Rapid Review Nichols Path Flashcards
Heartburn
GERD
Pathogen for acute sialadenitis? Which gland?
Staph aureus, parotid
Is surgery an option for GERD?
Yes
Cause of chronic sialadenitis?
Sialolith
Most common salivary gland tumor?
Pleomorphic adenoma – ductal epithelium and mesenchymal elements
Rx for a 50 y/o female that presents with rounded, well-circumscribed, painless, motile, firm mass at angle of jaw? Complication?
Surgery; CN VII injury (Bell’s)
Second MC tumor of parotid?
Warthin’s Tumor (Papillary Cystadenoma Lymphomatosum)
60 y/o male smoker presents with slow-growing, painless, firm mass?
Papillary Cystadenoma Lymphomatosum (Warthin’s)
Cystic spaces lined by double layer of oncocytes + prominent lymphoid stroma
Papillary Cystadenoma Lymphomatosum
Expresses CagA gene and causes degradation of p53 leading to activation of cell proliferation pathways? (Ras, Mek, Erk, NF-kB, B-cat)
H pylori
Syringe-like Type IV secretion system pilus
H Pylori
Difference b/w H. pylori gastritis and autoimmune atrophic gastritis?
G-cell hyperplasia
Is a Warthin’s tumor a true neoplasm?
No
MC malignant tumor of salivary glands? Prognosis?
Mucoepidermoid Carcinoma, pretty good
Treatment plan for Mucoepidermoid Carcinoma based upon what three factors?
Histologic grade, location, stage
Abdominal pain/discomfort + heartburn + N/V + massive hematemesis
Acute hemorrhagic gastritis
MCC Chronic gastritis?
H Pylori
What inflammatory cell type seen in chronic H pylori gastritis?
Neutrophil
Brain injury stress ulcers?
Cushing
Burn injury stress ulcers?
Curling
Diagnostic modality for esophageal cancer?
Endoscopy
Imaging to help stage and det. depth esophageal cancer?
CT and Ultrasound
MC gastric polyp?
Hyperplastic (H pylori)
Standard diagnostic modality for gastric cancer? Staging modality? Curative modality?
Endoscopy, CT, surgery
What two factors make a tumor malignant?
Invasion or malignancy
Main/Earliest mutation in esophageal SCC?
p53
Majority of esophageal SCC are protruding, flat, or excavated?
Protruding
Order of mutations in Esophageal SCC?
p53 –> FHIT and TOC –> DLC1, 9p31, Cyclin D1 –> EGFR, HIST, cMYC; everything from cyclin D1 on in this list is amplification
Mutations occurring in Esophageal Adenocarcinoma? Are they all necessary or sufficient?
p53, epigenetic silencing/hypermethylation of p16/INK4 cyclin dependent kinase inhibitor, RB; amplification of cERB-B2, Cyclin D, Cyclin E; no
Histologic type of gastric polyp – Dilated corpus oxyntic type glands?
Fundic gland polyp
Type of epithelium in an adenomatous polyp?
Stratified columnar
First-line therapy for constipation according to Nichols
Prunes (theoretical candy…?)
Together, the RFs obesity, alcohol, and low veggie diet are the three most important in what cancer?
Colon
Name that gene (loss of methylation just included for completeness): Chr 5q –> loss of DNA methylation –> Chr 12q –> Chr 17q –> Chr 18q
APC/B-cat –> loss of DNA methylation –> KRAS –> p53 –> Smad2/Smad4/DCC
MLH1, MSH2, BAX, BRAF mutations – what pathway?
Microsatellite instability pathway to colonic adenocarcinoma
BRAF mutation mimics?
KRAS
Signet rings?
Linitis plastica/Diffuse type gastric adenocarcinoma
Leather Bottle?
Linitis plastica/Diffuse type gastric adenocarcinoma
Order of events leading to esophageal adenocarcinoma?
Obesity –> GERD –> Barrett –> Dysplasia –> Adenocarcinoma (lower esophagus)
Definitive therapy for pancreatic carcinoma?
Surgery
Villous blunting and intraepithelial CD8 lymphocytes?
Celiac sprue/gluten-sensitive enteropathy
Cause for temporary disaccharidase (lactase) deficiency?
Viral gastroenteritis (Norwalk/Rotavirus I’m guessing)
PAS+, foamy macrophages in the lamina propria of a white, middle aged male presenting with GI, cardiac, and joint Sx? Cause?
Whipple disease; Tropheryma whipplei/actinomycete
What type of worm is Ascaris? How to differentiate from a protozoa like Giardia?
Roundworm; eosinophilia
27 y/o man with psychiatric hx admitted to ER in coma, hypothermic, with a hard/distended abdomen and fatal abdominal compartment syndrome related to the absorption of antidepressents and benzodiazepines – cause of death?
Acquired toxic megacolon
Gold standard for definitive Dx of Hirschprung? Treatment?
Rectal Biopsy; Surgical resection
Sessile serrated adenoma – which pathway?
Microsatellite instability
MC Symptom of colon cancer?
Abdominal pain
KRAS after APC mutation =
Cancer
KRAS without APC mutation =
Hyperplastic polyp
Color of a carcinoid?
Yellow
Small, sessile polyp in the rectum of an adult >60 y/o with a serrated/star-shaped lumen on histo? Mutation?
Hyperplastic polyp; KRAS
Length for progression of an adenoma to carcinoma?
10 yr
Highest risk adenomatous polyp?
Sessile villous
What are the most important mutations in esophageal adenocarcinoma? (ones he listed in TBL)
p53; EGFR (30% [15% are HER2 – RX trastuzumab])
p16/INK4, EGFR, TP53 together most important in which upper GI cancer?
Esophageal SCC
Cleaves E-cadherin, thus releasing B-cat
CagA from H Pylori
CDH1 mutation coding for E-cadherin important in which cancer?
Linitis plastica
Corkscrew glands (type of polyp)
Hyperplastic
Hamartomas in the small intestine (type of polyp)
Peutz-Jeghers
MC type of polyp?
Adenomatous
Longstanding IBD causes what type of polyp?
Inflammatory/Pseudopolyp
Location of colon cancer causing occult bleeding/anemia?
Right side
Location of colon cancer causing overt bleeding and obstructive symptoms?
Left side
ATG16L1, IRGM, NOD2 seen in Crohn’s or UC? Which activates NF-kB and is assoc. w/ epithelial integrity? Which is a/w defective Paneth cell granules and affects intestinal microbiota? (all key points from Robbins)
Crohn’s; NOD2; ATG16L1
IL23R, Stat3, IL12B – adaptive or innate immunity genes in IBD?
Adaptive
Role of SLC22A5, ZNF365, NKX2-3 in IBD – Innate or adaptive immunity or cell integrity?
Cell integrity
Location of colon cancer causing tenesmus, pain, and bleeding?
Rectum
Apple core lesion with barium enema
Left sided colon cancer
Th1, Th17, IL23 – Crohn’s or UC?
Crohn’s
Th1, Th2, Th17, IL13, IL10, IL10R, IL23
Ulcerative colitis
Annular, napkin ring lesion
Left sided colon cancer
Disease limited to mucosa/submucosa
Ulcerative colitis
Polypoid exophytic cancer
Right sided colon cancer
Why do a CT before you take someone to surgery to excise a polyp?
Look for metastasis
Flask-shaped ulcer in the submucosa? Geographic prevalence?
Entameoba Histolytica; Mexico
Organism that resembles human macrophages; how do you tell it’s not a macrophage?
Entamoeba Histolytica; ingests RBCs
What amoeba sits atop intestinal ductular cells and is extremely dangerous in immunocompromised patients?
Cryptosporidium
Toxic megacolon in which IBD? (big time bad complication)
Ulcerative colitis
Most sensitive evaluation of free air in the colon (for Dx of toxic megacolon)? What’s a quickie test in case of emergency (Uworld)
CT; flat plain of abdomen
Useful test to observe mucosal changes in IBD?
Barium enema
IBD with strong monozygotic concordance?
Crohn’s
MC age range of diagnosis of Crohn’s
20-29
Transmural involvement
Crohn’s
Fistula
Crohn’s
Noncaseating granuloma
Crohn’s – Excellent!!!!
Skip lesion
Crohn’s
Cobblestone mucosa
Crohn’s
Creeping fat
Crohn’s
Volcano appearance on H&E?
Pseudomembranous colitis
Thickened submucosal collagen layer w/ lymphs in the epithelium? Etiology? Responds to?
Collagenous colitis, decreased MMP1 or increased TIMP, budesonide
ANCA + anti-saccharomyces cerevisiae in IBD?
Crohn’s
Chromogranin stains?
Carcinoid
Hypergastrinemia in majority or minority of carcinoids?
Majority
Secretin stimulation test is used for dx of what?
Zollinger-Ellison
MC symptom and location of intestinal neuroendocrine carcinoid (not ZE)?
Abdominal pain; ileum/appendix
MC neoplasm of appendix
Carcinoid
CD 117 is also known as? Mutated in what? MC location?
cKIT, GIST, stomach
Tumor whose cells differentiate from interstitial cells of Cajal
GIST
MC presentations of GIST
overt GI bleed or abdominal mass
Detection of GIST? Biopsy method?
CT; FNA
Imatinib
GIST
Post-transplant lymphoproliferative disorder
EBV
MC GI lymphoma location?
Stomach (50% are MALTomas, rest are diffuse large B-cell lymphomas)
MC GI lymphoma presenting symptom? Next MC?
Epigastric pain; anorexia
Dermatitis herpetiformis associated with?
Celiac
Most specific antibody for Dx of Celiac? Other antibodies present?
IgA Anti-endomysium; Anti-gliadin, anti-tissue transaminase
Young female with lupus – think what GI complication?
Necrotizing vasculitis of GI tract (hypercoagulable –> ischemia)
Middle-aged man with polyarteritis nodosa – think what GI complication?
Necrotizing vasculitis of GI tract
Child with Henoch-Schonlein Purpura – think what GI complication?
Necrotizing vasculitis of GI tract
Lymphs in the epithelium without thickened submucosal collagen
Lymphocytic colitis
Oral and genital aphthous ulcers + uveitis + gastric ulcers + arthritis
Behcet’s (was in Marino’s part of Diarrhea lecture – just in case he gets sneaky!)
Embolus to the SMA – think what GI vascular issue?
Acute mesenteric ischemia
Congestive heart failure in the ICU – think what GI vascular issue?
Ischemic colitis
Atherosclerosis with pain after eating – think what GI vascular issue?
Chronic mesenteric ischemia
Middle age woman with autoimmune disorders/hypercoagulability – think what GI vascular issue?
Venous mesenteric ischemia
Upper GI bleed
Melena
Lower GI bleed
Hematochezia
Active bleeding of ulcer upon endoscopy + visible vessel (risk of rebleed?)
High
Completely white base of ulcer (risk of rebleed?)
Low
Ulcer in the posterior wall of the duodenum or lesser curvature of the stomach?
Rebleed
3 predictive factors of esophageal varices?
Pressure, size, color
Decreased risk by smoking and appendectomy
Ulcerative colitis
Increased risk by smoking, appendectomy, high childhood sanitation level, high carbohydrate miles
Crohn’s
Begins in rectum, no skip lesions
Ulcerative colitis
Rectum only; rectal bleed and tenesmus
Proctitis
Rectum + sigmoid colon; bloody diarrhea, tenesumus, abdominal cramps and pain
Proctosigmoiditis
Rectum + Sigmoid + Descending colon to flexure; bloody diarrhea, abdominal cramping, pain on left side, and unintended wt loss
Left-sided colitis
Entire colon; severe bouts of bloody diarrhea, abdominal cramps/pain, fatigue, and significant weight loss
Pancolitis
Is fulminant colitis common with IBD?
No
Sclerosing cholangitis
Ulcerative colitis
ANCA alone in IBD?
Usually ulcerative colitis
MALToma treatment
Antibiotics
MALToma prognosis with treatment
Good (other GI lymphoma prognoses bad)
Watershed infarct
Splenic flexure
Early severe abdominal pain without ileus but not actually tender on physical exam; doesn’t bleed
Acute mesenteric ischemia (medical or surgical emergency, poor prognosis)
Key diagnostic test of acute mesenteric ischemia?
Angiography
Dusky =
Small bowel infarct = dead = surgical excision
Key diagnostic test of ischemic colitis?
Colonoscopy
Pill-induced esophageal ulcer
Bisphosphonates
Ischemic esophageal ulcers (AIDS)
CMV
Punched out ulcers right above GEJ
Herpes
MCCs of acute lower GI bleed
Diverticulosis + angiodysplasia
MCCs of chronic lower GI bleed
Hemorrhoids + neoplasia
Degenerative change in blood vessels in cecum (dilated, tortuous) with mucosal telangiectasias; A/w advanced age (>70), chronic renal failure, Osler-Weber-Rendu, prior radiation, and watermelon stomach
Angiodysplasia
Intrahepatic cholangiocarcinoma – MCC?
Alcoholic
Rate limiting enzyme for cholesterol metabolism
7alfa-hydroxylase
Three factors in pathophys of gallstone formation
Cholesterol supersat, accelerated nucleation, gallbladder hypomotility
Hemolysis, advancing age, long-term TPN, cirrhosis – type of stone?
Black
Decreasing biliary secretory IgA, high B-glucuronidase activity, bacterial infection – type of stone?
Brown
MC gallbladder disease?
Cholelith
Diagnostic modality for gallstone?
Ultrasound
Extraction method for stone?
ERCP
Post-cholecystitis abdominal pain, melena, and jaundice and find a clot in the bile duct
Hemobilia
Cancer from PSC?
Cholangiocarcinoma
Cancer Sometimes Penetrates Benign Liver
Colon, stomach, pancreas, breast, lung
MCC of HCC
Chronic viral hepatitis
Four presenting Sx of HCC
Jaundice, encephalopathy, ascites, bleeding
Four predictors of prognosis in HCC
Size, differentiation, invasion and mets
HCC tumor marker
a-fetoprotein
Mainstay Rx of HCC? Are patients usually eligible?
Surgery; no
Central stellate scar grossly (liver tumor)
Focal nodular hyperplasia
Anabolic steroids or OCPs?
Hepatic adenoma
Complication of hepatic adenoma?
Rupture/massive peritoneal hemorrhage
MC benign liver tumor
Hemangioma
Liver tumor usually <2cm, commonly subcapsular, composed of blood-filled vascular spaces?
Hemangioma
Malignant epithelial neoplasm of liver in kids
Hepatoblastoma
What’s another name for a cholangiocarcinoma at the bifurcation of the common bile duct?
Klatskin tumor
MC mutations in cholangiocarcinomas?
KRAS (50% intra, 15% extra) and p53 (33% in all)
Mode of metastasis for cholangiocarcinoma?
Lymphatics
Mode of metastasis for HCC?
Hematogenous
Differentiate Extrahepatic Cholangiocarcinoma from intrahepatic.
EH has pruritis, fever, jaundice, and high bilirubin
Prognosis for cholangiocarcinoma?
Bad
Obstruction, hepatitis, Dubin-Johnson
Conjugated hyperbilirubinemia
Hemolysis, hepatitis, Gilbert
Unconjugated hyperbilirubinemia
Rx for severe hyperbilirubinemia damaging brain?
UV light
MCCOD from liver disease in childhood?
Biliary atresia
Jaundiced 3-6 weeks of age, conjugated hyperbilirubinemia, disproportionately high GGT, mild-moderately high ALT and AST – Dx?
Biliary atresia
Congenital lack of intrahepatic bile ducts?
Alagille syndrome (arteriohepatic dysplasia)
Mutation in JAGGED1 gene for ligand for NOTCH1 receptor? Inheritance?
Alagille, AD
Trichrome stain of portal triad shows blood vessels but no bile ducts
Alagille
Prognosis for Alagille?
Good
Defective excretion of bilirubin conjugates and other organic anions across hepatocyte canalicular membrane?
Dubin-Johnson
Brown-black liver pigment
Dubin-Johnson
Lysosomes containing polymers of epinephrine metabolites?
Dubin-Johnson (causes the pigmentation)
Recurring or fluctuating jaundice (general, but just for association with this disease)
Dubin-Johnson
Autosomal recessive deficiency of UGT?
Gilbert
Young adult with mild, primarily unconjugated hyperbilirubinemia brought on by febrile illness, exertion, fasting, or hemolysis and no other manifestations of disease?
Gilbert
Disease that causes hyperbilirubinemia but also decreased incidence of colon cancer and heart disease?
Gilbert
Dense lymphocytic infiltrate in and around interlobular bile ducts with granulomas and bile duct destruction and loss, and progressive portal fibrosis
Primary biliary cirrhosis
Anti-mitochondrial antibody
Primary biliary cirrhosis
Onion-skinning fibrosis of bile ducts
Primary sclerosing cholangitis
PSC presenting Sx
Fatigue, pruritis, jaundice
Beading of bile ducts
Primary sclerosing cholangitis
Portal hypertension due to thrombosis of hepatic veins
Budd-Chiari
MCC Budd-Chiari
Polycythemia vera (or myeloproliferative disease – he seemed to harp on that)
Hypertrophy of caudate lobe
Budd-Chiari
Patients lie still because pain is aggravated by movement. Usually have voluntary and involuntary guarding.
Acute Cholecystitis
Acute acalculous cholecystitis – 4 associations?
Postoperative state after major surgery, severe trauma, severe burns, or sepsis
Skin vesicles and bullae with sun exposure? Etiology?
Porphyria cutanea tarda; ROS from uroporphyrinogen
Porphobilinogen-deaminase deficiency
Acute Intermittent Porphyria; AD
Gallstones in the bile ducts
Choledocolithiasis
Infection of the intrahepatic biliary ducts
Ascending cholangitis
Bacterial ascending cholangitis – acute or chronic?
Acute (Gram negative intestinal anaerobes
Olive-like mass
Congenital pyloric stenosis
Parasitic ascending cholangitis – acute or chronic?
Chronic (Cryptosporidium, Fasciola hepatica, Schistosoma, Clonorchis)
N-acetylcysteine
Acetaminophen OD
Boiled cabbage? Inheritance?
Tyrosinemia, AR
Mousy/musty
Phenylketonuria
Rotting Fish
Trimethylaminuria
Sweaty feet
Isovalaric acidemia
Maple syrup
Maple syrup disease
Fumaryl-aceto-acetase deficiency
Tyrosinemia Type I
French Canadian baby presenting with failure to thrive in first few months of life, then vomiting, diarrhea, jaundice, lethargy, coma, and then death; high urine succinylacetone – Dx?
Tyrosinemia
Acetaminophen OD
Centrilobular necrosis
Yellow fever or mushrooms
Midzone necrosis
Phosphorous compounds
Periportal necrosis
Most common urea cycle disorder? Inheritance?
Ornithine transcarbamylase deficiency, X-linked
Beta-glucocerebrosidase deficiency? Inheritance?
Gaucher’s disease, AR
Most common lysosomal storage disease?
Gaucher’s
Kupffer cells and macrophages expanded with crinkled cytoplasm
Gaucher’s
Most common initial sign of Gaucher’s? Other main manifestations (2)?
Splenomegaly; Pancytopenia and bone pain
Glucose-6-phosphatase deficiency
Von Gierke’s Disease/Glycogen Storage Disease Type I
Marked hepatomegaly with hypoglycemia in the first year of life
Von Gierke
3 big Sx in Von Gierke?
Hyperlipidemia, Hyperuricemia, Lactic Acidosis
Most common porphyria?
Porphyria cutanea tarda
Urine becomes dark, even purple during an attack of this disease
Acute intermittent porphyria
Dx for Acute Intermittent Porphyria?
Urine test for porphobilinogen
Rx for Acute Intermittent Porphyria?
IV heme
Anchovy-paste
Amebiasis
Canalicular bile plugs
Canalicular cholestasis
Accumulation of bile in hepatocytes
Hepatocellular cholestasis
Epiallopregnanolone sulfate inhibition of farnesoid X receptor-mediated bile acid efflux
Intrahepatic cholestasis of pregnancy
Rx for intrahepatic cholestasis of pregnancy?
Ursodeoxycholic acid
Second MC drug class to cause liver injury in a hepatocellular/cholestatic pattern?
Psychoactive meds
What is NAPQI?
Toxic metabolite of acetaminophen that is conjugated with glutathione
First region of hepatocytes to run out of glutathione?
Centrilobular
ANCA + anti-smooth muscle
Autoimmune hepatitis
Subtle histologic difference between autoimmune hepatitis and viral hepatitis?
Plasma cells are more prominent in autoimmune hepatitis
MCC acute liver injury?
Alcohol
Failure of Na-K Pump in hepatocytes due to injury that causes depletion of ATP, leading to influx of Na and H2O – what histologic finding does this describe? Is it reversible?
Ballooning degeneration; yes
What do acute fatty liver of pregnancy, Reye syndrome, and multiple hornet stings all have in common?
Microvesicular steatosis
Mega-mitochondria
Microvesicular steatosis
Aggregates of intermediate filaments
Mallory bodies
Steatosis, Mallory Bodies and Neutrophils are triad for what?
Alcoholic Hepatitis
Severe hepatocyte damage leading to swelling of hepatocyte cytoplasm and wispy appearance
Feathery degeneration
How does NASH differ from alcoholic hepatitis? (2 ways)
Milder and lacks cholestasis
Key cytokines in Alcoholic Liver Disease?
TNFa, IL1, IL6, and L8
Key cytokines in NASH/NAFLD?
TNF, IL6, MCP-1
Type IV collagen in the space of Disse?
Normal
Type I and III collagen in the space of Disse?
Cirrhosis
