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Flashcards in GIT Deck (163):
1

A: normal gastroesophageal junction

B: Barrett esophagus; note the small islands of paler squamous mucosa within the Barrett mucosa

2

describe the image

C: histologic appearance of the gastroesophageal junction in Barrett esophagus; note the transition between esophageal squamous mucosa (left) and metaplastic mucosa containing goblet cells (right)

3

describe the etiology of the condition seen in the image

  • long-standing acid reflux esophagitis → GERD
    • more common in males
    • more common in whites
  • GERD is caused by:
    • obesity
    • limited scleroderma (CREST)
      • E = esophageal dysmotility → GERD
      • anti-centromere positive, hiatal hernia

4

describe the pathogenesis of the condition seen in the image

  • decreased tone in LES → genetic reprogramming of stem cells in the lower 1/3 of the esophagus
    • proliferation of progenitor cells for healing which then differentiate into columnar cells → more resistant to peptic acid injury

5

describe the presentation of the condition seen in the image

  • presentation is similar to reflux
    • heart burn → worse when lying down
    • dyspepsia
      • waterbrush (bad metallic taste of acid in mouth)
    • epigastric pain
    • substernal discomfort relieved by antacids

6

definitive diagnosis of the condition seen in the image is accomplished by ____

definitive diagnosis of the condition seen in the image is accomplished by upper GI endoscopy and biopsy

  • endoscopy: normal pearly white esophageal squamous mucosa → velvety pink columnar mucosa 

7

describe complications of the condition seen in the image

  • #1 risk factor for dysplasia → adenocarcinoma of the esophagus
    • ALWAYS d/t Barrett's
  • progressive dysphagia and odynophagia
  • melena → iron deficiency anemia

8

describe the etiology of the condition seen in the image

  • more common in US
  • precursor lesion = GERD, Barrett esophagus (dysplasia)
  • lower 1/3 of esophagus

9

_____ is the precursor lesion to the condition seen in the image

GERD → Barrett esophagus is the precursor lesion to the condition seen in the image

10

describe the risk factors for the condition seen in the image

  • white men, smokers, obese, previous radiation therapy

11

describe the presentation of the condition seen in the image

  • presentation:
    • signs and symptoms similar to SCC
    • dysphagia, initially to solid then to liquid
    • odynophagia
    • weight loss → cachexia
    • chest pain
    • vomiting

12

describe the complications of the condition seen in the image

  • complications:
    • melena → iron deficency anemia
    • TEF → aspiration pneumonia → lung abscess
    • invade heart → pericarditis → percardial effusion

13

describe the image

squamous cell carcinoma composed of nests of malignant cells that partially recapitulate the stratified organization of squamous epithelium

14

describe risk factors of the condition seen in the image

  • etiology:
    • fungal contamination
    • nitrites (smoked food)
    • alcohol
    • tobacco use
    • GERD
    • achalasia
    • Tylosis: oral leukoplakia, SCCE, hyperkeratosis of palms and soles
    • Plummer-Vinson
      • characterized by difficulty in swallowing, iron-deficiency anemia, glossitis, cheilosis and esophageal webs
    • Celiac disease

15

describe the pathogenesis of the condition seen in the image

  • usually in upper 2/3 of esophagus (middle 1/3 = more likely)
  • begins as in-situ lesion in the form of squamous dysplasia
  • growth pattern; exophytic, excavated (ulcerative), infiltrative

16

describe the presentation of the condition seen in the image

  • presentation:
    • progressive dysphagia (to solids then to liquids)
    • odynophagia
    • cachexia
    • fatigue (d/t melena → iron deficiency anemia)
    • hematemesis
    • hoarse voice and cough

17

describe investigations for the condition seen in the image

  • investigations:
    • GI endoscopy w/ biopsy: malignant squamous cells invading into the submucosa & muscularis propria
    • barium swalllow: shows obstruction of lumen 

18

describe complications of the condition seen in the image

  • complications:
    • can obstruct
    • bleed (melena) → IDA
    • perforate → mediastinitis
    • form a TEF (food can get into lungs → aspiration pneumonia → lung abscess)
    • can spread to cervical, mediastinal, paratracheal, tracheobronchial, gastric and celiac nodes depending on site of tumor
    • direct metastasis to adjacent mediastinal structures including trachea and heart

19

describe the image

lymphoid aggregates with germinal centers and abundant subepithelial plasma cells within the superficial lamina propria are characteristic of H. pylori gastritis

20

describe the image

spiral-shaped H. pylori bacilli are highlighted with Warthin-Starry silver stain. Organisms are abundant within surface mucus

21

the condition seen in the image is caused by chronic infection with ___ at the ____ region of lesser curvature

the condition seen in the image is caused by chronic infection with H. pylori at the antro-pyloric region of lesser curvature

22

describe the histology of the condition seen in the image

  • histology:
    • reactive lymphoid aggregates
    • chronic inflammatory infiltrate (lymphocytes, plasma cells) in lamina propria
    • H. pylori is G-ve and not invasive 
      • therefore always seen on luminal surface
    • addition of neutrophils = chronic ACTIVE gastritis

23

describe the pathogenesis of the condition seen in the image

  • produces urease (urea → ammonia to neutralize acid) and phospholipase (destroys phospholipid bilayer in mucosa of stomach) → diffuse effacement of the mucosa by lymphocytes → chronic gastritis/peptic ulcers
  • cytotoxin-associated gene A → increases risk for peptic ulcer disease and adenocarcinoma
  • flagella → motility in mucoid environment

24

describe investigations of the condition seen in the image

  • upper GI endoscopy + biopsy with Steiner Silver Stain 
    • black = organism
  • microscopy:
    • reactive lymphoid aggregates found just below epithelial lining (**hallmark of H. pylori**)
    • inflammatory infiltrate in lamina propria
    • PMNs in surface epithelium and glandular lumen
    • intestinal metaplasia and glandular atrophy +/- dysplasia

25

in the condition seen in the image, ____ are found just below the epithelial lining which is a hallmark of _____

in the condition seen in the image, reactive lymphoid aggregates are found just below the epithelial lining which is a hallmark of H. pylori

26

in the condition seen in the image, confirmation of the etiologic agent would be supported by _____

in the condition seen in the image, confirmation of the etiologic agent would be supported by regression of tumor with antibiotics

27

describe the complications of the condition seen in the image

  • chronic inflammation → intestinal metaplasia → dysplasia → intestinal gastric adenocarcinoma
  • lymphoid aggregates → uncontrolled prolif. of B cells → MALToma (gastric lymphoma)
  • peptic ulcer disease

28

describe the image

diffuse gastric cancers display an infiltrative growth pattern and are composed of discohesive cells with large mucin vacuoles that expand the cytoplasm and push the nucleus to the periphery, creating a signet ring cell morphology

29

describe the etiology of the diffuse form of the condition seen in the image

  • etiology:
    • mutation = E-cadherin (CDH1) → signet ring cells that contain mucin 
    • no intestinal metaplasia

30

describe the morphology of the diffuse form of the condition seen in the image

  • morphology:
    • "leather bottle stomach"/linitis plastica becuase signet ring cell infiltrates the stomach wall
    • no gland formation: single cells, sheets, clusters

31

describe the complications of the diffuse form of the condition seen in the image

  • complications:
    • ovarian metastasis → Krukenberg tumor → bilateral (only with diffuse type)
      • Krukenberg: from diffuse gastric adenocarcinoma, invasive lobular carcinoma of breast, and colon cancer

32

describe the etiology of the intestinal form of the condition seen in the image

  • etiology:
    • H. pylori = most common
    • autoimmune
    • smoked foods (nitrosamines)

33

describe the morphology of the intestinal form of the condition seen in the image

  • morphology:
    • neoplastic cells form glands
    • histology: malignant glands that make mucin → invading into the submucosa & muscularis propria

34

describe complications of the intestinal form of the condition seen in the image

  • complications:
    • bleed → IDA
    • left supraclavicular/Virchow's LN metastasis
      • one of the nodes that drains the stomach
    • periumbilical metastasis (intestinal) → Sister Mary Joseph nodule 

35

____ is a prognostic indicator of the intestinal form of the condition seen in the image

depth of invasion and nodal status is a prognostic indicator of the intestinal form of the condition seen in the image

36

___ is the tumor marker for the condition seen in the image

CEA is the tumor marker for the condition seen in the image

37

GIST tumors are derived from ____

GIST tumors are derived from interstitial cells of Cajal

38

a majority of GIST tumors express ____ and have mutations in ____

a majority of GIST tumors express CD117 and have mutations in c-Kit

39

describe the histology of cells seen in GIST

spindle-shaped tumor cells

40

GIST is treated with ____

GIST is treated with  TKI (Imatinic/Gleevec)

same treatment as CML (9,22 translocation)

41

describe predisposing factors for the condition seen in the image

  • predisposing factors:
    • tobacco chewing (most common)
    • alcohol
    • HPV 16 & 18
    • jagged teeth
    • ill-fitting dentures
       

42

describe what is seen on biopsy of the condition seen in the image

  • investigations:
    • biopsy = malignant squamous cells w/ keratin pearls

43

describe complications of the condition seen in the image

  • complications:
    • spreads via lymphatics → anterior cervical lymph​ nodes

44

describe the image seen

celiac sprue/disease

complete loss of villi or total villous atrophy

dense plasma cell infiltrates in the lamina propria

45

describe the etiology of the condition seen in the image

  • etiology = gluten (wheat, barley, oats, rye)
    • specifically gliadin protein
    • associated with HLA-DQ2 (more common) & HLA-DQ8

46

describe the morphology seen in the condition in the image

  • morphology:
    • increased intraepithelial lymphocytes (CD8 T cells) in lamina propria
    • elongated and hyperplastic crypts
    • marked atrophy (flattening) and loss of villi → decreased SA for absorption

47

describe the pathogenesis of the condition seen in the image

  • pathogenesis:
    • inappropriate immune cell mediated Type IV HS response to gliadin in the proximal small intestine (duodenum) →
    • gluten is deamidated to form gliadin by tissue transglutaminase (tTG) → phagocytosed by APC with HLA DQ2/DQ8 → presentation to CD4 T cells in lamina propria → cytokine production → destruction of villi

48

describe the pathogenesis of the condition seen in the image

  • presentation:
    • malabsorption → steatorrhea (foul-smelling, pale bulky stools)
    • weight loss
    • flatulence

49

the condition in the image mainly affects the ____

the condition in the image mainly affects the duodenum

50

describe complications of the condition seen in the image

  • T-cell lymphoma (EATL = enteropathy-associated T-cell lymphoma)
    • classic scenario = patient adherent to gluten-free diet with worsening symptoms
  • increased risk for small bowel carcinoma

51

in the condition seen in the image, too much IgA causes _____

in the condition seen in the image, too much IgA causes dermatitis herpetiformis (deposition of IgA in the dermal papillae)

52

describe the image

villi are stout and packed with foamy macrophages

lipid particles --> dilated lacteals

PAS stain --> foamy particles in LP

53

describe the etiology of the condition seen in the image

G+ve sickle-shaped actinomycete Trophyeryma whippeli (PAS +)

54

describe the pathogenesis of the condition seen in the image

phagocytosis and incomplete degradation G+ve Trophyerma whipplei, which accumulate inside lysosomes of the macrophages (foamy-looking) → mechanical lymphatic (lacteal obstruction) →​ distended/flattened villi →​ malabsorption

55

list the extra-intestinal manifestations of condition seen in the image

  • brain: dementia/seizures
  • skin: hyperpigmentation
  • lymphadenopathy: intestinal/mesenteric & peripheral
  • joints: migratory polyarthritis
  • heart: infective endocarditis and aortic valve regurg. 
  • eyes: uveitis → blindness

56

describe the investigations of the condition seen in the image

  • investigations:
    • small bowel biopsy:
      • distended PAS positive (red) foamy macrophages in lamina propria (mucosa)
    • EM → rod-shaped bacilli 

57

describe the etiology of the condition seen in the image in adults vs. children

  • adult: fecolith obstruction (obstruction of lumen)
  • children: d/t lymphoid hyperplasia in the lymphoid follicles of the appendix (follicles are aggregations of lymphoid cells)

58

describe the pathogenesis of the condition seen in the image

  • pathogenesis:
    • obstruction → continued secretion of mucinous fluid → increased intraluminal pressure → collapse of draining veins → ischemic injury → bacterial proliferation → inflammation and edema

59

describe the investigations of the condition seen in the image

  • investigation:
    • CBC: increased neutrophils and increased band cells
    • biopsy: presence of neutrophils all the way to muscularis propria
    • positive for Rovsing, Psoas and Obturator signs

60

describe complications of the condition seen in the image

  • complications:
    • perforation → peritonitis → septicemia
    • peri-appendiceal abscess → liver abscess, bacteremia

61

on biopsy of the condition seen in the image, there are ____ all the way to the _____

on biopsy of the condition seen in the image, there are neutrophils all the way to the muscularis propria

62

describe the image

diverticulosis

sigmoid diverticulum showing protrusion of the mucosa and submucosa through the muscularis propria

63

in the condition in the image, there is herniated of the ___ and ___ which makes it a ____

in the condition in the image, there is herniated of the mucosa and submucosa which makes it a false diverticulum (pseudodiverticulum) 

64

describe where the condition in the image are located (anatomical weakness)

diverticula are located on the mesenteric border where the vasa recta penetrate the muscle wall (anatomic weakness site)

65

describe the morphology of the condition seen in the image

  • morphology:
    • acquired pseudo-diverticulum (involves mucosa & a little submucosa -- NOT the entire wall)
    • most commonly seen as flask-like structure in the sigmoid colon

66

describe the predisposing factors of the condition seen in the image

  • predisposing factors:
    • elderly on a low-fiber diet
    • long-standing history of constipation

67

describe the pathogenesis of the condition seen in the image

  • pathogenesis:
    • decreased dietary fiber → sustained bowel contractions and increased intraluminal pressure → herniation of colonic wall at sites of focal defects

68

describe the presentation of the condition seen in the image

  • presentation:
    • asymptomatic, incidental finding on colonoscopy, can cause painless bleeding

69

list complications of the condition seen in the image

  • complications:
    • lower GI bleed → hematochezia
    • perforate → sepsis
    • acute diverticulitis (mimics appendicitis) → inflammation of diverticulum
    • enterovesical (colovesical) fistula → fistula with bladder due to perforation
    • chronic diverticulitis → strictures from narrowing of lumen from fibrosis → perforate → septic shock and DIC
    • NO malignant potential

70

describe the image

ulcerative colitis

total colectomy with pancolitis showing active disease, with red, granular mucosa in the cecum (left) and smooth, atrophic mucosa distally (right)

71

describe the image

ulcerative colitis

the disease is limited to the mucosa + submucosa

72

the condition seen in the image is associated with HLA-___ as well as _____

the condition seen in the image is associated with HLA-DRB1 as well as primary sclerosing cholangitis (p-ANCA)

73

describe the classic features seen in the condition in the image

  • classic features:
    • always starts the rectum & moves proximally; continuous
    • no skipped lesions → curable by surgery

74

describe the histology of the condition see in the image

  • histology:
    • mucosal and submucosal involvement
    • architectural distortion
    • dense chronic inflammation with basal plasmacytosis
      • basal plasmacytosis = presence of plasma cells between the base of the crypts and the muscularis mucosae
    • crypt abscesses (PMNs in the lumen of crypts)
    • no granulomas

75

describe the gross appearance of the condition seen in the image

  • gross:
    • mucosa red, granular and friable
    • broad-based ulcers
    • isolated islands of intervening regenerating mucosa bulge creating pseudopolyps

76

during a barium enema while investigating the condition in the image, a ____ appearance is seen due to ____

during a barium enema while investigating the condition in the image, a lead-pipe appearance is seen due to loss of haustra

77

flare-ups of the condition seen in the image is associated with ____

flare-ups of the condition seen in the image is associated with  physical and mental stress

78

in the condition in the image, in severe cases of pancolitis, the ____ can be affected as well, which is called _____

in the condition in the image, in severe cases of pancolitis, the ileum can be affected as well, which is called backwash ileitis

79

the condition in the image leads to a higher risk of ____

the condition in the image leads to a higher risk of colon cancer

80

describe the image

Crohn's disease

linear mucosal ulcers and thickened intestinal wall

81

describe the image

Crohn's disease

haphazard crypt organization results from repeated injury and regeneration

82

describe the image

Crohns disease

transmural Crohn disease with submucosal and serosal non-caseating granulomas

83

the condition in the image is associated with HLA- ____

the condition in the image is associated with HLA-DR7 and HLA-DQ4

84

describe the histology of the condition in the image

cobblestone appearance 

  • sharply delimited & transmural involvement 
  • non-caseating granulomas
  • mucosal fissuring with involvement of fistulas
  • skipped lesions that spare the rectum

85

describe the gross appearance of the condition 

  • gross:
    • linear (deep) ulcers & creeping mesenteric fat due to fibrosis
    • thick wall due to edema, hypertrophy, fibrosis and inflammation
    • long narrow thickened segments of small intestine
      • string sign on radiography

86

the most common location of the condition in the image is ____

the most common location of the condition in the image is the terminal ileum

  • malabsorption: vit. B12 deficiency, malabsorption of bile salts
  • may have non-bloody diarrhea due to malabsorption

87

on barium enema in the condition in the image, _____ is seen due to _____

on barium enema in the condition in the image, string-sign is seen due to narrowing of lumen from fibrosis (aka strictures)

88

on biopsy of the condition seen in the image, there is ____ involvement with ____ and inflammatory infiltrate

on biopsy of the condition seen in the image, there is transmural involvement with non-caseating granulomas and inflammatory infiltrate

89

describe the extra-intestinal features of the condition seen in the image

  • migratory polyarthriris = most common
  • erythema nodosum = inflammation of fat under skin (usually shin)
  • gallstones: malabsorption of bile acids → decreased bile solubility → cholecystitis
  • kidney stones
  • ankylosing spondylitis
  • uveitis

90

describe complications of the condition seen in the image

smoking can trigger a flare (unlike UC where it is protective)

  • intestinal obstruction due to fibrosis → perforation → peritonitis
  • malabsorption if small bowel is affected
  • strictures, fissures (deep ulcers)
  • fistulas:
    • perianal
    • abdominal
    • bladder → enterovesical
  • colon cancer ONLY when colon is involved

91

describe the image

pseudomembranous colitis

typical pattern of neutrophils emanating from a crypt is reminiscent of a volcanic eruption

92

describe the etiology of the condition seen in the image

  • hospitalized patients on broad-spectrum antibiotics (clindamycin; disruption of normal flora) → C. difficile exotoxin mediated damage

93

describe the morphology of the condition seen in the image

  • yellow plaques covering mucosal surface (mucosal itself is not eroded)
  • pseudomembrane
    • fibrinopurulent-necrotic debris, inflammatory cells (mainly neutrophil), necrotic epithelium & mucus 
    • congested vessels

94

describe the pathogenesis of the condition seen in the image

  • exotoxin mediated → denuded surface epithelium & superficially damaged crypts distended by mucopurulent exudate erupt to form a mushrooming cloud → coalescence of clouds to produce pseudomembrane → consists of inflammatory cells, necrotic debris and fibrin
  • most common location = rectosigmoid

95

describe the presentation of the condition seen in the image

  • fever, lower abdominal pain, cramps, massive bloody & mucoid diarrhea (dysentery)

96

describe investigations for the condition seen in the image

assay stool for exotoxin

97

list complications for the condition seen in the image

  • perforate → peritonitis → E. coli sepsis → septic shock
  • mucoid diarrhea → hypovolemic shock, hypokalemia & peripheral edema
    • hypokalemia → arrhythmias
  • toxic megacolon (but hallmark complication of UC)

98

describe the right vs. left sided presentation of the condition in the image

  • right sided = proximal/ascending colon due to microsatellite instability
    • iron deficiency anemia
    • weight loss
    • exophytic tumors polypoidal lesion → obstruction is uncommon
  • left sided = distal/descending → adenoma-carcinoma seq.
    • LLQ pain
    • blood streaked stool w/ a change in stool caliber
    • circumferential lesions → annular, encircling napkin ring constrictions → obstruction and altered bowel movements

99

describe the etiology of the condition in the image

  • gene = APC (tumor suppressor gene) which requires 2 hits → inherit 1 bad hit and get 2nd hit later in life → form polyps → mutations in KRAS → mutation in p53 → adenocarcinoma 

100

describe the gross morphology of the condition in the image

  • pedunculated morphology → tubular adenoma
    • numerous benign polyps on left side of colon (sigmoid, descending)
    • benign tumor with dysplastic cells and therefore can become cancer

101

describe the presentation of the condition in the image

  • asymptomatic in early stages
  • later stages: bright red bloody & mucoid diarrhea, intestinal obstruction and LLQ pain
  • screen with sigmoidoscopy (screen at age 12) and offer prophylactic colectomy

102

describe the complication of the condition in the image

  • diameter of left colon is smaller → napkin ring constriction → intestinal obstruction

103

explain the variants of the condition seen in the image

  • Gardner's syndrome = polyposis of colon + extra-intestinal signs and symptoms
    • multiple osteomas (especially mandible)
    • skin cysts: epidermal cysts, fibromas, lipomas
    • CT growth → desmoid tumors
    • hypertrophy of retinal pigment
    • supernumerary teeth 
    • papillary thyroid cancer
  • Turcot's syndrome = FAP + CNS gliomas and medulloblastomas

104

describe the image

carcinoid tumor

carcinoid tumors often form a submucosal nodule composed of tumor cells embedded in dense fibrous tissue

105

describe the image

carcinoid tumor

bland cytology that typifies neuroendocrine tumors

the chromatin texture, with fine and coarse clumps, frequently assumes a "salt-and-pepper" pattern

106

the condition in the image is most commonly found in the ____ (layer) of the ____ and ____

the condition in the image is most commonly found in the submucosa of the SI and appendix

107

describe the origin of the condition seen in the image

origin = enterochromaffin/Kulchitsky/neuroendocrine cells

108

describe type I of the condition seen in the image

  • type I: gastric atrophy and achlorydia
    • autoimmune chronic gastritis 
    • hypergastrinemia → ECL cell hyperplasia
    • may be multiple, but usually benign

109

describe type II of the condition seen in the image

  • type II: gastrinoma/Zollinger-Ellison syndrome (gastrinoma of the pancreas)
    • usually in MEN-1 syndrome
    • ZE: hypergastrinemia → increased acid but no negative feedback → multiple, large duodenal ulcers

110

describe type III of the condition seen in the image

  • type III: sporadic
    • malignant → very aggressive, sporadic

111

describe the the condition in the image when it affects the small intestine and appendix

  • small, occult primary tumors can metastasize widely leading to carcinoid syndrome if serotonin bypasses the liver, avoiding degradation to 5-HIAA by MAO
    • serotonin leaks out hepatic tributaries and can lead to carcinoid heart disease → R-sided valvular fibrosis (tricuspid regurg. & pulm. valve stenosis)
      • L-side of heart unaffected since lungs contain MAO and COMT

112

describe what is seen on biopsy of the condition seen in the image

  • biopsy: uniform cells with stippled oval nuclei & salt and pepper appearance in the submucosa

113

____ is increased in the urine in the condition seen in the image

5-HIAA

114

list the tumor markers for the condition seen in the image

synaptophysin, chromogranin, CD56 (origin of cells)

115

describe the image

cirrhosis

thick bands of collagen separate rounded cirrhotic nodules 

116

describe the hepatic diseases that can lead to the condition seen in the image

  • etiology: irreversible diffuse fibrosis of the liver with formation of regenerative nodules
    • hepatic diseases
      • viral hepatitis → B & C
      • auto-immune hepatitis → ANA, anti-smooth muscle Ab
      • steatohepatitis: alcohol 
        • see Mallory bodies (intermediate filaments as eosinophilic cytoplasmic inclusions)

117

describe the biliary diseases that can lead to the condition seen in the image

  • biliary diseases
    • primary biliary cirrhosis = anti-mt Ab
    • primary sclerosing cholangitis = causes strictures; beaded appearance; p-ANCA positive
      • can be caused by UC

118

describe the metabolic diseases that can lead to the condition seen in the image

  • metabolic diseases:
    • hemochromatosis: increased iron; increased ferritin; decreased TIBC (total iron binding capacity)
      • diabetes mellitus
      • increased skin pigmentation
      • cardiomyopathy
    • Wilson's disease: decreased serum ceruloplasmin, increased hepatic Cu, increased urinary Cu excretion and KF rings
    • A1AT deficiency caused by PiZZ 

119

describe the pathogenesis of the condition in the image

  • activate ito/stellate cells (store vit. A) to deposit type III collagen and type I collagen in space of Disse
    • loss of fenestrations in endothelial cells → impaired secretion of proteins (albumin, clotting factors)
    • new vascular channels in fibrous septae → shunting of blood
    • obstruction of biliary channels → jaundice

120

describe the presentation of the condition seen in the image

  • estrogen metabolism impairment:
    • palmar erythema
    • spider nevi/angioma
    • testicular atrophy
    • gynecomastia
  • finger clubbing, jaundice, leukonychia (white nails due to low albumin), Dupuytren contracture, xanthomas

121

describe the investigations of the condition seen in the image

  • biopsy with trichrome stain (stains collagen blue)
  • increased AST, increased bilirubin, decreased clotting factors, decreased albumin

122

list complications of the condition seen in the image

  • hepatic failure
  • synthetic function abnormalities (albumin, clotting factors)
  • portal HTN → ascites, varices, splenomegaly, hepatic encephalopathy
    • hepatic encephalopathy because of defective urea cycle → build-up of ammonia in the brain
      • asterixis (hand flapping tremor) due to increased ammonia
  • HCC
  • increased bleeding
    • loss of coagulation cascade proteins and vit. K

123

describe the etiology of the condition seen in the image

  • global distribution strongly related to the prevalence of HBV
  • cirrhosis of any etiology
    • most common = alcohol and HBV
  • Aspergillus flavus (aflatoxin → cirrhosis)
  • A1AT def.
  • NAFLD/NASH

124

describe the histological morphology of the condition seen in the image

  • histology:
    • trabecular, sinusoidal, or pseudoacinar pattern
    • hallmark: bile production by tumor cells → increased bile output → seen as cytoplasmic inclusion (increased globules of bile in cytoplasm)

125

describe the investigations of the condition seen in the image

  • increased AFP as well as a sudden increase in ALP and GGT

126

describe the complications of the condition seen in the image

  • spreads to:
    1. lungs 
    2. bone (via blood)
  • increased risk of Budd-Chiari

127

describe the trabecular type of the condition seen in the image

nests and cords of hepatocytes

128

describe the fibrolamellar type of the condition seen in the image

  • fibrolamellar type
    • no association with viral hepatitis or cirrhosis = idiopathic
    • well differentiated polygonal cells in cords or nests separated by fibrous septa
    • best prognosis of all types

129

describe the risk factors for the condition seen in the image

  • RF:
    • 6 F's: female, fat, forty, fertile (oral contraceptives), fair skin, family history
    • reduced bile salts due to poor absorption or underproduction:
      • Crohns = inflammation of ileum → malabsorption of bile salts
      • cirrhosis = decreased bile salt synthesis

130

describe the etiology of the condition seen in the image

  • etiology:
    • gallbladder stasis
    • inborn error of bile salt metabolism
    • hyperlipidemia syndromes

131

the condition in the image is ___ and is therefore not seen on ____

the condition in the image is radiolucent and is therefore not seen on x-ray

132

describe the etiology of the condition seen in the image

pigment stones = bilirubin calcium salts

  • etiology:
    • chronic hemolytic anemia
      • HS, B-thalassemia, SCD
    • biliary infections → bacteria have glucorinidases that convert bilirubin → unconjugated
    • liver cirrhosis or chronic liver disease → lack of conjugation of bilirubin

133

describe the pathogenesis of the condition seen in the image

  • pathogenesis:
    • bile is supersaturated with cholesterol → bile hypomotility promotes nucleation (precipitation of cholesterol from bile into vesicles)
    • mucous hypersecretion traps the crystal permitting aggregation into stones → acts like glue

134

list complications of the condition seen in the image

  • complications:
    • empyema 
    • acute cholecystitis
    • chronic cholecystitis
      • porcelain gallbladder = extensive dystrophic calcification → gallbladder cancer
    • gallstone ileus → fistula with small bowel → gallstone obstructs the ileocecal valve
    • acute pancreatitis  → obstruction of the common bile duct (biliary tree)
    • acute cholangitis → obstruction of the common bile duct (biliary tree)
    • gallbladder adenocarcinoma
      • most common predisposing factor

135

describe the risk factors for the condition seen in the image

all RFs for cholangiocarcinoma cause chronic inflammation and cholestasis

  • primary sclerosing cholangitis
  • parasitic infections
    • Clonorchis sinensis, Opisthorchis viverini
  • cystic dilatations of biliary system → Caroli's disease
  • gallstones
  • chemicals 
    • benidene
    • nitrosamines

136

describe the presentation of the condition seen in the image

  • presentation:
    • patients typically have non-cirrhotic livers & present with obstructive symptoms
      • malaise, weight loss, jaundice
      • ascending cholangitis
        • Charcot's triad: jaundice, fever, chills
        • Raynaud pentad: Charcot triad + hypothension and mental status changes 
          • poor prognosis
    • more likely to spread beyond liver than HCC

137

primary biliary cholangitis is a non-____, ____ destruction of ____-sized bile ducts

primary biliary cholangitis is a non-suppurative, granulomatous destruction of medium-sized bile ducts

138

describe the pathogenesis of PBC and name a differential

chronic non-suppurative (non-caseating granulomatous) granulomatous inflammation caused by autoimmune CD4 T cell-mediated destruction of the intrahepatic bile ducts

PSC = intrahepatic AND extrahepatic bile ducts

139

describe the presentation of PBC

  • pruritus (itching) caused by bile salts
    • increased bile acids deposited in skin 
  • steatorrhea
  • liver tries to compensate by making cholesterol → xanthomas, xanthelasma

140

PBC is associated with anti-_____

PBC is associated with anti-mitochondrial antibodies

141

list complications of PBC

  • ductopenia
  • malabsorption of fat and fat-soluble vitamins
  • hypercholesterolemia → xanthomas

142

describe the hallmarks of primary sclerosing cholangitis

  • inflammation, fibrosis, strictures and dilatations of intra- AND extrahepatic ducts
  • associated with UC and is p-ANCA positive

143

on ERCP of suspected PSC, there is ___ of the biliary tree

on ERCP of suspected PSC, there is beading of the biliary tree

144

describe the histology in PSC

periductal fibrosis → onion-skin fibrosis → obliterating of bile ducts

145

describe the etiology of the condition seen in the image

  • MCC = alcohol and gallstones
    • I GET SMASHED
      • Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps/Malignancy, Autoimmune, Scorpion sting, Hypercalcemia, ERCP, Drugs (diuretics, estrogen)

146

describe the morphology of the condition seen in the image

  • focal fat necrosis in pancreas and peripancreatic tissue and abdominal cavity
    • calcium deposition in these areas → appear radiopaque on radiographs
    • pancreatic injury → release of amylase & lipase → breaks down lipids to release FAs which combine with Ca2+ → saponification 
  • liquefactive necrosis of the exocrine pancreas

147

describe the pathogenesis of the condition seen in the image

  • acinar cell injury → enzymatic auto-digestion of pancreas → trypsin → constant activation of all other enzymes

148

describe the investigations of the condition seen in the image

  • 24-48 hours: measure amylase (highly sensitive, not specific)
  • 72-96 hours: measure lipase (specific, not sensitive)

149

describe the complications of the condition seen in the image

  • ARDS
  • hemolysis with peripheral vascular collapse
  • hypovolemic shock → acute tubular necrosis → acute renal failure
  • secondary infection by bacteria → sepsis → DIC
  • hypocalcemia → tetany and heart murmurs 
  • pancreatic abscess = infection of pancreatic pseudocyst most commonly by intestinal bacterial (like E. coli)

150

describe the image

acute pancreatitis

microscopy shows a region of fat necrosis (right) and focal pancreatic parenchymal necrosis (center)

151

in the condition seen in the image, there is ___ of parenchyma due to repeated ____

in the condition seen in the image, there is fibrosis of parenchyma due to repeated bouts of acute pancreatitis

152

describe the etiology of the condition seen in the image

  • adults: most common cause = chronic alcoholism
  • children: CF, pancreatic divisum, mumps

153

describe the presentation of the condition seen in the image

  • repeated attacks or persistence of moderately severe abdominal pain and back pain
  • possible progression to pancreatic insufficiency and diabetes
    • malabsorption (b/c no amylase or lipase) & steatorrhea & jaundice
    • malabsorption corrected by pancreatic enzyme supplements
  • intraluminal hydrolysis of fats, proteins, carbs by enzymes is defective → malabsorption

154

describe what would be seen on CT/x-ray of the condition in the image

fibrotic pancreas w/ dystrophic calcification of pancreas

155

the most important prognostic indicator of the condition seen in the image is ____

the most important prognostic indicator of the condition seen in the image is hypocalcemia due to malabsorption of vit. D →​ cardiac arrhythmias 

156

describe the complications of the condition seen in the image

  • pancreatic pseudocyst: fluid-filled cavity NOT lined by epithelium; fibrous scar
  • pancreatic insufficiency: diabetes (if islets are damaged), fat malabsorption, steatorrhea, fat-soluble vit. deficiencies
  • pancreatic carcinoma → esp. with alcohol

157

the most common location for the condition seen in the image is ____

what can this affect?

the most common location for the condition seen in the image is the head of the pancreas

  • adenocarcinoma of the head of the pancreas/ampulla obstructs bile flow
    • jaundice → increase ALP, light colored stools, palpable gallbladder (Courvoisier sign)

158

list the predisposing factors for the condition seen in the image

  1. smoking (most common)
  • familial relapsing chronic pancreatitis
  • KRAS mutation

159

describe the presentation of the condition seen in the image

  • majority are silent until late 
    • therefore classically called "painless jaundice"
    • the first symptom is pain due to invasion of the posterior abdominal wall and nerves (perineural)

160

in the condition seen in the image, the first symptom is ____ due to ___

the first symptom is pain due to invasion of the posterior abdominal wall and nerves (perineural)

161

describe the histology of the condition seen in the image

  • majority ductal type adenocarcinomas
  • dense stromal fibrosis → desmoplasia
  • propensity for perineural invasion

162

there is no single specific marker for the condition seen in the image, but ___ is raised sometimes

there is no single specific marker for the condition seen in the image, but CA 19-9 is raised sometimes

163

describe the complications of the condition seen in the image

  • Trousseau's sign: recurrent migratory thrombophlebitis
    • due to release of platelet factors and procoagulants from tumor
  • renal vein thrombosis 
  • diabetes (if islets are destroyed)
  • perineural invasion
  • metastasis to the mesenteric lymph nodes and liver