Stomach disorders Flashcards by Rachel Muxlow

Risk factors for congenital hypertrophic pyloric stenosis

Down and Turner syndromes
Trisomy 18
Erythromycin or azithromycin (PO or in breastmilk)

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Concentric hyperplasia and hypertrophy caused by fibrosis and elastosis of pyloric muscularis that is sometimes associated with mucosal erosions and inflammation

Congenital hypertrophic pyloric stenosis

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4 wk old infant is brought in within new-onset regurgitation, projectile non-bilious vomiting after feeding, and frequent demands for refeeding. A firm, ovoid, 1-2 cm abdominal mass is palpated on exam.

Congenital hypertrophic pyloric stenosis

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Curative treatment for hypertrophic pyloric stenosis

Myotomy –> surgical splitting of muscularis

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Causes of acquired hypertrophic pyloric stenosis

Antral gastritis or peptic ulcer close to pylorus

Carcinomas of distal stomach and pancreas

Fibrosis or malignant infiltration

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Finding to differentiate acute gastritis from gastropathy

Presence of neutrophils

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Inflammation of the gastric mucosa with associated intestinal metaplasia and atrophy. Lymphocytes and plasma cells are present

Chronic gastritis

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Signs and symptoms of more severe gastritis with mucosal erosion/ulceration

Hemorrhage
Hematemesis
Melena
Massive blood loss (rare)

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Gross appearance of erosive gastritis

Mucosal denudation

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Gross appearance of hemorrhagic gastritis

Dark puncta within hyperemic mucosa

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Gastric biopsy shows intact surface epithelium with foveolar cell hyperplasia and corkscrew profiles of epithelial proliferation. Neutrophils are present among the epithelial cells and within mucosal gland lumina. Moderate edema and slight vascular congestion of the lamina propria is also present.

Reactive gastropathy/gastritis

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Abrupt onset of abdominal pain and bleeding with multiples erosions in the gastric mucosa associated with trauma.

Stress-related mucosal disease

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Features of curling ulcers in stress-related mucosal disease

Proximal duodenal ulcers
Associated with severe burns

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Features of Cushing ulcers in stress-related mucosal disease

Gastric, duodenal, and esophageal ulcers with an increased risk of perforation.
Associated with intracranial disease

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Multiple, small, rounded gastric ulcers with a brown to black base due to acid digestion of extravasation of blood. Microscopy is absent for scarring and blood vessel thickening.

Stress-related mucosal disease

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Characterized by the presence of chronic mucosal inflammatory changes that may lead to mucosal atrophy and intestinal metaplasia. Associated with increased risk of carcinoma.

Chronic gastritis

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Most common cause of chronic gastritis

H pylori infection

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Systemic diseases associated with chronic gastritis

Crohn’s disease
Amyloidosis
GVHD

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Predominantly causes antral gastritis. Associated with gastric and/or duodenal peptic ulcer disease. Can lead to atrophic gastritis.

H pylori infection

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Complications of H pylori chronic gastritis

Gastric adenocarcinoma –> atrophy
Duodenal ulcers
B cell lymphoma –> lymphoid aggregates

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Chronic gastritis type that spares the antrum and is associated with hypergastrinemia

Autoimmune

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CD4+ T cells against parietal cell components leading to loss of parietal cells and decreased or absent secretion of gastric acid and intrinsic factor

Autoimmune gastritis

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Gastric biopsy shows diffuse mucosal damage of the oxyntic mucosa within the body and fundus. Mucosa is thinned and there is loss of rugae.

Autoimmune gastritis

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Distinctive endoscopic appearance of the stomach characterized by thickened folds covered by small nodules with central aphthous ulceration

Varioliform gastritis, associated with lymphocytic gastric

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Gastric mucosal atrophy is generally protective against what?

Antral and duodenal ulcers

Ulcers on greater curvature of the stomach are associated with what etiology?

NSAID use

Biopsy of gastric ulcer shows superficial zone of fibrinopurulent exudate, necrotic tissue, granulation tissue, and fibrotic tissue with chronic inflammation in base with thrombosed vessel.

Chronic peptic ulcer

Complications of PUD

Obstruction Bleeding Perforation

Uncommon diseases of giant cerebriform enlargement of the rugal folds due to epithelial hyperplasia without inflammation. Linked to excessive growth factor.

Hypertrophic gastropathies

Types of hypertrophic gastropathies

Menetrier disease Zollinger-Ellison syndrome

Rare acquired disorder involving the gastric body that is associated with gastric rugal hypertrophy, protein-losing gastropathy, and hypochlorhydria. Associated with CMV or H pylori infection.

Menetrier disease

Causes of Menetrier disease

Increased TGF-alpha Hyperactivation of EGFR on gastric epithelial cells

Endoscopy shows irregular enlargement of the gastric rugae in body and fundus with sparing of antrum. Biopsy shows hyperplasia of foveolar mucous cells, elongated corkscrew-like glands, and cystic dilation with glandular atrophy and hypoplasia of the parietal and chief cells.

Menetrier disease

Manifestation of hypoproteinemia in Menetrier disease

Peripheral edema

Menetrier disease in children

Self-limited Associated with CMV infection

Triad of Zollinger-Ellison syndrome

Hypergastrinemia Increased acid production PUD

Cause of hypergastrinemia in Zollinger-Ellison syndrome

Gastrin-secreting neuroendocrine tumors

Condition associated with formation of gastrinomas leading to Zollinger-Ellinger syndrome at a younger age

Multiple endocrine neoplasia type 1 (MEN1)

Endoscopy shows massive hypertrophy of the gastric rugae in the body and fundus with reduction of the antral mucosa. Biopsy shows hypertrophy and hyperplasia of Parietal cells, which extend up to the foveolar neck region and to the gastric antrum.

Zollinger-Ellison syndrome

Main determinant of long term survival in Zollinger-Ellison syndrome

Gastrinoma

Adenocarcinoma type in stomach that forms bulky masses

Intestinal type

Adenocarcinoma type in stomach that infiltrates and thickens the gastric wall

Diffuse type

Precursor lesions of intestinal type gastric adenocarcinoma

Flat dysplasia Adenomas

Mutation in familial gastric cancer

Loss of function in CDH1, a tumor suppressor that codes E-cadherin

Mutations associated with intestinal type gastric adenocarcinoma

Increased signaling in Wnt pathway APC Beta-catenin TGF-beta signaling BAX CDKN2A

Key step in the development of diffuse type gastric adenocarcinoma

E-cadherin loss --> loss of function of CDH1 in 50%

Endoscopy reveals ulcer with heaped up margin and loss of spoke wheel pattern

Malignancy --> gastric adenocarcionma

Features of linitis plastica

Diffuse rugal flattening and rigid, thickened wall Associated with diffuse type of gastric adenocarcinoma

Malignant gastric ulcer present on endoscopy. Gastric biopsy shows atypical glandular structures with apical mucin vacuoles, abundant mucin in glandular lumina, and infiltrating irregular glands of columnar cells with high N:C ratio and irregular nuclear membrane.

Intestinal type gastric adenocarcinoma

Endoscopy shows malignant gastric ulcer. Gastric biopsy shows signet ring cells with large mucin vacuole.

Diffuse type gastric adenocarcinoma

Paraneoplastic syndromes associated with gastric adenocarcinoma

Acanthosis nigricans Leser-Trelat sign

Metastasis sites of gastric adenocarcinoma

Supraclavicular and periumbilical lymph nodes Ovaries L axillary lymph nodes Pouch of Douglas

5 yr survival rate of gastric adenocarcinoma in US

<30% due to advanced stage at diagnosis

Most common type of gastric lymphoma/MALToma

Extra-nodal marginal zone B cell lymphoma

Translocations associated with gastric lymphoma/MALToma

t(11;18)(q21;q21) --> API2-MALT1 fusion protein (common) t(1;14)(p22;q32) --> BCL-10 t(14;18)(q32;21) --> MALT1

Endoscopy shows ulcerated, polypoid, granulonodular, erythematous, edematous gastric folds. Biopsy shows monotonous infiltrate of monocytoid cells mixed with immunoblasts and plasmacytoid cells. Infiltrate expands the lamina propria and reactive follicles are often present

Gastric MALToma

5 year survival rate of gastric MALToma

50-90%

Most common mesenchymal tumor of the abdomen

GIST

Syndrome with increased risk of developing GIST

NF1

Nonhereditary Carney triad

GIST Paraganglioma Pulmonary chondroma

Mutations associated with GIST

Gain of function in cKIT PDGFR-alpha

Metastasis of GIST

Multiple serosal nodules throughout peritoneal cavity and/or within liver Spread outside abdomen is uncommon

Excised solitary, well-circumscribe, fleshy mass from stomach. Cut surface has a whorled appearance. Microscopy shows thin, elongated cells that are cKIT positive.

GIST

Classifications of GIST

Spindle cell type Epitheloid cell type Mixed

Targeted therapy for tumors with mutations in KIT or PDGFR-alpha that can be used in unresectable GIST

Imatinib

Gastric neuroendocrine neoplasm with endocrine cell hyperplasia is associated with what?

Autoimmune chronic atrophic gastritis

Gastric neuroendocrine neoplasm of MEN1 is associated with what?

Zollinger-Ellison syndrome

Yellow or tan intramural or submucosal gastric masses that create polypoid lesion and typically arise within the oxyntic mucosa. Microscopy shows round to oval nuclei with salt and pepper chromatin.

Gastric neuroendocrine tumor/gastric carcinoid

Symptoms of carcinoid syndrome

Cutaneous flushing Sweating Bronchospasm Colicky abdominal pain Diarrhea

Cause of carcinoid syndrome

Vasoactive substances released by neuroendocrine tumors

Complication of carcinoid syndrome

R-sided cardiac valvular fibrosis