Upper GI pathology Flashcards
We have (2) normal mechanisms that keep gastric acid in the stomach and prevents reflux:
We have (2) normal mechanisms that keep gastric acid in the stomach and prevents reflux:
1. Lower esophageal sphincter which is closed most of the time
2. Diaphragm creates pressure at the gastroesophageal junction
Foods or medications that lower LES pressure will increase the risk of _
Foods or medications that lower LES pressure will increase the risk of GERD
* Caffeine, chocolate, alcohol
* Progesterone (pregnancy or medication)
* Ca+ channel blockers, nitrates, B2 agonists
Obesity increases the risk of GERD due to _
Obesity increases the risk of GERD due to increased intra-abdominal pressure which alters the diaphragm
* Recall that the diaphragm normally increases pressure at the gastroesophageal junction to reduce reflux
* Pregnancy has the same effect
_ hernias can cause the stomach to move up above the diaphragm and increase the risk of GERD
Hiatal hernias can cause the stomach to move up above the diaphragm and increase the risk of GERD
Pepsinogen –> pepsin after contact with _
Pepsinogen –> pepsin after contact with HCl
_ cells make pepsinogen
Chief cells make pepsinogen
Management for mild GERD (sx < 2x per week) involves changes in _ as well as medication as needed including _
Management for mild GERD involves changes in lifestyle (weight loss, avoidance of triggers) as well as medication as needed including antacids, alginate
Over-the-the counter medication such as antacids and alginate help to _
Over-the-the counter medication such as antacids and alginate help to “buffer” gastric acid but don’t reduce production
Treatment for mild GERD (sx > 2x per week) includes medications like _
Treatment for mild GERD (sx > 2x per week) includes medications like PPI (first line) or H2 blockers
* Ex: Omeprazole, pantoprazole
* Also recommend lifestyle modifications
* If not improving –> endoscopy
Alarm symptoms for GERD include:
Alarm symptoms for GERD include:
bleeding, dysphagia, weight loss
How do we approach GERD that is causing bleeding, dysphagia, weight loss?
- Upper endoscopy to rule out complications
- If no serious pathology on EGD, start medical therapy (PPI)
Important to rule out severe esophagitis, stricture, esophageal cancer
PPI mechanism of action:
PPI’s irreversibly bind to and inhibit H/K ATPase on the luminal surface of parietal cells
* However, overtime we can upregulate the receptors for gastrin, histamine, etc
H2 blockers mechanism of action
H2 blockers are receptor antagonists that bind to histamine receptors on the basal surface of parietal cells
Why are H2 blockers sometimes not effective enough?
H2 blockers block histamine receptors; however, histamine is not the only signal that can stimulate parietal cell acid production
Explain the most common progression from normal mucosa –> adenocarcinoma (gastric cancer)
Normal mucosa –> (H. pylori) –> chronic gastritis –> intestinal metaplasia –> dysplasia –> adenocarcinoma
What types of cells would you expect on histology?
Columnar epithelium with goblet cells
(Gastric adenocarcinoma/ MALTomas) can often be cured by eradicating H. pylori
MALTomas can often be cured by eradicating H. pylori
(Gastric adenocarcinoma/ MALToma) is associated with a poor prognosis
Gastric adenocarcinoma is associated with a poor prognosis
* Eradicating H. pylori will not treat/cure the cancer –> patient needs surgery and chemo
Pathogenesis of MALTomas:
Pathogenesis of MALTomas:
1. T cells trigger cytokine production
2. Cytokines trigger polyclonal B cell proliferation
3. Gene mutations in B cells
4. Monoclonal B cell tumor (MALToma)
Esophageal adenocarcinoma is associated with _ precursor lesion
Esophageal adenocarcinoma is associated with barrett’s esophagus
Gatric cancer is associated with _ precursor lesion
Gatric cancer is associated with intestinal metaplasia
Colorectal cancer is associated with _ precursor lesions
Colorectal cancer is associated with adenomas –> dysplasia
Risk factors for esophageal adenocarcinoma include:
Risk factors for esophageal adenocarcinoma include:
* GERD
* Obesity
* Family history
* Male gender
Risk factors for esophageal squamous cell cancer include:
Risk factors for esophageal squamous cell cancer include:
* Smoking
* Alcohol use
Risk factors for gastric cancer include:
Risk factors for gastric cancer include:
* H. pylori
* Smoking
* High salt diet
* Chronic gastritis
Barrett’s esophagus is a metaplastic change in the distal esophagus; normal _ is replaced with _
Barrett’s esophagus is a metaplastic change in the distal esophagus; normal stratified squamous epithelium is replaced with intestinal columnar epithelium
Barrett’s esophagus predisposes an individual to _
Barrett’s esophagus predisposes an individual to esophageal adenocarcinoma
(True/False) Barrett’s esophagus causes symptoms
False; Barrett’s does not cause sx; instead sx often develop as a consequence of chronic GERD
Risk factors for Barrett’s:
Risk factors for Barrett’s:
* Chronic GERD
* Male gender
* Age > 50
* Obesity
* Smoking
* Caucasian
* Family hx of barrett’s esophagus or cancer
(True/False) Antibiotics are always needed for diverticulitis
False; Antibiotics are not always needed for diverticulitis
* We do not treat mild/uncomplicated cases of diverticulitis with antibiotics
* Offer supportive care: clear liquid diet, acetaminophen
A diverticulum is an _
A diverticulum is an outpouching of the bowel wall
A true diverticulum is an outpouching of the bowel wall, including the _ layers
A true diverticulum is an outpouching of the bowel wall, including the muscularis, submucosa, mucosa layers
A false diverticulum is an outpouching of _ layers of the bowel wall
A false diverticulum is an outpouching of mucosa & submucosa
* Does not involve the muscularis
The risk of perforation is so high that we do not perform endoscopic or colonoscopic intervention in or near a (true diverticulum/pseudodiverticulum)
The risk of perforation is so high that we do not perform endoscopic or colonoscopic intervention in or near a pseudodiverticulum
Meckel’s diverticulum is a type of (true/pseudo) diverticulum
Meckel’s diverticulum is a type of true diverticulum
* Often presents in children
The most common site for Meckel’s diverticulum is the _
The most common site for Meckel’s diverticulum is the distal ileum
* This can lead to brisk GI bleeding
Colonic diverticula are (true/pseudo) diverticula
Colonic diverticula are pseudodiverticulum
A pseudodiverticulum at the esophagus is called _
A pseudodiverticulum at the esophagus is called Zenker’s diverticula
Zenker’s diverticula occur due to _
Zenker’s diverticula occur due to herniation of pharyngeal mucosa through the cricopharyngeal muscle
Clinical presentation of zenker’s diverticulum:
Clinical presentation of zenker’s diverticulum:
* Dysphagia
* Regurgitation of food
* Bad breath (halitosis)
* Aspiration pneumonia
Zenker’s diverticulum
Meckel’s diverticulum rule of 2’s:
Meckel’s diverticulum rule of 2’s:
* 2 inches long
* 2 ft proximal to the IC valve
* 2% of the population
* Often before the age of 2
* 2:1 male: female
Meckel’s diverticulum can be caused by an embryologic failure of the _ to obliterate
Meckel’s diverticulum can be caused by an embryologic failure of the vitelline duct to obliterate
* Also called the omphalomesenteric duct
How does Meckel’s diverticulum present clinically?
Meckel’s diverticulum:
* GI bleeding
* Occasional bowel obstruction
* Can act as a lead point for intussusception
* Can lead to diverticulitis (abdominal pain)
Diverticulosis is the presence of diverticula in the _
Diverticulosis is the presence of diverticula in the colon
* Diverticulosis is very common with age
Colonic diverticula often occur where the _ penetrate into the _
Colonic diverticula often occur where the vasa recta penetrate into the muscularis externa
* Weakened area of muscularis in these areas of the sigmoid colon where the vasculature runs
Colonic diverticulosis is often asymptomatic unless…
Colonic diverticulosis is often asymptomatic unless…
1. Inflammation –> diverticulitis
2. Bleeding –> brisk GI bleed
These are separate phenomenons
The treatment for moderate or severe diverticulitis is _
The treatment for moderate or severe diverticulitis is antibiotics +- hospitalization
Possible complications of diverticulitis include _ , _ , _
Possible complications of diverticulitis include abscess , stricture , fistulas
The most common cause of lower GI bleeding in older adults is _
The most common cause of lower GI bleeding in older adults is diverticular bleeding
Diverticular bleeding is (painful/painless)
Diverticular bleeding is painless
* But it is brisk, acute bleeding
* Usually self-resolves but often requires hospitalization for a few days
When is surgical intervention needed for diverticulitis?
- Perforation
- Abscess
- Not improving with antibiotics and drainage
Recurrent diverticulitis can be treated with segmental colonic resection
Diverticular bleeding can present with (melena/ hematochezia)
Diverticular bleeding can present with hematochezia (bright red stools)
* This is more common in older patients
IBD includes two pathologies, _ and _
IBD includes two pathologies, Crohn’s disease and ulcerative colitis
(Crohn’s/UC) is deep, transmural inflammation
Crohn’s is deep, transmural inflammation
(Crohn’s/UC) is superficial, mucosal inflammation
UC is superficial, mucosal inflammation
(Crohn’s/UC) affects the colon only
UC affects the colon only
Crohn’s disease affects _ regions
Crohn’s disease affects any part of the GIT
Sx of Crohn’s disease:
Sx of Crohn’s disease:
* Diarrhea
* Abdominal pain
* Malnutrition
* Systemic complications
Sx of UC:
Sx of UC:
* Diarrhea
* Urgency
* Less common: abdominal pain, malnutrition, systemic sx
(Crohn’s/ UC) is associated with bloody, mucoid diarrhea
UC is associated with bloody, mucoid diarrhea
Three possible complications of Crohn’s
Three possible complications of Crohn’s
1. Strictures
2. Fistulas
3. Abscess
Toxic megacolon is also called _
Toxic megacolon is also called fulminant colitis
* Complication of UC
(Crohn’s/ UC) is associated with fistulas, strictures, abcesses
Crohn’s is associated with fistulas, strictures, abcesses
* UC is not associated with these
Crohn’s disease can affect any part of the GI tract; it tends to be “patchy” but the _ is a very commonly affected part
Crohn’s disease can affect any part of the GI tract; it tends to be “patchy” but the terminal ileum is a very commonly affected part
_ always involves the rectum, while _ tends to spare the rectum
UC always involves the rectum, while Crohn’s tends to spare the rectum
(True/False) UC can affect the small bowel
False; UC has no small bowel involvement
Name some of the extra-intestinal manifestations associated with IBD
- Skin
- Joints (arthritis)
- Eyes (uveitis)
- Mouth ulcerations
- Liver (PSC)
_ is a classic pre-tibial rash that can occur with IBD flares; involves raised red nodules that are painful to the touch
Erythema nodosum is a classic pre-tibial rash that can occur with IBD flares; involves raised red nodules that are painful to the touch
Pyoderma gangrenosum can occur with IBD but is independent of disease activity; it should not be _
Pyoderma gangrenosum can occur with IBD but is independent of disease activity; should not be debrided!
How do we work up IBD?
Esophageal dysphagia can either be caused by a _ problem or a _ problem
Esophageal dysphagia can either be caused by a mechanical problem or a motility problem
Mechanical causes of esophageal dysphagia include:
Mechanical causes of esophageal dysphagia include:
* Esophageal stricture
* Esophageal ring/web
* Esophageal cancer
Motility causes of esophageal dysphagia include:
Motility causes of esophageal dysphagia include:
* Achalasia
* Diffuse esophageal spasm
* Jackhammer esophagus
* Scleroderma
* GE-J outflow obstruction
If a patient has solid AND liquid dysphagia, that points us to a (mechanical/motility) problem
If a patient has solid AND liquid dysphagia, that points us to a motility problem
* Often EGD to rule out cancer or strictures (mechanical)
* Manometry if concerned for motility issue
If a patient has solid dysphagia but can swallow liquids, that points us to a (mechanial/motility) problem
If a patient has solid dysphagia but can swallow liquids, that points us to a mechanical problem
* Such as esophageal stricture, ring/web, cancer
* Start with EGD
Diverticulitis often presents with _ signs
Diverticulitis often presents with LLQ pain, fever, leukocytosis
