GI Path Flashcards
1
Q
Which has better prognosis: pedunculated or sessile polyps?
A
Pedunculated– easier to resect
2
Q
What is the MCC of pseudopolyps in the colon?
A
Ulcerative colitis
3
Q
Juvenile polyps: benign or malignant
A
Rarely malignant; can rarely get Polyposis Syndrome
4
Q
ID
A
Peutz-Jeghers Syndrome: hyperpigmentation @ lips/gingiva + harmatomatous polys (benign)
Have increased risk of cancer, but not from polyps themselves
5
Q
Colonic Hyperplastic Polyps:
- Common or rare?
- Benign or malignant?
A
Common
Benign but MUST be distinguished from Sessile Serrated Adenomas
6
Q
When might you suspect Colonic Hyperplastic Polyps may actually be Sessile Serrated Adenomas?
A
Large (>1cm) in RIGHT colon
– DNA mismatch repair pathway affected
7
Q
Adenoma of Colon:
- common or rare?
- Benign or malignant?
A
- Common
- ALWAYS have dysplasia – ALWAYS pre-malignant
8
Q
Most colon cancers arise from what?
A
Adenoma of colon- always pre-malignant, but good to find because they can be removed before they become malignant
9
Q
How can you tell if Adenoma of Colon has invaded?
A
Stromal desmoplasia
10
Q
Familial Adenomatous Polyposis
A
- Rare APC gene mutation
- 100% develop colon cancer
- Wall-to-wall adenomas = FAP until proven otherwise
11
Q
Main risk factor for Colon Cancer besides genetics?
A
Diet– better to eat high fiber & fruits & veg
12
Q
Dirty necrosis
A
Probably coming from colon
13
Q
Mucin all up in that peritoneal cavity…
A
Check appendix!
14
Q
Yellow tumor in small intestine
A
Carcinoid
15
Q
Carcinoid syndrome:
A
HTN, flushing, diarrhea
MC metastatic site = liver (CT scan)
16
Q
GIST: prognosis based on? diagnosis?
A
Prognosis based on size & mitotic rate
CD-117 stain helps confirm dx & prognosis
17
Q
Appendiceal carcinoids: location? common? prognosis?
A
@ tip usually
Common
Good prognosis
18
Q
Appendiceal Mucinous Cystadenocarcinoma: morphology
A
- Mucin + epithelial cells in peritoneal wall
- Pseudomyxoma peritonei (lots of mucin in peritoneal cavity)
19
Q
ID
A
Tubulovillous Adenoma
(Intestinal adenomas can be Tubular, Villous, or Tubulovillous)
20
Q
Morphology of Esophagus with Achalasia
A
Loss of inhibitory neurons in wall of intestine (enteric)
21
Q
How are esophageal webs & rings formed?
A
Post-inflammational scarring (most common)
Tumors
22
Q
What is the cause of diverticuli?
A
Esophageal spasms
23
Q
What is the cause of Mallory-Weiss syndrome?
A
Persistent vomiting (alcoholics, eating disorder)
Usually not too severe
24
Q
Cause of Esophageal Varices? Severity?
A
Portal HTN (from cirrhosis)
Can rupture– 50% mortality :(
25
What is the main complication of a hiatal hernia?
Reflux --\> ulcer --\> Barrett's --\> cancer
26
Histology of **Reflux Esophagitis**?
Long papillae
Inflammatory cells
27
What is a histological feature that MUST be present to diagnose Barrett's Esophagus?
Goblet cells above gastroesophageal junction
28
ID cause of esophagitis
Herpes:
Multinucleate, fine chromatin cells in epithelium
29
ID cause of esophagitis
CMV-- usually in *stroma*
30
White plaques in esophagus?
**Candida esophagitis**
**-**- ONLY IN IMMUNOCOMPROMISEED
31
Concentric rings in esophagus?
Eosinophilic esophagitis -- Must have eosinophila (causes contractions of muscularis propria)
32
Esophageal biopsy:
High-grade dysplasia-- still benign but predisposes to cancer
33
Adeno vs Squamous Cell CA of Esophagus
**_Adenocarcinoma_** has **Barrett's** surrounding
**_Squamous cell CA_** has **keratin** **pearls**
34
Celiac Disease:
* demographics
* Histology
* Mechanism
* Complications
* Management
* White people with **HLA-DQ2, -DQ8**
* Flat & inflamed histology
* **IgG** or **IgA** ab aganst **gliadin**;
* *IgA** against **transglutaminase**
* Can cause T-cell lymphoma, adenocarcinoma
* Avoid gluten
35
Patient has celiac symptoms, but recent diarrhea and trip to Dominica....
**Tropical sprue**
tx: abx
36
Whipple's disease
@ small intestine
Foamy macrophages-- plugs up lymphatics
Caused by atypical mycobacteria in immunocompromised (use Acid-Fast stain)
37
**Lactase (disacccharide) deficiency**: histo
NORMAL histo
38
**Abetalipoproteinemia**
Rare
See vaculoated epithelium with spur cells in blood (acanthocytes)
39
Where is helicobacter located?
Antrum of stomach (by pyloric sphincter)
40
What part of the stomach does autoimmune gastritis affect?
Body of stomach
41
Actue gastritis: S/S
quick course, can cause hemorrhage
Almost everyone in ICU has mucosal damage
42
Automimmune chornic gastritis
* @ body & fundus- ab against parietal cells
* More likely to get carcinoid tumors
* less likely to get ulcers than H.pylori
43
Hyperplastic polyps
* Assoc w/ H.pylori
* Made of foveolar glands
44
Fundic Gland Polyps
* Chief & parietal cells
* Caused by PPIs
45
Gastric Adenomas
Assoc w/ FAP or atrophic gastritis w/intestinal metaplasia
Risk of adenocarcinoma increases with size
46
Tumor Adenoma vs Hyperplastic Polyp
Adenomas have DYSPLASIA
47
Histology of **Diffuse Gastric Adenocarcenoma**
Signet rings (lots of mucin pushese nucleus to side)
Diffuse thickening
Grossly: linitis plastica
48
Malignant vs Peptic Ulcers
Malignant ulcers have masses, heaped edges
Peptic ulcers are benign, clean and "punched out"
49
Marginal Zone Lymphoma
Look for H.pylori & treat it (can advance to more serious lymphoma)
50
Diffuse Large B-cell Lymphoma
**LCA+ (leukocyte common ag)**
50% respond to therapy
51
Prognosis of Autoimmune Gastritis w/ lots of Gastric Carcinoid Tumors
Good prognosis in stomach, esp with atrophic gastritis
resection usually curative
52
GI Stromal Tumors
* Large submucosal masses-- MC mesenchyma tumor of stomach
* Mostly spindle cells
* Prognosis directly correlated w/size & mitotic activity
* Dx: **c-KIT** or **CD117**
* Tx: **Imantanib**
53
**Infectious bacterial colitis**: histology
* Toxin-producing organisms: _NORMAL_ histo
* All others show **ACUTE COLITIS** (**Neutrophils**)
54
***C. dificil***
* In 3% normal people, 30% hospital pts
* Most important risk factor for developing **_Pseudomembranous Colitis_ = abx tx**
* see pseudomembranes & inflammatory debris on surface
55
**Irritable Bowel Syndrome**: biopsy
NORMAL biopsy, stress related
56
You have a stressed patient with chronic diarrhea. Endoscopy looks normal. Should you biopsy?
YES-- could be microscopic colitis (lymphocytic or collagenous)
57
**Angiodysplasia**: gross & complications
- dilated vessels on endoscopy
- causes bleeding in elderly
58
IBD vs Acute Infectious Colitis
Changes of _CHRONIC colitis_ (**gland distortion +/- paneth cell metaplasia**) seen in IBD
59
**Chron's Disease**: gross characteristics
* Skip lesions @ small bowel
* Transmural inflammation
* Granulomas
* Fistulas
* Cobblestone
60
**Ulcerative Colitis:** gross feats
* Broad ulcers @ rectum
* Pseudopolyps
* Crypt abscesses
* Toxic megacolon
61
Patient has had IBD for 10 years... what is your concern?
Cancer. look for Dysplasia (screening endoscopy)
62
Can **Chron's** show crypt abscesses?
YES- but more common in UC
63
Extra-intestinal lesions of IBD?
64
What causes **diversion colitis?**
Blind pouch-- no fecal flow
Tx: enema with short-chain FAs, or resection to restore fecal flowa
65
**Ischemic Bowel Disease**: causes
Serious disease-- don't have to be transmural to cause problems
Mucosal Infarction comes before transmural infarct
* _Obstruction_ (increased luminal pressure or kinked /twisted bowel compromises blood supply)
* _Acute occlusion of arterial supply_ (atherosclerosis, thrombosis, emboli)
* _Hypoperfusion_ (shock, marked dehydration, heart failure, vasoconstrictive drugs)
66
**Diverticular disease**
Common- caused by low fiber diet
Main complcations: diverticulitis, perforation, infection
67
**Acute Appendicitis** requires inflammation of \_\_\_?
**MUCOSAL inflammation**
68
Tests if you think pt has **Carcinoid Syndrome**?
**_This will be on final_**
* Urine: 5-hydroxyindolacetic acid (5 HIAA)- serotonin metabolite
* 5HT -\> 5HIAA
* Blood: Chromogranin A
69
Esophagus: dx?
Squamous Cell CA-- squamous epithelium on both sides-- no Barrett's
70
Bipsy of Polyps in stomach (1, 3, 4)
1. HYPERPLASTIC polyp
3. Fundid gland Polyps
4. Adenoma (Dysplasia- stratification)
71
Stomach- dx?
Helicobacter
* chronic gastritis (MCC = helicobacter)
* yellow picture shows microorganism
72
Gastric Biopsy
Dx?
adenocarcinoma w/_signet rings_
Any time you see clear cells in stomach in between normal glands...
73
Gastric Biopsy
Lots of stroma, but glands are malignant (complex, mitotic activity, necrosis)
Desmoplastic adenocarcinoma- intestinal type
74
Stomach. Dx?
CLEAR CELLS -- signet rings
ADENOCARCINOMA
75
Stomach. Dx?
Linus plastica
thickening of wall
Adenocarcinoma-- diffuse (signet ring)
76
Benign or Malignant?
Left: malignant
Right: benign
77
Gastric Mass. Dx?
Marginal Zone Lymphoma
-bland, large lymphocytes
78
Gastric Mass
Infiltrating into gland
B-cell marker (CD20)
Marginal Cell lymphoma
79
Stomach Mass
Diffuse Large B Lymphoma
large lymphocytes
\*diffuse adenocarcinoma can appear similar-- immunostain (LCA, CD45, cytokeratin) to distinguish
80
Stomach dx?
Benign ulcer
81
Normal small intestine
82
**Celiac disease**
@ small intestine, NO villi, lymphocytes @ surface
Problem: reaction to gliadin, glutan
83
**Whipple's:**
Foamy macrophages in lamina propria
84
**Abetalipoproteinemia**
lack of transfer factor --\> defx of lipid sol vitamins
acanthocytes
85
Microscopic colitis
A. Collagenous colitis
B. Lymphocytic colitis
86
**Chron's**-- segmental lesions (ends are normal)
87
**Chron's**
linear, sharp fissure-like ulcers
88
**Ulcerative Colitis**
## Footnote
broad-based ulcers that form pseudopolyps when they heal
89
**Chron's Disease**
* granulomas
* transmural inflammation
90
Left: **Chron's**
- linear ulcers
Right: **Ulcerative Colitis**
- broad-based ulcers, pseudopolyps
91
Low-grade dysplasia
92
Acute appendicitis:
Must see **MUCOSAL inflammation** -- if it's just on the serosa - may be coming from elsewhere
93
Mucosal acute inflammation (acute appendicitis)
94
Polyp biopsy
Tubuladenoma
dark band of cells down center-- piled up nuclei = feature of dysplasia
95
**Villous adenoma**
* Long papillary projections
* On cross section- no evidence of invasion
96
**Villous Adenoma**
* long projections
97
Pedunculated Tubulovillous Adenoma
98
_High grade dysplasia_:
* complex glands, shared walls, large ugly nuclei
* Not invasive because no desmoplasia
99
Dx? Bx would show? Gene assoc?
Familial Polyposis
Bx: tubularadenomas
Gene: APC (same as with sporadic colon cancers)
100
**Adenocarcinoma**
* complex glands
* reactive desmoplastic stroma
101
Dirty necrosis- colon
102
Mucinous Adenocarcinoma
Extracellular mucin w/islets of tumor cells
worse prognosis in colon
103
**Carcinoid**
yellow
104
**Carcinoid**
## Footnote
Left: Ulcer w/ tumor invading down to wall
Right: Round, monotonous, clumpy chromatin
105
**GIST**
## Footnote
prognostic factors: size, mitotic activity
Stain with: CD117 (c-KIT?)
106
**Carcinoid**-- obstruction of lumen by tumor @ tip
Uniform cells, clumpy chromatin (same histology as the other carcinoid)
Good prognosis
107
**Mucinous Cystadenoma**
No invasion, just some stratification
108
Pseudomyxoma peritonei
look @ appendix!
109
Left: cholesterol- fat female forty
Right: bilirubin- blood disorders
110
**Acute pancreatitis** (lots of hemorrhage)
## Footnote
2 risk factors: alcohol & obstruction
stone would have to be @ *ampulla* to cause this
111
**Acute pancreatitis**
lots of neutrophils, hemorrhage
112
**Fat necrosis**
Fat necrosis all over belly? Pancreatitis (activation of lipase)
113
**Chronic Pancreatitis**
## Footnote
lots of fibrosis
alcoholics, chronic obstruction
114
**Fibrous adhesion**
* usually caused by post-inflammatory (surgery)
* can cause ischemic bowel
115
**Ischemic Bowel**
50% fatal-- bad prognosis
116
**Diverticular disease**
## Footnote
old peeps, low-fiber diet
complications: inflammation, diverticulitis, perforation, rupture
117
Hemochromatosis
118
**a1-atrypsin deficiency**
* blue balls in cytoplasm
* Also get **emphysema** b/c can't turn off inflammation quick enough
* Can cause jaundice in newborn
119
**Primary Biliary Cirrhosis**
* intralobular bile duct under attack of lymphocytes
* check for **anti-mitochondrial antibodies**
120
**Cholestasis**
121
**Sclerosing Cholangitis**
## Footnote
Extrahepatic ducts --\> beaded appearance
Assoc w/ ulcerative cholitis
122
**Esophageal Varices**
* portal HTN (mainly from cirrhosis)
* If they rupture & hemorrhage.. 50% mortality
123
**Hemorrhoids**
124
**Cirrhosis:**
jaundice + ascites
125
Nutmeg Liver-- chronic passive congestion
* due to RHF
* Patients are very ill
126
**Adenocarcinoma**
dysplastic stroma, complex glands
127
**Bile Duct Harmatoma**
won't cause problem, but if you seen them while doing sx, might be worried about metastatic disease
128
**Focal nodular hyperplasia**
* central scar
* needle biopsy is NORMAL
* not serious
129
**Hemangioma**
* most common tumor of liver
* benign
130
**Adenoma**
* bland, thin cords, no portal tracts, no central veins
* SERIOUS-- can rupture and cause hemorrhage
* often seen in young women on Oral contraceptives
131
**Cirrhosis + Hepatocellular Carcinoma**
* Green-- bile
* Bad prognosis
132
**Hepatocellular Carcinoma**
| (normal on Left)
133
**Fibrolamellar Variant Hepatocellular Carcinoma**
seen in YOUNG
better prognosis (still 50% but better)
134
**Metastatic Disease**
135
**Hepatoblastoma**
## Footnote
poor prognosis without treatment
with treatment - 80% cure
in young children
136
**Angiosarcoma**
* freely anastomosing vascular pattern
* Caused by vinyl chloride, arsenic, thorotrast
* Decades-long latent period
* Very serious
137
55-year old man with heartburn and sub-sternal chest pain.
See he has **Barrett's**
2 years later, comes back with dysphagia. See a mass. What is it most likely to be?
**Adenocarcinoma**
Biopsy, then Esophagectomy
138
Esophagus
**Barrett's**
GOBLET CELLS
139
Edge of adenocarcinoma
Dysplasia-- looks like tubularadenoma -stratefied
140
Middle of mass
**Adenocarcinoma**
Muscle strand surrounded by cancer
141
What is the major predisposing condition for **adenocarcinoma**?
**Reflux**
142
55-year old woman, stomach pain, GI endoscopy
See ulcer- benign or malignant?
Benign- Peptic Ulcer
debris, granulation tissue, fibrosis-- just reactive necrosis
143
31-year old woman- has had intermittent bloody diarrhea for 10 years
Sigmoidoscopy shows friable, ulcerated colonic mucosa extending from anus -\> splenic flexure
Dx?
**Ulcerative Colitis**
continuous, crypt abscesses, 10 years
144
56 year old woman with positive stool occult blood test.
Colonoscopy: large mass-- probably adenocarcinoma
Biopsy:
**Adenocarcinoma**
145
**Adenocarcinoma**
## Footnote
Within fat (right-hand side)
Large blue blob = lymph node - probably involved because not uniform in color
146
Resected Lymph node
Cancer- adenocarcinoma
