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.Path Slides Exam 3 > GIT > Flashcards

Flashcards in GIT Deck (163):
1

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A: normal gastroesophageal junction

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

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2

describe the image

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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)

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3

describe the etiology of the condition seen in the image

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  • 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

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4

describe the pathogenesis of the condition seen in the image

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  • 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

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5

describe the presentation of the condition seen in the image

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  • 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

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6

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

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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 

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7

describe complications of the condition seen in the image

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

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8

describe the etiology of the condition seen in the image

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

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9

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

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

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10

describe the risk factors for the condition seen in the image

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  • white men, smokers, obese, previous radiation therapy

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11

describe the presentation of the condition seen in the image

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

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12

describe the complications of the condition seen in the image

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

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13

describe the image

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

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14

describe risk factors of the condition seen in the image

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  • 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

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15

describe the pathogenesis of the condition seen in the image

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  • 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

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16

describe the presentation of the condition seen in the image

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

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17

describe investigations for the condition seen in the image

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

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18

describe complications of the condition seen in the image

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  • 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

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19

describe the image

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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

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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

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

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22

describe the histology of the condition seen in the image

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  • 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

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23

describe the pathogenesis of the condition seen in the image

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  • 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

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24

describe investigations of the condition seen in the image

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  • 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

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25

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

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

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26

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

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

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27

describe the complications of the condition seen in the image

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

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28

describe the image

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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

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29

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

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

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30

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

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

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31

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

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

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32

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

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

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33

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

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

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34

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

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

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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

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36

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

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

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37

GIST tumors are derived from ____

GIST tumors are derived from interstitial cells of Cajal

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38

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

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

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39

describe the histology of cells seen in GIST

spindle-shaped tumor cells

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40

GIST is treated with ____

GIST is treated with  TKI (Imatinic/Gleevec)

same treatment as CML (9,22 translocation)

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41

describe predisposing factors for the condition seen in the image

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

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42

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

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

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43

describe complications of the condition seen in the image

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

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44

describe the image seen

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celiac sprue/disease

complete loss of villi or total villous atrophy

dense plasma cell infiltrates in the lamina propria

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45

describe the etiology of the condition seen in the image

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

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46

describe the morphology seen in the condition in the image

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  • 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

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47

describe the pathogenesis of the condition seen in the image

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  • 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

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48

describe the pathogenesis of the condition seen in the image

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

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49

the condition in the image mainly affects the ____

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the condition in the image mainly affects the duodenum

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50

describe complications of the condition seen in the image

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  • 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

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51

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

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

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52

describe the image

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villi are stout and packed with foamy macrophages

lipid particles --> dilated lacteals

PAS stain --> foamy particles in LP

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53

describe the etiology of the condition seen in the image

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

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54

describe the pathogenesis of the condition seen in the image

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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

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55

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

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

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56

describe the investigations of the condition seen in the image

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

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57

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

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

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58

describe the pathogenesis of the condition seen in the image

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

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59

describe the investigations of the condition seen in the image

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  • 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

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60

describe complications of the condition seen in the image

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

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61

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

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

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62

describe the image

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diverticulosis

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

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63

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

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

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64

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

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

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65

describe the morphology of the condition seen in the image

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

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66

describe the predisposing factors of the condition seen in the image

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

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67

describe the pathogenesis of the condition seen in the image

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

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68

describe the presentation of the condition seen in the image

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

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69

list complications of the condition seen in the image

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  • 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

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70

describe the image

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ulcerative colitis

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

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71

describe the image

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ulcerative colitis

the disease is limited to the mucosa + submucosa

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72

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

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

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73

describe the classic features seen in the condition in the image

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

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74

describe the histology of the condition see in the image

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  • 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

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75

describe the gross appearance of the condition seen in the image

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

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76

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

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

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77

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

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

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78

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

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

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79

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

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

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80

describe the image

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Crohn's disease

linear mucosal ulcers and thickened intestinal wall

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81

describe the image

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Crohn's disease

haphazard crypt organization results from repeated injury and regeneration

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82

describe the image

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Crohns disease

transmural Crohn disease with submucosal and serosal non-caseating granulomas

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83

the condition in the image is associated with HLA- ____

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

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84

describe the histology of the condition in the image

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cobblestone appearance 

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

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85

describe the gross appearance of the condition 

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  • 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

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86

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

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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

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87

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

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

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88

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

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

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89

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

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  • 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

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90

describe complications of the condition seen in the image

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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

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91

describe the image

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pseudomembranous colitis

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

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92

describe the etiology of the condition seen in the image

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

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93

describe the morphology of the condition seen in the image

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

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94

describe the pathogenesis of the condition seen in the image

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  • 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

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95

describe the presentation of the condition seen in the image

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

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96

describe investigations for the condition seen in the image

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assay stool for exotoxin

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97

list complications for the condition seen in the image

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

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98

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

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  • 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

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99

describe the etiology of the condition in the image

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  • 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 

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100

describe the gross morphology of the condition in the image

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

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101

describe the presentation of the condition in the image

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  • 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

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102

describe the complication of the condition in the image

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

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103

explain the variants of the condition seen in the image

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  • 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

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104

describe the image

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carcinoid tumor

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

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105

describe the image

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carcinoid tumor

bland cytology that typifies neuroendocrine tumors

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

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106

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

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

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107

describe the origin of the condition seen in the image

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origin = enterochromaffin/Kulchitsky/neuroendocrine cells

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108

describe type I of the condition seen in the image

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

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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

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110

describe type III of the condition seen in the image

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

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111

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

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  • 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

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112

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

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

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113

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

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5-HIAA

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114

list the tumor markers for the condition seen in the image

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synaptophysin, chromogranin, CD56 (origin of cells)

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115

describe the image

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cirrhosis

thick bands of collagen separate rounded cirrhotic nodules 

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116

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

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  • 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)

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117

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

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

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118

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

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  • 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 

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119

describe the pathogenesis of the condition in the image

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  • 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

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120

describe the presentation of the condition seen in the image

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

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121

describe the investigations of the condition seen in the image

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

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122

list complications of the condition seen in the image

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  • 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

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123

describe the etiology of the condition seen in the image

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  • 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

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124

describe the histological morphology of the condition seen in the image

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  • 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)

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125

describe the investigations of the condition seen in the image

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

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126

describe the complications of the condition seen in the image

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

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127

describe the trabecular type of the condition seen in the image

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nests and cords of hepatocytes

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128

describe the fibrolamellar type of the condition seen in the image

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  • 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

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129

describe the risk factors for the condition seen in the image

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  • 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

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130

describe the etiology of the condition seen in the image

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

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131

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

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

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132

describe the etiology of the condition seen in the image

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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

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133

describe the pathogenesis of the condition seen in the image

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  • 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

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134

list complications of the condition seen in the image

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  • 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

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135

describe the risk factors for the condition seen in the image

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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

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136

describe the presentation of the condition seen in the image

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  • 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

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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

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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

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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

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140

PBC is associated with anti-_____

PBC is associated with anti-mitochondrial antibodies

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141

list complications of PBC

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

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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

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143

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

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

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144

describe the histology in PSC

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

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145

describe the etiology of the condition seen in the image

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

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146

describe the morphology of the condition seen in the image

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  • 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

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147

describe the pathogenesis of the condition seen in the image

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

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148

describe the investigations of the condition seen in the image

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

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149

describe the complications of the condition seen in the image

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  • 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)

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150

describe the image

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acute pancreatitis

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

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151

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

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

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152

describe the etiology of the condition seen in the image

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

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153

describe the presentation of the condition seen in the image

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  • 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

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154

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

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fibrotic pancreas w/ dystrophic calcification of pancreas

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155

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

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

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156

describe the complications of the condition seen in the image

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  • 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

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157

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

what can this affect?

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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)

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158

list the predisposing factors for the condition seen in the image

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

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159

describe the presentation of the condition seen in the image

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  • 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)

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160

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

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

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161

describe the histology of the condition seen in the image

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

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162

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

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

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163

describe the complications of the condition seen in the image

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  • 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

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