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Pathology Flashcards

1
Q

What is a polyp?

A

A protrusion above an epithelial surface

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2
Q

Classify the vast amount of polyps in the large bowel

A

Benign, epithelial and neoplastic

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3
Q

Differential diagnosis of a colonic polyp

A

Adenoma
Serrated polyp
Polypoid carcinoma
Other

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4
Q

Three macroscopic appearances of removed colonic polyps

A

Pedunculated
Sessile
Flat

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5
Q

Explain adenoma of the colon

A

Benign tumours of the colon. Not yet invasive, and do not metastasise. All dysplastic = must be removed

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6
Q

Adenoma-Carcinoma Sequence

A

Normal epithelium -> mutations to APC -> small adenoma -> further mutation e.g. k-ras -> large adenoma -> chromosomal mutations e.g. p53 -> Invasive adenocarcinoma

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7
Q

Why remove all adenomas?

A

They are premalignant

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8
Q

Removal of adenomas by…?

A

Endoscopy

Surgery

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9
Q

Primary treatment of Adenocarcinoma

A

Surgical removal of colon/rectum for staging

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10
Q

What kind of tumours are majorly found in the large bowel?

A

Malignant Adenocarcinomas

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11
Q

Colorectal Carcinoma - Dukes Staging

A

Dukes A = Confined by muscular propria
Dukes B = Through muscular propria
Dukes C = Metastatic to lymph nodes

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12
Q

Left Sided Colorectal Carcinoma

A

75%
P/R Bleeding
Altered Bowel Habit
Obstruction

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13
Q

Right Sided Colorectal Carcinoma

A

25%
Anaemia
Weight Loss

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14
Q

Colorectal carcinoma - Gross appearance

A

Varied =
Polypoid
Stricturing
Ulcerating

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15
Q

Colorectal carcinoma - Histopathological appearance

A

Typical adenocarcinoma

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16
Q

Colorectal carcinoma - Local invasion

A

Mesorectum, peritoneum, other organs

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17
Q

Colorectal carcinoma - Lymphatic spread

A

Mesenteric nodes

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18
Q

Colorectal carcinoma - Haematogenous spread

A

Liver, distant sites

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19
Q

Inherited Colorectal Carcinoma - HNPCC

A

Late onset (50/60s)

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20
Q

Inherited Colorectal Carcinoma - FAP

A 
Early onset (teens)
>100 polyps
Mutation to FAP gene
Tumours throughout colon
Adenocarcinoma NOS
Desmoid tumours & thyroid carcinomas
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21
Q

Diverticular Disease - Histopathology

A

Out-pouchings of mucosa

These are at increased risk of bursting and releasing septic contents into the abdominal cavity

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22
Q

Diverticular Disease - Complications

A 
Inflammation 
Rupture
Abscess
Fistula
Massive Bleeding
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23
Q

Ischaemia of the Large Bowel - Endoscopic View

A

Diffusely ulcerated and erythematous mucosa

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24
Q

Ischaemia of the Large Bowel - Histopathology

A

Withering of crypts
Smudging of lamina propria
Fewer chronic inflammatory cells

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25
Ischaemia of the Large Bowel - Aetiology
CVS disease, A Fib, Embolus, Atherosclerosis (usually IMA), Shock, Vasculitis
26
Ischaemia of the Large Bowel - Clinical Context
Elderly Left sided Segmental on endoscopy
27
Ischaemia of the Large Bowel - Complications
Massive Bleeding Rupture Stricture
28
Antibiotic-Induced "Pseudomembranous" Colitis - Endoscopic View and Gross Appearance
Speckled, spotted appearance | Patchy, yellow membranous exudate on mucosal surface
29
Antibiotic-Induced "Pseudomembranous" Colitis - Histopathology
Explosive fibrinopurulent exudate on surface (volcano lesions)
30
Antibiotic-Induced "Pseudomembranous" Colitis - Causes
Patients in broad spectrum of antibiotics - C Diff proliferates Toxins A and B attack endothelium and epithelium, causing mini-infarcts along the membrane
31
Antibiotic-Induced "Pseudomembranous" Colitis - Symptoms
Massive diarrhoea and bleeding
32
Antibiotic-Induced "Pseudomembranous" Colitis - Treatment
Flagyl/Vancomycin May need colectomy May be fatal
33
Collagenous Colitis - Appearance
``` Endoscope = Normal Histology = Increase in thickness of sub epithelial collagen ```
34
Collagenous Colitis - Clinically
Watery diarrhoea Normal endoscopy History of causative drugs
35
Lymphocytic Colitis - Appearance
``` Endoscope = Normal Histology = Normal architecture, but massive increase in intraepithelial lymphocytes ```
36
Lymphocytic Colitis - Clinically
Watery diarrhoea Normal endoscopy Raise possibility of Coeliac disease
37
Radiation Colitis - Endoscopy Appearance
Red, angry bowel
38
Radiation Colitis - Histology
Bizarre stream cells | Bizzarre vessels
39
Radiation Colitis - Cause
History of cervical/prostate cancer | Radiation therapy damaged cells
40
Acute (infective) Colitis _ Endoscopy Appearance
Very red Very ulcerated Very inflamed
41
Acute (infective) Colitis - Histology
Busy epithelium but not crypt irregularity | Florid diffuse acute cryptitis
42
Acute (infective) Colitis - Causes
Infection | Rarely: Drugs, ischaemia, endoscopy prep.
43
Acute (infective) Colitis - Diagnosis
Stool sample culture
44
Normal Appearance of the Liver
Light, tan in colour | Smooth regular surface
45
Pathogenesis of Liver Disease
Insult to hepatocytes Inflammation Fibrosis Cirrhosis
46
Causes of Acute Onset of Jaundice
Viruses Alcohol Drugs Bile duct obstruction
47
Histological Appearance of Paracetamol Poisoning
Confluent necrosis produce massive acute necrosis and liver failure (lots of hepatocyte death)
48
Consequences of Acute Liver Failure
Complete recovery Chronic liver disease Death from liver failure
49
Pre-Hepatic Jaundice
Too much harm to break down Haemolysis of any cause Haemolytic anaemias Unconjugated billrubin
50
Hepatic Jaundice
``` Liver cells injured or dead Acute liver failure Alcoholic hepatitis Cirrhosis (decompensated) Bile duct loss Pregnancy Conjugated jaundice ```
51
Post-Hepatic Jaundice
``` Biel cannot escape into the bowel Congenital biliary atresia Gallstones blocking CBD Strictures of CBD Tumours ```
52
Appearance of a Cirrhotic Liver
Nodular, craggy, scarred
53
Histological Appearance of Cirrhosis
Bands of fibrosis separating regenerative nodules of hepatocytes Loss of function of hepatocytes due to alteration of hepatic microvasculature
54
Complications of Cirrhosis
Portal hypertension = Oesophageal varices Caput medusa Rectal varices Ascites Liver Failure
55
Alcoholic Liver Disease - Pathology Influenced By
Extent of the alcohol abuse | Individual factors
56
Pathogenesis of Alcoholic Liver Disease
Increased peripheral release of fatty acids Increased synthesis of fatty acids within the liver cells Acetaldehyde, a product of alcohol metabolism, is probably responsible for liver cell injury (manifested by the formation of Mallory's hyalin) Increased collagen synthesis by fibroblasts
57
Appearance of Alcoholic Fatty Liver - Days
Yellow | Greasy
58
Histological Appearance of Alcoholic Fatty Liver - Days
Fat vacuoles appear clear in hepatocytes
59
Histological Appearance of Alcoholic Fatty Liver - Heavy Drinking Weeks to Months
Accumulation of bile Hepatocytes with thick dark pink cytoplasm Accumulation of neutrophils
60
Histological Appearance of Alcoholic Fatty Liver - Heavy Drinking Months to Years
Collagen played down around cells | Collagen appears blue
61
Appearance of Alcoholic Cirrhosis
Micro-nodular cirrhosis with abundant white scarring
62
Histological Appearance of Alcoholic Cirrhosis
Bands of fibrosis separating regenerative nodules
63
Alcoholic Liver Disease - Outcome
``` Cirrhosis Portal hypertension Malnutrition Hepatocellular carcinoma Social disintegration ```
64
Non-Alcoholic Steatohepatitis
Non-drinkers Pathologically identical to alcoholic liver disease Occurs in patients with diabetes, obesity, hyperlipidaemia May lead to fibrosis and cirrhosis Increasing incidence
65
Common causes of viral hepatitis
Hep A, B, C, E
66
Rarer causes of viral hepatitis
``` Hep D Epstein-Barr virus Yellow fever virus Herpes Simplex virus Cytomegalovirus ```
67
Hepatitis A - Histological Appearance
Death of hepatocytes Directly cytopathic No immunological phase
68
Chronic Viral Hepatitis -Histological Appearance
Visible immune cells are damaging the liver Dense portal chronic inflammation (erodes the border) Interface hepatitis (piecemeal necrosis) Fibrosis forms bridges between different portal areas (bridges filled with collagen) Cirrhosis Not distinguishable from other chronic hepatitis causes
69
Hepatits B - Outcomes
``` Fulminant acute infection (death) Chronic hepatitis Cirrhosis Hepatocellular carcinoma Asymptomatic (carrier) ```
70
Hepatitis C - Outcomes
Chronic hepatitis | Cirrhosis
71
Causes of Chronic Hepatitis
Viruses = Hep B and C Drug induced Autoimmune = Primary biliary cirrhosis/cholangitis Autoimmune hepatitis Primary sclerosing cholangitis
72
Primary Biliary Cirrhosis - Aetiology and Clinical
Rare autoimmune disease, unknown aetiology Associated with autoantibodies to mitochondria Females (90%) Biopsy is to stage disease or diagnose uncertain cases Outcome is unpredictable
73
Primary Biliary Cirrhosis - Histological Appearance
Chronic portal inflammation Inflamed bile ducts Granulomas around bile ducts Cirrhosis
74
Primary Biliary Cholangitis - Pathogenesis
If untreated, bile duct loss leads to cholestasis liver injury, inflammation, fibrosis and cirrhosis
75
Autoimmune Hepatitis - Clinical
Commoner in females Associated with other AI Chronic hepatitis pattern May have triggers, including some drugs
76
Autoimmune Hepatitis - Histological Appearance
Numerous plasma cells Autoantibodies to smooth muscle, nuclear or LKM Raised IgG
77
Chronic Drug-Induced Hepatitis - Clinical
Similar features to all other types of chronic hepatitis May trigger an autoimmune hepatitis Chronic active process Many causes
78
General Points about Drugs and the Liver
Innumerable drugs can damage the liver May be dose related or idiosyncratic Can cause hepatitis, granulomas, fibrosis, necrosis, failure, cholestasis or cirrhosis Can mimic any liver disease
79
Primary Sclerosing Cholangitis - Clinical
Chronic inflammatory process affecting intra- and extra-hepatic bile ducts Leads to pericardial fibrosis, duct destruction, jaundice and fibrosis Associated with UC More common in males Increased risk of malignancy in bile ducts and colon
80
Primary Sclerosing Cholangitis - Histological Appearance
Periductal onion-skinning fibrosis | Loss/damage of bile ducts
81
Storage Disease - Types
Haemochromatosis Wilsons Disease Alpha-1-Antitrypsin Deficiency
82
What is haemochromatosis?
Excess iron within the liver
83
Primary Haemochromatosis - Causes
``` Genetic condition Inherited autosomal recessive condition Gene defect very complex Exces absorption of iron from intestine, abnormal iron metabolism Worse in homozygotes, men ```
84
Primary Haemochromatosis - Histological Appearance
Iron accumulates in hepatocytes | Iron confirmed by Perls Stain
85
Primary Haemochromatosis - Clinical
Iron deposited in liver, assymptomatic for years Eventually deposited in portal connective tissue and stimulates fibrosis Cirrhosis if not treated Predisposes to carcinoma Also causes diabetes, cardiac failure and impotence
86
Secondary Haemochromatosis - Causes
Iron overload from diet Transfusions Iron therapy
87
Haemochromatosis - Outcomes
Depends on genetics, therapy (venesection), cofactors like alcohol Cirrhosis Hepatocellular carcinoma
88
Wilson's Disease
Inherited autosomal recessive disorder of copper metabolism Copper accumulates in liver and brain (basal ganglia) Kayser-Fleischer rings at corneal limbus Low serum caeruloplasmin Causes chronic hepatitis and neurological deterioration
89
Alpha-1-Antitrypsin Deficiency
Inherited autosomal recessive disorder of production of an enzyme inhibitor Causes empysema and cirrhosis Cytoplasmic globules of unsecreted globules of protein in liver cells
90
Tumours of the Liver
Primary (rare) Hepatocellular adenoma Hepatocellular carcinoma (Hepatoma) Secondary (common) Multiple Metastases from colon, pancreas, stomach, breast, lung and others
91
Hepatocellular Adenoma
Benign Females May become large - can rupture or bleed Most remain asymptomatic
92
Hepatocellular Carcinoma
Rare in Europe Associated with Hep B, Hep C, Cirrhosis, PBC, PSC Usually presents as mass, pain, obstruction usually advanced unless discovered incidentally Poor prognosis
93
Hepatocellular Carcinoma - Histopathological Types
``` Hepatocyte = Malignant tumour of liver cells Cholangio = Malignant tumour of bile ducts ```
94
What is Cholelithiasis?
Gallstones | Defined as hard stone-like or gravel-like material formed within the biliary system most commonly the gallbladder
95
What is normal bile made from?
Micelles of cholesterol, phospholipid, bile salts and bilirubin
96
Where is normal bile stored and how is it released?
Stored and concentrated in gallbladder, released by common cystic duct into the 2nd part of the duodenum through common bile duct and Ampulla of Vater
97
Pathogenesis of Cholesterol Gallstones
Gallstones form when there is an imbalance between the ratio of cholesterol to bile salts, disrupting micelle formation Free crystallisation on micelle surface
98
Risk Factors for Cholesterol Gallstones
``` Cholesterol excess in bile Female Obesity Diabetics Genetic ```
99
Pathogenesis of Pigment Gallstones
Excess bilirubin cannot be solubilised in bile salts | Tend to be black
100
Risk Factors for Pigment Gallstones
Excess bilirubin Due to excess haemolysis e.g. Haemolytic anaemia
101
Pathogenesis of Gallstones
Gallbladder pH and mucosal glycoproteins may be contributory factors Infection and inflammation of biliary lining Most gallstones are a mixture (mixed stones) Pure cholesterol and pure pigment stones do occur Calcium carbonate stones do occur
102
Pathology of Gallstones
``` Acute Cholecystitis Chronic Cholecystitis Mucocoele Empyema Carcinoma Ascending Cholangitis Obstructive Jaundice Gallstone Ileus Acute Pancreatitis Chronic Pancreatitis ```
103
What is cholecystitis?
Inflammation of gallbladder Usually associated with gallstones Acute or chronic Common
104
Acute Cholecystitis
Gallstones obstructing outflow of bile Initially sterile, then becomes infected May cause empyema, rupture, peritonitis Causes intense adhesions within 2-3 days
105
Acute Cholecystitis - Appearance
``` Gross = Red, haemorrhage, mixed gallstones embedded in pus Histology = Acute inflammation indicated by neutrophils ```
106
Chronic Cholecystitis
Associated with Gallstones May develop insidiously or after bouts of acute cholecystitis Galbladder wall is thickened but not distended
107
Chronic Cholecystitis - Appearance
``` Gross = Mixed stones and thickened gallbladder wall due to fibrosis Histology = Chronic inflammation and Rokitansky-Aschoff sinuses ```
108
What do stones in the common bile duct cause?
Obstructive jaundice
109
Carcinoma of the Gallbladder
``` Rare Adenocarcinoma Associated with gallstones Local invasion of liver Poor prognosis ```
110
Carcinoma of Bile Ducts (Cholangiocarcinoma)
Rare Associated with Ulcerative Colitis and Primary Sclerosing Cholangitis Presents with obstructive jaundice Adenocarcinoma
111
What is a Klatskin Tumour?
Cholangiocarcinoma at bifurcation of hepatic ducts
112
Cholangiocarcinoma - Histology Appearance
Densely packed call glands in a fibrous stroma
113
What is Pancreatitis?
Inflammation of the pancreas | May be acute or chronic (overlap exists between the two)
114
Acute Pancreatitis - Clinical
Adults (rare in children) Sudden onset severe abdominal pain Patients may be severely shocked Elevated serum amylase
115
Acute Pancreatitis - Aetiology
``` Alcohol Cholelithiasis Shock Mumps Hyperparathyroidism Hypothermia Trauma Iatrogenic (post ERCP) ```
116
Acute Pancreatitis - Pathogenesis
Bile reflux, duct obstruction due to stone damage to sphincter of Oddi all cause pancreatic duct epithelial injury Loss of protective barrier allows autodigestion of pancreatic acini Release of lytic pancreatic enzymes proteases and lipases Intra- and peripancreatic fat necrosis (lipases) Tissue destruction and haemorrhage (proteases)
117
Appearance of Acute, Mild Pancreatitis
Focal areas of necrosis
118
Appearance of Acute, Moderate Pancreatitis
Intrapancreatic fat necrosis (may bind large amounts of calcium)
119
Appearance of Acute, Severe Pancreatitis
Complete pancreatic destruction with haemorrhage and fat necrosis
120
What is a Pancreatic Pseudocyst?
Fleshy pseudocyst complicating pancreatitis
121
Acute Pancreatitis - Histological Appearance
Large areas of pancreas and fat necrosis
122
Acute Pancreatitis - Complications
``` Death Shock Pseudocyst formation Abscess formation Hypocalcemia Hyperglycaemia ```
123
What is Chronic Pancreatitis?
Relapsing disorder may develop insidiously or following bouts of acute pancreatitis
124
Chronic Pancreatitis - Aetiology
``` Alcohol Cholelithiasis Cystic fibrosis Hyperparathyroidism Familial ```
125
Chronic Pancreatitis - Pathology
Replacement of pancreas by chronic inflammation and scar tissue Destruction of exocrine acini and islets
126
Gross Appearance of Chronic Pancreatitis
Fibrotic and necrotic | Inflammation and fibrosis can mimick a tumour in the head of the pancreas
127
Chronic Pancreatitis - Histological Appearance
Exocrine pancreas is replaced by chronic inflammation and fibrosis (first)
128
Carcinoma of Pancreas
Adenocarcinoma Aetiology Unknown Weak associated with smoking, diabetes, familial pancreatitis Poor prognosis (pancreas is intimately related to many important structures. Also, resistant to most forms of chemo)
129
Gross Appearance of Adenocarcinoma of Head of Pancreas
Can invade duodenal wall | Can constrict the common bile duct
130
How can Carcinoma of the Tail of the Pancreas spread?
By direct invasion of the spleen
131
Adenocarcinoma of Pancreas - Histological Appearance
Irregular abortive glands in a dense stroma
132
Adenocarcinoma of Pancreas - Spread
Direct spread to other organs e.g. duodenum, stomach, spleen Spread to local lymph nodes Haematogenous spread to the liver

GI (24 decks)

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