Stomach Path - SRS Flashcards
Identify the regions shown here.
Gastritis is a mucosal inflammatory process, when neutrophils are present, what do we refer to it as?
Acute gastritis
What do we refer to gastric inflammation when inflammatory cells are rare or absent?
Gastropathy
What are two examples of hypertrophic gastropathy?
Menetrier disease
Zollinger-Ellison Syndrome
In a normal persons body, gastric acid and peptic enzymes can cause tissue damage. What are some protective factors that prevent this?
Surface mucus secretion
bicarb secretion into mucus
Mucosal blood flow
Epithlial barriers
Epithelial regeneration
Elaboration of prostaglandins
What are some common sources of gastric damage?
H. pylori
NSAIDs
Tobacco
ETOH
Gastric hyperacidity
duodenal-gastric reflux
What is the difference between an erosion and an ulcer?
Timeline for repair of each?
Erosion - goes down to the muscularis mucosa takes 2-3 days to grow back
Ulcer - muscularis mucosa is breached also. Takes weeks to recover.
NSAIDs inhibit what enzyme that produces what products?
cyclooxygenase - (COX)
Synthesis of prostaglandins E2 and I2.
What are the six functions of prostaglandins E2 and I2 in the stomach?
Stimulate nearly all defense mechanisms including:
- mucus
- bicarbonate
- phospholipid secretion
- mucosal blood flow
- epithelial restitution
- reduce acid secretion
What is the gastric injury that occurs in uremic patients and those infected with urease secreting H. pylori likely due to?
inhibition of gastric bicarbonate transporters by ammonium ions.
What are two factors that have been suggested as explanations for the increased susceptibility of older adults to gastritis?
Reduced mucin
Reduced bicarbonate secretion
Why the increased incidence of acute gastritis at high altitudes?
Likely d/t decreased O2 delivery
What does this look like?
Acute erosive hemorrhagic gastritis
How can you differentiate between gastropathy and acute gastritis based on clinical presentation?
You cannot.
Must biopsy
A 45 year old man with history of chronic back pain presents with new onset persistent epigastric pain that responds to antacids and PPIs. What is this persons likely dx?
NSAID induced gastropathy
Your next patient is a 38 year old with a history of back pain also. They present with CC of persistent epigastric pain, report no relief from antacids and PPI, and have reported episodes of green vomiting.
What is this patient’s likely dx?
bile reflux - refractory to antacids and ppi, may be accompanied by bilios vomiting.
What type of ulcers are common in individuals with shock, sepsis or severe trauma?
Stress ulcers
What is a curling ulcer?
Ulcer occuring in the proximal duodenum and associated with severe burns or trauma.
What is a Cushing ulcer?
Gastric, duodenal and esophageal ulcers arising in persons with intracranial disease.
It is important to be able to identify a Cushing’s ulcer for what reason?
Have a high incidence of perforation
What do most critically ill patients admitted to ICU have evidence of?
Histological evidence of gastric mucosal damage.
On endoscopy you find this lesion squirting blood in the stomach. What is this?
What caused it?
Dieulafoy lesion
caused by a submucosal artery that does not branch properly within the wall of the stomach resulting in an enlarged arterial diameter. When erosive processes degrade the overlying epithelium you can see self-limited but copious bleeding.
What is the bleeding in a dieulafoy leasion often associated with?
NSAID use.
What is shown here?
GAVE - gastric associated vascular ectasia
How can you recognize GAVE?
What is this sometimes referred to as?
On endoscopy, shows up as longitudinal stripes of edematous erythematous mucosa that alternate with less severely injured, paler mucosa.
Also referred to as “watermelon stomach”
In GAVE, the erythematous stripes are created by ectatic mucosal vessels. Histologically the antral mucosa shows reactive gastropathy with dilated capillaries containing fibring thrombi. While most often idiopathic, what are two conditions associated with onset of GAVE?
What are two possible consequences of this condition?
- Cirrhosis
- Systemic sclerosis
- occult fecal blood
- Iron anemia deficiency
What is the most common cause of chronic gastritis?
Infection with the bacillus H. pylori
What is the most common cause of diffuse atrophic gastritis?
Autoimmune gastritis (represents only 10% of cases of chronic gastritis)
In a patient with H. pylori infection, where is the gastritis predominantly?
What is the level of acid production?
Antral gastritis
Normal or increased acid production
What are four key components of H. pylori that make it a pathogen?
- Flagella - allows motility in viscous mucus
- Urease - generates ammonia from endogenous urea and elevates pH
- Adhesins - enhance bacterial adherence to surface foveolar cells
- Toxins - cytotoxin-associated gene A (CagA)
This patient presented with antral gastritis, describe the findings in the images.
What is the stain shown in the upper right.
H. pylori derived gastritis
A. Upper left is stained with Warthin-Starry silver stain to identify H. pylori.
B. Intraepithelial and lamina propria neutrophils are prominent
C. Lymphoid aggregates with germinal centers and abundant subepithelial plasma cells within the superficial lamina propria are characteristic of H. pylori
Identify the following for H. pylori associated gastritis
- Inflammatory infiltrate
- Acid production
- Gastrin levels
- Other lesions
- Serology
- neutrophils, subepithelial cells
- increased to slightly decreased
- normal to decreased
- hyperplastic/inflammatory polyps
- antibodies to H. pylori
What are three possible sequelae from H. pylori gastritis?
What are some demographic associations to be aware of?
- peptic ulcer
- adenocarcinoma
- MALToma
Poor, low socioecon status, residence in rural areas
Identify the following for autoimmune associated gastritis
- Region
- Inflammatory infiltrate
- Acid production
- Gastrin levels
- Other lesions
- Serology
- Body (pangastritis)
- lymphos and macros
- decreased
- increased
- neuroendocrine hyperplasia
- antibodies to parietal cells and intrinsic factor
What are four possible sequelae from autoimmune gastritis?
- Atrophy
- Pernicious anemia
- adenocarcinoma
- carcinoid tumor
What are four associations to be aware of with respect to autoimmune gastritis?
- Autoimmune disease (derp)
- thyroiditis
- diabetes mellitis
- Graves disease
What are three non-invasive tests for H. pylori?
Fecal bacterial detection
Urea breath test
Serological analysis for antibodies to H. pylori
What can gastric biopsy specimens be tested with to identify H. pylori?
Rapid urease test
culture
DNA via PCR
Individuals with H. pylori gastritis usually improve after treatment but relapses can occur with incomplete eradication or reinfection, which is common in highly endemic areas.
What is the effective treatment protocol in this case?
Combination of antibiotics and proton pump inhibitors
Autoimmune gastritis accounts for less than 10% of cases of chronic gastritis, and typically spares the antrum. What is it associated with?
Hypergastrinemia
In autoimmune gastritis, what are some of the lab findings you might come across?
Histology?
Lab
- Antibodies to intrinsic factor
- reduced serum pepsinogen I
- Vitamin B12 deficiency
- Defective gastric acid secretion
Histo
- Endocrine cell hyperplasia
Autoimmune gastritis is associated with the loss of what cells and cellular products?
Parietal cells, which normally secrete gastric acid and intrinsic factor.
In autoimmune gastritis the CD4+ T cells are directed against what cellular components of the stomach?
The parietal cell components including the H+, K+, ATPase.
What is the principle agent of injury in autoimmune gastritis?
CD4+ T cells
Autoimmune gastritis is characterized by diffuse mucosal damage of what?
The oxyntic (acid-producing) mucosa within the body and fundus.
Pernicious anemia and autoimmune gastritis are often associated with other autoimmune disease, including?
(give examples)
- Hashimotos thyroiditis
- DM I
- Addison Disease
- Primary ovarian failure
- primary hypoparathyroidism
- Graves disease
- Vitiligo
- Myasthenia gravis
- Lambert-Eaton syndrome
What may the clinical presentation of chronic gastritis be linked to?
Symptoms of anemia, especially B12, with megaloblastic anemia, atrophic glossitis, peripheral neuropathy, spinal cord lesions and cerebral dysfunction.
Oh, also malabsorptive diarrhea.
What are the neuropathic changes that are seen in B12 defifiency?
Demyelination
axonal degeneration
neuronal death
The spinal lesions in B12 deficiency result from the demyelination of the dorsal and lateral spinal tracts, giving rise to a clinical picture that is often referred to as what?
Subacute combined degeneration of the cord.
Attached is an example of eosinophilic gastritis. What should we associate this finding with?
Food allergies
(autoimmune to a degree but less so)
What is this?
What are two things to associate with it?
Lymphocytic gastritis
- Celiac disease
- Chron’s disease
What is shown here?
Granulomatous gastritis
What is a major complication of chronic gastritis?
Peptic Ulcer Disease (PUD) - chronic mucosal ulceration affecting the duodenum or stomach.
Overall the incidence of PUD is falling in developed countries d/t recognition and treatment of H. pylori infections. There is however a group in which incidence is on the rise, what population is this?
Patients over 60 who develop PUD d/t NSAID use.
What are 6 major risk factors for PUD?
- H. pylori infection
- cigarette use
- chronic obstructive pulmonary disease
- Illicit drugs
- NSAIDS
- Alcoholic cirrhosis
This patient presented with free air under the diaphragm. You find the attached lesion. What is this?
Ulcer - note the mucosal defect has sharply demarcated edges that resemble a “punched-out” portion of tissue.
What are 4 main problems that patients present with that indicate the presence of peptic ulcers?
- Epigastric burning or aching pain
- iron deficiency anemia
- hemorrhage
- perforation
When does the pain from a peptic ulcer tend to begin?
What will relieve it?
1-3 hours post prandial
Alkali or food will relieve the pain.
What are some additional signs/symptoms that can accompany peptic ulcer disease?
- Nausea/vomiting
- bloating
- belching
- significant weight loss
To what locations is the pain from PUD referred?
Back
LUQ
Chest (oft mistaken for cardiac origin pain)
What typically is are the three medications you’ll give a patient with an ulcer?
Which one is doing most of the work on the ulcer itself?
Xylocane - actually closes the ulcer
Antacid
PPI
In order of occurance, from most often to least, what are the complications associated with PUD?
- Bleeding
- Perforation
- Obstruction
Bleeding, as mentioned a moment ago, is the most common complication of PUD, occurring in ~15 - 20% of patients, and may be the first indication of an ulcer. What percent of ulcer deaths does bleeding account for?
25%
Perforation occurs in ~5% of patients, and is rarely the first indication of an ulcer. What percent of ulcer related deaths does perforation account for?
2/3 (so this is the bad one)
Identify each step along the way, beginning with normal gastric tissue on the top and cancer at the bottom.
- Normal
- Acute Gastritis
- Chronic Gastritis
- Atrophic Gastritis
- Intestinal metaplasia
- Dysplasia
- Cancer
This biopsy was taken from a patient who complained of epigastric pain a year and a half after gastric bypass surgery was performed.
Describe the findings indicated by the arrows.
What is this condition?
Arrows at top = diverticulae in the gastric mucosa
Arrow at right = cystic formation
Gastritis Cystica
Hypertrophic gastrophathies are uncommon diseases characterized by what?
Giant Cerebriform enlargement of the rugal folds d/t epithelial hyperplasia without inflammation.
What are two important examples of hypertrophic gastropathies we discussed?
Menetrier disease
Zollinger-Ellison syndrome
Menetrier disease typically presents between 30-60 years of age, and can be accompanied by hypoprotienemia, weight loss and diarrhea. What portion of the stomach is affected?
What cell type?
Is this associated with adenocarcinoma?
- Body and fundus
- Mucous
- Yes, it is
Zollinger-Ellison Syndrome typically occurs around age 50, and presents with peptic ulcers. A major risk factor for this condition is multiple endocrine neoplasia.
What portion of the stomach is affected?
What cells are primarily involved?
Is this condition associated with adenocarcinoma?
- Fundus
- Parietal more than mucous, endocrine
- No, it is not
What are the inflammatory infiltrates in Menetrier Disease?
Limited, but lymphocytes
What are the inflammatory infiltrates in Zollinger-Ellison Syndrome?
Neutrophils
Menetrier disease is a rare disorder associated with excessive secretion of what?
TGF-Alpha
Describe the findings shown attached, and identify the disease.
Menetrier Disease
Gross: Marked hypertrophy of rugal folds
Micro: Foveolar hyperplasia with elongated and focally dilated glands
What is the treatment protocol for Menetrier disease?
- Supportive, with IV albumin and parenteral nutritional supplementation.
- In severe cases, gastrectomy may be required.
- Recent trials indicate that anti-TGF-alpha drugs have promise for future treatment options.
What is the triad of Zollinger-Ellison syndrome?
- Gastric acid hypersecretion
- Tumour of the pancreas
- Peptic ulcers
What does the tumour in Zollinger-Ellison syndrome secrete?
Gastrin
Tx of Zollinger-Ellison syndrome includes blockade of acid hypersecretion. This can be done with PPIs generally. This allows ulcers to heal and prevents gastric perforation.
What percentage of gastrinomas are malignant?
What is the treatement option for the tumor itself?
- Though slow growing, 60 - 90% of gastrinomas are malignant.
- These tend to be solitary and are surgically resectable.
Gastrinomas are sporadic in 75% of patients, what leads to gastrinomas in the other 25% of patients?
MEN type I
Where are ulcers most commonly located?
Duodenum, surprisingly (to me at least)
What two places are gastrinoma’s found to occur in equal amounts?
50% in the duodenum
50% in the pancrease, particularly the head and body located towards midline.
What is shown here?
Inflammatory and hyperplastic polyps
Describe the gross and microscopic findings shown here, and identify the disease process.
Gastric Adenoma
- Gross - seen occuring in a backdrop of chronic gastritis with atrophy.
- Micro - intestinal metaplasia with loss of mucin glands
Gastric adenocarcinoma is the most common malignancy of the stomach, comprising more than 90% of all gastric cancers.
What types are there?
Seperated morphologically into….
- Intestinal type - tends to form bulky masses
- Diffuse type - infiltrates the wall diffusely, thickening it.
What type of cells is a diffuse gastric adenocarcinoma typically composed of?
Signet ring cells
What is this lesion most likely to be?
Gastric Adenocarcinoma, Intestinal type - note the “heaped” up tissue at the irregular border with abnormal rugal folds.
The shown sample came from a gastric adenocarcinoma.
What type?
Justify your response.
Diffuse gastric cancer - Stain with E-cadherin that is negative is strongly indicative of gastric adenocarcinoma.
Loss of E-cadherin is a key step in the development of diffuse gastric cancer.
What mutation(s) is associated with the lesion depicted i in the attached images?
- Loss of function in the adenomatous polyposis coli (APC) tumor suppressor gene.
- gain of function mutations in the gene encoding Beta-catenin
This is an example of an Intestinal type gastric adenocarcinoma.
This histo came from a gastric tumor, you note the composition includes columnar gland forming cells infiltrating through desmoplastic stroma.
What would happen if you stain with…
Mucicarmin?
E-cadherin?
Intestinal type adenocarcinoma
Mucicarmin = positive, stains pink
E-Cadherin = Positive
What is shown here?
Linitis Plastica (leather bottle) - diffuse desmoplastic carcinoma
You’re the attending physician in the oncology department and you decide to grill the new residents. You hand them this image obtained from a gastric carcinoma and ask, “What is this and how would you support your diagnosis?”
Diffuse gastric adenocarcinoma
Immunohistochem for E-cadherin should be negative.
Note the presence of the signet ring cells in the image.
What node should you check for metastasized gastric cancer?
Celiac node
You find a lymphoid neoplasm in the stomach of your patient. You do staining and find that the cells are +CD45, +CD19, +CD20 and +BCL2. What is this?
What is it associated with?
MALToma
H. pylori
On endoscopy you find this lesion in a patient’s stomach. Based on the histology, what is this neoplasm?
How would you confirm the diagnosis?
MALT lymphoma - the histo depicts numerous blue staining lymphocytes
Can confirm with FISH
To confirm your suspected case of MALToma, you perform a FISH study and obtain the attached image revealing a positive test.
What are the possible mutations that this could indicate?
Malt lymphoma can have one of three possible mutations…
- t(11;18)(q21;q21) - most common
- t(1;14)(p22;q32)
- t(14:18)(q32;q21)
What are the most common presenting clinical symptoms of a MALToma?
dyspepsia
epigastric pain
You find this lesion in your patient and notice the presence of Zellballen. What is this mass?
Carcinoid Tumor
Carcinoid tumours are well differentiated neuroendocrine tumors. What color will they be?
What histological layer will they be under?
Yellow, submucosal mass
What is this mass?
Carcinoid tumor
You biopsied a carcinoid tumor and obtained the attached images on low and high power microscopy and EM.
Describe the characteristic findings at each level of magnification that aid in making this diagnosis.
Low Power: Zellballen pattern is visible
High Power: Fine, “salt and pepper” chromatin
EM: Dense core granules (indicate endocrine in nature)
Where do most carcinoid tumors appear?
Typically in the jejunum or ileum
The peak incidence of carcinoid tumors is in the sixth decade but they can appear at any age. The symptoms are determined by the hormones produced. What is an example of this?
Those carcinoid tumors that produce gastrin cause ZE syndrome
What are the three main carcinoid tumors by location?
- Foregut carcinoid tumor
- midgut carcinoid tumor
- hindgut carcinoid tumor
Foregut carcinoid tumors are found in the stomach, duodenum proximal to the ligament of treitz, and esophagus.
Do these tend to metastasize?
Prognosis?
Rarely metastasize
generally cured by resection
Midgut carcinoid tumors arise in the jejunum and ileum. Characterize these tumors based on their aggro level.
What are outcomes associated with?
Often multipe and tend to be aggressive.
Greater depth of local invasion, increased size and presence of necrosis and mitoses are associated with worse outcomes.
Hindgut carcinoids arise in the appendix and colorectum and are typically discovered incidentally. Those in the appendix appear at any age and are typically located at the tip.
Rectal carcinoid tumors tend to produce pulypeptide hormones and when symptomatic present with abdominal pain and weight loss.
Do these tend to metastasize?
They are almost always benign and very rarely metastasize.
What are five examples of mesenchymal neoplasms that may arise in the stomach?
GI stromal tumor (GIST)
Leiomyomas
Leimyosarcomas
Schwannomas
Glomus tumors
What is the most common mesenchymal tumor of the abdomen?
GI stromal tumor (GIST)
What type of lesions are present on this example of a GIST?
Volcano lesions
What do 75% to 80% of GISTs have a mutation in?
Gain-of-function mutation in the RTK KIT.
You are handed the images attached and told that the immunohistochem is for c-KIT (CD117). What is the disease?
How should you treat?
GIST
Imatinib (gleevec)
On gross inspection you see a whorled texture within this white fleshy tumor. The mass is covered by intact mucosa, and histologically is composed of bundles/fascicles of spindle shaped tumor cells.
What is this tumor?
GIST
What symptoms do patients with GISTs present with?
Excessive Blood loss d/t mucosal ulceration
Anemia
What is the treatment for GIST?
Localized GIST = Surgical resection
IF mutations in KIT, or PDGFRA, then will respond well to imatinib.
What is shown here?
Gastrochesis
What is shown here?
Esophageal Webs
What is shown here?
Gross image of esophageal web
What is indicated by the red arrows in this image?
Esophageal rings
What is this?
Zenker Diverticulum
What is this?
What does this result from?
What can it cause?
Where is it located?
Zenker diverticulum
result of motor dysfunction
can cause aspiration pneumonia and halitosis
Located in the upper 1/3 of esophagus
Man comes into the emergency room d/t MVA, with this x-ray. What do the arrows show?
What is this?
Boorhaeve’s syndrome
Arrows indicate air level around the pericardium
What are the tears like in mallory-weiss?
Longitudinal tears
What do we have here?
Is it…
Metaplastic?
Dysplastic?
Carcinoma?
Barret’s esophagus
Metaplastic = yes
dysplastic = can be
carcinoma = possible sequelae
What is the large arrow indicating?
Squamous cell carcinoma most likely
What is shown here?
What is it seen with in the GI tract?
Why?
CMV
Linear Superficial ulcers
Affinity for blood vessels
What is a pemphigus?
Watery blisters
If Hertz says Linear esophagitis?
CMV
Hertz says pseudomembrane you say?
Candida
Hertz says punched out lesion in the esophagus, you say?
Herpes
What does this view of the esophagus reveal?
Esophageal varices
Old guy with trouble swallowing. What is this?
Squamous cell carcinoma
2 week old baby with projectile vomiting. What is this?
More likely male or female?
Familial?
Congenital pyloric stenosis
Male more than female
Familial association = yes
In acute gastritis do you have ulcers or erosion?
Erosion
A patient in renal failure presents with acute gastritis. What caused it?
Uremia
What are four tests for H. pylori?
IgM serology (not great, high false positive)
Stool antigen
Breath test
Bx with CLOtest
What color is a normal CLOtest?
How about an H. pylori positive CLOtest?
NL = yellow
H. pylori = red
Patient has duodenal AND gastric ulcers, what should you think of?
Zollinger-Ellison Syndrome
Do gastric ulcers become cancer?
Almost never
What is this?
GAVE
What are three things to keep in mind for Menetrier’s disease?
Is this a setting for cancer?
- Males
- Mucus (no acid)
- Protein losing enteropathy
- Yes, especially adenocarcinoma
This patient has multiple ulcers in a variety of GI locations. What is this finding on CT?
Gastrinoma
ZE syndrome
Are gastrin levels high or low in chronic gastritis?
PUD?
ZE syndrome?
High - d/t atrophy of the acid cells
Normal - d/t lots of acid
SUPER HIGH - in the 1000’s
