Systemic Pathology Flashcards

Question

What is the difference between hamartoma and choristoma?

Answer 1

**_Hamartoma_** = disorganized growht composed of tissue _normally found_ in a given location **_Choristoma_** = growth composed of histologically normal tissue found at a site where it is _not normally found_ in the body

Answer 2

***_Edema_*** * Abnormal accumulation of fluid in intestinal spaces or body cavities * Fluid moves out of intravascular space * Results from some combination of: * Increased capillary permeability (with histamine) * Increased capillary hydrostatic pressure * Increased interstitial fluid colloid osmotic pressure * Decreased plasma colloid osmotic pressure

Answer 3

***_Edema_*** * Types of Edema: * ***_Transudate_*** * More **_watery (serious)_** edema fluid * Usually **_noninflammatory_** * From **altered** intravascular hydrostatis or osmotic pressure * ***_Exudate_*** * More **_protein-rich edema_** fluid * usually **_inflammatory_** * From **increased** vascular permeability (with **inflammation**)

Answer 4

Examples of Transudate * **Anasarca**: Generalized edema * **Hydrothorax**: Excess serous fluid in pleural cavity * **Hydropericardium**: Excess watery fluid in pericardial cavity * **Ascites (hydroperitoneum):** Excess serous fluid in peritoneal cavity (stomach)

Answer 5

* **_Right-sided conjestive heart failure_** * results in peripheral edema * **_Left-sided conjestive heart failure_** * results in pulmonary edema

Answer 6

Edemas and causes * ***_Congestive Heart Failure_*** * Increase in plasma/capillary hydrostatic pressure * ***_Nephrotic syndrome_*** * Decrease in plasma oncotic pressure * ***_Cirrhosis_*** * Increase in capillary hydrostatic pressure * Decrease in plasma oncotic pressure * ***_Elephantitis_*** * Increase in plasma/capillary hydrostatic pressure * Secondary to decrease lymphatic return

Answer 7

**_Shock_** Decreased cardiac output is the major factor in all types of shock (because either decrease HR, decrease Stroke Volume, or both) * Decrease tissue perfusion * Hemodynamic changes result in * Decrease blood flow, thereby * Decrease oxygen and metabolic supply to tissue * Can result in multiple organ damage or failure * Symptoms * Fatigue * Confusion * Signs * Cool pale skin (pallor) * Weak rapid pulse (tachycardia = icncrease HR) * Decrease BP (hypotension) * Decrease urine output * Shock requires immediate medical treatment and can worsen rapidly

Answer 8

Major Categories of Shock * **_Hypovolemic_** * Decrease blood volume * Ex: Hemorrhage, Dehydration, Vomiting, Diarrhea * **_Cardiogenic_** * Pump failure, Usually Left ventrical failure, Sudden decrease in Cardiac Output * Ex: Massive MI, Arrhythmia * _Distributive_ * **_Septic_** * Infection (endotoxin release), Gram negative bacteria, Causes vasodilation * Ex. Severe infection * **_Neurogenic_** * CNS injury, Causes vasodilation * Ex. CNS injury * **_Anaphylactic_** * Type I hypersensitivity, Histamine release, Vasodilation * Ex. Anaphylactic allergic reaction (insect sting)

Answer 9

Stages of Shock (decreased blood flow) * ***_Nonprogressive (early)_*** * = compensated * Increase sympathetic NS * Increase Cardiac Output * Increase Total periferal resistance * Try to maintain perfusion to vital organs * ***_Progressive_*** * Decrease cardiac perfusion * Cardiac depression * Decreased Cardiac output * Metabolic acidosis (Compensatory mechanism are no longer adequate) * ***_Irreversible_*** * Organ damage * Decrease high energy phosphate reserves * Death (even if blood flow is restored)

Answer 10

**_Congestion (Hyperemia)_** * Increased volume of blood in local capillaries and small vessels * **_Active congestion (active hyperemia)_** increased arteriolar dilation (inflammation, blushing) * **_Passive congestion (passive hyperemia):_** decreased venous return (obstruction, increased back pressure) * Two forms: * Acute * Shock or right sided heart failure * Chronic * In **lungs** (usually secondary to **left** sided heart failure) * In **liver** (usually secondary to **right** sided heart failure)

Answer 11

***_Thrombosis_*** * Blood clot attached to endothelial surface (blood vessel or heart - endocardium) * usually a vein * Virchow's triad * **_Arterial thrombi_** * **Lines of Zahn** (morphologically) * Alternating red and white laminations * **_Venous Thrombi_** * Propagate: enlarge while remaining attached to vessel wall * **Embolize** * Detach as large embolus * Fragment off as many small emboli; shower emboli

Answer 12

Virchow's Triad for Thrombosis * Endothelial injury * Alteration in blood flow * Hypercoagulability of blood

Answer 13

***_Lines of Zahn (arterial thrombi)_*** * **White** (fibrin and platelet) layers **alternating** with **dark** (RBC) layers * Indicated **_thrombosis in aorta or heart_** before death

Answer 14

Types of Thrombus **_Agonal_** * Intracardiac thrombi * After _prolonged heart failure_ **_Mural_** * Thrombus from **endocardial surface** (or endothelium of large vessel) protrudes into lumen of heart or large vessel) * Forms after * MI; damage to ventricular endocardium (LV most often) * Atrial fibrillation * Aortic atherosclerosis can cause cerebral embolism **_White_** * Thrombus composed mostly of blood **platelets** **_Red_** * Thrombus composed of **RBCs** (rather than platelets) * Occurs rapidly by _coagulation_ with blood stagnation **_Fibrin_** * Thrombus composed of **fibrin** deposits * _Does not completely occlude_ the vessel

Answer 15

predisposing factors to thrombosis * **_Atrial Thrombosis_** * Atherosclerosis (major cause) * **_Venous Thrombosis_** * Heart failure * Tissue damage * Bed rest (immobilization) * Pregnancy * Oral contraceptive pills * Age * Obesity * Smoking

Answer 16

***_Embolus_*** * Intravascular mass * Solid, liquid, gas * Travels within a blood vessel * Lodges at distant site * Occludes blood flow to vital organs * Possibly leads to infarction * **_Thromboemboli_** (most common): blood clot * Breaks off existing thrombus * Forms and is released downstream in the circulation (eg. from heart chambers in atrial fibrillation) * **_Fat embolism:_** Especially in long bone fracture * **_Gas embolism:_** air into circulation (eg. Caisson disease) * **_Amniotic fluid embolism_**: With delivery; can activate diffuse/disseminated intravascular coagulation (DIC) * **_Tumor embolism_**

Answer 17

Pulmonary Embolism * Embolism causing pulmonary artery obstruction * Usually arises from * Deep vein thrombosis (DVT); usually from lower extremeties (above popliteal fossa) * Course * Systemic vein * Right heart * Pulmonary artery * Causes * Right heart strain * Possible infacrtion in the affected segment * Possible pleurisy (pleuritic chest pain) * Predisposing factors * Virchow's triad * Especially immobilization (leading to stagnation) * Thrombophlebitis (inflammation of veins related to blood clot) * Hypercoagulable states

Answer 18

**_Arteriosclerosis_** * Hardening of the arteries * General term for several diseases causing changes to artery wall: * Thicker * Less elastic **_Atherosclerosis_** * ***_Degenerative changes in artery walls_*** * _Most common cause of arteriosclerosis_ * **__Most important contributor to arterial thrombosis** * **Most susceptible arteries = aorta and coronary arteries** * **_Atherosclerostic plaques:_** Fatty material accumultating under the arterial walls inner lining * Occurs in arteries (no veins) * Risks * Men and postmenopausal women (estrogen = protective) * Smoking, Hypertension, Hereditary (Familial hypercholesterolemia), Nephrosclerosis, Dibetes, Hyperlipidemia * Sites * Carotid, coronary, Circle of willis, Renal and mesenteric arteries * Can lead to: * Ischemic heart disease (CAD) * Heart attack (myocardial infarction (MI)) * Stroke or aneurysm formation * Pathogenesis: * Fatty streak * Foam cells in intima (lipid laden macrophages) * Atheromas * Cholesterol, Fibrous tissue, Necrotic, debris, Smooth muscle cells * Complications * decreased elasticity of vessels * Ulceration of plaque; predisposing to thrombus formation * Hemorrhage into the plaque;narrowing lumen, possibly occluding blood flow * Thrombus formation * Embolization; overlying thrombus or plaque material itself * Symptoms * Depend on sites * Visual changes, dizziness; Carotid or intracerebral arteries * Angina: Coronary arteries * Leg pain (claudication): lower extremity arteries

Answer 19

Familial hypercholesterolemia * Autosomal dominant diseae * Anomalies of LDL (low-density lipoprotein) receptors * Atherosclerosis and its complications * Xanthomas * MI by age 20

Answer 20

Hypertension = silent killer (asymptomatic) **_Primary (Essential) Hypertension_** * Accounts for 90-95% of hypertension * No identifiable cause; related to increased Cardiac Output and increased Total Peripheral Resistance * Risks * Genetic * Family history, African Americans * Environment * Incresed dietary salt intake, Stress, Obesity, Cigarette smoking, Physical inactivity * Pathologic findings * Hypertrophy of arteries and arterioles NOT capillaries (because no smooth muscle) * Increase wall to lumen ratio * Increased smooth muscle cell growth (because increased pressure, stretch) * Decreased arteriolar and capillary density * Decreased total cross-sectional area of capillaries and arterioles * Three organs most often damaged: * Heart : 60% die due to complications * Kidney : 25% die due to renal failure * Brain : 15% die due to stroke or neurologic complications **_Secondary Hypertension_** (related to another disease) * Hypertension (HTN) from known causes * 5-10% of HTN cases * Identifiable, often correctable cause * Renal disease * Most common cause of secondary hypertension * Renin-angiotensin-aldosterone system * Two categories * Renal parenchymal diseases * Renal artery stenosis * Endocrine Disorders * Hyperaldosteronism (Conn syndrome) * Cushing syndrome * Hyperthyroidism * Diabetes * Pheochromocytoma * Other causes: * Coarctation of the aorta * Preeclampsia/eclampsia/toxemia of pregnancy * **_Preeclampsia_**: * Occurs in pregnant patients * Hypertension: \> 140 systolic, or \>90 diastolic after 20 weeks gestation * Proteinuria * Edema

Answer 21

***_Aortic Aneurysm_*** * Abnormal, localized dilation of the aorta * True aneurysm = dilation of all three layers (intima, media, adventitia) * Causes * Atherosclerosis * Cystic medial necrosis * Marfan * Ehler-Danlos * Infectious aortitis * Syphilitic aortitis * Vasculitis * Risk: RUPTURE ***_Aortic Dissection_*** * Most often ruptures into the pericardial sac (hemopericardium) causing fatal tamponade * Blood in media layer of aorta

Answer 22

Infections of the heart * **_Pericardium_** * pericarditis * **_Myocardium_** * myocarditis, often viral * **_Endocardium and heart valves_** * Endocarditis, often bacterial or inflammatory

Answer 23

***_Endocarditis_*** * **_Inflammation of endocardium and/or heart valves_** * Symptoms: Develop quickly (acute) or slowly (subacute) * **Fever (hallmark)** * Nonspecific constitutional signs, Fatigue, Malaise, headache, Night sweats * Findings * Murmur (secondary to vegetations); may change with time * Splenomegaly * Splinter hemorrhages (small dark line) under fingernails

Answer 24

**_Endocarditis_** ***_Infective_*** * Usually **bacterial** * _****Acute Endocarditis:_ **Staph. aureus** (50%) and secondary infection to somewhere else in body (IV drug users) * _Subacute (Bacterial) Endocarditis_: **Strep. viridans** (\>50%). Patients with preexisitng valve disease * Intrinsic bacteremia * dental, Upper respiratory, Urologic, Lower GI, Introduced bacteremia, IV drug users (tricuspid valve) * Valvular involvement * Vegetations * Mitral * Tricuspid (IV drug users) ***_Rheumatic_*** * Complication of rheumatic fever * Acute inflammatory disease (after streptococcal infections, age 5-15 yrs) * Type III hypersensitivity * Mitral valve most often calcification: * Stenosis, Insufficiency, both * Pathology: **Aschoff bodies** * Findings/criteria for diagnosis = Jones criteria * Rheumatic carditis usually disappears within 5 months. However, permanent damage to heart/heart valves usually occur, leading to **rheumatic heart disease** **_Libmann-Sacks_** * Occurs in SLE (**Systemic lupus erythematosus = autoimmune disease**) * Nonbacterial endocarditis * Mitral valve most often small vegetations on either or both surfaces of valve leaflets

Answer 25

***_Coronary Artery Disease (CAD)_*** * **CAD = narrowing of coronary arteries** * Atherosclerosis plaques * Decreased blood supply to myocardium * Decreased O2 and nutrients to myocardium * Consequences * Ischemia, Infarction * Symptoms * Classic symptom of CAD = **_angina_ = ischemia** * **Infarction** (MI = heart attack with ECG changes and enzymes released from infarcted myocardial tissue)

Answer 26

Angina * Squeezing (tight) substernal chest discomfort; may radiate to: * left arm * neck * Jaw * Shoulder blade * Caused by decreased myocardial oxygenation * Atherosclerotic narrowing * Vasospasm * Types: * **_Stable Angina_** * Most common type * coronary artery disease (CAD)/atherosclerotic narrowing * Precipitated by exertion * Relieved by rest or nitrates * **_Unstable Angina_** * Occurs even at rest * More severe CAD * Often imminent MI * **_Primzmetal Angina_** * Intermittent chest pain at rest * Vasospasm

Answer 27

**_Myocardial Infarction_** * **Most important cause of morbidity from CAD** * ***_Prolonged interruption of coronary blood flow to myocardium; coagulative nerosis_*** * Cause: usually thrombus formation in the setting of a ruptured, unstable plaque * Types: * **_Complete Occlusion_** * Transmural infarction * ST elevation MI * **_Partial Occlusion_** * Subendocardial infarction * Non-ST elevation MI * Symptoms * **Angina** (that does not remit), sweating, nausea, stomach upset * Signs * **ECG changes** (ST elevation, ST depression, T waves, Q waves) * Enzyme leak * Prognosis * Good (if patient reaches hospital) * Compliations * Arrhythmia, Myocardial (pump) failure, cardiac rupture, papillary muscle rupture, ventricular aneurysm

Answer 28

CPK: Enzyme found in (increases when damage to): Heart Brain Skeletal muscle **NOT** found in the liver....

Answer 29

**Heart Failure** * Heart's ability to pump does not meet needs of the body * usually a chronic progressive condition * Can occur suddenly * Causes: Secondary to heart muscle damage * After MI * Cardiomyopathy * Valvular diseases * Signs and symptoms (Left and Right side heart failure) * **_Left heart failure_** * Exertional dyspnea, Fatigue, Orthopnea, cough, cardiac enlargement, Gallop rhythm (S3 or S4), pulmonary venous congestion * **_Right heart failure_** * Elevated venous pressure, Hepatomegaly, Dependent edema * usually caused by left side failure * Isolated RHF = uncommon * When right HF occurs: Corpulmonale * lung disease due to pulmonary hypertension * increased pulmonary vascular resistance causing increased R heart strain * RHF leads to systemic venous congestion and peripheral edema * **_Two earliest and most common signs of heart failure:_** * Exertional dyspnea (labored breathing) * Paroxysmal nocturnal dyspnea (coughing at night)

Answer 30

Cardiovascular Pulmonary Cross-correlation **_Carbon Monoxide (CO) poisoning_** * Symptoms * Cherry-red discoloration of skin, mucosa, and tissues * Mental status changes * Coma -\> death * (Cyanide poisoning poisons oxidative phosphorylation) * Mild poisoning: Presents with exhaustion and symptoms similar to a common cold or flu, delaying diagnosis **_Pulmonary Edema_** * Fluid in alveolar space of the lungs (decrease O2 exchange) * Cause * usually left heart failure (increase hydrostatic pressure) * Fluid extravasation into lung spaces * Increased intracapullary hydrostatic pressure (heart failure) * Increased capillary permeability (Acute respiratory distress syndrome (ARDS) * Mechanism * Backlog of blood in left heart (increase volume) * Increased left heart pressure * Incresaed pressure in pulmonary veins (transmitted backward from heart) * Symptoms * Shortness of breath (SOB)/dyspnea * Orthopnea, cough, tachypnea, dependent crackles, tachycardia, neck vein distention * Treatment * Decreased vascular fluid (Diuretic) * Increased gas exchange and ehart function * O2, Antihypertensive, Positive inotropic agents, antiarrhythmics * **_Primary Pulmonary Hypertension:_** * Not known heart or lung diseases * Unknown etiology * **_Secondary pulmonary hypertension_** * Most common form * **COPD** (most often) * Left to right shunt * Increased pulmonary resistance * Embolism * Vasoconstriction from hypoxia * Left heart failure * **Pulmonary hypertension can lead to Righ Ventrical hypertrophy and R heart failure** (**_corpulmonale_**)

Answer 31

**_Angina Pectoris_** * Occurs when the heart’s demand for oxygen is greater than the supply * Stable Angina * Most common form * Repeating patterns of chest pain with no change in character, frequency or intensity * Precipitated by exertion and relieved by rest or vasodilators such as nitroglycerin * Unstable Angina * Variable chest pain * Prolonged/recurrent pain at rest * Often indicates an MI is about to occur * Prinzmetal’s/Variant Angina * Caused by a vasospasm that narrows the coronary artery and lessens blood flow to the heart Intermittent chest pain at rest

Answer 32

* **_Allergic (immune) = Extrinsic_** * **Type I hypersensitivity** * Atopic asthma * IgE vs. allergin (IgE crosslink) * Fc binds mast cell * Mast cell degranulate: * Histamine * Causes: bronchospasm/inflammatory * **_Intrinsic (nonimmune) = Intrinsic_** * **_Direct Bronchoconstriction Release_** * Caused by chemical inhalation or medication * **_Increased Vagal stimulation_** * Respiratory threshold to vagal stimulation is lowered by * Viral infection * URIs (cold or flu) * Parasympathetics activity causes *_bronchoconstriction_* * **_COX Inhibitors (NSAIDs, ASA)_** * Cyclooxygenase pathway blocked * Arachidonic acid metabolism * Causes: * Increased leukotrienes * Bronchoconstrictors (as opposed to prostaglandins = bronchodilators)

Answer 33

***_Chronic Obstructive Pulmonary Disease (COPD)_*** * **Group of lung diseases characterized by increased airflow resistance** * **Emphysema** * **Chronic bronchitis** * Types: * **_Obstructive Lung Diseases (Increase TLV)_** * Asthma * COPD * Emphysema = Pink Puffer * Chronic bronchitis = Blue Blower * **_Restrictive Lung Diseases (decrease TLV)_** * Intrinsic lung diseases: * Pneumoconioses * Sarcoidosis * Idiopathic pulmonary fibrosis * Extrinsic lung diseases * Kyphosis * Obesity * Neuromuscular weakness

Answer 34

**_Emphysema (COPD)_** * **"Pink puffer"** * Adults, usually smokers * Types of Emphysema * Centrilobular * **Cigarette smoking** * Upper lobe of lungs * Panlobular * Familial antiproteinase deficiency * Upper and lower lobes * Pathology: * ***_Destruction of elastic fibers in alveolar wall_*** * **Decrease elastic recoil** * Distal airspaces enlarged (dilated alveoli) with inhalation * Lungs overexpand (increased total lung capacity) * **Decreased radial traction (airways _collapse_ w/exhalation)** * leaving air behind, air trapped * Decreased functional parenchyma * Microscopic * Enlarged air spaces, broken septae projecting into alveoli (no fibrosis) * Clinical * Pink puffer * Dyspnea - labored breathing * No productive cough * Scant clear mucoid sputum production * Increased infection suscepibility * Findings: **_PO2 = normal_** * **No cyanosis (they are pink)** * Barrel chest * Pulmonary function test (PFTs) * Increased TLC = total lung capacity * Increased residual volume (RV) * Decreased FEV1/FVC (forced expiratory volume in 1 second/forced vital capacity) * Damage worsens with time = continue smoking

Answer 35

***_restrictive lung diseases_*** **Decreased lung compliance** **Decreased all lung volumes** **Increased FEV1/FVC** = forced expiratory volume in 1 second/forced vital capacity **_Discussed Diseases of Restriction:_** Intrinsic lung diseases (Pneumoconiosis, Sarcoidosis) Extrinsic lung diseases (Obesity, Kyphosis, NM weakness)

Answer 36

***_airway obstruction_*** * Airway hyperreactivity (bronchoconstriction): **Asthma** * Decreased elastic recoil (airways collapse): **Emphysema** * Increased Mucous: **Chronic bronchitis** **_Discussed Diseases of Obstruction:_** **Asthma** **COPD (Emphysema, Chronic Bronchitis)**

Answer 37

***_Chronic Bronchitis (COPD)_*** * "**_blue bloaters"_** * Adults with history of **cigarette** smoking * Definition: chronic productive cough for at least 3 months of the year for 2 yrs * Microscopic * **Mucous hypersecretion** * Bronchi: Hypertrophy of mucous glands and smooth muscle * Smaller airways: Goblet cell hyperplasia * Increased Reid index * increased ratio mucous gland thickness: bronchial wall thickness * Clinical * **_Productive cough (increased sputum)_** * Wheezing * Auscultation * Noisy chest * Rhonchi * FIndings: ***_Decreased PO2 - Cyanosis (looks blue)_*** * Complications: * Pulmonary hypertensition * RV overlaod; corpulmonale (RHF) * **peripheral edema (bloaters)** * Increased lung cancer risk (bronchogenic carcinoma) -\> squamous metaplasia

Answer 38

* **_Atelectasis_** = lung collapse (alveolar collapse) * causes: Failure of expansion, Bronchial obstruction, External compression * Atelectasis neonatorum = alveolar collapse in newborn, usually due to decreased surfactant (premature infants) * **_Anthracosis_** * Coal workers pneumoconiosis = black lung disease * **_Silicosis_** = Most common and most serious pneumoconiosis (inhalation of silica) * Silica dust in alveolar macrophages * Thick pleural scars * Increased susceptibility to Tb (silicotuberculosis) * **_Asbestos_** * Inhalation of asbestos fibers * Can develop 15-20 yrs after exposure * Results in diffuse interstitial fibrosis * Findings: Ferruginous bodies (yellow-brown) * Stain with prussian blue

Answer 39

**_Sarcoidosis_** * **Unknown etiology** * **Diagnosis/biopsy; noncaseating granulomas** * _Black females:_ manifests in teens or younger adult years * Findings: * Interstitial lung disease * Enlarged hilar lymph nodes * Uveitis * Erythema nodosum * Polyarthritis * Hypercalcemia * Pathology * **_Noncaseating granulomas_** * Schaumann and asteroid bodies * Clinical * Bilateral hilar lymphadenopathy on CXR * Interstital lung disease (restrictive lung disease) * Cough/Dyspnea * Skin findings

Answer 40

Rare tumor involves parietal or visceral pleura Associated with asbestos exposure: 25-45 year latency Diffuse lesion; spreads over lung surface

Answer 41

Pneumonia * Lung infection * Bacterial, Viral, Fungi * Clinical: * Fever, chills, productive cough, Blood-tinged sputum, Dyspnea, Chest pain * Findings * Hypoxia * Infiltrate on CXR * Crackles, other noises on auscultation

Answer 42

Types of Pneumonia * **_Lumbar pneumonia_** * Cause: * Pneumococcus * *_Streptococcus pneumoniae_* * Findings: **Exudate within alveolus**, Consolidation, Lobe or entire lung * Age: **Middle age** * **_Bronchopneumonia_** * Cause: * *_Staph. aureus_* * *_Haemophilus influenzae_* * *_Klebsiella_* * *_Strep. pyogenes_* * Findings: **Bronchiole and alveolar infiltrates**, Patchy, 1+ lobe * Age: **Infants and elderly** * ***_Interstitial pneumonia_*** * Cause: * *_Viruses: RSV and adenovirus_* * *_Mycoplasma_* * *_Legionella_* * Findings: **Diffuse patchy infiltrates (within _interstitum_**), 1+ lobe * Age: **Young Children** ***_Viral Pneumonia:_*** * Most common cause of pneumonia in **young children** * Peaks between age 2 and 3 yrs ***_Bacterial Pneumonia_*** * Most serious pneumonias (typically) * Pneumococcus (**strep. pneumo**) is the most common cause * Most common **fatal** infection in the hospital

Answer 43

**_Lung Abscess_** * **_Localized collection of pus in lungs_** * Causes: * Aspiration * Altered mental status * Bronchial obstruction * Cancer, pneumonia, bronchiestasis * Septic emboli * **_Most common predisposing factor = alcoholism_** **-**\> in particular, aspiration (fluid to lungs bringing bacteria with it from oral cavity) * Organisms * **_Staphylococcus_** (most common) * other organisms: * Pseudomonas * Klebsiella (alcoholics) * Proteus * Anaerobes * Clinical * Productive cough; large amounts of foul-smelling sputum * Fever * Dyspnea * Chest pain * Cyanosis * Chest x-ray with fluid filled cavity

Answer 44

**_Hemoptysis_** Coughing up **blood** (or blood-streaked sputum) * Respiratory infections (minor URIs) * Bronchitis * TB * Pneumonia * Bronchogenic carcinoma * Idiopathic pulmonary hemosiderosis (iron in lungs)

Answer 45

**_Tuberculosis (TB)_** * Worldwide condition * Increased in conditions of * Poor sanitation * Poverty * Overcrowding * ***_Mycobacterium TB_*** * ***_Acid-fast bacilli_*** * ***_Strict aerobe_*** * Transmitted by aerosolized "droplets" * Pathology * **granuloma** * **giant cell** * **caseous necrosis** * Clinical * Hemoptysis, weight loss, night sweats, Malaise, weakness

Answer 46

Types of Tuberculosis * ***_Primary TB_*** * Site: * **Between upper and middle lobes** * Lower part of upper lobe or upper part of lower lobe * Characteristics * **Ghon's complex** * Parenchymal lesion(Calcified primary lesion + lymph node (LN) involvement) * Hilar LN's * ***_Secondary TB_*** * Site: **Lung apices** (high O2 tension) * Characteristic: Reactivation of Ghon's complex * ***_Miliary TB_*** * Site: Widely disseminated (**spread**) * Characteristics: * Lesions like "millet seed" * Multiple extrapulmonary sites Clinical presentation: * Usually secondary TB, only 5% patients that have have primary TB have symptoms * Secondary TB = reactivation of the primary Ghon's complex, which has remained quiescent (subclinical) and /or occurs years earlier Pott's disease = TB involving the vertebral body

Answer 47

Ghon's complex = calcified primary lesion + lymph node involvement Seen in Primary TB and reactivated in Secondary TB

Answer 48

Mild to major bleeding (usually painless) at distal esophagus due to tears in the epithelium, proximal stomach Most common in Men\>40, Alcoholics, Hiatal hernia Vomiting of blood (hematemsis) seen

Answer 49

* **_Achalsia_** * Decreased propulsion of food down the esophagus (decreased peristalsis) * Failure of LES to relax * Nerve related cause to smooth muscle * **_Hiatal hernia_** * Protrusion of part of the stomach through diaphragm into the thoracic cavity * **_Gastroesophageal Reflex Disease (GERD)_** * Acid reflex * Backflow of acidic stomach contents up into esophagus (LES leaky) * Risks: Hiatal hernia, Scleroderma * Symptoms: heartburn, Regurgitation of food, Hoarse voice, wheezing, coughing * Treatment: Proton pump inhibitor, Antacids * Complications * Can lead to *_Barrett's esophagus_* (premalignant) * Type of **metaplasia** * Changes from squamous cell to columnar epithelium * Complication of chronic heartburn * **_Esophageal Ulcers_** * Erosion on the esophageal lining mucosa * usually caused by repeated regurgitation of stomach acid (HCL) to lower part of esophagus * Can also get esophageal infections causing erosion (candidal or viral) ***_What is the Zollinger-Ellison triad?_*** * Increased gastric acid * Peptic ulcers * Panreatic gastrinoma

Answer 50

Peptic Ulcer Disease (PUD) * **_Erosion in the lining of the stomach or duodenum_** * Circumscribed lesions in the mucous membrane * Occurs mostly in men aged 20-50 * **~80% duodenal ulcers** * **Hemorrhage is the most common complication of PUD.** * Causes: * **Imbalance between acid and mucosal protection** * NSAIDs (decrease mucosal protection: decreased prostaglandins) * Acid hypersecretion (Zollinger-Ellison) * Infection * ***_Helicobacter pylori_*** * Risks * Asprin, NSAIDs, Cigarette smoking, Older age * Symptoms: Pain * Complications: * Bleeding * When erode deep into blood vessels, Bleeding ulcers * Perforation (causes acute peritonitis) * Malignant change = uncommon * Treatment = antibiotics, anticid medications, proton pump inhibitors

Answer 51

***_Hematemesis_*** * Vomiting of bright red blood, indicating rapid upper GI tract bleeding * Assoicated with **esophageal varices** (common in *_alcoholics_*) or **peptic ulcers**

Answer 52

Small and Large Intestines * **_Meckel Diverticulum_** * **Most common congenital anomaly of the small intestine** * *_Remnant of embryonic vitelline duct_* * Located in distal small bowl * May contain ectopic gastric and duodenal, colonic, or pancreatic tissue * ***_Intestinal Lymphangiectasia_*** * In **children**, young adults in which **lymph vessels** supplying lining of small intestine becomes **enlarged**; fluid retention is massive

Answer 53

**Inflammatory Bowl Disease** * Crohn's and ulcerative colitis (UC) * Both can present with: * Abdominal pain * Obstruction * Bloody diarrhea (occult or gross) **_Crohn’s Disease_** * Can ***affect entire GI from mouth to anus*** * Cobblestone appearance * Transmural inflammation (giant cell) * **Chronic inflammation** of the intestinal wall * Non-necrotizing granulomatous inflammation with ulcers, strictures and fistulas * No known cause and no cure ***_Ulcerative Colitis_*** * ***Only the colon*** * Inflammation limited to mucosa and submucosa * Increased risk of secondary **malignancy**

Answer 54

Malabsorption Syndromes * Nutrients from food are not absorbed properly * Not absorbed across small intestine into the blood * Clinical: * Children: Growth retardation, failure to thrive * Adults: Weight loss * Types: * ***_Celiac disease:_*** * Causes: Autoimmune disease triggered by **gluten** protein * Comments: Child or adult. Increase risk of GI lymphoma. MALToma * ***_Tropical sprue_*** * Cause: **unknown**, Probably infection * Comments: Travelers to the tropics, Steatorrhea (fatty diarrhea), Diarrhea, Weight loss, sore tongue (dec. vit B) * ***_Whipple's disease_*** * Cause: Tropheryma whippelii * Comments: Middle-aged men, Slow onset of symptoms * Skin darkening * Inflamed painful joints * Diarrhea * Can be fatal

Answer 55

***_Pancreatitis_*** * Inflammation of infection of the pancreas * **Severe mid-abdominal pain** * *_Obstruction of the pathway of secretion of pancreatic enzymes into the intestine -\> enzymes act on pancreas instead_* * Associated with *_alcoholism (chronic) and biliary disease/gallstones (acute)_* * Cause: * Injury to pancreatic cells * Obsruction of normal pancreatic outflow * Autodigestion/autolysis by pancreatic enzymes * Chronic cases, inflammation and fibrosis cause destruction of functional glandular tissue * Symptoms: * **_Severe Mid-adominal pain_**, destruction of pancrease * Laboratory: * Increase Lipase (important) * Increase amylase * ***_Acute Pancreatitis:_*** * Causes: **Gallstones** (#1), other biliary disease, Trauma, Cystic fibrosis in children * Symptoms: Abdominal pain, knifelike, radiation to back, Nausea and vomitting, Jaundice (if gallstone), pale/clay colored stool * Complication: Enzymatic hemorrhagic fat necrosis w/calcium soap formating with resultant hypocalcemia * ***_Chronic pancreatitis:_*** * Causes: **Alcoholism** (most often), hyperlipidemia, hyperparathyroidism * Symptoms: Abdominal pain, nausea, vomiting, fatty stool * Complications: pseudocyst, Pancreatic abscess, ascites

Answer 56

***_Cholelithiasis_*** * Stones in the gallbaladder = **gallstones = jaundice** * Choledocholithiasis = gallstones in the common bile duct (CBD) * result in obstructive jaundice, with yellow skin color caused by bile pigments being deposited in the skin

Answer 57

**_Cholesterolosis_** * Called strawberry gallbaladder * Small yellow cholesterol flecks against a red background in the lining of the gallbladder * Polyps may form insde GB **_Gallbladder Diverticulosis_** * Small fingerlike outpouches of the GB lining may develop as a person ages; may cause inflammation and require GB removal

Answer 58

***_Cirrhosis (of liver)_*** * Most common **chronic liver disease** * assicoated with ***increase in hepatocellular carcinoma*** * Occurs twice as often in males as in females * **Third most common cause of death** among people aged 45-65 (behind heart disease and cancer) * Characteristics: * ***Scarring/fibrous*** * ***Loss of hepatic architecture*** * ***Formation of regenerative nodules*** * Cause * ***Alcoholism (75%)*** * ***Viral hepatitis (Hep B, C)*** * Hemochromatosis * ***Wilson disease*** * ***Hepatolenticular degeneration - hereditary accumulation of copper in liver, kidney, brain, and cornea (green pigment in cornea)*** * Drugs/toxic injury, Biliary obstruction, Other inborn errors of metabolism (Galactosemia, Glycogen storage disease, Alpha-1 antitrypsin deficiency) * Clinical Findings * Ascites (accumulation of fluid in the peritoneal cavity, causing abdominal swelling) * Splenomegaly * Jaundice * Coagulopathy/bleeding disorders * Confusion/hepatic encephalopathy * Portal Hypertension (and its complications) * Esophageal varices (with hematemesis)

Answer 59

Portal Hypertension * Abnormally high blood pressure in the portal vein/system * Factors increase BP in portal vessels * Decrease volume of blood flow through the portal system * Increase resistance to blood flow through the liver * \*\****Splenomegaly*** = most important sign of portal hypertension \*\* * Causes * ***Cirrhosis of liver = most common cause*** * Splenic or portal vein thrombosis (prehepatic) * Results/complication * Development of venous collaterals * ***Esophageal varices (hematemesis in alcoholics)*** * ***Dilated tortuors veins in Lower esophagus) = first sign of cirrhosis and portal hypertension*** * Hemorrhoids * Enlarged veins on anterior abdominal wall * Spider angiomas * Ascites (fluid in abdominal cavity) * LIVER DISEASE = MOST COMMON CAUSE * Splenomegaly (congestive)

Answer 60

* **_Kernicterus_** * newborn infants with high levels of bilirubin that accumulates in the brain (form of crippling) * ***_Hepatitis_*** (with relation to liver) * Inflammation of the liver * ***_Transaminitis_*** * Damage to liver cells -\> release enzymes into blood -\> increase serum levels of enzymes (transaminases = AST = aspertate, ALT = alanine) * Increase transaminases used to diagnose liver disease * ***_Viral hepatitis_*** * Liver inflammation caused by a virus

Answer 61

***_Nephroliniasis_*** ***_(Kidney stones)_*** * Forms in renal pelvis, calyces and passes into urinary system * More often in M\>F; rare in children * Predisposing factors * Dehydration, infection, changes in urine pH, obstruction of urine flow, immobilization with bone reabsorption, Metabolic factors (hyperparathyroidism with hypercalcemia), renal acidosis, increased uric acid, defective oxalate metabolism * Stone composition * ***Calcium oxalate or calcium phosphate (most common)*** * ******Calcium stones account for 80-90% of urinary stones. They are composed of calcium, oxalate, calcium phosphate, or both * ***Struvite (from infection)*** * Uric acid (from metabolic disorders, obesity) * Cystine (inborn errors of metabolism) * Clinical symptoms: * Usually asymptomatic (until stone passes) * ***Renal colic*** (sever pain) - once stone is in ureter * Complications * ***obstruction of ureter*** (presure and pain) * ***Pyelonephritis*** (acute or chronic) * ***Hydronephrosis*** (urine cannot get out)

Answer 62

***_Hydronephrosis_*** * **Abnormal dilation of renal pelvis and calyces of one or both kidneys** * Caused by ***urinary track obstruction (Stone!!)*** * Decreased urine flow * Increased pressure behind the obstruction * Renal pelvis and calyces dilate * Physical manifestion * NOT a disease process itself * Disease = stone, stricture (restrict activity), benign prostatic hyperplasia, etc

Answer 63

***_Pyelonephritis_*** * ***Infection of the renal pelvis (kidney and ureter), usually _E. coli_*** * Cause: * Most often from a urinary tract infection (***_UTI_***) * ***Retrograde/backflow bacteria***-laden urine from bladder into ureter up to kidney pelvis (vesicoureteral reflex) = from LUT * Forms: * Acute * Active infection of the renal pelvis * Abscess can develop; renal pelvis fills with pus (neutrophil rich) * Chronic * Scarring fibrosis; renal failure is possible

Answer 64

* ***_Hematuria_*** * blood in urine (Women = in urine; Men = bloody ejaculation from prostate; Children = bleeding disorder, recent strep infection may imply post-strep GMN) * Poststreptococcal GMN is the classic cause of blood in urine in children * Kidney or urinary tract disease * ***_Glucosuria_*** * Glucose in urine * Diabetes mellitus * ***_Ketonuria_*** * Ketone in urine; acetonelike odor * Starvation, uncontrolled Dibetes mellitus, Alcohol intoxicaation * ***_Proteinuria_*** * Protein in urine * Kidney disease

Answer 65

***_Polycystic Kidney Disease (PCKD)_*** * ***_Adult form (APCKD)_ = Autosomal dominant*** * Inherited disorder with multiple cysts on the kidney * Caused by mutation in the PKD gene * Course * Early stages * **Kidney enlargement (as cysts form and grow)** * Kidney function altered, resulting in: * Chronic high blood pressure; hypertension caused by polycystic kidneys is difficult to control * Anemia * Erythrocytosis; if cysts cause increased erythropoietin (increases RBC) * Kidney infection * Flank pain, if bleeding into a cyst also * Later * Slow progressive * Ultimately resulting in end stage kidney failure (and liver cysts) * APCKD also associated with liver disesae and infection of liver cysts * ***_Childhood form_*** * ***_Autosomal recessive_*** form of polycystic kidney disease * More ***serious*** form appears in infancy or childhood * Course: * Progressive rapidly * Resulting in ESRD (end stage renal disease) * Kidney failure leads to death in infancy or childhood * NOTE: kidney stones are less common in PCKD

Answer 66

Kidney disease is often associated with malignant hypertension. Malignant hypertension is defined as BP over 200/140 and can cause papilledema and CNS dysfunction

Answer 67

Nephrosclerosis * Renal impairment secondary to artherosclerosis or hypertension * **Arterial nephrosclerosis** * ****Atrophy and scarring of the kidney * Due to artheriosclerotic thickening of the walls of large branches of renal arteries * ***_Arteriolar nephrosclerosis_*** * Arterioles thicken * Areas they supply undergo ischemic atrophy and interstitial fibrosis * Associated with Hypertension * ***_Malignant nephrosclerosis_*** * Inflammation of renal arterioles * Results in rapid deterioration of renal function * Accompanies malignant hypertension

Answer 68

Nephr***_o_***tic Syndrome * Not a disease itself * Glomerular defect underlies the process, indicating renal damage * Can affect anyone at any age * Characterized by: * *_Pr**o**teinuria (LOTS OF PROTEIN IN THE URINE)_* * *_Hypoalbuminemia_* * *_Hyperlipidemia - **Fat = edema**_* * ***__***Secondary to increased hepatic fat synthesis and decreased fat catabolism * *_Edema (increased salt and water retention)_* * Cause: increased glomerular capillary permeability * Leads to decrease blood protein (albumin) * Leads to increased protein in urine * Associated diseases: * ***Malignancy such as leukemia, lymphoma and multiple myeloma*** * ***Autoimmune disease such as lupus, Goodpasture's syndrome and Sjogren's syndrome*** * Infections such as bacterial and HIV * Diabetes mellitus * NSAIDS * Clinical symptoms * Loss of appetite, malaise (sick feelign), puffy eyelids, abdominal pain, muscle wasting, tissue swelling/edema, ***_Frothy urine (protein-laden)_*** Primary NS = limited to kidneys only Secondary NS = disease affets the kidneys and other organs (NOTE: Lipiduria: cholesterol, triglycerides, lipoprotiens leak into the urine)

Answer 69

Glomerularnephropathies * Kidney disorders where inflammation affects mainly the glomeruli * Varied causes, but glomeruli respond to injury similarly * ***_Acute nephritic syndrome_*** * Ex. Acute post-streptococcal glomerulonephritis * most common in boys 3-7. Starts suddenly and resolves quickly * Acute glomerular inflammation * Sudden hematuria (**clumps of RBCs (casts)**) * Protein in urine * ***_Rapidly progressive nephritic syndrome_*** * Ex: RPGN * Uncommon disorder; usually occurs 50-60 * Starts suddenly and worsens rapidly * Most of the gomeruli are partialy destroyed = Kidney failure -\> Idiopathic or associated with proliferative glomerular disease (Acute GN) * ***_Nephrotic Syndrome_*** * Finding: * ***_Proteinuria_*** (LOTS!!!!!) * Hypoalbuminemia * Generalized edema * Hyperlipidemia * Hypercholesterolemia * ***_Chronic Nephritis Syndrome_*** (AKA chronic glomerulonephritis) * Examples: * SLE * Goodpasture's syndrome * Acute GN * Slowly progressive disease * ***_Inflammation_*** of the glomeruli * Sclerosis * Scarring * Eventual renal failure