size (>4cm = 45%) - Proportion of villous component (finger-like projections) - Degree of dysplasia
39
List some observations that have given rise to adenoma-carcinoma sequence theory.
* Areas with a high prevalence of adenomas have a high prevalence of carcinoma * Adenomas tend to appear 10 years before a carcinoma * Risk of cancer is proportional to the number of adenomas
40
What are some genetic causes of colon cancer?
Familial adenomatous polyposis - Gardner's - Turcot Hereditary non-polyposis colon cancer (Lynch syndrome) ## Footnote All are autosomal dominant
41
What is Lynch syndrome (HNPCC)?
- Autosomal dominant condition - Affects DNA mismatch repair genes - **MSH2** most commonly affected - Few polyps but fast progression to malignancy - Associated with increased risk of colorectal, endometrial, gastric, and ovarian cancers
42
What is familial andeomatous polyposis?
- Autosomal dominant condition - Caused by mutation in **APC** tumour supressor gene (chr 5) - Characterised by numerous (average 1000) colorectal polyps - Virtually 100% will develop colorectal cancer within 10-15 years
43
What is Gardner's syndrome?
FAP plus extra-intestinal manifestations e.g. - Cranial osteomas - Desmoid tumours - Epidermoid cysts
44
Where does colon cancer typically arise in HNPCC?
Colon cancer typically arises proximal to splenic flexture (**proximal colon**) and is typically poorly differentiated
45
Describe the epidemiology of colorectal cancer?
- 98% are adenocarcinoma - Average age affected is 60-79 - If <50 years consider familial syndrome - Primarily affects western population
46
List some risk factors for colorectal cancer
- Familial - Diet (low fibre, high fat) - Lack of exercise - Obesity
47
List some prediposing conditions to colorectal cancer
- Adenomas - IBD
48
What are the symptoms of CRC?
- Change in bowel habit - Blood in stool - Anaemia - Weight loss - Pain
49
Describe the grading and staging of CRC?
Dukes staging: A: confined to the mucosa B1: extending into muscularis propria B2: transmural invasion, no lymph invasion C1: extending to muscularis propria, with LN involvement C2: transmural invasion with LN involvement D: distant metastasis TNM staging is also used.
50
List some types of stromal lesions that occur in the GI tract.
* Stromal tumours * Lipoma * Sarcoma * Other: lymphoma
51
How does smoking affect IBD?
Crohns - worsens symptoms UC - improves symptoms/protective
52
What gives Crohn's tissue the 'cobblestone appearance'?
Areas of healthy mucosa lie above the diseased mucosa
53
Describe the pattern of athropathy in IBD
Migratory asymmetrical polyarthropathy of large joints Affects 15% patients.
54
How does UC increase the risk of developing colorectal cancer?
20-30x increased risk
55
What are the most common antibiotics that cause c.difficle colitis?
4 Cs Ciprofloxacin Co-amoxiclav Cephalosporins Clindamycin
56
What is the pathophysiology of antibiotic use causing colitis?
The antibiotics cause commensal bacteria to die, allowing C. difficult to flourish, with its exotoxins causing pseudomembranous colitis
57
What is carcinoid syndrome?
A triad of: - Bronchoconstriction - Flushing - Diarrhoea As a result of a neuroendocrine tumour (enterochromaffin cell origin) that produces serotonin (5-HT).
58
What is meant by a carcinoid crisis?
A life-threatening complication of carcinoid syndrome resulting in bronchoconstriction, vasodilation, hypotension, tachycardia and hyperglycaemia
59
Where are carcinoid tumours typically found?
Usually in the bowel but can also be found in the lung, ovaries and testes. They are usually slow growing.
60
What is the investigation of choice for carcinoid syndrome?
24hr urine 5-HIAA (main metabolite of serotonin)
61
What is the treatment of choice for carcinoid syndrome?
Octreotide (somatostatin analogue)
62
Above what size do adenomas require surveillance?
>3.4cm
63
What is Peutz-Jeghers syndrome?
Autosomal dominant (LKB1 mutation) that results in: - Multiple polyps - Mucocutaneous hyperpigmentation - Freckles around the mouth, palms and soles
64
What are patients with Peutz-Jeghers syndrome at increased risk of?
Intussusception and malignancy (require surveillance of GI tract, pelvis and gonads)
65
What investigations would you order for suspected colorectal cancer?
FBC, coag, U&Es, LFTs, CRP CEA (carcinoembryonic antigen) Proctoscopy/sigmoidoscopy/colonoscopy CT/MRI

YEAR 5: Histopathology (20 decks)

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