Path GI tract Flashcards
1.5cm long distal oesophageal mass is biopsied yielding diagnosis of adenocarcinoma. Origin of lesion most likely ? Rob p553
- Barrett’s oesophagus
- Extension from adjacent Ca lung
- Extension from fundal Ca stomach
- Barrett’s oesophagus
- Barrett’s oesophagus Adenocarcinoma : 30 - 40X increased risk with > 2cm of Barrett mucosa. UTD: most if not all oesophageal adenocarcinoma arises from Barrett’s metaplasia.
2.Tracheo-oesophageal fistula, MOST COMMON ? Rob p549
- Proximal fistula, distal blind pouch
- “H” type
- Distal fistula, proximal pouch
- Misnomer because no atresia
- Misnomer because no fistula
- Distal fistula, proximal pouch
- Tracheo-oesophageal fistula, MOST COMMON ? Rob p (TW)
- Proximal fistula, distal blind pouch
- “H” type
- Distal fistula, proximal pouch - T - oesophageal atresia and tracheo oesophageal fistula not in communication with proximal oesophagus (82%)
- Misnomer because no atresia
- Misnomer because no fistula
3.Classic appearance of Malloy Weiss tear is ? Rob p550
- Linear at gastro-oesphageal junction
- Linear with hiatus hernia
- Undermined proximal mucosa
- Circular at GOJ
- Circular with
- Linear at gastro-oesphageal junction
- Classic appearance of Malloy Weiss tear is ? Rob p768 (–)
1.Linear at gastro-oesphageal junction (linear lacerations in axis of oesophagus lumen, at or below the G-E junction)
2.Linear with hiatus hernia
3.Undermined proximal mucosa
4.Circular at GOJ
5.Circular with
Note : Boerhaave syndrome = oesophageal rupture (rare)
4.What are risk factors for malignancy in a stomach ulcer ?
- pernicious anaemia
- Crohn’s disease
- coeliac disease
- H. Pylori
- pernicious anaemia
- H. Pylori
4.What are risk factors for malignancy in a stomach ulcer ?
Not sure if this means an ulcerating malig lesion vs malig tranformation of a benign ulcer (rare)… (GC & TW)
- pernicious anaemia (Pernicious anaemia + gastritis- 3x risk only)
- Crohn’s disease
- coeliac disease (lymphoma)
4.H. Pylori (H.P associated chronic gastritis is assoc. with 5x increased risk – Robbins middle p556)
Long-term risk of gastric cancer in Autoimmune gastritis = 2 – 4%
Even in heavily colonized stomachs, the organisms are absent from areas with intestinal metaplasia
As such, they probably account for the increased incidence of gastric cancer in atrophic forms of gastritis, particularly in association with pernicious anemia
2004 QUESTION SAID OCCURS IN AREAS OF ATROPHY
- Malignant gastric ulcer. What would be the indicator of malignancy? Rob p561
- > 4cm diameter
- single ulcer of greater curvature
- heaped edges
- heaped edges
- Malignant gastric ulcer. What would be the most concerning for malignancy? Rob p780 (TW)
- > 4cm diameter - size does not diffentiate a benign from malignant ulcer, usually less than 2cm)
- single ulcer of greater curvature – Robbins p780 – size & location do not differentiate benign & malignant ulcers. location of gastric carcinoma within stomach is: pylorus and antrum 50-60%; cardia 25%; remainder in body an fundus. The lesser curvature is involved in about 40% and the greater curvature in 12%. Thus, a favored location is the lesser curvature of the antropyloric region. Although less frequent, an ulcerative lesion on the greater curvature is more likely to be malignant.
- heaped edges - heaping up of the margins is rare in the benign ulcer but is characteristic of the malignant lesion.
6.Stomach cancer, which is NOT TRUE? Rob p561
- Benign ulcers on lesser curvature at antrum
- Alcohol is not a risk factor
- Most common is adeno-carcinoma/ then lymphoma/ then carcinoid/then GIST
- Early gastric cancer is confined to the mucosa/submucosa with negative perigastric nodes
- Macro – excavated, exophytic,flat
- Early gastric cancer is confined to the mucosa/submucosa with negative perigastric nodes
- Stomach cancer, which is NOT TRUE? Rob p784 (TW)
- Benign ulcers on lesser curvature at antrum - T - gastric ulcers are predominantly located along the lesser curvature, in or around the border zone between the corpus and the antral mucosa.
- Alcohol is not a risk factor - T
- Most common is adenocarcinoma/ then lymphoma/ then carcinoid/then GIST - T - Adeono 90-95%, Lymphoma 4%, Carcinoids 3%, malignant stromal cell tumours (2%).
- Early gastric cancer is confined to the mucosa/submucosa with negative perigastric nodes - F - regardless (ie not influenced by) of presence of perigastric nodes (Robbins).
- Morphological types – excavated, exophytic or flat (true)
Note : Ulcerated carcinomas usually have nodular raised margins with “dirty” necrotic bases, and lack surrounding radiating folds
Early gastric carcinoma: lesion confined to mucosa and submucosa, regardless of presence or absence of perigastric lymph node metastases.
Advanced gastric carcinoma: neoplasm that has extendd below the submucos into the muscular wall.
**LJS - Depth of invasion and extent of nodal spread/mets at dx most imp indicator of prognosis
If found early and surgical resection still possible, 5YS 90% even if nodal mets present
7.Which of the following statements concerning GIT diseases IS INCORRECT:
- Most gut lymphomas are T-cell type
- Villous adenomas are most common in the rectum
- In Hirshsprung’s Disease, the rectum is always involved
- Angiodysplasia is most common in the proximal colon
- Necrotising enterocolitis is most common in neonates
- Most gut lymphomas are T-cell type
- Which of the following statements concerning GIT diseases IS INCORRECT: (JS)
- Most gut lymphomas are T-cell type - F - most are B cell lymphomas (90%)
- Villous adenomas are most common in the rectum - T - only 1% of adenomatous polyps, more common in rectum and rectosigmoid but can occur anywhere.
- In Hirshsprung’s Disease, the rectum is always involved - T
- Angiodysplasia is most common in the proximal colon - T - most common in caecum and right colon
- Necrotising enterocolitis is most common in neonates - T
8.Coeliac disease. What is the least likely?
- anti-gliadin antibodies
- treatment prevents development of lymphoma
- treatment prevents development of lymphoma
- Coeliac diseasease What is the least likely? (JS)
- anti-gliadin antibodies - T - due to a sensitivity to gluten (gliadin)
2.treatment prevents development of lymphoma - F - there is a long term risk of malignant disease at 2 times the usual rate - intestinal lymphomas (including disproportionately high number of T-cell lymphomas) and GIT and breast cancers.
SK – UTD 2011 – “Whether the degree of compliance with a gluten-free diet influences the rates of these cancers is uncertain. In one study, the increased risk of non-Hodgkin lymphoma persisted for five years after diagnosis despite adherence to a gluten-free diet”
- Celiac disease associated with?
- Less than 2x risk of malignancy
- Bowel wall thinning
- LW:
- Option stated LESS than 2x risk of cancer, most of the large research studies quote risks > 2, so this answer is favored to be FALSE.
- Bowel wall thinning, seems a non specific term, but given villi are part of the bowel wall, and there is villous atrophy, I would favour this to be correct.
- Less than 2x risk of malignancy
- Coeliac disease associated with? Rob p571 (JS)
1.2x risk of malignancy - T - there is a long term risk of malignant disease at 2 times the usual rate - intestinal lymphomas (including disproportionately high number of T-cell lymphomas) and GIT and breast cancers.
SK – studies give variable numbers for increased risk of malignancy, would be safe with at least double risk (more like 5 x’s for lymphoma)
2.Bowel wall thinning - F - crypts are elongated, hypoplastic and tortuous but the overall mucosal thickness remains the same
**LJS - Rob just says incr lymphoma/adenoca, no indictation of how much.
Loss of mucosal and brush border surface area = malabsorption
- Coeliac disease, most correct statement is
- definitive diagnosis is shown by showing histological total villous atrophy
- 10-20% have anti-gliadin Ab’s without having the disease
- Coeliac disease, T/F (JS)
- definitive diagnosis is shown by showing histological total villous atrophy - T - diagnosis requires documentation of malabsorption, demonstration of intestinal lesion by small bowel biopsy and improvement in symptoms with gluten free diet.
- 10-20% have anti-gliadin Ab’s without having the disease - T - 90% of patients with coeliac disease will have a positive IgA AGA before treatment but 10-20% of people will have a false positive IgA AGA and a normal small bowel biopsy. IgG EMA (Endomysial antibodies) has a much lower false positive rate (1%) and is found in 95-100% of patients with the disease.
- Which of the following statements concerning gastrointestinal diseases is most correct?
- The colon is the most common site for GIT lymphoma
- Pseudomembranous colitis is due to toxins of clostridium difficile
- Inflammatory pseudo-polyps are a characteristic feature of Crohn’s colitis
- Apthous ulcers are a characteristic feature of ulcerative colitis
- Juvenile polyps typically occur in the ascending colon.
2.Pseudomembranous colitis is due to toxins of clostridium difficile
- Which of the following statements concerning gastrointestinal diseases is most correct? (JS)
- The colon is the most common site for GIT lymphoma - F - Stomach (55-60%), small intestine (25-30%), proximal colon (10-15%) and distal colon (10%) with appendix and oesophagus rarely involved.
- Pseudomembranous colitis is due to toxins of clostridium difficile - T - Caused by exotoxins A and B of C. difficle after antibiotic therapy
- Inflammatory pseudo-polyps are a characteristic feature of Crohn’s colitis - F - associated with UC but can occur in Crohns
- Apthous ulcers are a characteristic feature of ulcerative colitis - F - associated with Crohns
- Juvenile polyps typically occur in the ascending colon. - F - hamartomatous malformations of mucosa, typically in the rectum
- In which one of the following are granulomas NOT a characteristic feature?
- Crohn’s disease
- Sarcoidosis
- Foreign body response
- Ulcerative colitis
- Tuberculosis
4.Ulcerative colitis
- In which one of the following are granulomas NOT a characteristic feature? (JS/SK)
- Crohn’s disease – found in 50-60% (characteristic??), non-caseating
- Sarcoidosis T non-caseating
- Foreign body response T
- Ulcerative colitis F
- Tuberculosis T caseating
- Which of the following IS NOT a recognised feature of diverticular disease of the colon:
- Hypertrophy of the circular muscle layer of the bowel
- Dissection into the appendices epiploicae
- Crypt abscesses
- Fistulae
- Haemorrhage
3.Crypt abscesses
- Which of the following IS NOT a recognised feature of diverticular disease of the colon: (JS)
- Hypertrophy of the circular muscle layer of the bowel - T
- Dissection into the appendices epiploicae - T
- Crypt abscesses - F - Typical lesion of UC - collections of neutrophils within crypt lumens
- Fistulae - T
- Haemorrhage - T
- Concerning carcinoid tumours of the gastro-intestinal tract, which of the following statements IS LEAST correct:
- The appendix is the most common site
- They have a characteristic desmopiostic reaction
- They are benign tumours
- A characteristic feature is a solid, yellow-tan appearance on transections
- They are a more common small bowel neoplasm than primary adenocarcinomas
3.They are benign tumours
14.Concerning carcinoid tumours of the gastro-intestinal tract, which of the following statements IS LEAST correct: (JS)
1.The appendix is the most common site - T - Appendix most common, followed by terminal ileum, stomach, rectum & colon
*LW:
More recent robbins has jejunum and ileum as > 40%, and appendix < 25%, while stat Dx has 90% of jejunal-ileal carcinoids being in ileum (of total 45%), while appendix only 16%.
So although option 5 is not true, I think option 2 is more incorrect, especially based on older Robbins data, likely from which question was written.
- They have a characteristic desmoplastic reaction - T
- They are benign tumours - F - all are potentially malignant
- A characteristic feature is a solid, yellow-tan appearance on transactions - T - Solid, yellow-tan appearance on cut section
- They are a more common small bowel neoplasm than primary adenocarcinomas - T - most common lesion of small bowel – about the same incidence (both about half)
- Amebiasis which is TRUE ? Rob p314,569 Dan p791
- Organsism is Ngareri foweri
- Invasion through mucosa into Peyers patches
- 10% of infected people have dysentry
- cysts release trophozoites secondary to pancreatic enzymes (? Pancreatic ?)
- release exotoxin and denude epithelium
- 10% of infected people have dysentry
- Amebiasis which is TRUE ? Rob p806 (JS)
- Organism is Ngareri Fowleri - F - Entamoeba histolytica
- Invasion through mucosa and into peyers patches - F - invade the crypts of the colonic glands and burrow through the lamina propria and are halted by the muscularis mucosae.
- 10% of infected people have dysentery - T
- Cysts release trophozoites secondary to pancreatic enzymes. - F - release trophozoites under anaerobic conditions in colon (cysts resistant to gastric acid)
- Release exotoxin and denude epithelium - F - This is referring to C difficle in pseudomembranous colitis. Amoebae produce proteins involved in tissue invasion including proteinases, lectin and amebapore, resulting in ulcers and sloughing of the mucosa
- Crohn’s disease in counselling a sibling of risk
- 1% risk
- No increased risk
- 10% risk.
- 10% risk.
- Crohn’s disease in counselling a sibling of risk (JS)
- 1% risk
- No increased risk
- 10% risk - T - lifetime risk if either a parent or sibling is affected is 9% (Robbins): PathOutlines 15% have affected first degree relatives
- Crohns disease is NOT ASSOCIATED with ?
- Hydronephrosis
- Carcinoma
- Hip arthopathy
- Sclersoing cholangitis
- Sclerosing peritonits
- Sclerosing peritonits
* LW: agree this is least likely, not mentioned in robbins or radiopedia - Crohns diease is NOT ASSOCIATED with ? Rob p573 (JS)
- Hydronephrosis - obstructive uropathy (calcium oxalate urolithiasis)
- Carcinoma - increased risk (not as high as UC)
- Hip arthopathy - sacroiliitis and polyarthritis (enteropathic arthritis)
- Sclerosing cholangitis - yes
- Sclerosing peritonitis - T - associated with peritoneal dialysis
- Patient with ulcerative colitis with elevated CEA (Carcinoembryonic antigen)? Rob p574, 208,585
- Likely colon cancer
- May be colon cancer but also raised in UC active inflammation
- Active ulcerative Colitis
2.May be colon cancer but also raised in UC active inflammation
- Patient with ulcerative colitis with elevated CEA (Carcinoembryonic antigen)? Rob p574, 208,585 (JS)
- Likely colon cancer
- May be colon cancer but also raised in UC active inflammation - T - produced in embryonic tissue of the gut, pancreas and liver. Elevated in 60-90% of colorectal, 50-80% of pancreatic and 25-50% of gastric and breast cancer. Also elevated in cirrhosis, hepatitis, UC, Crohns and in smokers. Lacks specificity and sensitivity for early cancer detection but can be used in prognosis and detection of recurrence.
- Active ulcerative Colitis
19.Which does not cause bowel obstruction? Rob p578
- Tuberous Sclerosis
- GVHD
- Collagen vascular disorders
- Viral infections
- Ingested toxins
3.Collagen vascular disorders (scleroderma, dermatomyositis – muscle dysfunction – marked dilatation of small bowel simulating small bowel obstruction)
- Which does not cause bowel obstruction? mRob (–)
- Tuberous Sclerosis ?? by leiomyoma ??
- GVHD
- Collagen vascular disorders (scleroderma, dermatomyositis – muscle dysfunction – marked dilatation of small bowel simulating small bowel obstruction)
20.In colonic polyps which is TRUE ? Rob p579
- Peutz Jeger is sporadic hamartomatous polyps
- HNPCC (Hereditary Nonpolyposis Colorectal Cancer) not associated with adenoma
- Most common type in adults is villous
- Juvenille polyps occur in ileum
2.HNPCC (Hereditary Nonpolyposis Colorectal Cancer) not associated with adenoma
*LW: probably most true out of options listed:
Robbins states: HNPCC…adenomas occur in low numbers and considerably earlier than in genral population, however colonic malignancies that develop are multiple and not usually associated with pre exisiting adenomas. Hallmark is mutations in DNA repair genes.
20.In colonic polyps which is TRUE ? Rob p815 (JS)
1.Peutz Jeger is sporadic hamartomatous polyps - F - Autosomal dominant syndrome (not sporadic) characterised by multiple hamartomatous polyps
2.HNPCC (Hereditary Nonpolyposis Colorectal Cancer) not associated with adenoma – T/F -
JS: HNPCC is characterised by familial carcinoma of the colon, affecting predominantly caecum and proximal colon, which DON’T arise within adenomatous polyps.
SK: Robbins & Mayo both mention adenomatous polyps occurring in HNPCC. Other reference (SemSurgOnc 1995) “It appears that HNPCC patients form adenomas at about the same rate as the general population and there is circumstantial evidence that adenoma is the precursor to colorectal carcinoma in the syndrome. It is hypothesized that HNPCC features accelerated progression from colonic adenoma to carcinoma”
3.Most common type in adults is villous - F - Tubular adenomas are the most common (90%) followed by tubulovillous (5-10%) then villous (1%)
4.Juvenille polyps occur in ileum F - Focal hamartomatous polyps found most frequently in the rectum in children younger than 5y
21.Adenomatous polyps are NOT a feature of ? Rob p820
- Gardners Syndrome
- Familial Polyposis
- Turcot’s Syndrome
- Peutz-Jeghers Syndrome
- Sessile Villous lesions
- Peutz-Jeghers Syndrome
- Adenomatous polyps are NOT a feature of ? (JS) Rob p815
- Gardners Syndrome - F - AD variant of FAP with intestinal polyps, osteomas and soft tissue tumours
- Familial Polyposis - F - AD disorder with innumerable adenomatous polyps with progression to adenocarcinoma in 100%
- Turcot’s Syndrome - F - rare variant of Gardners syndrome with colonic polyposis and tumours of the CNS
- Peutz-Jeghers Syndrome - T - hamartomatous lesions which don’t have malignant potential themselves, but patients have an increased risk of colon & other cancers (pancreas, breast, lung, ovary and uterus)
- Sessile Villous lesions - F - type of adenomatous polyps
22.Following associated with increased risk of bowel malignancy EXCEPT? Rob p579
- Obesity
- Diabetes
- Crohns
- Meat/low fibre diet
- Diabetes
- Following associated with increased risk of bowel malignancy EXCEPT? Rob p579 (JS)
1.Obesity
2.Diabetes - T
3.Crohns
4.Meat/low fibre diet
Risk factors for colorectal cancer include diet (low fibre, high intake of refined carbs, intake of red meat, reduced intake of protective micronutrients such as vitamins A, C and E), obesity, physical inactivity, family history, IBD, previous XRT, FAP, HNPCC.
23.A 60 year old male has colonic carcinoma which involves muscularis mucosa. No regional lymph nodes, no distant metastasis. What is prognosis? Rob p582
- 100% 5 year survival
- 95% 5 year survival
- 60% 5 year survival
- 40% 5 year survival
- 10% 5 year survival
- 60% 5 year survival
- A 60 year old male has colonic carcinoma which involves muscularis mucosa. No regional lymph nodes, no distant metastasis. What is prognosis? Rob p582 (–) (GC & TW)
- 100% 5 year survival
- 95% 5 year survival
- 67% 5 year survival B1 = 67% (path notes); TNM staging is 90%
- 40% 5 year survival
- 10% 5 year survival
*LW:
RP Dukes staging prognosis:
Overall 5-year survival rate is 40-50%, with the stage at operation the single most important factor affecting prognosis.
Duke A: 80-90%
Duke B: 70%
Duke C: 33%
Duke D: 5%
This tumour is T1 or Duke B1
STAGING
Single most important prognostic indicator = extent of tumour at time of diagnosis
Modified Dukes Classification / Astler-Coller Staging:
A Limited to the mucosa (TNM – ‘T is’ (in situ))
B1 Extending into but not through muscularis propria, no nodal spread (TNM – T1)
B2 Through muscularis propria, no nodal spread (TNM – T2)
C1 Into muscularis propria + nodal spread (ie B1 + nodes)
C2 Through muscularis propria + nodal spread (ie B2 + nodes)
D Distant metastases
Staging can only be applied after resection of neoplasm and surgical exploration
Recurrences most common (10%):
at operation site, near anastomoses
in peritoneal cavity
in liver and distant organs
PROGNOSIS
Related to stage:
A = ~100% 5YS
B1 = 67% MR says for TNM staging prognosis is 90%
B2 = 54% MR says for TNM is 78%
C1 = 43%
C2 = 23%
Overall 5 year survival 40 – 50%
24.Commonest site for adenocarcinoma colon commonest to rarest are ? Rob p582
- Caecum and ascending colon (38%) > Sigmoid (35%)> transverse (18%)> descending (8%) > multiple sites (1%)
- Rectosigmoid > Ascending > Transverse > Descending
- Ascending > Descending > Rectosigmoid > transverse
*LW Robbins states: Rectosigmoid 55% Cecum / ascending 22% Tarnsverse 11% Descending 6% Other sites 6%
**LJS - new Rob says equally distributed over the entire length of the colon