Lecture 81 - Pathology of Gastric Disease

Question 1

what are the different parts of the stomach?
what cells are located in each?
what are two kinds of epithelium?

where does H pylori like to live?

Answer 1

Cardia — distinct region that resembles the pylorus
Body and Fundus – Parietal cells, Chief Cells
Parietal cells – targetted by Auto-immune gastritis
Antrum – Mucus Cells; G Cells
H pylori likes to live here (+ antrum)
Pylorus –

The stomach has two types of mucosa: Antral and Fundal

Question 2

Gastritis vs Gastrophy

symptoms of gastropy?
common causes of gastrophy?

Answer 2

Gastritis – marked inflammation; often in an acute or severe phenomena

Gastrophy -- more common but less severe; 
	Catch all for mild inflammation 

Uncertain clinical significance; some asymptomatic
Common symptoms: pain and heart burn
Causes: NSAIDs, bile reflux, EtOH, Coffee, Cocaine,

Question 3

major causes of Gastritis?

Answer 3

H. Pylori -- main cause 
Autoimmune Gastritis -- second most common cause of gastritis 
Chemical Gastritis : Bile, Iron 
Crohn's Gastritis: 
Zollinger Ellison Syndrome -
Infectious

Question 4

H. Pylori Gastritis

what are you looking for on histology?

Answer 4

Histology – PMNs (active gastritis); THe organism itself (lives in the mucous glands of the cardia and the antrum)

Question 5

H. Pylori Gastritis - complications

Answer 5

PUD
Intestinal Metaplasia —-> Gastric Carcinoma
Similar to progression in Barrett’s

Lymphoma (MALToma)

Question 6

*Intestinal Metaplasia – A complication in the setting of H pylori:

the good?
the bad?

Answer 6

Short Term: good function –
H pylori can’t live in intestinal type epithelium,

Long term: Bad -- not wide spread enough to actually eradicate the infection; predisposes to carcinoma

Question 7

*Lymphoma (MALToma) - marginal zone lymphoma —complication of H. pylori gastritis

Answer 7

Stimulated by H. Pylori ongoing exposure

Question 8

Autoimmune Gastritis

– what is it –
where in the stomach?

whats seen on histology?

Answer 8

Auto-immune destruction of intrinsic factor and Parietal cells
Presents with Pernicious Anemia
A/w other auto immune phenomena

Histology – Antrum and the Fundus (parietal cell locations)
(Can get a form a metaplasia – Fundal – > Antral Mucosa)
Gradual destruction of the mucosa (“atrophic gastritis”)
Lots of Inflammation

Question 9

Autoimmune Gastritis -

Complications:

Answer 9

Anemia, PUD, Intestinal Metaplasia,

Neuro-endocrine cell Tumors

Question 10

Neuro-endocrine cell Tumors — complication of the auto-immune gastritis

whats happening?
prognosis?

what should you stain for?

Answer 10

Loss of acid secretion –> hypergastrinemia –> overgrowth of ECLs

Linear hyperplasia –> nodular hyperplasia –> Neuro-endocrine Tumors

	Typically indolent; low malignant potential 

	Positive for Synaptophysin

Question 11

Chemical Gastritis
- what can cause it?

histological changs?

Answer 11

bile and iron

Foveolar hyperplasia/elongation; may resemble villi of the small intestine
Complex glandular architecture (“corkscrew”)
Vascular congestion – looks red and inflammed

Question 12

Chemical Gastritis – Iron Pill –

histology?
treatment?>

Answer 12

Iron apparent in the lamina propria and crusted along surface
Tx – stop taking Iron pills

Question 13

Zollinger Ellison Syndrome leading to gastrin?

why/how?

Answer 13

hypergastrinemia, increased acid, duodenal ulcers

Overgrowth of the fundic mucosa in response to gastrin

Question 14

what is a heterotopias ?

what are the two types of the Stomach?

Answer 14

clinically insignificant; Right kind of tissue but in the wrong place;
Antral heterotopias

Pancreatic Heterotopias

Question 15

Antral heterotopias
Pancreatic Heterotopias

what are they?

Answer 15

Antral heterotopias –
Histologically unremarkable antral type mucosa in the body or the fundus
Clinically inconsequential

	Pancreatic Heterotopias -- Piece of normal pancreatic that during embryogenesis wound up in the stomach. Usually incidental and clinical

Question 16

what are the two types of Polyps seen in the stomach?

Answer 16

Hyperplastic Polyps –

Fundic gland polyp –

Question 17

Hyperplastic Polyps –
what is it?
histology?
risk factors?

Answer 17

Abnormal growths of the stomach which may harbor intestinal metaplasia, dysplasia or carcinoma

		Histology: Overgrowth of Foveolar epithelium;  cystically dilated glands 
			Antral type mucosa 

Risk factor: Gastritis (h pylori, auto immune)

Question 18

Fundic gland polyp –
two associations:

benign of malignant?

Answer 18

Associations;

• • long term PPI use — totally benign
• • FAP (familial adenomatous polyposis; mutation of APC)

polyp itself is benign, but condition itself dangerous ( Risk of colon cancer – 100%)

Question 19

Gastric Polyposis Syndrome

what is the mutation?
what is it?
clinical significance?

Answer 19

Characterized by multiple gastric polyps; usually fundic gland polyps
Associated with mutations in APC
Cancer Risk – need screening and colonoscopy

Question 20

Two premalignant conditions of gastric cancers?

what is the gross path distinction?

Answer 20

Gastric Dysplasia — appears as a flat lesion; often associated with metaplasia;

Adenoma – denotes glandular polyp with at least a low grade dysplasia
The bigger the polyp – the higher the grade/chance of malignancy

Question 21

histological features of adenoma?

types of gastric adenomas?

Answer 21

May be intestinal (goblet cell)
May be gastric type (foveolar cells)

Dark Epithelium  = increased replication; high N:C ratio 

Mucin Depletion = cells spending less time on normal function;

Question 22

two gastric malignancies to know

Answer 22

Adenocarcinoma –

Neuro-Endocrine Tumors:

Question 23

Gastric Adenocarcinoma –

– what are two types?

Answer 23

Intestinal vs Diffuse

• E cadherin (classically associated with breast cancer), KRAS, p53, APC

Question 24

Intestinal type Gastric adeno-carcinoma 
- Risk factors? 
- histological features? 
Gross path: 
- prognosis? 

– mutations?

Answer 24

Risk factors: H pylori, Smoking
Diet – more so in Japan

histological: Cohesive glands;
gross path: typically discrete fungating masses or ulcers

prognosis: Much better prognosis; good outcomes if caught early enough
- E cadherin (classically associated with breast cancer), KRAS, p53, APC

Question 25

Diffuse type Gastric adeno-carcinoma

• (not associated with…)
• histological feature?
  gross path?
• Genetics?

-prognosis?

Answer 25

Not associated with H Pylori

gross: Diffuse thickening of the stomach (linitis plastica = leather bottle stomach” )
histo: Very dis-cohesive; Signet Ring

			EPI: usually younger patients (30s); typically found at late stage 

Genetics: Usually sporadic

			Outcomes: very poor; rapid progression to death

Question 26

Neuro-Endocrine Tumors:

classifed by associatieon and morphology?
which has the worse prognosis?

Answer 26

Type 1 - - associated with auto immune gastritis; indolent (best prognosis)
Type 2 – associated with ZE (intermediate severity)
Type 3– sporadic; worst prognosis

Question 27

Neuro-Endocrine Tumors:

— stains for…?

Answer 27

Histo – dark nodulating groups of cells

Synpatophysin Stain

Question 28

Two vascular d/o of the stomach to know …

Answer 28

GAVE – Gastric Antral vascular Ectasia – “Watermelon Stomach”

CAP -(Caliber Persistent Artery)- Dieulafoy Lesions

Question 29

GAVE – Gastric Antral vascular Ectasia – aka ….?

who gets these?
what are they?
a/w?
outcomes?

Answer 29

Elderly women

Dilated Capillaries with fibrin thrombi; in the setting of gastropathy

Autoimmune assocation

	• Can Bleed- acute or chronic - -but usually just chronic discomfort

Question 30

CAP -(Caliber Persistent Artery)

aka?
what is it?
outcomes?
managment?

Answer 30

Dieulafoy Lesions

• Large-caliber artery going up to surface — if it erodes just starts spurting tons of blood;

Recurrent bleeding without other symptoms

can be fatal

	• Typically managed endoscopically