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GI- Week 5 > Nelson: Small Intestine and Colon Pathology > Flashcards

Nelson: Small Intestine and Colon Pathology Flashcards

1
Q

Crohns and ulcerative colitis are both forms of…

A

IBD

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2
Q

What is IBD?

A

Chronic inflammation d/t inappropriate mucosal immune response to luminal bacteria

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3
Q

How does IBD usually present? How do you dx?

A

Ages 15-30 OR 50-80 (less common)
Bloody diarrhea

Clinical presentation and colonoscopy

(10-20% of patients with Crohn’s or ulcerative colitis can have extra intestinal disease, sclerosing colangitis, erythema nodoa)

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4
Q

How do you tx IBD?

A

immunosuppression & resection for refractory cases

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5
Q

What complications are associated w/ IBD?

A
  1. UC fulminant colitis w/ toxic megacolon → perforation

2. CD bowel stricture & obstruction w/ perforation & fistula formation

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6
Q

What are the characteristics of crohn’s disease?

A

transmural inflammation
any part of the GI tract (*ileum)
skip lesions

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7
Q

A pt presents w/ mild diarrhea, fever, abdominal pain as well as sxs of malabsorption.

A

Crohns Disease

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8
Q

What gross pathological signs of crohns?

A
  1. Segmental, “patchy” disease
  2. Longitudinal deep ulcers
  3. Cobblestone appearance of mucosa @ sites where transverse ulcers are also present
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9
Q

What are microscopica signs of Crohns?

A
  1. small erosions w/ neutrophillic infiltrate

2. non-caseating granulomas

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10
Q

What are the characteristics of ulcerative colitis?

A

ONLY mucosa and superficial submucosa

limited to colon and rectum

continuous

LEFT sided

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11
Q

A pt presents w/ bloody diarrhea w/ mucous discharge, abdominal pain and cramps and tenesmus.

A

Ulcerative colitis

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12
Q

How does ulcerative colitis appear grossly?

A

inflammatory polyps

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13
Q

What does ulcerative colitis appear microscopically?

A

crypt distortion
dense lymphoplasmacytic infiltrate
neutrophillic crypt abscess

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14
Q

What is diversion colitis?

A

SCFA def>
colitis in distal, blind segment of colon (isolated from fecal stream) following surgery w/ diverting ostomy

Tx by res-establishing normal fecal stream

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15
Q

What is the pathology of diversion colitis?

A

mucosal erythema nad friability

nodular and aphthous ulcers (can mimic IBD)

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16
Q

What is radiation enterocolitis?

A

irradiation →
damage to epithelium acutely and ischemia chronically →
Mucosal changes

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17
Q

What mucosal changes are seen w/ radiation enterocolitis?

A

patchy erythema
mucosal telangiectasia
thickened vessel walls ( hyalinization with reduced luminal diameter)

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18
Q

What is normal necrotizing colitis?

A

transmural necrosis of small and large bowel in premature infants during 1st week of life

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19
Q

What is microscopic colitis?

A

autoimmune condition associated w/ celiacs disease

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20
Q

What are the two main types of ulcerative colitis?

A

Lymphocytic & Collagenous (both display intact crypt architecture)

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21
Q

A pt presents w/ watery diarrhea and a normal colon exam.
Dx?
Tx?

A

Microscopic collitis

Glucocorticoids

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22
Q

What is lymphocytic colitis?

A

normal crypt architecture
increased intraepithelial lymphocytes
increased lymphocytic and plasma cell infiltrate in the lamina propria

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23
Q

What is collagenous collitis?

A

intact crypt architecture and a thickened subepithelial collagen layer (arrows).

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24
Q

How do the pathological findings of lymphocytic and collagneous colitis differ?

A

LC: lamina propria inflam, intraepithelial lymphocytes, & epithelium damage

CC: band of subepithelial collagen is superior to inflammation

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25
Q

What drugs can cause drug induced enterocolitis?

A
  1. NSAIDS: may cause gastric, proximal duodenal, jejunal, ileal, or colonic erosions/ulcers. (can be confused w/ Crohn’s)
  2. CHEMO drugs: can cause lesions
  3. ABX: can result in pseudomembranous colitis, secondary to C. diff infection
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26
Q

A pt presents w/ chronic, relapsing abdominal pain, bloat & changed bowel habits w/ unknown etiology.

Endoscopic, colonoscopic and microscopic exams are normal.

A

IBS

Dx: clinical criteria, exclude organic causes

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27
Q

What factors contribute to IBS?

A

Colon transit rate changes
Excess bile
Enteric nervous system dysfunction
Immune activation or shift in microbiome

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28
Q

What is the Rome II diagnostic criteria for diagnosing IBS?

A

recurrent abd pain/discomfort >3 days/mo w/ 2+ of following

  1. Improvement w/ defecation
  2. Onset assoc. w/ change in frequency of stool
  3. Onset assoc. w/ change in form (appearance) of stool
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29
Q

What is sigmoid diverticulitis?

A

Increased intraluminal pressure → outpouchings at points where muscle is not continuous –>

Multiple inflamed diverticulae in the sigmoid colon → diverticulitis

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30
Q

A 63 y/o pt presents w/ lower abd discomfort, pain, and possible GI bleed.

  • 50% of pts are over 60
  • Pts are usually asymptomatic

Dx?
Tx?

A

Sigmoid Diverticulitis

Uncomplicated cases tx w/ clear diet, abx, & increased fiber

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31
Q

What are common complications of sigmoid diverticulitis?

A
  1. Inflammatory colitis in the affected sigmoid colon segment
  2. Perforation & abscess formation possible
  3. Complications> surgery
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32
Q

What is solitary rectal ulcer syndrome?

A

Malfuncitoning puborectalis→increased strain on defecation→rectal mucosal prolapse→ulceration + polypoid masses (inflammatory polyp) on anterior rectal wall

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33
Q

A young pt w/ bloody stool presents w/ pain on defecation and alternating constipation and diarrhea.

Dx?

A

Solitary Rectal Ulcer Syndrome

*can mimic adenocarcinoma or Crohns

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34
Q

What condition has fibromuscular hyperplasia of LP w/ inflammation and ulceration as well as reactive crypt hyperplasia?

A

Solitary Rectal Ulcer Syndrome

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35
Q

What are intestinal polyps?

A

Spontaneous or part of polypoisis syndrome

Inflamed, regenerating mucosa that projects above level of surrounding mucosa that is frequently ulcerated

Either:

  • sessile
  • pedunculated
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36
Q

What is the clinical significance of NON-neoplastic inflammatory polyp?

A

Assoc. w/ conditions like solitary rectal ulcer syndrome, ulcerative colitis & Crohn’s
• Occurs anywhere in GI tract
• In Ulcerative Collitis & Crohn’s Disease = “inflammatory psuedopolyps”

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37
Q

What the MC type of polyp in young children (but also seen in adults)

A

NON-neoplastic juvenile polyp AKA hamartomatous polyp

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38
Q

What are the two types of juvenile polyps?

A
  1. Sporadic → solitary polyp in colon (usually rectum)

2. Polyposis syndrome → multiple polyps in stomach, small bowel & colon (mut SMAD4> increased risk of adenocarincoma)

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39
Q

What percent of pts w/ juvenile polyposis syndrome may develop adenocarcinoma by age
45?

A

30-50%

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40
Q

What type of polyp appears rounded, smooth and unilobular w/ erythematous cap of eroded tissue?

A

classic juvenile polpy

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41
Q

What is Preutz Jeghers syndrome?

A

NON-neoplastic hamatomatous polyp

Pts present w/ multiple polyps and mucocutaneous hyperpigmentation

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42
Q

What is the MC site for PJ polyps?

A

small bowel> colon> stomach

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43
Q

PJ polyps that undergo STK11 loss of fxn mutation increase the risk of…

A

adenocarcinoma and other malignancies

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44
Q

What type of polyp is frequently peducnulated and has an aborizing smooth muscle pattern?

A

PJ polyp

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45
Q

What is the MC type of colonic polyp in adults?

A

NON-neoplastic Hyperplastic polyp

46
Q

Where are hyperplastic polyps usually found?

A

LEFT colon esp rectum

47
Q

What types of polyps contain glands that show serration in the mid portion?

A

Hyperplastic polyp

48
Q

What is an adenoma?

A

BENIGN but can become malignant

49
Q

Where are adenomas usually located?

A

COLON> small bowel (ampulla of d)

50
Q

What type of polyp is characterized by dysplastic glandular proliferation?

A

ADenoma

51
Q

If an adenoma has a high grade dysplasia it increases hte likelihood of…

A

adenocarcinoma

52
Q

What are the two types of adenomas?

A
  1. tubular (tubular proliferation of glands)

2. Villous (more likely to contain adenocarcinoma)

53
Q

What is sessile serrated syndrome?

A

Resembles hyperplastic polyps but LACKS adenomatous epithelium

HAS neoplastic potential

54
Q

Where is sessile serrated syndrome usually located?

A

RIGHT colon

55
Q

What accounts for 1% of CRC cases?

A

FAP

56
Q

What causes FAP?

A

AD germline mut in APC (TSG)

57
Q

A pt presents w/ a large number of adenomatous polyps in the colon and rectum in childhood/adolescence/early adulthood.

Dx?
Tx?

A

FAP

(>100 polyps)

Colectomy

58
Q

FAP increases the risk for what type of cancer?

A

GI adenocarcinoma

59
Q

How do Gardener’s syndrome and Turcot syndrome relate to FAP?

A

FAP variants w/ extra intestinal manifestations

60
Q

What pts develop desmoid tumors, osteomas, epidermal cysts, dental abnormalities, and thyroid tumors?

A

Pts w/ Gardener’s syndrome

61
Q

What is Turcot syndrome? What mutations are associated with that?

A

Coexistence of hereditary colon cancer syndrome along w/ CNS tumors

Some pts: APC mut → FAP → medulloblastoma (BRAIN)

Others: DNA mismatch mut → HNPCC → glioblastoma multiforme

62
Q

What causes HPNCC (Lynch syndrome)?

A

AR MMR mut> microsatellite instability>

increased risk of malignant transformation

63
Q

A pt presents before age 50 w/ multiple right sided colonic tumors as well as extra-colonic endometrial cancer.

Dx?

A

HPNCC

64
Q

What is the MC location of adenocarcinoma?

A

50% in duodenum

65
Q

What are RFs for small bowel adenocarcinoma?

A

FAP
Crohns disease (from dysplasia in the hileum)
Celiac disease

66
Q

A pt presents w/ sxs of bowel obstruction, bleeding, intussusception, or perforation and has tumors @ ampulla → bile obstruction, pancreatitis, jaundice.

Dx?

A

Small bowel adenocarcinoma

67
Q

What is the MC location for GI neuroendocrine tumors?

A

Ileum

68
Q

Where is a sml bowel functional tumor located? What can it lead to?

A

Duodenal tumors: some secrete gastrin → Zollinger-Ellison syndrome

69
Q

Where is a sml bowel non-functional tumor located? What can it lead to?

A

Jejunum & ileum: Often >2 cm w/ transmural invasion & metastasis

Carcinoid syndrome possible

70
Q

A pt presents w/ crampy abdominal pain, nausea, vomiting and weight loss.

A

Non-functional tumor

71
Q

What type of tumor presents as a bulky RIGHT sided high grade neuroendocrine carcinoma?

A

Colonic GI NE tumor (rare)

72
Q

What NE tumor presents as polyps <1cm and has a favorable prognosis?

A

Rectal NE tumor

73
Q

What NE tumor occurs at the tip of the appendix and leads to increased secretion of serotonin?

A

Appendix

Present in ALL ages

Asymptomatic and benign.

74
Q

What is associated w/ the use of anthraceneline laxatives?

A

melanosis coli (brown mucosa and lipofuscin like pigment in mucosal mphages)

75
Q

What is lymphomatosis polyposis?

A

small or large bowel lymphomas, usually B cell type.

Can be systemic or GI primary.

(Mantle cell lymphoma → lymphomatous polyposis)

76
Q

What is acute appendicitis?

A

acute inflammation involving at least the muscularis propria

77
Q

What is seen in severe cases of acute appendictis?

A

suppurative inflammation w/ gangrenous necrosis → perforation & suppurative peritonitis

78
Q

What is the pathogensis of appendicitis?

A

Obstruction (fecalith [stone-like mass of hard stool] or lymphoid hyperplasia following viral infection) → Increased intraluminal pressure → compromised venous outflow →
ischemic injury & stasis of luminal contents → bacterial overgrowth → trigger acute inflammatory response w/ edema and neutrophilic infiltration

79
Q

How does appendicitis appear grossly?

A

Thick purulent coating marked w/ hyperemia of serosa, increased appendix diameter

80
Q

How does appendicitis appear micro?

A

massive inflammatory infiltrate, extensive ulceration & hemorrohage.
Island of heavily inflamed mucosa

81
Q

A pt presents w/ periumbilical pain that localizes to RLQ, abd tenderness over McBruney’s pt and nauesea & vomiting following the abd pain.

Dx?

A

Acute appendicitis

MC in adolescents and young children

82
Q

What labs are used to dx appendicitis?

A

elevated WBC and neutrophil

83
Q

What imaging is used to dx appendicitis?

A

US- mucosal and submucosal walls have become discontinuous

CT- appendicolith, fluid inside appendix and free fluid

84
Q

What complications are associated w/ appendicitis?

A

Perforation w/ perappendiceal abscess

Pyelophlebitis

Portal venous thrombosis

Liver abscess

Bacteremia, sepsis

Death

85
Q

What are the two types of appendiceal carcinomas?

A
  1. Appendicular mucinous tumors

2. Signet ring adenocarcinoma

86
Q

What constitutes the majority of appendix tumors?

A

Appendicular mucinous tumors

87
Q

What are the different grades of Appendicular mucinous tumors?

A

Mucinous adenoma (mucinous cystadenomas) - confined to appendix, no high grade cytologic atypia or architectural complexity, and no invasion, often cystic (where it gets its name)

Low grade mucinous neoplasm – invasive, low grade cytology

Mucinous adenocarcinoma (invasive, high grade cytology)

88
Q

What is signet ring adenocarcinoma?

A

can occur in the appendix (or stomach) and its rare

VERY aggressive tumor that looks like colonic adenoma

89
Q

What is a pseudomyoxma peritonei?

A

presence of abundant mucinous material on the peritoneal surfaces

90
Q

What causes a pseudomyoxma peritonei?

A

Almost all cases d/t appendiceal mucinous tumors

91
Q

What is the pathology of pseudomyxoma peritonei?

A

Low grade mucinous adenocarcinoma – pools of mucin are acellualr or low, atypical cellularity

High grade mucinous adenocarcinoma – pools of mucin w/ high cellularity or high grade cytology

92
Q

What are hemorrhoids?

A

ectasia of rectal venous plexus d/t elevated venous P

93
Q

What are external hemorrhoids? and what causes them?

A

Straining at stool d/t constipation or venous stasis in pregnancy >
Dilation of superior rectal vessels BELOW the pectinate line

94
Q

What hemorrhoids can prolapse out of hte rectum?

A

internal

95
Q

A pt presents w/ rectal bleeding that is especially bright red on TP.

Dx?

A

Hemorrhoids

96
Q

How do you tx hemorrhoids?

A

sclerotherapy
rubber band ligation
hemorrhoidectomy (severe)

97
Q

What is an anal fissure?

A

linear separation of tissues of anal canal extending through mucosa

90% are posteriorly located and caused by firm BM

98
Q

What is an anal fistula?

A

tract may lead to skin or end blindly in the perianal soft tissue

99
Q

What are hte MC causes of anal fistula?

A

interspincteric abscess arising in anal duct d/t trauma, Crohn’s or UC

100
Q

What is a rectal prolapse?

A

Associated w/ straining at stool >
intussusception of rectum through anus d/t weak rectal support

*Common in elderly

101
Q

What is a condyloma accuminatum?

A

polypoid wart, HPV associated (STI)

papillary formations and acanthosis of the epithelium

102
Q

What is an anal epithelial neoplasm?

A

premalignant squamous dysplasia of anal canal, HPV associated (STI)

103
Q

What are the stages of AINs?

A

ANI – mild squamous dysplasia
ANII – moderate
ANIII – severe squamous dysplasia/ carcinoma in situ

104
Q

How does AIN present in immunocompromised individuals?

A

invasive cancer

105
Q

What type of neoplasm that is associated w/ HPV presents microscopically w/ thickened mucosa and an inflammatory lymphocytic infiltrate as well as atypia and increased mitotic activity?

A

AIN

106
Q

What is hte MC type of anal carcinoma?

A

SCC

107
Q

What is the primary RF for SCC?

A

HPV (esp type 16 and 18)

108
Q

Where do anal carcinomas MC arise and how does this relate to LN drainage?

A

at the pectinate line>
dual LN drainage>
Rectal OR inguinal LN

109
Q

A pt presents w/ anal bleeding, pain, a mass lesion, and pruritis.

Dx?

A

Anal carcinoma

110
Q

HOw do you tx advanced stage anal carcinoma?

A

radiation and chemo

GI- Week 5 (9 decks)

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