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GI tract Flashcards

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1
Q

What is the oeseophagus made up of?

A

It is a 25cm muscular tube lined by squamous epithelium.
There is a sphincter at the upper end and the gastro-oesophageal junction at the lower end.
Bottom 1.5-2cm is below the diaphragm and lined by glandular (columnar) mucosa
Squamo columnar junction is around 40cm from the incisor teeth.

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2
Q

What is reflux oesophagitis?

A

Most common form is GORD - gastro oesophageal reflux disease.
It is caused by a reflux of gastric acid - gastro-oesophageal reflux
Or - bile - duodeno-gastric reflux

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3
Q

What are the risk factors for reflux oesophagitis?

A
  • obesity
  • hiatus hernia
  • pregnancy
  • smoking
  • NSAID’s, aspirin
  • spicy foods
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4
Q

Symptoms of reflux oesophagitis?

A
  • heartburn
    belching, bloading, cough
  • can mimic heart pain
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5
Q

What is a hiatus hernia?

A

Stomach slides into thorax cavity from abdominal cavity via diaphragmatic opening.
It is due to - increased intra-abdominal pressures and/or decreased diaphragm tone (age)

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6
Q

What does a hiatus hernia result in?

A

Less sphincter competence -> gastric acid regurgitation -> oesophagitis/GORD

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7
Q

What are the two types of hiatus hernia?

A

Sliding - lower oesophageal sphincter incompetence - regurgitation of acid -> reflux

Paraoesophageal - sphincter okay but can trap the stomach - the protruding portion can become strangled and ischaemic –> emergency

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8
Q

What is the histopathology of reflux oesophagitis?

A

Normally have a small basal cell layer in squamous epithelium but in reflux oesophagitis there is basal cell hyperplasia, elongation of papillae and increased cell desquamation.
In lamina propria - inflammatory cell infiltratration (neutrophils, eosinophils and lymphocytes)

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9
Q

What are the complications of reflux oesophagitis?

A

Ulceration - if severe
Haemorrhage - if ulcers are severe they expose blood vessels and bleed
Perforation
Benign structure (narrowing)
Barrett’s oesophagus
Erosive tooth wear

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10
Q

What is Barrett’s oesophagus?

A

Complication of chronic gastro-oesophageal reflux disease
Up to 10% of patients with reflux suffer
Upward extension of squamo-columnar junction affected

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11
Q

What is the histology of Barrett’s oesophagus?

A

At the squamocolumnar junction squamous mucosa is replaced by columnar mucosa with goblet cells.

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12
Q

What condition does Barrett’s oesophagus predipose to?

A

Adenocarcinoma - there is an increased risk of developing this due to the process of metaplasia. 30x greater than general pop.

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13
Q

What is recommended for patients with Barretts oeseophagus?

A

Regular endoscopic surveillance recommended for early detection of neoplasia.

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14
Q

What are the two histological types of oesophageal cancer?

A

Squamous cell carcinoma
Adenocarcinoma

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15
Q

What increases the risk of adenocarcinoma?

A
  • industrialised countries
  • male gender (7:1)
  • Caucasian’s
  • Barretts oesophagus
  • Smoking
  • radiation
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16
Q

Where is the location of adenocarcinoma?

A

Lower oesophagus

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17
Q

Macroscopic features of adenocarcinoma

A
  • Plaque like
  • Nodular
  • Fungating
  • Ulcerated
  • Depressed
  • Infiltrating
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18
Q

Microscopic features of adenocarcinoma

A

Malignant cells forming glandular structures infiltrating connective tissue

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19
Q

Where is the incidence of squamous cell carcinoma high?

A
  • Iran
  • China
  • South Africa
    Southern Brazil
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20
Q

What are the risk factors for squamous cell carcinoma?

A
  • Tobacco and alcohol
  • Nutrition
  • Thermal injury (hot beverages)
  • HPV
  • Male
  • Ethnicity (black)
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21
Q

Where is the location of SCC?

A

Middle to lower 1/3rd

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22
Q

What precedes SCC?

A

Squamous dysplasia - normal squamous epithelium to high grade squamous dysplasia
Dysplasia - neoplasia confined to epithelium
Have squamous nests - cells invading surrounding tissue

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23
Q

What is the aetiology of gastric adenocarcinoma?

A

Diet - smoked/cured meat or fish and pickled vegetables
H. pylori infection
1% hereditary

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24
Q

What are the histological subtypes of adenocarcinoma?

A

Scattered growth - diffuse type (signet ring cell carcinoma)
Non scattered growth - intestinal type (tubular adenocarcinoma)

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25
What is coeliac disease?
Chronic immune mediated enteropathy Ingesition of gluten containing cereals - wheat, rye or barley Genetically predisposed individuals - prevalence 0.5-1% Any age
26
What is the pathogenesis of coeliac disease?
Gluten broken down to gliadin -> which is resistant to further breakdown due to amino acid sequence In specific individuals gliadin activates CD4 T cells These cause local inflammation, stimulates B cells to produce anti-gliadin/anti TTG antibodies Gliadin causes IL15 to be produced by the epithelium -> activation/proliferation of CD8+ IELs (intraepithelial lymphocytes) These IEL's are cytotoxic and kill enterocytes (gut cells)
27
What are the symptoms of coeliac disease?
Diarrhoea and abdominal pain
28
What are other disease associations with coeliac disease?
Dermatitis herpetiformis Lymphocytic gastritis Lymphocytis colitis Enteropathy associated T cell lymphoma Small intestinal adenocarcinoma - rare
29
What are the oral manifestations of coeliac disease?
Enamel defects Recurrent aphthous stomatitis Delayed tooth eruption Risk of caries Smaller teeth Angular chelitis Oral lichen planus Salivary gland dysfunction Glossitis Burning tongue Geographic tongue
30
How do you diagnose coeliac disease?
Serologic blood tests usually performed before biopsy Sensitive tests: IgA antibodies to tissue transglutaminase TTG IgA or IgG antibodies to deaminated gliadin Anti-endomysial antibodies - specfic but less sensitive Tissue biopsy
31
What is the treatment of coeliac disease?
Gluten free diet
32
What is inflammatory bowel disease and what two main conditions encompass it?
Chronic inflammatory process within the bowel resulting from inappropriate mucosal immune cell activation, encompassing: Crohn's disease and ulcerative colitis
33
What are the affected bowel regions of UC and Crohn's?
UC - colon only CD - ileum +/- colon (any region)
34
What is the mucosal surface like in UC and CD?
UC - granular, red with broad flat ulcers with mucosal islands called pseudo-polyps CD - linear fissuring ulceration (cobblestoning)
35
What are the 3 types of ulcerative colitis depending on their distribution?
UC is continuous from the rectum and moves up the colon Rectum only - proctitis Rectum/sigmoid - distal colitis All colon - pan-colitis
36
How is crohn's disease distributed?
Skip lesions - areas are affected at different parts of the colon
37
Is there stricture (narrowing) in either UC or CD?
UC - rare CD - yes
38
What is the bowel wall like in UC and CD?
UC - thinned CD - thickened
39
Prevalence of anal lesions in UC and CD?
UC - 25% CD - 75%
40
Is there fistulae in either CD or UC?
UC - no CD - yes
41
Is there fat wrapping in UC and CD?
UC - no CD - yes
42
Is there a presence of granulomas in either CD or UC?
UC - no CD - yes (35-60%)
43
What type of inflammation in CD and UC?
UC - superficial (mucosal) CD - deep (transmural and can affect the outside and way through)
44
What are the pseudo polyps like in UC and CD?
UC - marked CD - mild/moderate
45
Type of ulceration in UC and CD?
UC - superficial/broad CD - deep/fissuring
46
Is there lymphocyte reactions in UC and CD?
UC - moderate CD - marked
47
Is there fibrosis in UC and CD?
UC - mild/no CD - marked (thick wall)
48
Is there serosal inflammation in UC and CD?
UC - mild/no CD - marked (fat wrapping)
49
Can fistulas form in UC and CD?
UC - no CD - yes
50
What are the clinical features of ulcerative colitis?
- diarrhoea - rectal bleeding - abdo pain - weight loss - constipation - anaemia - anorexia - clinical pattern - most commonly intermittent, chronic continuous disease is rare
51
What are the oral manifestations of ulcerative colitis?
- associated with disease severity - Ulceration Tongue coating Halitosis Pyostomatitis vegetans - multiple small pustules on oral mucosal surface (can be seen in Crohn's disease)
52
What are the symptoms of Crohn's disease?
- affects all levels of GIT from mouth to anus - Diarrhoea Colicky abdo pain Palpable abdominal mass Weight loss/failure to thrive Anorexia Fever Peri-anal disease Anaemia
53
What are the oral manifestations of Crohn's disease?
- Diffuse labilal/buccal swelling - cobblestoning - mucosal tags - deep linear ulcerations - mucogingivitis - granulomatous cheilitis
54
What are the complications in the bowel for both UC and CD?
UC - toxic megacolon Haemorrhage Strictures - rare CD - toxic megacolon and perforation - fistula - stricture (common) - haemorrhage - short bowel syndrome (repeated resection) causes malabsorption
55
What are some complications that can arise from both conditions?
Ulcers Erythema nodusum Percholangitis Iritis Clubbing
56
Who is more at risk of malignancy in UC and CD?
UC and colonic CD
57
What are risk factors of colorectal cancer in inflammatory bowel disease?
Early age of onset Pancolitis Primary sclerosing cholangitis Family history of CRC Severity of inflammation (pseudopolyps) Premalignant changes
58
What is a polyp?
Tissue mass that protrudes from a surface In the colon a polyp is a projection of mucosa that protrudes into the bowel lumen - can be single or multiple (polypopsis)
59
What are examples of non-neoplastic polyps?
Inflammatory polpys, hamartomatous (juvenile), hamartomatous (Peutz-Jeghers) and hyperplastic
60
What are examples of neoplastic polyps?
Adenomas (sessile - flat), malignant
61
What are pseudopolyps?
Islands of retained mucosa following ulceration
62
What are hamartomatous polyps?
Non neoplastic tissue elements typical for the site of origin but abnormal in organisation
63
What are juvenile polyps?
May be genetic SMAD4/BMPR1A genes Increased risk of cancer Sporadic (not inherited) no cancer risk <3cm in rectal
64
What are Peutz-Jeghers polyps?
Multiple polyps in small intestine, stomach, colon Positive family history Increase cancer risk Characteristic appearance (abourizing) Mucocutaneous pigmentation in 95% - often the first sign before any GI symptoms
65
What are hyperplastic polyps?
Commonly in left colon Often multiple <5mm Very characteristic - shaggy, teeth like, serrated
66
What are adenomas?
Benign tumours of colonic glandular epithelium - polypoid but also flat Precursor lesions of colorectal cancer >80% 25-35% population >50 years Small prop progress to cancer (10-15 years)
67
Where are adenomas distributed?
Evenly distributed around colon, larger in recto sigmoid and caecum
68
What are adenomas defined by?
Presence of pre-malignant change - called dysplasia but not malignant at this stage
69
What factors contribute to colorectal cancer?
Diet - fibre, milk, calcium, fruit, veg, vitamin D decrease Red processed meat, dietary fat and alcohol
70
What lifestyle factors contribute to colorectal cancer?
Activity, cigarettes, drinking, obesity and age
71
What drugs affect risk of colorectal cancer?
Aspirin, NSAID's, statins, OCP decrease risk
72
What health conditions increase risk of colorectal cancer?
Diabetes and IBD
73
What is the probable predisposition to colorectal cancer?
Genetics Increases with more first degree relatives
74
What are hereditary cancer syndromes?
5-10% of colorectal cancers Familial adenomatous polyposis Lynch syndrome
75
What is autosomal dominant CRC syndrome?
In 80% of familial adenomatous polyposis - mutation in adenomatous polyposis coli tumour suppressor gene develops >100 of adenomatous polyps in colon. If left untreated -> 100% risk of colorectal cancer by 40 years
76
What are the oral manifestations with Gardner syndrome?
Osteoma Odontome Supernumerary teeth
77
What are the majority of CRC's?
Simple adenomatous
78
What are symptoms of colorectal cancer?
Change in bowel habits - diarrhoea, constipation Feeling that bowel does not empty completely (tenesmus) Stools Bright red or dark blood Narrower or thinner than usual Abdominal pain Unexplained weight loss, tiredness or unexplained anaemia (iron deficiency)

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