Seminar 8 - Alcohol and Upper GI Bleeds Flashcards

Question

Which microscopic features are seen in autoimmune type 2 chronic pancreatitis

Answer 1

neutrophilic infiltrates within epithelium and lumen of medium sized pancreatic ducts

Answer 2

Can cause both acute and chronic pancreatitis

Answer 3

Alcohol damages the acinar cells of the pancreas through oxidative stress which causes inappropriate release of enzymes that damage the pancreas itself. Also increases contraction of the sphincter of Odi and secretion of protein rich fluid that is likely to cause plugs. Both processes cause blockage of the ducts.

Answer 4

H. pylori bacteria weakens the protective mucous coating of the stomach and duodenum Acid gets through to the sensitive lining beneath Acid + bacteria cause irritation to the lining which causes the ulcer Also causes impaired secretion of somatostatin and gastrin which leads to acid hypersecretion

Answer 5

True Multiple episodes of rebleeding can occur from damaged vessels This is most common soon after the initial haemorrhage and occurs in 10-30% of cases.

Answer 6

Surgical hemostasis / angiographic embolization after failure of repeated endoscopy Refractory bleeding peptic ulcer: surgical intervention with open surgery Intraoperative endoscopy

Answer 7

Enlarged - splenomegaly Degree of enlargement varies widely – weight can reach as much as 1000g (5-6x its normal) Irregular pale-tan plaques of collagen over the purple capsule (aka. “sugar icing” or “hyaline peri-splenitis”).

Answer 8

May cause penetration of other organs, such as the pancreas, without spreading into the peritoneum

Answer 9

Results in stupor. | Anything over this puts the individual at risk of brainstem depression and therefore respiratory depression.

Answer 10

The resident macrophages of hepatic sinusoids | They are attached to the luminal surface of endothelial cells

Answer 11

cricoid cartilage to gastroesophageal junction

Answer 12

Haematochezia - fresh blood in stool, either mixed in or present on wiping

Answer 13

SCC is the most common worldwide but adenocarcinoma is becoming increasingly common in the US and western world

Answer 14

True | Only in 10% of cases though and more common in infants

Answer 15

7X more common in men and most common in Caucasians Highest rates in US, UK, Canada, Australia, Netherlands and brazil Lowest rates in Korea, Thailand, Japan and Ecuador >1/2 of all oesophageal cancers in the US

Answer 16

Bile duct Portal vein Hepatic artery

Answer 17

Fatty change | Can be caused by alcoholism

Answer 18

Loss of sinusoidal endothelial cells fenestration

Answer 19

Surgical resection Can do a total, subtotal, or distal gastrectomy Attempt to maintain a 5-cm surgical margin proximally and distally to primary lesion Esophagogastrectomy for tumors of cardia & gastroesophageal junction Subtotal gastrectomy for tumors of distal stomach

Answer 20

They are spindle-shaped cells in the exocrine pancreas Their nuclei and cytoplasm do not stain as intensely as the secretory cells

Answer 21

Incompetence of LOS - hiatus hernias, pregnancy, Transient oesophageal sphincter relaxation Raised intra-abdominal pressure - obesity, pregnancy, asthma, increased gastric volume, coughing, straining and bending down Slow transit of food -diabetes, peptic ulcer disease, CTDs Alcohol and tobacco use CNS depression

Answer 22

Many of the effects are due to the toxic nature of acetaldehyde

Answer 23

Epigastric burning / Aching pain - occurs 1-3 hours after meals, worse at night (11-2), relieved by alkali or food Present with iron deficiency anemia, hemorrhage, or perforation Nausea, vomiting, bloating, belching, significant weight loss

Answer 24

Lots of mucus and lysozymes - protection | HCl secreted from parietal cells -

Answer 25

The pyloric antrum

Answer 26

Metabolism cause release of ROS which causes lipid peroxidation of liver cells and provokes endotoxin release by GI flora which causes further liver damage

Answer 27

In the smooth endoplasmic reticulum of hepatocytes

Answer 28

Operable gastric cancers beyond T1N0

Answer 29

SPINK1 gene mutation | Autosomal dominant

Answer 30

Splenic and superior mesenteric veins | This occurs behind the neck of the pancreas

Answer 31

The size and location of the haematoma

Answer 32

``` Spider naevi Palmar erythema Clubbing Gynaecomastia - impaired oestrogen metabolism Splenomegaly Hepatomegaly None!! ```

Answer 33

False | Not recommended

Answer 34

Evident chronic inflammatory infiltrate that surround slobules and ducts Acinar loss is a constant feature w sparing of Islets of Langerhans (become embedded in sclerotic tissue) Ductal epithelium = atrophic or hyperplastic or metaplastic

Answer 35

Haemorrhoids | Anal Fissures

Answer 36

Hepatic stellate cells differentiate into highly myofibroblasts in response to injury. Release cytokines, growth factors, chemotactic Kupffer cells or recruited macrophages & lymphocytes. ECM deposition + scar formation often in space of Disse. Loss of sinusoidal endothelial cells fenestration (sinusoidal capillarisation).

Answer 37

Model for End-Stage Liver Disease Created to predict survival of patients undergoing Transjugular intrahepatic portosystemic shunts (TIPS) procedure Used to predict 3-month mortality in cirrhosis and aid liver transplant allocation (US).

Answer 38

Primary biliary cholangitis (even in absence of cirrhosis) Infiltrative malignancy, primary or metastatic Pre-sinusoidal: Schistosomiasis Diffuse, fibrosing granulomatous disease e.g., sarcoid Sinusoidal: Cirrhosis (any cause; accounts for most cases of portal HTN). Nodular regenerative hyperplasia (effects portal microcirculation). Massive fatty change (steatohepatitis) Amyloidosis Post-sinusoidal: Focal malignancy w/ invasion into hepatic vein (esp. hepatocellular carcinoma) Budd-Chiari syndrome

Answer 39

Unable to differentiate disease severity in the top subgroup of cirrhotic patients. E.g., those with serum bilirubin >3mg/dL had the same CTP score as those with levels 20+mg/dL

Answer 40

Treatment centers on resting the inflamed pancreas by total elimination of oral intake and supportive therapy via analgesia and IV fluids

Answer 41

The extent of associated brain damage

Answer 42

No | May however be appropriate in high risk patients

Answer 43

Comprises serum bilirubin, INR, creatinine, and sodium

Answer 44

Normal portal blood flow: 1000-1500ml/min. | Normal portal vein pressure: 5-10mmHg

Answer 45

Hepatic encephalopathy Ascites Portosystemic venous shunts Congestive splenomegaly

Answer 46

Has consistently sized nodules on liver Diameter <3mm Rare in portal area.

Answer 47

Cardia Fundus Body Pylorus - has antrum, canal and sphincter

Answer 48

Reversible pancreatic parenchymal injury

Answer 49

Paraumbilical subcutaneous metastases (or Sister Mary Joseph nodule or nodules)

Answer 50

Incidence is rising rapidly 10% of symptomatic GORD patients and 2% of the general population will be affected More common in Caucasians, 3X as common in men and increases in incidence with age ( usually being seen between 40-60yrs)

Answer 51

Dilated, congestive cardiomyopathy - caused by injury to the myocardium Hypertension Coronary Heart Disease

Answer 52

They are found between plates of hepatocytes Lined with fenestrated endothelium making sinusoids very leaky - allows for easy movement of large proteins backwards and forwards Space of Disse lies beneath these endothelial cells and the hepatocytes

Answer 53

Hyper-oestrogenaemia form impaired oestrogen metabolism, pruritus, and hypogonadism in females

Answer 54

Loose connective tissue Contains; vessels, lymphatics, miessners plexus and nerves, occasional white cells, lymphoid follicles and submucosal glands * Glands lined by mucinous cells producing acid mucin that drains through ducts lined by cuboidal or squamous cells

Answer 55

Flase | They are scattered and so only occupy a small volume.

Answer 56

Flagella – allow bacteria to be motile in viscous mucus Urease – generate ammonia -> elevate gastric pH -> enhance survival Adhesins – enhance bacterial adherence Toxins – e.g. cytotoxin-associated gene A

Answer 57

20% in stomach and 80% in small intestine | Not altered at this stage

Answer 58

False | In approx. 25% of cases, the source of bleeding cannot be definitively identified

Answer 59

Elevated ammonia levels - cause impaired neuronal function and cerebral oedema Principle source is the GIT (produced by microorganisms and enterocytes during glutamine metabolism) Ammonia is normally transported in the portal vein to the liver (for urea cycle). In severe liver disease, BBB and astrocytes clear it (glutamate -> glutamine); excess glutamine -> osmotic imbalance and a shift of fluid into these cells -> cerebral oedema

Answer 60

dura mater, arachnoid mater and pia mater.

Answer 61

Hepatic artery has highest pressure (100mg/Hg) but carries least amount of blood (ml)/min and the hepatic vein has the lowest pressure (4mmHg) but transports the most blood(ml)/min

Answer 62

I: Altered mood/behaviour; sleep disturbance (e.g., reversed sleep pattern); dyspraxia; poor arithmetic. No liver flap. II: increasing drowsiness, confusion, slurred speech ± liver flap, inappropriate behaviour/personality change. III: incoherent; liver flap; stupor. IV: coma

Answer 63

True Lower risk of dysplasia and therefore adenocarcinoma too Usually asymptomatic of GORD

Answer 64

``` Jaundice Ascites Encephalopathy Anorexia, weight loss Bruising ```

Answer 65

After the vessels are torn, blood will accumulate in the subdural space . As blood accumulates it puts more pressure on the brain, causing injury and gradually raising ICP. If untreated this can cause shifting of the brain and eventual herniation This can be fatal

Answer 66

Superior Descending Horizontal Ascending

Answer 67

Infants and children – veins are still relatively thin-walled The elderly – higher fall risk and veins more fragile due to stretching from brain atrophy Alcoholics are also at an increased risk due to their propensity for falls and head trauma alongside the disordered bleeding associated with alcoholism (thrombocytopenia, prolonged bleeding times)

Answer 68

Most early gastric cancers are small, measuring 2 to 5 cm in size Often located at lesser curvature around angularis Can be multifocal (indicative of a worse prognosis) Features classified by Borrman classification - other card

Answer 69

Undergoes diffuse remodelling into parenchymal nodules (often regenerative) surrounded by fibrous bands & variable degrees of vascular shunting (circulation is rebuilt) The whole liver can become deformed and hardened

Answer 70

Trauma/impact to the head causes the bridging veins to tear and venous blood escapes into the subdural space They are vulnerable to tearing as they are fixed relative to the dura – on impact the brain suddenly moves and pulls on the fixed structure (shearing force)

Answer 71

Administration of pre-endoscopy erythromycin Endoscopic treatment: achieve hemostasis + prevent rebleeding Nonoperative management: 1st –line management after endoscopy Initiation of PPI therapy asap (high-dose PPI as a continuous infusion for the first 72 hours) + PPI for 6-8 weeks after endoscopic treatment

Answer 72

Digestive enzymes are synthesized as inactive proenzymes and packed into secretory granules They are activated by trypsin which itself is activated by an enzyme from the small bowel (intrapancreatic activation is minimal) Acinar and ductal cells also secrete tryptin inhibitors – all of these minimize the activation of digestive enzymes Pancreatitis occurs when these protective mechanisms are disrupted

Answer 73

Non keratinised stratified squamous epithelium

Answer 74

Classic crescent moon appearance

Answer 75

The basal part of the cells are typically basophilic due to extensive RER, while the apical part is very eosinophilic due to the presence of zymogen (pre-enzyme) granules

Answer 76

Impaired oestrogen metabolism | It reflects local vasodilation

Answer 77

``` Primarily due to arterial vasodilatation in the splanchnic circulation. Increased arteriolar blood flow -> increased venous efflux into portal venous system. Nitric oxide (NO) is the most significant mediator in splanchnic arterial vasodilatation (others: prostacyclin, TNF). ```

Answer 78

By measuring the difference between the area under the waiting list survival curve and the area under the post-transplant survival cure over a 5-year interval Difference between the expected survival with the transplant and the expected survival on the waiting list Utility – Need = Transplant benefit Utility – liver offered to patient with shortest predicted survival time without liver transplant. Need – liver offered to longest predicted survival time with a liver transplant

Answer 79

bleeding, perforation, stricture formation, narrowed oesophagus = dysphagia

Answer 80

Head trauma is the leading cause of subdural haemorrhage. However, in vulnerable groups such as the elderly this trauma can seem minor Other rarer causes include coagulation disorders, vascular malformations and glutaric aciduria type 1.

Answer 81

Symptoms of chronic GORD Rarely can be completely asymptomatic May have globus sensation as well as dysphagia

Answer 82

4X as common in males and usually >45yrs Most common in Europe and Asia In Us much more common in African Americans than Caucasians due to alcohol and tobacco use as well as other unidentified factors

Answer 83

All ulcers seen on endoscopy should be biopsied to assess for malignancy Patients may require stabilisation and resuscitation Most haemorrhage can be treated endoscopically via a mechanical method such as clips, coagulation, or fibrin +/- adrenaline The use of PPIs should be considered, especially as prophylaxis where NSAID use cannot be stopped

Answer 84

The pancreas has a thin connective tissue capsule that is continuous with connective tissue septa that divide the gland into lobules.

Answer 85

Chronic mucosal ulceration affecting the duodenum or stomach

Answer 86

``` Bumpy surface nodules Hardened liver Thickened capsule Depressed areas of fibrosis. Yellow hue: fatty change ```

Answer 87

Drains blood from the small + large intestines, stomach, spleen, pancreas and gallbladder

Answer 88

Regenerative nodules | They are formed from the surviving hepatocytes in CLD replicating in an attempt to restore the parenchyma

Answer 89

Withdraw the drug | Same goes for any other offending agents that may interfere with mucosal healing

Answer 90

Surgery Chemotherapy Neoadjuvant therapy

Answer 91

True | 50% of alcohol related deaths caused by DUI, homicide and suicide

Answer 92

Usually clinically detectable when at least 500ml has accumulated

Answer 93

the pyloric antrum

Answer 94

NO | unless refractory after PPI

Answer 95

``` Hepatic encephalopathy Hypoglycaemia Sepsis Head trauma Post-ictal Wernicke’s encephalopathy Hyponatraemia Withdrawal syndromes ```

Answer 96

Plicae circulares - folded from mucosa & submucosa Intestinal villi (mucosal outgrowths) - for absorption Intestinal crypts Submucosa of duodenum has Brunner’s glands - branched tubular mucous glands Lamina propria & submucosa in ileum - Peyer’s patches (a component of GALT)

Answer 97

Nutritional deficiencies associated with chronic liver failure or a primary hormonal alteration which disrupts the HPA

Answer 98

Solitary in more than 80% of patients Most common in duodenum Form a round to oval, sharply punched-out defect - clear margin Mucosal margin is usually level with surrounding mucosa May overhang the base (particularly on proximal side) Depth of ulcer correlated with diameter Base of peptic ulcers is smooth and clean as a result of peptic digestion of exudate may be evidence of infiltrated vessels and evidence of thrombosis

Answer 99

Yes | Surveillance is still required as several treatments may be needed to eliminate the lesion

Answer 100

You get lipid accumulation, and fat vacuoles formed within cytoplasm of the liver cell

Answer 101

Ballooning degeneration | Fatty degeneration

Answer 102

Starts with the causal disease This causes recurrent inflammation and fibrosis This will lead to compensated cirrhosis Then decompensated - causing acute-on-chronic liver failure Eventually death

Answer 103

Zone 1 | Due to higher exposure level and more oxygen present

Answer 104

Over 60% Excluding patients who use NSAIDs

Answer 105

Via duct obstruction, acinar cell damage

Answer 106

Treated with chlordiazepoxide and may need thiamine replacement

Answer 107

Most recover but about 5% with severe cases die in first week

Answer 108

Hepatic Encephalopathy Ruptured oesophageal varices Bacterial infection Hepatocellular carcinoma

Answer 109

Leads to hyper-oestrogenaemia Palmar erythema + spider angioma Males: hypogonadism + gynaecomastia

Answer 110

Thought to be due to a failure to relax the gastroesophageal musculature during prolonged vomiting During prolonged vomiting or intense coughing fits, there is a sudden rise in abdominal pressure The gastroesophageal mucosa tears as it is unable to fully distend

Answer 111

Stain for collagen fibres (e.g., Masson's trichome) | Type 1 collagen & nerve fibres blue; cytoplasm/muscle red; nucleus black/blue

Answer 112

endoscopic ablative therapy or 6-12 month surveillance plan

Answer 113

likely already have haematogenous and lymphatic spread

Answer 114

Barrett’s esophagus Increasing incidence of chronic GERD Obesity

Answer 115

Unlike in other acinar glands, such as the parotid, the smallest ducts in the pancreas (the intercalated ducts) do not start where the acinus ends, but rather extend into the acinus They represent an extension of the intercalated duct into each pancreatic acinus.

Answer 116

Portal hypertension | Usually as a result of liver disease - cirrhosis

Answer 117

The main one is that if left untreated it can progress onto Barrett's oesophagus It also has the potential to cause ulceration and strictures due to chronic inflammation

Answer 118

Peripheral neuropathies Wernicke-Korsakoff Syndrome (later cerebral atrophy, cerebellar degeneration and optic neuropathy can occur)

Answer 119

Can occur as lesions or ulcers heal as scarring leads to stenosis, particularly at the gastric outlet

Answer 120

aqueous bicarbonate solution This occurs under stimulation by the hormone secretin

Answer 121

False | It can be if there is herniation etc. but typically it is slow and progressive

Answer 122

Appear in ~40% of individuals with advanced liver cirrhosis Cause massive haematemesis and death in about 50% of those affected. Each episode of bleeding is assoc. with ~30% mortality

Answer 123

Varices protruding into oesophageal lumen | May be inflammation or ulceration present along with evidence of past episodes of bleeding

Answer 124

It divides liver into the larger right and smaller left lobes. It has 2 layers of peritoneum and attaches the antero-superior surface of the liver to the anterior abdominal wall and diaphragm. The free edge of this ligament contains the ligamentum teres hepatis

Answer 125

In general, this doesnt lead to long term harms (if you follow safe drinking guidelines) Studies have shown that moderate consumption of around 20 to 30g of alcohol per day actually appears to protect against coronary heart disease. May be due to increasing HDL levels, inhibition of platelet aggregation and lower fibrinogen levels

Answer 126

Interaction of H. pylori with surface mucosa -causes the release of IL-8 This leads to recruitment of PMNs which begin inflammatory process This is enhanced by Class II molecules expressed by gastric epithelial cells as they cause activation of transcription factors This leads to further cytokine release and more inflammation

Answer 127

Acinar cells can be damaged by a variety of endogenous, exogenous and iatrogenic insults – oxidative stress, generation of free radicals, membrane lipid oxidation, transcription factor activation and various other molecular pathologies This damage causes the release of intracellular enzymes

Answer 128

It is prolonged inflammation of the pancreas associated with irreversible destruction of exocrine parenchyma, fibrosis, and in the later stages endocrine parenchyma

Answer 129

Neoadjuvant therapy can be given in the form of chemo +/_ radiotherapy

Answer 130

Painless obstructive jaundice

Answer 131

ED, depression, gynaecomastia, hallucination, liver dysfunction, leukopenia, agranulocytosis, AV block, pancytopenia, thrombocytopenia and vasculitis

Answer 132

ductal dilation + protein plugs and calcifications

Answer 133

Varices form when pressure in collaterals is >10mmHg | Bleeding will occur if pressure >12mmHg

Answer 134

Platinum-based combination chemotherapy Trastuzumab + cisplatin + capecitabine/5-FU Ramucirumab following a fluoropyrimidine- or platinum-containing regimen Pembrolizumab

Answer 135

Divided into 1-2mm hexagonal lobules oriented around the terminal tributaries of the hepatic vein (central veins). So the central vein is in the centre of the lobule At the periphery of the lobule are portal triads

Answer 136

Hypovolaemic Shock -common Obstruction Perforation - rare but serious

Answer 137

Palliative chemotherapy / Supportive care

Answer 138

Men | M:F ratio: 2:1

Answer 139

Acute onset of severe central epigastric pain (over 30-60 min) Poorly localised tenderness and pain exacerbated by supine positioning Radiates through to the back in 50% of patients

Answer 140

infection, bleeding, perforation, sedation caused hypotension, breathing difficulties or reaction

Answer 141

Attached to inferior surface of liver between segment IV on right and III on left

Answer 142

It was introduced as a prognostic tool for operative mortality assoc. with portocaval shunt surgery for variceal bleeding Current use is to predict life expectancy in patients with advanced cirrhosis e.g. a CTP score 10 or above is assoc. with 50% chance of death within 1 year.

Answer 143

Variables for ascites and hepatic encephalopathy (HE) are included in the score

Answer 144

Mucous neck cells - secrete mucus at neck region Parietal cells - secrete HCl, gastric intrinsic factor and mucous coating at neck region Chief cells - synthesize & release zymogens (including pepsinogen and precursors of rennin & lipase) at base region Enteroendocrine cells - secrete various peptide hormones and act as neurotransmitters Undifferentiated cells - they have high mitosis rates and give rise to the above cell types

Answer 145

adenocarcinoma or squamous cell carcinoma

Answer 146

Portal vein, hepatic artery proper, common bile duct.

Answer 147

Ulcers generally occur on a background of chronic gastritis which is also caused by alcohol

Answer 148

Islets of Langerhans

Answer 149

80-90% of cases are self-limiting | Else, treatment with clips or ligation are performed endoscopically, often in conjunction with adrenaline administration

Answer 150

It is actually segment 1 and not a lobe It lies in the lesser sac between the IVC on the right, the ligamentum venosum on the left and porta hepatis in front The caudate process attaches the caudate lobe to the right lobe.

Answer 151

Significant wait loss

Answer 152

Allows for Vitamin B12 absorption in the small intestine

Answer 153

Grossly – redness of the oesophagus representing hyperaemia Microscopically – histology is often unremarkable

Answer 154

Often in the space of DIsse

Answer 155

Visible outpouchings of colonic mucosa - may contain impacted stool In the case of infection or inflammation, this may be seen as hyperaemia, ulceration or rupture

Answer 156

The head - relatively short at only 1-2cm and lies over the superior mesenteric vessels. The uncinate process - small projection from the inferior part of the head of the pancreas and lies posterior to the superior mesenteric artery. The body - continues from the neck, lies over the aorta and L2 vertebra. The tail - lies anterior to the left kidney

Answer 157

Any form of brain surgery comes with many risks – brain damage, infection etc. Risk of recurrence.

Answer 158

True | ~40% are asymptomatic until most advanced stages of disease.

Answer 159

In the liver

Answer 160

Diverticulosis – formation of diverticular | Diverticulitis – inflammation of diverticular

Answer 161

Goblet Cells Paneth cells - secretion of antibacterial, defensins, lysozyme Columnar epithelial cells - – for absorption (brush border enzymes) Enteroendocrine cells – secrete Gi hormones Undifferentiated cells

Answer 162

Usually occurs in distal 3rd of oesophagus and may involve the gastric cardia Initially comprised of patches that are raised or flat within an intact mucosae Eventually it will become a large mass 5cm or more in diameter Alternatively the tumours can ulcerate and invade deeply or can infiltrate diffusely

Answer 163

Both supplies enter on inferior aspect of liver at hilum (aka. porta hepatis).

Answer 164

Gastritis Gastric Ulcers Oesophageal Varices

Answer 165

Runs from the oral cavity up to and including the duodenum Oral cavity Pharynx - nasopharynx, oropharynx and larnygopharynx Oesophagus Stomach Duodenum

Answer 166

ADH is the main enzyme and is found in the cytosol of hepatocytes. The p-450 enzymes become more important at high alcohol levels - part of the microsomal ethanol-oxidising system Catalase has minor effect - only deals with around 5% of the alcohol

Answer 167

Pain is occasionally referred to the back , left upper quadrant, or chest May be misinterpreted as cardiac in origin

Answer 168

Central vein lesions caused by perivenous fibrosis etc. | Veno-occlusive changes

Answer 169

Hypovolaemic Shock

Answer 170

UKMELD used in conjunction with the Transplant Benefit Score (TBS) UKELD must be calculated monthly to update patient illness severity.

Answer 171

Mainly affects the CNS but can also impact the GI system and the liver acutely

Answer 172

True Persistent or repeated episodes of acute pancreatitis will lead onto chronic pancreatitis Alcoholics are at a risk of repeated pancreatitis

Answer 173

Hepatic venous pressure gradient (HVPG): Gradient between portal vein and IVC >10mmHg

Answer 174

With long-standing ascites, seepage of peritoneal fluid through trans-diaphragmatic lymphatics may lead to the hydrothorax

Answer 175

Around 10% is excreted unchanged via the urine, sweat and breath. The rest is distributed around the body via the bloodstream. This distribution is dependent on blood level and water content of tissues

Answer 176

True | It has a synergistic effect

Answer 177

Pancreatitis is initiated by an injury that leads to auto-digestion of the pancreas by its own pancreatic enzymes Normally regulation would stop this so it occurs when the protective mechanisms are disrupted

Answer 178

First will have chronic GORD before progressing to BO | There is a risk if left untreated that it will progress, although slowly, to adenocarcinoma

Answer 179

Fewer cells present Secrete less HCl than other regions H. pylori can grow here

Answer 180

Micronodular Macronodular Mixed

Answer 181

Adenocarcinoma | Accounts for more than 90% of all gastric cancers

Answer 182

Severe right-sided heart failure Congestive pericarditis Hepatic vein outflow obstruction

Answer 183

Falciform ligament Ligamentum teres hepatis Ligamentum venosum Left and right triangular ligaments – branches of the coronary ligament

Answer 184

Exact mechanism unknown Infections may develop in diverticular as a result of food particles or faecal matter This leads to inflammation, ischaemia, necrosis, ulceration

Answer 185

Has inner and outer longitudinal layers Skeletal muscle at top and smooth muscle distally Has myenteric plexus

Answer 186

NSAIDs disrupt the permeability barrier | 30% of adults taking NSAIDs have GI adverse effects

Answer 187

Elevation of serum amylase and lipase are 90-95% specific for the diagnosis Can be normal though - especially on an background of chronic

Answer 188

Involves both chemo and radiotherapy in order to control disease and its symptoms

Answer 189

Comprised of a cardia, fundus, body/corpus and pyloric antrum

Answer 190

Found in the fundus and body Straight, branched at base Have an isthmus, Neck, Base Secretion regulated by vagus nerve & hormones

Answer 191

If less than 72 hours old they are classed as acute, subacute from days 3-21 and chronic from 3 weeks onwards

Answer 192

Endoscopic mucosal resection if small and confined to inner lining of oesophagus If it has spread out with the inner lining then oesopahgectomy is done Chemoradiation may be done if cant have/doesn’t want surgery or neoadjuvantly

Answer 193

Contraction of vascular smooth muscle cells + myofibroblasts - increases portal flow. Hepatocyte degeneration and remodelling can reduce sinusoid calibre Collagen deposition in space of Disse alters the elastic properties of the sinusoidal wall Periportal inflammation, fibrosis and/or necrosis can block sinusoids Decreased NO production, increased endothelin-1 + angiotensinogen release -> intra-hepatic vasoconstriction Intrahepatic shunts interfere with the metabolic exchange between sinusoidal blood & hepatocyte

Answer 194

Upper GI Lower is approx 20% as common as upper GI bleeding

Answer 195

``` NSAIDs H. pylori infection Alcohol Bile salts Acid Pepsin ```

Answer 196

Peptic Ulcer Disease Gastritis Gastric Cancer

Answer 197

Hypercalcaemia

Answer 198

Superior part of oesophagus drains to azygous vein | Inferior part drains to hepatic portal vein

Answer 199

Has several sublayers Epithelium - changes from stratified squamous in esophagus to simple columnar (for absorption) Lamina propria - loose connective tissues, lymphatics, fenestrated blood vessels, mucosal gland, unencapsulated lymphoid nodules and plasma cells ``` Muscularis mucosae (controlled by Meissner’s plexus) Raises into folds – rugae ``` Gastric pits: tiny epithelial recess where glands open into Mucous lining to protect against acidity

Answer 200

Strongly urease positive | Silver stain: Warthin-Starry stain

Answer 201

The duration and severity of the pancreatitis e.g. acute interstitial pancreatitis vs acute necrotizing and haemorrhagic pancreatitis

Answer 202

Managed with chemo +/- radiotherapy Potentially herceptin or immunological therapy depending on cancer type

Answer 203

Portal vein enters at hilum It then splits into the right and left portal vein Right supplies segments 5-8 and left supplies segments 1-4

Answer 204

They occur in around 15% of head trauma cases and up to 30% of fatal trauma cases. More common in men than women (3:1 ratio) and highest incidence in the 50s-70s

Answer 205

Most common cause of oesophagitis Prevalence of 10-20% in the west but only 5% in Asia Most common in individuals >40yrs

Answer 206

Has differing size of nodules Diameter >3mm (can be >1cm+) May contain >1 portal vein + central vein

Answer 207

Into pre, intra- and post-hepatic causes Pre-hepatic – alterations to portal venous system (tributaries: splenic and SM veins). Intra-hepatic – disease which affects the liver architecture or microcirculation. Post-hepatic – aka. Supra-hepatic disease, from the IVC and beyond

Answer 208

typically classified by their location in relation to the ligament of Treitz (suspensory muscles of the duodenum) ``` UGI = Oesophagus, stomach and duodenum LGI = Jejunum, ileum, colon, rectum and anus ```

Answer 209

~95% of duodenal ulcer and~75% of gastric ulcer patients

Answer 210

Signs of clot lysis after 1 week. After around 2 weeks, fibroblasts will be seen in the haematoma. Hyalinised connective tissue can form after 1-3 months.

Answer 211

Upper GI endoscopy

Answer 212

``` dysphagia/odynophagia - usually starts with solids and progresses Weight loss Anaemia and heamatemesis Epigastric or retrosternal pain Pain over bony structures of neck Hoarseness Persistent cough Recurrent pneumonia ```

Answer 213

Once diagnosed are put onto optimum dose PPI therapy and given periodic endoscopy and biopsy to monitor for disease progression

Answer 214

Get depression of the limbic system and cerebellum. | Leads to confusion, loss of memory/orientation and problems with movement and speech.

Answer 215

Prevalence increases with age Affecting approx. 4.6 million in the US Non-variceal causes have mortality of 8-14%

Answer 216

It can cause Foetal Alcohol Syndrome | Caused by ethanol intake during pregnancy - particularly during the first trimester

Answer 217

Caused by mutations in the CDH1 gene Causes dysfunction of gastric epithelial cells This causes a failure to maintain cell polarity and differentiation Leads to tumour invasion & progression

Answer 218

May secondarily induce haematologic abnormalities attributable to “hypersplenism” – esp. thrombocytopenia or even pancytopenia Largely due to sequestration of blood elements in the expanded splenic red pulp.

Answer 219

Ascites and HE are subjective and the use of diuretics and lactulose (treatment) can vary. INR reflects hepatic synthetic function but not naturally occurring anticoagulants like protein C and S. Inter-laboratory variation in INR calculation.

Answer 220

approximately 1 case per 100 person per year

Answer 221

It leads to cholestasis in the small bile ducts - pruritus | Can lead to new ducts forming in fibrous tissue.

Answer 222

behind the medial end of the left clavicle

Answer 223

Mortality in symptomatic cases is very high – 50-90%.

Answer 224

Progression of the BO to the adenocarcinoma over an extended period of time due to step wise acquisition of genetic and epigenetic changes Specific changes not well understood but thought to be due to mutations within tp53 and CDKN2A as well as amplification of EGFR, ERBB2, MET, cyclin D and cyclin E oncogenes Obesity also plays a role additional to causing GORD as the hypertrophied adipocytes and inflammatory cells within fat deposits create an environment of low grade inflammation and promote tumour development by releasing adipokines and cytokines Also supply energy and support tumour growth

Answer 225

Hepatic stellate cells

Answer 226

Dilated vessels sitting within the mucosa and submucosa | May be associated with inflammation +/- tissue necrosis

Answer 227

Yes | Class 1 carcinogen (WHO)

Answer 228

Increase in vascular resistance in portal system leads to development of collateral vessels to allow some shunting of blood around the liver This causes congestion and dilation of venous plexuses within the oesophagus and stomach

Answer 229

``` Hx of previous peptic ulcer disease Older age Female sex High doses or combinations of NSAIDs Long-term NSAID use Concomitant use of anticoagulants Severe comorbid illnesses ```

Answer 230

Rectum and superior anal canal drain to IMV; inferior part of GI tract drains to internal iliac veins.

Answer 231

May be managed conservatively with serial head CTs. This is because venous bleeding usually self-limiting and the haematoma may resorb If there are clotting abnormalities these should be reversed immediately. Should also address the initial cause of the trauma if possible (e.g. assess fall risk or treat alcoholism.)

Answer 232

Biopsy | If biopsy shows dysplasia this must be confirmed by a second pathologist experienced with BO neoplasia

Answer 233

``` Microvascular leak and oedema Fat necrosis Acute inflammation Damage Blood vessel destruction with interstitial haemorrhage ```

Answer 234

inner circular, outer longitudinal smooth muscles

Answer 235

More research needs to be done to define which score should be used and when Each is better in different sitautions

Answer 236

Made of fibrovascular connective tissue Has scattered inflammatory cells and mucus glands lined with foveolar like cells releasing neutral mucin Will fold into papillae that protrude into epithelium

Answer 237

Administration of broad-spectrum antibiotics Microbiological sample collection for analysis of pathogen Initiation of empiric broad-spectrum antibiotics asap Targeting gram-negative, gram-positive and anaerobic bacteria Short course of 3-5 days or until inflammatory markers normalize

Answer 238

A palpable enlarges stomach with succussion splash Hepatomegaly Periumbilical metastasis (Sister Mary Joseph nodule) Enlarged lymph nodes e.g. Left supraclavicular node & anterior axillary node Blumer shelf - tumour in pouch of Douglas Weight loss Melena Pallor from anemia

Answer 239

Duct obstruction Acinar cell injury Defective intracellular transport

Answer 240

Glands are not visible Rows of infiltrating neoplastic cells with marked pleomorphism Neoplastic cells have clear vacuoles of mucin pushing cell nucleus to one side -> signet ring

Answer 241

Measures total bilirubin, creatinine, INR and serum sodium levels

Answer 242

Acts as a valve and prevents backflow of contents to stomach

Answer 243

It is bleeding between the dura and arachnoid layers - in the subdural space

Answer 244

Mucosa - composed of epithelium, lamina propria, muscularis mucosa Submucosa Muscularis externa Serosa

Answer 245

Prevalence increases with age with approximately 50% of over 50s having some degree of disease. Thought to account for 15-40% of LGI bleeds

Answer 246

Hyperchromatic (big N/C ratio) | Increased mitosis

Answer 247

The enzymes are produced as inactive proenzymes. Once the pancreatic secretion arrives in the duodenum an enteropeptidase converts the inactive proteolytic enzyme trypsinogen into the active form, trypsin. This begins a cascade that results in the activation of the other enzymes.

Answer 248

Stigmata of cirrhosis May be an incidental finding May have portal HTN Symptoms of cause - may have been present earlier

Answer 249

Outlook is poor: 25 year mortality rate of 50%

Answer 250

Presence of ascites, a palpable abdominal mass, hepatomegaly from liver metastases, or splenomegaly from portal vein obstruction

Answer 251

Significant weight loss Mid-epigastric pain - sometimes with radiation of the pain to the midback or lower-back region Often, unrelenting pain: Night-time pain often a predominant complaint Onset of diabetes mellitus within the previous year Painless obstructive jaundice Pruritus: Often the patient's most distressing symptom Depression Migratory thrombophlebitis (ie, Trousseau sign) and venous thrombosis: May be the first presentation Palpable gallbladder (ie, Courvoisier sign)

Answer 252

It is a complex process involving sinusoidal hypertension, hypoalbuminemia, increased hepatic lymph flow, and splanchnic vasodilatation and hyperdynamic circulation

Answer 253

More than 20% of patients have a family history of duodenal ulcers, compared with only 5-10% in the control groups

Answer 254

Though there are certain features that are more characteristic of one source of bleeding or the other, these are not always the case In 15% of patients who present with LGI bleeding, the source is actually an UGI bleed UGI bleeds may present as frank blood in stool if severe enough

Answer 255

There will be loss of the normal histological structure of the gut wall Active ulcers may be lined by a thin layer of fibrinoid debris with a predominantly neutrophilic inflammatory infiltrate Granulation tissue with immature vessels, mononuclear leukocytes, a fibrous/collagenous scar forms ulcer base Scarring usually at base but may involve the entire thickness of the wall - this can draw surrounding mucosa into folds that radiate outward There may also be some metaplastic changes present

Answer 256

GORD can lead to Barretts Oesophagus and then Adenocarcinoma which can be fatal Ulceration has the potential to cause an upper GI bleed

Answer 257

PPI irrespective of symptoms and surveyed every 3-5yrs

Answer 258

tremor, nausea & vomiting, malaise, headache, insomnia, weakness, sweating, tachycardia, hypertension, anxiety, depression, irritability Hallucinations - particualrly visual or tactile - insect crawling is a common one In severe cases patients can have withdrawal fits or develop delirium tremens (DTs) which involves sudden onset of confusion and hallucinations alongside the other symptoms.

Answer 259

Once the epithelial cells invade the lamina propria - defining feature

Answer 260

The urine, sweat and breath | Excretion via breath is the reason why you can do breath tests

Answer 261

YES Reduced risk of gastric cardia cancer Thought to be related to decline in stomach acidity which is often seen after decades of H. pylori colonization

Answer 262

Stabilisation and resuscitation if needed Endoscopy within 12 hrs – if haemorrhage found, then Endoscopic Variceal Ligation (EVL) performed TIPS – Trans-jugular Intrahepatic Porto-systemic Shunt

Answer 263

Falling due to the reduced prevalence of H. pylori infection BUT Increasing in patients older than 60 years due to growing NSAIDs use - these cases can be amplified by H.pylori

Answer 264

Grossly – there may be erosions on top of the hyperaemia (redness) Microscopically – eosinophils within the squamous mucosae, elongation of the papillae of the lamina propria and basal zone hyperplasia are all often seen

Answer 265

Appears as a collection of freshly clotted blood on the brain surface. It is not limited by the skull sutures but instead by the dural reflections. The clot does not extend into the sulci of the brain and the arachnoid space is usually clear. The underlying brain can be flattened by the pressure and after a long period the area can become atrophied. Once organisation has occurred the haematoma can become firmly attached to the dura but free from the arachnoid. May retract until it is only a thin layer of connective tissue or repeated bleeding can form a chronic haematoma.

Answer 266

Chronic pancreatitis often follows repeated episodes of acute pancreatitis It has been proposed that the acute episodes initiate a sequence of perilobular fibrosis, duct distortion and altered secretions lead to loss of exocrine parenchyma and fibrosis

Answer 267

bleed at surgical site, peritonism, dysphagia, perforation/tear of oesophageal lining, slippage of the wrapped stomach

Answer 268

It is an accessory digestive organ Has exocrine and endocrine functions Exocrine - releases pancreatic digestive enzymes (produces 1L of juice per day) Endocrine - releases insulin and glucagon

Answer 269

The alcohols are a group of chemical compounds containing a hydroxyl group and a varying number of carbons Produced via the fermentation of various products such as grains, fruit and vegetables

Answer 270

Chronic portal hypertensions leads to vascular dilation + remodelling Creates thin-walled collateral venous circulation (shunts) between portal & systemic circulations (bypass the liver) Shunts can form anywhere the systemic & portal circulations share pre-existing vascular beds

Answer 271

Depression of higher cortical function. | Leads to excitement, loss of self consciousness, typical drunk/tipsy behaviour

Answer 272

Most frequently found in proximal duodenum within a few cm of pyloric valve

Answer 273

``` Tight intercellular junctions Mucus Bicarbonate Mucosal blood flow Cellular restitution Epithelial renewal ``` All help prevent ulceration normally

Answer 274

1-year post-liver transplant mortality (UK) is ~9%. | So they must have a worse mortality than that for the transplant to give them a survival benefit

Answer 275

parenchymal fibrosis, acinar atrophy and dropout, and variable ductal dilation

Answer 276

RLN runs on its surface with thoracic duct to left and carotid sheath down the side

Answer 277

Can develop into adenocarcinoma | Most cases will NOT

Answer 278

``` Idiopathic Gallstones (rare : genetic e.g. CF) Ethanol (alcohol) Trauma - BF, surgery etc. Steroids Mumps (and other infections)/malignancy Autoimmune - SLE etc Scorpion stings/spider bites Hyperlipidaemia/hypercalcaemia/hyperparathyroidism (aka the metabolic disorders) ERCP Drugs (tetracyclines, furosemide, azathioprine, thiazides and many others) ```

Answer 279

significant pneumoperitoneum, extraluminal contrast extravasation, or signs of peritonitis Performing surgery asap (particularly in patients w/ delayed presentation or those >70 yo)

Answer 280

``` Viral hepatitis (B/C/D) Alcoholism NAFLD Metabolic disease Cholestasis Hepatic venous outflow obstruction Toxins & some drug-induced (MTX) hepatitis Intestinal bypass (TPN) Autoimmune hepatitis Cryptogenic cirrhosis. ```

Answer 281

The walls of colonic diverticula are comprised of flattened mucosa +/- submucosa, without muscularis. In the case of infection, inflammatory infiltrate may be present at the base. Granulomas may begin to form, especially in the case of perforation

Answer 282

False | Wont develop in every chronic GORD patient but its not known why some are effected and not others

Answer 283

Type I: polypoid Type II: fungating Ischemic-> necrotic -> shed off Type III: ulcerated Heaped up/everted edges Type IV: diffusely infiltrating Thickening of stomach wall Very firm (leather-bottle stomach/linitis plastica)

Answer 284

All laboratories in transplant units measure serum bilirubin and creatinine conc. using the same methods - consistent

Answer 285

``` Mumps Coxsackievirus Hepatitis Infectious mononucleosis HIV/AIDS parasitic: ascariasis ```

Answer 286

Has an equivalent no. of micro- and macro-nodules so cannot be clearly classified as one of the other types

Answer 287

Results from imbalance between defence mechanisms & aggressive factors that cause chronic gastritis Under normal conditions: a physiologic balance exists between gastric acid secretion & gastroduodenal mucosal defense Aggressive factors alter mucosal defense by allowing back diffusion of hydrogen ions and subsequent epithelial cell injury

Answer 288

From the gastroesophegeal junction at T11 to the duodenum at l1-l2

Answer 289

Primarily by replication of mature hepatocytes adjacent to those that have died (even with significant confluent necrosis) Will however reach replicative senescence - can no longer replicate

Answer 290

Muscular tube that’s normally collapsed In the neck is within the deep cervical visceral fascia with the trachea and thyroid Runs behind the aortic arch and to left and descending aorta Travels behind the left main bronchus and right pulmonary artery Comes in front of the descending aorta at the oesophageal diaphragmatic hiatus (passes through at T10) Gastroesophageal junction at T1

Answer 291

possible disseminated intra-abdominal cancer

Answer 292

Primary brain injury can occur from the haematoma itself or the causative trauma . Secondary injuries can include oedema, infarction, secondary hemorrhage, and brain herniation (all of which cause further brain damage and potentially death)

Answer 293

Lifestyle modification - stop smoking, wt loss (if obese), avoid provoking factors i.e. certain foods Antacids and H2 antagonists for symptomatic relief PPI for symptom relief and healing of the oesophagus – GOLD standard Nissen Fundoplication – rarely used and only for young patients with severe refractory disease and complications

Answer 294

Where cirrhosis arises without any clear cause.

Answer 295

along lesser curvature near the interface of the body & antrum

Answer 296

Quality of life is often impaired due to loss of function

Answer 297

Impaired blood flow through the portal system and liver leads to increased pressure in collateral vessels, such as those in the oesophagus. These vessels become dilated and are at risk of rupture and fatal bleeding

Answer 298

According to Robbins, prevalence is 0.04% - 5% | Middle age males most affected

Answer 299

Causes confusion, loss of fine motor control and emotional control and slurring of speech

Answer 300

To relive symptoms, heal oesophagitis and prevent complications ( mainly BE)

Answer 301

Ethanol provides calories but not nutrition. Chronic drinkers are therefore at risk of many nutritional deficiencies, particularly B vitamins as they often won't eat properly

Answer 302

With haemorrhoids

Answer 303

With the signs + symptoms of liver failure Stigmata of cirrhosis and symptoms of cause may also be present

Answer 304

Reflux of gastric bile and acid into oesophagus irritates the stratified squamous epithelium as it's not designed to deal with corrosive acids Leads to irritation and inflammation causing symptoms and if not resolved then chronic pathological changes occur

Answer 305

It’s a chronic rather than acute condition that lasts for many years Can progress to Barretts and cancer

Answer 306

80% are adenocarcinomas of the ductal epithelium

Answer 307

Incidence varies markedly with geography Japan, Chile, Costa Rica, Eastern Europe: Incidence is up to 20-fold higher than in North America, Northern Europe, Africa and Southeast Asia Highest death rates are recorded in western Asian countries (Iran, Turkmenistan, Kyrgyzstan) Mass endoscopic screening programs have been successful in regions where the incidence is high

Answer 308

Alcohol acts as a depressant and mainly affects subcortical structures and therefore cortical activity This leads to the common ‘symptoms’ of drunkenness such as loss of motor and cortical functions (e.g., decision making) and decrease in intellectual function. At higher levels it affects cortical neurones and medullary centers including the respiratory centre = respiratory arrest

Answer 309

Typically, pancreatic cancer first metastasizes to regional lymph nodes, then to the liver and, less commonly, to the lungs. It can also directly invade surrounding organs such as the duodenum, stomach, and colon, or it can metastasize to any surface in the abdominal cavity via peritoneal spread. It may spread to the skin as painful nodular metastases.

Answer 310

Diverticulitis Colonic Angiodysplasia ``` Infective Colitis Colonic Polyps IBD Colorectal Ca Ischaemic Colitis ```

Answer 311

Impaired oestrogen metabolism | Each spider angioma is a central, pulsating, dilated arteriole from which small vessels radiate

Answer 312

Mainly branches from splenic artery - pancreatic branches Gastroduodenal artery - superior pancreaticoduodenal Superior mesenteric artery- inferior pancreaticoduodenal Close relationship to the duodenum so similarities in blood supply

Answer 313

for primary defense against mucosal infection

Answer 314

Aimed at H. pylori eradication & neutralization of gastric acid (primarily with proton pump inhibitors)

Answer 315

Areas of hepatocyte loss transformed into dense fibrous septa -> encircle surviving hepatocytes. Prominent feature in most cirrhotic livers: regenerative nodules

Answer 316

Appear as dilated subcutaneous veins extending from the umbilicus toward the rib margins - called caput medusae It is a clinical hallmark of portal HTN

Answer 317

Hepatic stellate cells differentiate into highly myofibroblasts in response to injury. Release cytokines, growth factors, chemotactic Kupffer cells or recruited macrophages & lymphocytes. ECM deposition + scar formation often in space of Disse. Loss of sinusoidal endothelial cells fenestration (sinusoidal capillarisation).

Answer 318

Hepatocyte degeneration Inflammatory cell infiltration-induced necrosis Liver fibrous tissue hyperplasia (fibrosis) Hepatocyte nodular regeneration

Answer 319

It can cause alcoholics to go into withdrawal | This is a very dangerous state

Answer 320

the obliterated umbilical vein

Answer 321

Usually present with peritonitis and shock

Answer 322

Some people have very low levels of ADH due to a genetic variant Approximately 50% of the Asian population have this Leads to nausea, flushing, tachycardia and hyperventilation after alcohol intake

Answer 323

Cause 5-10% of UGI bleeds Present in up to 90% of patients with cirrhosis, more in those with decompensated cirrhosis Mortality of 15-20%/ haemorrhagic episode, with >50% of patients having a recurrent bleed within the first year

Answer 324

Have a lower life expectancy than the average population May die due to progression to adenocarcinoma May die from complications of screening and treatment May die due to comorbidities which are common due to risk factors for the original GORD including obesity, smoking and alcohol

Answer 325

A palpable metastatic mass in the rectal pouch | Seen in pancreatic cancer

Answer 326

Acetaldehyde

Answer 327

Derived from persistent cholestasis

Answer 328

1st line treatment is lifestyle modification +/- oral Abx In acute bleeding, patients may require stabilisation and resuscitation, followed by endoscopic haemostasis (via clips, powders, stitching) In the case of perforations, these should be surgically drained and IV Abx prescribed

Answer 329

Increased risk of cancer of the oral cavity, larynx oesophagus, liver and breast

Answer 330

Obstructive thrombosis of portal vein Structural abnormalities e.g., narrowing of portal vein before it ramifies in liver. Massive splenomegaly w/ increased splenic vein blood flow

Answer 331

The molecular pathogenesis is not well understood but recurrent abnormalities are seen as amplifications of transcription factor SOX1, over expression of the cell cycle regulator cyclin D and LOF mutations in tp53, CDH1 and NOTCH1 tumour suppressors Generally thought to be linked to inflammation of the squamous epithelium which leads to dysplasia and in situ malignant transformation

Answer 332

Alcohol damages the cellular DNA by decreasing metabolic activity in the cell This promotes oxidation by blocking detoxification Tobacco then has the synergistic effect and because alcohol is a solvent it allows the tobacco to penetrate into the oesophageal epithelium with more ease

Answer 333

Diagnosis often based on clinical findings Portal pressure can be measured if required but patency of portal vein should be assessed by Doppler USS before attempting to measure pressure in it

Answer 334

bleeding and stricture formation

Answer 335

``` Smoking Alcohol use Caustic oesophageal injury Achalasia Plummer vinson syndrome, Tylosis - rare genetic HPV Consumption of very hot beverages Caustic strictures Use of oral bisphosphonates Poor oral hygiene Prior gastrectomy ```

Answer 336

Patients may require careful management, including fluid resuscitation and blood products Treat underlying bleed

Answer 337

Approximately 60% arise in the head of pancreas, 15% in the body, 5% in the tail and in 20% the entire pancreas is involved

Answer 338

endoscopic mucosal resection followed by ablation of remaining BE mucosae

Answer 339

Loose connective tissues, larger blood & lymph vessels, lymphoid tissue, Meissner’s plexus, no submucosal glands

Answer 340

Lobular architecture destroyed by dense bands of fibrosis. Hepatocyte degeneration – fatty, ballooning, eosinophilic, hydropic, etc. Patterns of necrosis Damaged/altered vasculature – central vein, bile ducts. Nodular regeneration. Specific cell types may be seen – e.g., Mallory bodies in alcoholic hepatitis/cirrhosis, Wilson’s disease

Answer 341

pain, bleeding, scarring, dysphagia

Answer 342

Confluent - begins in zone 3 (near CV) w/ hepatocyte dropout (space filled with cellular debris Bridging -may extend from the central veins to portal tracts, or across adjacent portal tracts Pan-acinar – entire lobule obliterated Piecemeal, zonal, spotty, etc.

Answer 343

T1a - well-differentiated, ≤2 cm, confined to the mucosa, and not ulcerated May be amenable to endoscopic resection

Answer 344

Alcoholic steatosis Alcoholic hepatitis Cirrhosis (with portal hypertension and hepatocellular carcinoma as a consequence)

Answer 345

Alcohol abuse Non-linear dose-response relationship 1.2x risk with ~40 g/day alcohol consumption 4x risk with ~100 g/day alcohol consumption

Answer 346

``` Encepathology - which grade Ascites - presence/extent Bilirubin level Bilirubin in those with PBC or PSC Albumin level Prothrombin time or INR ```

Answer 347

UKELD score ⩾ 49 is the minimum criteria for entry to waiting list under this category. Unless patient has hepatocellular carcinoma and variant syndromes. Those with alcoholic liver disease, past IVDU or current methadone use must be assessed individually.

Answer 348

The precise treatment depends on the location, but endoscopic dilation is often a first line treatment

Answer 349

``` Neoadjuvant chemotherapy - pre-op and then post-op too Intraoperative radiotherapy (IORT) Adjuvant chemotherapy (eg, XELOX) Adjuvant radiotherapy - post-op Adjuvant chemoradiotherapy ```

Answer 350

It harms the mucosa | Smoking in the setting of H. pylori infection may increase the risk of relapse of peptic ulcer disease

Answer 351

Venous bleeding is typically self-limiting. | The resulting haematoma can be broken down and organised with time

Answer 352

Compression of hepatic venules | e.g., by regenerative nodules (cirrhosis), cysts (polycystic disease), granulomatous disease or metastases

Answer 353

High grade is differentiated from low grade as it has more severe architectural and cytological changes

Answer 354

It’s a complications of chronic GORD - not known why some affected and some not You have intestinal type metaplasia within the oesophageal squamous mucosae due to chronic inflammation by the gastric contents There are some autosomal dominant familial genetic mutations that will cause it but it’s a minority cause

Answer 355

Gram negative Spiral-shaped bacterium Has 4-6 unipolar flagellae

Answer 356

It actually resembles the parotid gland Has numerous serous acini and ducts The cells are very basophilic because they contain large amounts of Rough Endoplasmic R.

Answer 357

Is almost always associated with H. pylori infection, NSAIDs, or cigarette smoking

Answer 358

Hemorrhage, Perforation/Penetration, Pyloric stenosis

Answer 359

Increased nuclear to cytoplasm ration Atypical mitoses Irregularly clumped chromatin Nuclear hyperchromasia Failure of epithelial cells to mature as they travel to the surface of the oesophagus Dysplastic glands show budding, cellular crowding and irregular shapes

Answer 360

Also called Ito cells They are modified fibroblasts found in the space of Disse They produce CT and store vitamin A in fat droplets.

Answer 361

Made of 3 layers - epithelium, lamina propria and mucularis mucosae

Answer 362

Lined by columnar epithelial cells with abundant goblet cells Lymphocytes, plasma cells, eosinophils present in lamina propria Smooth muscle cells extend from muscularis mucosae – modulate height of villi Fenestrated blood capillaries & lacteals – for fat absorption Microvilli – further increase surface area

Answer 363

``` Anastomotic failure Bleeding Ileus Transit failure at the anastomosis Cholecystitis (often occult sepsis without localizing signs) Pancreatitis Pulmonary infections Thromboembolism ``` Direct mortality after 30 days - 1-2%

Answer 364

D1: perigastric lymph nodes D2: hepatic, left gastric, celiac, splenic arteries, in the splenic hilum D2 recommended Try to spare pancreas and spleen

Answer 365

``` Hepatocytes in moderate-severe fatty degeneration Presence of Mallory bodies Eosinophilic degeneration & bodies Bridging necrosis Bile duct proliferation ```

Answer 366

Non-keratinised stratified squamous epithelium | Also contains melanocytes, Langerhans cells, Merkle cells, endocrine cells and squiggle cells

Answer 367

Acinar cells

Answer 368

Surgery is sometimes necessary but most can be treated in the same way as the underlying pathology

Answer 369

Oxidation cause by alcohol leads to reduction of NAD to NADH which decreases the overall amount of NAD available As this is required for fatty acid oxidation in the liver it leads to an accumulation of fat in the liver

Answer 370

Get chronic reflux of acidic gastric contents through the LOS into the distal oesophagus The squamous epithelium is inflamed by the acidic contents and continued exposure leads to persistent inflammation as the squamous cells release Il8 and Il 1b signalling T lymphocytes and neutrophils A columnar type metaplastic reaction occurs developing an intestinal phenotype characterised by goblet cells Bile acid in particular up regulates CDX2 and MUC2 and therefore plays a role in the cellular transformation Clonal abberations of p16 as well as mutations in CDX2 and tp53 are also found in early BE lesions and therefore potentially linked to the disease Embryonic stem cells at the squamocolumnar junction or stem cells derived from undifferentiated mesenchymal cells in the lamina propria of the oesophagus or bone marrow may be the epithelial cells of origin for BO

Answer 371

Caused increased transit time in colon and decreased stool volume This leads to increased intraluminal pressure then increased colonic segmentation Causes the formation of diverticular

Answer 372

perforation or bleeding

Answer 373

Symptoms of anaemia - fatigue, syncope | Epigastric or wider abdominal pain

Answer 374

mesothelium and connective tissue

Answer 375

Long-term presence of inflammatory response leads to increased expression of a single cytokine interleukin-1-beta in stomach of transgenic mice This results in sporadic gastric inflammation + cancer (increased cell turnover from ongoing cellular damage -> increase likelihood of cells developing harmful mutations) Infection with CagA- positive H. pylori was associated with inactivation of tumor suppressor proteins (p53)

Answer 376

Dumping syndrome, vitamin B-12 deficiency, reflux esophagitis, and bone disorders, especially osteoporosis

Answer 377

Duodenum: adventitia | Jejunum & ileum: serosa

Answer 378

Caused by cirrhosis in 85% of cases

Answer 379

In portal HTN, portal vein diverts 90% of increased blood flow to collaterals

Answer 380

Varices Oesophagitis Mallory-Weiss Tears Boerhaave Syndrome Oesophageal Cancer

Answer 381

Stable: Laparoscopic approach Unstable: Open surgery

Answer 382

Bridging veins | They cross the subdural space and drain blood from the brain into the larger dural sinuses

Answer 383

Single or multiple vertical lacerations at the gastroesophageal junction, measuring anywhere between a few millimeters and several centimeters

Answer 384

True Supplied by both the hepatic portal vein and left & right hepatic arteries (come from the hepatic artery proper, a branch of the coeliac trunk).

Answer 385

They recapitulate normal ductal epithelium by forming glands and secreting mucin

Answer 386

False | Size is not necessarily correlated with other features of portal HTN

Answer 387

The various underlying causes will result in squamous dysplasia which the progresses into invasive lesion

Answer 388

Liver followed by the lung and lymph nodes

Answer 389

Smoking Diabetes Chronic inflammation of the pancreas (pancreatitis) Family history of genetic syndromes that can increase cancer risk, including a BRCA2 gene mutation, Lynch syndrome and familial atypical mole-malignant melanoma (FAMMM) syndrome Family history of pancreatic cancer Obesity Older age, as most people are diagnosed after age 65

Answer 390

Between villi & in lamina propria of the small intestine

Answer 391

The majority of the alcohol is metabolised to acetaldehyde in the liver by 3 enzymes - alcohol dehydrogenase, cytochrome P-450 and catalase The acetaldehyde will eventually be converted to acetate by alcohol dehydrogenase which can be used in the respiratory chain or lipid synthesis

Answer 392

Normal epithelium can be damaged by chronic gastritis This can lead to atrophic gastritis This can progress to intestinal metaplasia, then dysplasia Finally the cancer forms Huge number of factors can trigger/influence each step in this progression - including mutations, lifestyle factors etc

Answer 393

``` CT chest and abdo PET Endoscopic USS Bronchoscopy Barium swallow ```

Answer 394

Endoscopic mucosal resection if small and confined to inner lining of oesophagus If it has spread out with the inner lining then oesopahgectomy is done Chemoradiation may be done if cant have/doesn’t want surgery or neoadjuvantly

Answer 395

Most cases are caused by chronic GORD and its progression to BO Lesser causes include tobacco smoke and exposure to radiation

Answer 396

Gastric cancer

Answer 397

Starts as GORD, progresses to BO then adenocarcinoma due to dysplasia

Answer 398

Mucosa Submucosa Muscularis externa Adventitia/Serosa

Answer 399

Intestinal type metaplasia is characterised by replacement of squamous epithelium with goblet cells Goblet cells are diagnostic of BE and have distinct mucous vacuoles that stain pale blue and shape the rest of the cytoplasm like a wine glass Non goblet columnar cells such as gastric type foveolar cells may be seen also – not enough for diagnosis

Answer 400

Some people inadvertently alter their diet - less solids so problem is less obvious

Answer 401

Longitudinally orientated smooth muscle bindles | Will thicken as the oesophagus descends

Answer 402

Most likely to be a defence response or adaptation to excess acid reaching the duodenum

Answer 403

Cytokines e.g. TNF-alpha (produced by Kupffer cells, macrophages) Altered interactions with ECM Toxins Reactive oxygen species

Answer 404

Organ dysfunction due to metastasis Local invasion resulting in asphyxia, haematemesis or recurrent infection = respiratory failure and sepsis Invasion of the aorta ( SCC) causing fatal exsanguinations

Answer 405

NASH | Also a feature of the abnormal sinusoids seen in hepatocellular carcinoma.

Answer 406

(Rare) signs of haemorrhage on the physical exam include: Cullen sign: periumbilical bruising Grey-Turner sign : flank bruising

Answer 407

1) highly invasive extending into peripancreatic tissues | 2) they elicit a desmoplastic response that results in deposition of dense collagen

Answer 408

The morphology of acute pancreatitis ranges from limited inflammation and oedema to extensive necrosis and haemorrhage

Answer 409

COX-1 pathway promotes prostaglandin production, which contributes to maintaining the mucus-bicarbonate barrier in the stomach, optimal submucosal blood flow, and improved healing when tissues are damaged NSAIDs inhibit this pathway, rendering the gastric mucosa more susceptible to damage Also have anti-platelet action, which increases bleeding risk

Answer 410

When it has spread to nodes, liver, lungs or stomach

Answer 411

Connection between para-umbilical + small epigastric veins

Answer 412

Shorter & more branched glands | Deeper pits

Answer 413

The fundus and body of the stomach | It is for digestion - contains water, HCl, mucus, digestive enzymes, electrolytes

Answer 414

Store vitamin A in fat droplets normally Transform into myofibroblasts in setting of chronic liver injury. Myofibroblasts are fibrogenic and are involved in scar formation.

Answer 415

50% of cases will be in the middle 1/3 of the oesophagus and all will start as squamous dysplasia Early lesions - small plaque thickenings that are gray-white in colour Over months to years will grow into a tumour mass that is either polypoid or exophytic and protrudes into and obstructs the lumen Otherwise tumours mat be diffuse infiltrated lesions that will spread in the oesophageal wall and cause rigidity, thickening and narrowing of the lumen or they may also be ulcerated

Answer 416

It is a national set of rules offering livers to named adult patients on the elective liver waiting list Livers offered to named patients throughout the UK who are predicted to gain the most survival benefit from receiving the particular liver graft on offer

Answer 417

Starts with hepatocyte degeneration (ballooning, fatty change) Then hepatocyte necrosis Then hepatocyte regeneration Then scar formation and regression Eventually will have extensive, diffuse scarring with dense fibrous septa surrounding remaining normal hepatocytes (cirrhosis).

Answer 418

Sympathetic – abdominopelvic splanchnic nerves Parasympathetic – vagus nerves Both of these pass through the diaphragm, then follow arteries from the celiac and superior mesenteric plexus to reach the pancreas

Answer 419

``` Heartburn Dysphagia and odynophagia Regurgitation of sour tasting gastric contents, usually postprandial Coughing Hoarseness Chest pain that differs from heartburn ```

Answer 420

The two most common causes of acute LGI bleeding with significant blood loss are diverticulitis and colonic angiodysplasia

Answer 421

The accumulation of fluid in the peritoneal cavity

Answer 422

``` Acute renal failure Acute respiratory distress syndrome Sterile pancreatic abscesses Pseudocysts In around half of patients with acute necrotizing the debris becomes infected ```

Answer 423

Lymph node dissection during open surgery (limited to perigastric nodes & local N2 nodes)

Answer 424

Gastric acid oxidises the haem in RBCs after a period of time giving these appearances

Answer 425

Myenteric plexus | Found in the muscularis externa

Answer 426

Reduced rate of H. pylori infection Decreased consumption of dietary carcinogens such as N-nitroso compounds and benzo[a]pyrene Widespread availability of refrigeration -reduced use of salt and smoking for food preservation

Answer 427

Usually begins 6-12 hours after last drink (can be up to 72hours) and lasts a few days

Answer 428

Thought to be multifactorial with both genetic and environmental factors contributing Low fibre diet thought to be main contributing factor in Western countries May also be due to dysfunction of the colonic wall, changes in colonic motility, and disruptions to the gut microbiome Other RF – Obesity, smoking, excessive alcohol and caffeine intake, NSAID use

Answer 429

Usually normal but may show enlargement of laterocervical or supraclavicular nodes or hepatomeagaly

Answer 430

SARS-CoV-2 has been shown to infects cells of the human exocrine and endocrine pancreas ex vivo and in vivo Has been detected in pancreas cells PM Infection is associated with morphological, transcriptional and functional changes Can affect insulin and contribute to the metabolic dysregulation observed in patients with COVID-19.

Answer 431

Paraneoplastic syndromes e.g. dermatomyositis, acanthosis nigricans, circinate erythemas

Answer 432

Haematemesis “coffee-ground” vomit Melaena

Answer 433

Palliative radiotherapy Palliative-intent procedures (eg, wide local excision, partial gastrectomy, total gastrectomy, simple laparotomy, gastrointestinal anastomosis, bypass)

Answer 434

Centroacinar cells | Commonly called duct cells

Answer 435

``` Unusual adenocarcinoma Undifferentiated carcinoma Neuroendocrine carcinoma Melanoma Lymphoma Sarcoma ```

Answer 436

Caused by lipase leads to “saponification” Fatty acids combine with calcium to form insoluble soaps that impart a granular blue microscopic appearance to surviving fat cells

Answer 437

proteases to break down proteins lipases to break down lipids nucleases to breakdown DNA/RNA amylase to break down starch

Answer 438

Form glands and produce mucin - glands tend to have intestinal type morphology Less commonly the tumours may be made of diffusely infiltrating signet ring cells or rarely small poorly differentiated cells Its also common to find BO beside the tumour

Answer 439

Thiamine (vitamin B1) deficiency - common in chronic alcoholics

Answer 440

mucosae, submucosae, muscularis propria and adventitia

Answer 441

The lateral aspects of the cerebral hemispheres

Answer 442

By-products of metabolism cause hepatic injury and inflammation though exact mechanism uncertain

Answer 443

UK-specific version of the MELD score which was designed to predict waiting list mortality and improve distribution of liver grafts

Answer 444

True | Only 2% of tumours in the exocrine pancreas

Answer 445

pancreatic adenocarcinoma | lymphoma

Answer 446

H. pylori are present in majority of individuals w/ chronic antral gastritis

Answer 447

First-line eradication therapy: standard triple therapy i.e. amoxicillin, clarithromycin, PPI Should be started after 72-96 hours of intravenous proton-pump inhibitor and continued for 14-day duration Other options: PPI-based triple therapy, clarithromycin-based triple therapy, quadruple therapy

Answer 448

Imbalance between aggressive factors & defensive factors leads to gastric metaplasia (defence adaptation) of duodenum/stomach This causes duodenitis/gastritis Further addition of aggressive factors causes a duodenal/gastric ulcer Ulcer penetrates through muscularis and adventitia (ulcer perforates into peritoneal cavity!) causes peritonitis and eventually death

Answer 449

Red velvety mucosae extending upwards in tongues from the gastroesophageal junction The metaplastic mucosae alternates with the squamous epithelium that remains (it is pale) and will interface with the gastric mucosae distally which is a light brown columnar gastric mucosae Separated into short segment ( <3cm) and long segment ( >/3cm)

Answer 450

Base of skull to criciod cartilage

Answer 451

Hematogenous spread & lymphatic spread can lead to: Pathologic peritoneal & pleural effusions Liver failure Intrahepatic jaundice caused by hepatomegaly Extrahepatic jaundice Obstruction of gastric outlet, gastroesophageal junction, or small bowel

Answer 452

Most will have had symptoms of underlying GORD | The cancer may be diagnosed before symptoms occur if picked up on GORD/BO screening

Answer 453

Made of loose connective tissue. | Most of the oesophagus is surrounded by fascia

Answer 454

``` Alcohol NAFLD Hep C and B PBC Autoimmune hepatiti ```

Answer 455

True If the other drug uses the same enzymes in their metabolism then the person is more susceptible - e.g. cocaine However, when both are present the alcohol competes for the enzyme and may slow drug metabolism (potentiated effect)

Answer 456

Each with a branch of the hepatic artery and portal vein, a bile duct and venous drainage (to IVC).

Answer 457

bleeding, infection, anastomotic leak, change to voice, pneumonia, dysphagia, AF, death

Answer 458

Associated with activities which cause a transmural pressure gradient between the abdomen and thorax Coughing, vomiting, CPR, hiccups, medications (particularly NSAIDS), instrumentation Hiatus hernias are thought to be a risk factor Most commonly associated with prolonged retching or vomiting during alcohol intoxication

Answer 459

Coronary heart disease

Answer 460

Fluctuating rigidity and hyperreflexia. Asterixis – nonrhythmic, rapid flexion-extension movements of head and extremities Best seen when arms held in extension with dorsiflexed wrists. Aka. ‘liver flap’.

Answer 461

Most common cause is alcohol Also associated with long-standing obstruction of pancreatic duct, autoimmune injury and hereditary factors Genetics - CFTR

Answer 462

Transversely orientated retroperitoneal organ extending from the c-loop of the duodenum to the hilum of the spleen Lies between the duodenum on the right and the spleen on the left, posterior to the stomach

Answer 463

``` Chronic alcohol misuse Epilepsy Coagulopathies Anticoagulant use Diabetes ```

Answer 464

Back up of enzymes such as lipase cause extensive damage such as fat necrosis as well as oedema Common in gallstones and cancer

Answer 465

hypomagnesium, hypocalceamia, c. diff infection, pneumonia

Answer 466

2 main lobes - L&R | Also has 8 functional segments

Answer 467

If chronic injury is interrupted – e.g., clearance of hepatitis viral infection, EtOH cessation The stellate cell activation and scarring ceases and the fibrous septae may be broken down by metalloproteinases Leads to partial resolution However, vascular remodelling + other architectural changes that occur in cirrhosis may not revert to normal, even with extensive scar resorption – may explain why portal HTN fails to improve in some patients

Answer 468

It is secreted into a branching system of pancreatic ducts that extend throughout the gland. In the majority of individuals, the main pancreatic duct empties into the second part of duodenum at the ampulla of Vater.

Answer 469

Patients may scratch their skin raw and risk bouts of potentially life-threatening infection Relief may only come with transplantation.

Answer 470

Usually present on a background of head trauma. Typically the deterioration is slow and progressive but patients can also suddenly decompensate as blood accumulates. Consciousness may fluctuate. Focal neurological signs (e.g. unequal pupils, hemiparesis) that are dependant on the location of the haematoma. Non-focal signs such as headache, unsteadiness, personality change, seizures and confusion. Symptoms of raised ICP – headache, vomiting, altered GCS etc

Seminar 8 - Alcohol and Upper GI Bleeds Flashcards

(518 cards)