Oesophageal and gastric pathology left over

Question 1

Define an ulcer

Answer 1

An ulcer is a local defect of the mucous membrane or the skin due to gradual disintegration of the surface epithelial cells

Question 2

What is the mechanism of action of a PPI?

Answer 2

-Binds irreversibly to H+/ATPase enzyme (proton pump) on gastric parietal cells and blocks secretion of H+, which combine in the stomach with Cl- to form HCL

Question 3

What is the action of HCL in the stomach?

Answer 3

-Activates pepsinogen to pepsin which helps in proteolysis
-Antimicrobial

Question 4

How can NSAIDs cause PUD?

Answer 4

-Prostaglandins are important for gastric mucosal protection: NSAIDS suppress their production (cyclooxygenase inhibitors)
-Topical irritant effect on epithelim
-Reduced gastric mucosal blood flow

Question 5

Why can hypercalcaemia cause peptic ulcer?

Answer 5

Hypercalcaemia –> increased gastrin release –> increased HCL production

Question 6

What are the common causes of hypercalcamiea?

Answer 6

-Hyperparathyroidism
-Malignancy
-Renal failure

Question 7

How can you localise parathyroid glands?

Answer 7

-Sestamibi scan (pre operative)
-Frozen section (intra operative)

Question 8

What is the epithelium of gastric mucosa in the antrum?

Answer 8

-Simple columnar with mucosal and goblet cells

Question 9

What immune endocrine diseases and malignancy associated with helicobacter infections?

Answer 9

-Hashimoto’s thyroiditis
-MALT
-Adenocarcinoma

Question 10

What is the histology of a parathyroid adenoma?

Answer 10

-Uniform, polygonal chief cells with small, centrally placed nuclei
-A few nests of larger oxyphil cells are present as well. Uncommonly, adenomas are composed entirely of this cell type (oxyphil adenomas)
-A rim of compressed, non-neoplastic parathyroid tissue, generally separated by a fibrous capsule, is often visible at the edge of the adenoma

Question 11

Where can you find the parathyroid gland if you do not see them in the normal position?

Answer 11

-The superior mediastinum: the thymus originates from the third branchial arch, so it occasionally drags the inferior glands down to the mediastinum

Question 12

How would you treat a parathyroid adenoma?

Answer 12

Excision

Question 13

What is the treatement of hypercalcaemia?

Answer 13

-Hydration
-Forced diuresis
-Bisphosphonates: IV pamidronate
-Calcitonin

Question 14

What is the normal lining of the oesophagus?

Answer 14

-Non keratinised stratified squamous

Question 15

What would be the cause of a pleural effusion in a pateitn with oesophageal adenocarcinoma

Answer 15

-Spread of cancer cells to pleura
-Lung mets
-Obstruction of thoracic duct

Question 16

In pt with pleural effusion and oesophageal carcinoma, what pathological test would you want to do?

Answer 16

Effusion cytology

Question 17

How can you treat such a pleural effusion

Answer 17

Palliative treatments
-Thoracocentesis
-Indwelling pleural catheters
-Pleurodesis
-Pleuroperitoneal shunting

Question 18

What is troponin?

Answer 18

A complex of three regulatory proteins (Troponin C, I and T) that is integral to muscle contraction

Question 19

Where is troponin found?

Answer 19

Cardiac muscle and skeletal muscle

Question 20

What is the pathogenesis of gastric carcinoma?

Answer 20

-Believed to develop by a sequence of pathological changes
-Normal mucosa –> chronic gastritis –> intestinal metaplasia –> dysplasia –> intramucosal carcinoma –> invasive gastric carcinoma

Question 21

Patient with LIF pain and gastric cancer. Surgery was done (gastrectomy with splenectomy) pathology report inside

On entering you are given a histopath report showing:
–> signet ring carcinoma
–> positive lymph nodes
–> margin positive
–> spleen involved

Discuss the report with the family

Answer 21

Discuss the pathology report with the family
–> cancer of the stomach
–> incomplete resection
–> high possibility of recurrence
–> patient will require further resection and chemotherapy

Question 22

Describe the classification of gastric cancer

Answer 22

WHO classification

–> Tubular adenocarcinoma: made up of different sized small branching tubules

–> Papillary adenocarcinoma: this tumour grows outward from stomach wall and contains finger-like growths that stick out into stomach cavity.

–> Mucinous addenomacrcinoma: lots of mucin (main substance in mucus) outside the cancer cells

–> Poorly cohesive carcinomas (including signet ring cell carcinoma and others): these are arranged into clumps of cancerous cells

–> mixed carcinoma: mix of types of adenocarcinoma of the stomach

Question 23

Describe the lauren classification

Answer 23

-Intestinal type: tumours are well differentiated, slow growing and tend to form glands. Found more often in men than women and occurs more in older people

-Diffuse type: tumour cells are poorly differentiated, behave aggressively and scatter throughout stomach (ratbher than form gladns). Metastasises much quicker than intestinal type

Question 24

7-10 days later after gastric ca the patient had axillary vein thrombosis, what predisposes to that?

Answer 24

-Hypercoagulable state in malignancy
-Venous stasis from virchow LN

Question 25

6 months later the patient came with ascites, deranged LFT, hepatic metastasis. What 2 pasthagolical tests would you do?

Answer 25

-Ascitic tap and cytology
-Liver biopsy from metastasis
-FNA from left supraclavicular lymph node

Question 26

How would you treat the patient with metastatic gastric ca with hepatic mets and ascies?

Answer 26

-Feeding jejunostomy
-Palliation of ascites by repeated tapping
-Anticipatory medications for symptom control
-Palliative chemotherapy

Question 27

What is the mechanism of malignant ascites in cirrhotic liver?

Answer 27

-Hypoalbuminaemia leading to raised oncoting pressure
-Portal hypertension leading to ascites

Question 28

What is the borrmann classification of gastric ca?

Answer 28

-Polypoid growth
-Fungating growth
-Ulcerating growth
-Diffusely infiltrating growth (linitis plastica)

Question 29

Which para-neoplastic syndromes are associated with gastric ca?

Answer 29

-acanthosis nigricans
-Dermatomyositis

Question 30

What are the procedure specific complications of total gastrectomy?

Answer 30

Early:
–> anastamotic leak
–> pancreatitis
–> cholecystitis
–> haemorrhage
–> infection

Late
–> dumping syndrome
–> vitamin B12 defiency (lack of intrinsic factor)
–> metabolic bone disease
–> recurrence of malignancy

Question 31

What is dumping syndrome?

Answer 31

-Loss of the resevoir function of the stomach (e.g. following gastrectomy) results in rapid transit of highly osmotically active substances into the duodenum following meals and may cause ‘dumping syndrome’

-Early dumping: 30-60 minutes following meal, rapid transit of hyperosmolar gastric contents into the small bowel results in a fluid shift from the intravascular compartment to the gastric luman and small bowel distension, colicky abdominal pain, diarrhoea and vasomotor symptoms, such as tachycardia and postural hypotension

-Late dumping: 1-3 hours following meals. Rapid transit of carbohydrate into the small bowel results in sudden absorption of high levels of glucose and compensatory hyperinsulinaemia resulting in subsequent hypoglycaemia