pathology III: esophageal and gastric disorders quiz review

here are some study questions for the quiz on esophageal and gastric disorders.

questions
esophageal disorders...
1. what is the etiology of achalasia?
2. what is the morphology of achalasia?
3. what are the possible sequelae of achalasia?
4. what is DES?
5. what is the morphology of DES?
6. what are the clinical manifestations of DES?
7. what is nutcracker esophagus?
8. what are the clinical manifestations of nutcracker esophagus?
9. what is the etiology of diverticula?
10. what are diverticula called in the proximal vs. distal portion of the esophagus?
11. what are the two types of hiatal hernia? which is most common?
12. what are some complications of hiatal hernias?
13. what is the etiology of mallory weiss syndrome?
14. what is the morphology of mallory weiss?
15. what are the sequelae of mallory weiss?
16. what is the etiology of esophageal varices?
17. what layer of the esophageal wall are esophageal varices?
18. what is a complication of esophageal varices?
19. what is the clinical presentation of esophageal varices?

esophagitis...
20. what are the etiologies for esophagitis that involve external irritation?
21. what are the etiologies for esophagitis that involve decreased LES tone?
22. what are some other etiologies of esophagitis?
23. what are the histomorphological characteristics of esophagitis?
24. what is the morphology of candida esophagitis?

barrett's esophagus, adenocarcinoma...
25. what is the most common etiology of barrett's esophagus?
26. what is the gross morphology of barrett's esophagus?
27. patches that are bigger than what size are at greater risk for developing adenocarcinoma?
28. what is the histomorphology of barrett's esophagus?
29. what is the etiology of esophageal adenocarcinoma?
30. risk of adenocarcinoma might be decreased by...
31. what is the morphology of esophageal adenocarcinoma? where in the esophagus does it affect?

squamous cell carcinoma vs. adenocarcinoma...
32. what is the difference in epidemiological factors in SCC vs. adenocarcinoma?
33. what is the etiology of SCC?
34. what is the difference in location for SCC vs. AC?
35. what is the morphology of SCC?
36. what is the 5 year prognosis for SCC?
37. what is the prognosis for AC?

h. pylori...
38. h. pylori is present in what percentage of chronic gastritis?
39. what are the characteristics of h. pylori that allow it to flourish in the GI system?
40. what are two outcomes of h. pylori infections?
41. what is the morphology of a stomach infected with h. pylori?
42. what are the techniques used to diagnose h. pylori infection?

figure 17-11, robbins 8th ed...
43. what are some "defensive forces" present in normal gastric mucosa?
44. what are injurious forces that can damage gastric mucosa?
45. what are the layers in a gastric ulcer from the lumen to the serosa?

acute gastritis...
46. what are the most common etiologies of acute gastritis?
47. what is the gross morphology of acute gastritis?
48. what kind of exudate is associated with acute gastritis?
49. what are the clinical manifestations of acute gastritis?

chronic gastritis...
50. chronic gastritis is characterized by...
51. what is the incidence of chronic gastritis in the US?
52. what are the etiological mechanisms for chronic gastritis?
53. what are some examples of autoimmune conditions that could result in chronic gastritis?
54. what is the gross morphology of chronic gastritis?
55. what are the clinical manifestations of chronic gastritis?
56. diagnosis of chronic gastritis is made by...
57. what are the complications of chronic gastritis?
58. what is a MALToma?

gastric cancer...
59. which countries does gastric cancer have a particularly high incidence in?
60. which blood type has a high incidence for gastric cancer?
61. which races are particularly affected by gastric cancer?
62. what are some diet related risk factors for gastric cancer?
63. what is the gross morphological difference between a gastric ulcer and gastric cancer?
64. what locations are gastric cancer and a gastric ulcer most prone to affect?
65. what is the histomorphological features of the intestinal and diffuse variants of gastric cancer?
66. both the intestinal and diffuse variants of gastric cancer spread to...
67. describe the stages of pathological progression in gastric cancer.

virchow's node and sister mary joseph nodule...
68. what does virchow's node refer to?
68. what does the sister mary joseph nodule refer to?

answers
1. nerve degeneration causes increased LES tone, decreased LES relaxation, and aperistalsis.
2. progressive dilation, variable wall thickness, loss of myenteric plexus.
3. from increased pressure: SCC, candida esophagitis, diverticula.
4. failure of functional peristalsis: entire esophagus contracts simultaneously.
5. twisted corkscrew shaped esophagus.
6. dysphagia, odynophagia.
7. functional peristalsis but with high amplitude contractions.
8. odynophagia.
9. abnormal motility / spasm.
10. proximal: Zenker. distal: traction.
11. 95% are sliding. 5% paraesophageal.
12. ulceration, hemorrhage, perforation, strangulation, obstruction. [hi. strangle and tear the ham which is perfectly obstructing you]
13. severe alcoholism.
14. longitudinal lacerations, mm to cm in length.
15. inflammatory ulcers, mediastinitis, chronic blood loss.
16. increase in portal hypertension. can be from alcoholic cirrhosis, non-alcoholic cirrhosis, portal vein thrombosis.
17. submucosa.
18. rupture and hemorrhage into into lumen and esophageal wall.
19. asymptomatic until rupture.

20. reflux, radiation, gastric intubation, alcohol, hot fluids, hiatal hernia.
21. hypothryoidism, scleroderma, smoking, obesity, pregnancy.
22. infection / immunosuppression, chemical toxicity, skin disease.
23. eosinophils in the epithelium, basal zone hyperplasia, extended lamina propria papillae.
24. grey/white pseudomembrane loaded with fungal hyphae.

25. long standing GERD.
26. red and velvety patches.
27. 3cm.
28. esophageal epithelium turns into columnar intestinal epithelium with goblet cells.
29. generally occurs in areas of barrett esophagus in patients over 40 years old.
30. h pylori overgrowth.
31. distal esophagus, flat or raised patches that progress to nodular masses that may ulcerate.

32. SCC: older than 50, male, black, iran/china/HK/south africa/PR/eastern europe. AC: older than 40, male, white, US/canada/UK/australia/brazil/netherlands.
33. toxic influences, HPV
34. SCC in mid esophagus, AC in distal esophagus.
35. plaque-like thickenings, tumors that encircle the lumen.
36. superficial: 75%. nodal: 9%.
37. 80%, unless advanced stage: 25%.

38. 90%.
39. motility, urease, protease, adhesion molecules, toxins.
40. antral gastritis / atrophic gastritis, abnormal acid production.
41. intra-epithelial neutrophils, lymphoid aggregates, sub-epithelial plasma cells, hyperplastic / inflammatory polyps.
42. antibody tests, urea breath tests, stool tests, rapid urea test, bacterial culture tests, DNA detection.

43. bicarbonate, mucosal blood supply, mucous secretion, epithelial regeneration.
44. h. pylori
NSAIDs
aspirin
cigarettes
alcohol
hyperacidity
45. necrotic debris
acute inflammation
granulation tissue
scarring (fibrosis)

46. GI irritants, systemic toxins, stress.
47. neutrophils above basement membrane
superficial epithelium erosion
infiltrate and exudate in the lumen
48. fibrin purulent exudate.
49. ulcer like pain
nausea, vomiting
hematemesis

50. chronic mucosal inflammation without erosions that lead to mucosal atrophy and epithelial metaplasia.
51. over 50% in the later decades of life.
52. autoimmune
chronic infection
toxic
mechanical
53. hashimoto, addison's, IDDM.
54. attenuated / flat / reddened mucosa
lymphocytes and plasma cells in lamina propria
metaplasia with intestinal epithelial cells
55. hunger pains
pain at night and with gastric emptying
pain that refers to chest, thoracic spine, left shoulder
56. endoscopy or barium swallow xray.
57. anemia
obstruction
penetration into neighboring organs
perforation
carcinoma in an ulcer [A O P P C] [an outstanding pathologist prevents catastrophe]
58. low grade gastric lymphoma of the MALT tissue.

59. japan and china.
60. type A.
61. african americans, native americans, native hawaiians.
62. food preserved with nitrates
lack of refrigeration
lack of fresh fruits and vegetables
charred foods / polycyclic hydrocarbons
63. gastric ulcer: level margins, smooth base, red/edematous surrounding mucosa.
gastric cancer: raised margins, shaggy/necrotic base, neoplastic tissue extends into surrounding mucosa.
64. GC: lesser curvature, antrum, pylorus. GU: lesser curvature, duodenum.
65. intestinal: broad, cohesive growths, bulky tumors of glandular structures. diffuse variant: signet ring cells, gastric type cells.
66. regional and distant lymph nodes, especially the sentinel node.
67. normal
acute gastritis
chronic gastritis
chronic atrophic gastritis
intestinal metaplasia
dysplasia
gastric adenocarcinoma

68. the sentinel lymph node, the lymph node to which gastric carcinoma often metastasizes.
68. a nodule in the periumbilical region that can be an indicator of metastasis of gastric carcinoma.

CPD II: ischemic colitis, irritable bowel, appendicitis, diverticulitis

this lecture is a continuation of intestinal disorders, specifically focusing on inflammatory bowel diseases. ischemic colitis is the first disorder we covered, and is an inflammation of the mucosa and submucosa of the intestine that results either from insufficient perfusion (CHF) or an occlusive event (atherosclerosis), and accordingly is associated with elderly, smokers, and those who live sedentary lifestyles. acute cases, generally from occlusive events, present with sudden onset lower left abdominal pain, rectal bleeding, fever / hypotension, and peritoneal signs. chronic cases of ischemic colitis present with rectal bleeding as well, but have longer periods of vague abdominal pain, diarrhea, and generally a spared rectum, similar to crohn's. IC might present similar to diverticulitis or CA if there is frank blood.

irritable bowel syndrome is an extremely common disorder that contributes to 50% of all gastroenterologist visits. patients can be any age, and are more typically female. IBS can be the result of many different factors, and the exact etiological mechanism is unclear and oftentimes heavily influenced by emotional factors such as stress. other potential etiologies are: food allergy, abnormal transit profile, local histamine sensitization, epigenetics. diagnosis of IBS is made by the "rome III" criteria: lower abdominal pain for 3 days for 3 months in a row which is relieved by defecation and was accompanied at the onset by a change in stool frequency or appearance. diagnosis is also made by excluding "alarm signs" which might indicate a more serious, acute condition: onset after 50, severe diarrhea, nocturnal symptoms, severe weight loss, hematochezia, and positive family history for organic GI disease. the physical exam might be unremarkable, or reveal tenderness over the course of the colon. lab tests are generally only useful for excluding other diagnoses.

appendicitis is an inflammation of the appendix, which can be caused by fecaliths, lymphoid hyperplasia, parasites, and presents as epigastric pain that migrates to the right lower quadrant accompanied by weight loss and vomiting (which generally occurs after the onset of pain, as opposed to intestinal obstruction). there are a number of physical exam tests which can diagnose appendicitis with varying success, such as mcburney's, rovsing, obturator, cough, markle signs. a CBC might show WBC levels above 10,000 and neutrophilia above 75%.

diverticula present similarly to appendicitis in that they both cause localized lower abdominal pain-- but on opposite sides. diverticula are relatively common outpouchings of the colon caused by any factor that increases the intraluminal pressure of the colon, such as a low fiber diet or constipation. the sigmoid colon is particularly vulnerable to diverticula and thus typically pain is in the lower left quadrant of the abdomen.

while diverticula by themselves can be asymptomatic, inflammation and infection can result in diverticulitis, a more acute and serious condition which might even lead to perforation. patients with diverticulitis might have had a recent history of recurrent UTI's or pneumaturia, and present with severe LLQ pain, fever, altered bowel habits, and nausea/vomiting. complications of diverticula are manifold and can be detected by the symptoms that result: a vaginal fistula would result in feculent vaginal discharge. diffuse peritonitis would result in severe generalized abdominal pain. perforation would cause back or lower extremity pain, absent bowel sounds, and a high grade fever. lower GI bleeding might appear suddenly, be accompanied by an urge to defecate, and stop spontaneously. hemorrhoids or anal fissures might result in pain with defecation. diverticulitis is diagnosed by history, PE, and sigmoidoscopy imaging-- take note that barium xray should not be used in acute cases due to the danger of perforation.

questions
ischemic colitis...
1. what is ischemic colitis?
2. the morphology of ischemic colitis is similar to...
3. what are the risk factors for ischemic colitis?
4. what are the two etiological mechanism for ischemic colitis?
5. what is the clinical presentation of an acute case of ischemic colitis?
6. what is the clinical presentation of a chronic case of ischemic colitis?
7. what are the ddx's of ischemic colitis?
8. what are the imaging techniques used to diagnose ischemic colitis?

irritable bowel syndrome...
9. how common is IBS?
10. what is the age and gender that most commonly suffers from IBS?
11. what are the postulated etiological mechanisms for IBS?
12. what are the the "alarm symptoms" diagnostic criteria for IBS and what are their significance??
13. what is the primary symptom for the rome III criteria for diagnosis of IBS?
14. what must the primary symptom of the rome III criteria be associated with?
15. what is the clinical picture of patients with IBS?
16. what are some PE findings for patients with IBS?
17. how useful are labs in diagnosing IBS?
18. IBS can be confidently diagnosed by...
19. what are some naturopathic treatment strategies for IBS?

appendicitis...
20. what is the most common age of appendicitis sufferers?
21. what are the different etiological mechanisms for appendicitis?
22. what are fecaliths?
23. what is the "classic" history / symptom picture of an appendicitis patient and how often does it actually occur?
24. if vomiting occurs in a case of appendicitis, is it more likely to occur before or after the onset of pain?
25. duration of symptoms is typically...
26. what symptoms can be caused by appendicitis near the bladder?
27. what PE finding may male infants and children present with and why?
28. what are the tests one can perform in a PE that can diagnose appendicitis?
29. what are the expected CBC findings for a patient with appendicitis?
30. what are the imaging studies that can diagnose appendicitis?
31. what are the possible differential diagnoses for appendicitis?
32. what are some differential diagnoses for appendicitis in children?

diverticula...
33a. what are diverticula?
33b. what percentage of 60 and 80 year olds have diverticula?
34. what percentage of people with diverticula are asymptomatic?
35. which part of the GI tract is most prone to diverticula?
36. what are some factors that can increase intraluminal pressure?
37. what are some possible symptoms for diverticula?

diverticulitis...
38. what is diverticulitis?
39. what are some risk factors for diverticulitis?
40. what are some main differences and similarities between diverticulitis and appendicitis?
41. what are some signs / symptoms of diverticulitis?
42. patients with diverticulitis might have a recent history of...
43. what is a complication of diverticulitis related to the female reproductive tract?
44. if diverticulitis is accompanied by diffuse peritonitis, it might present as...
45. if diverticulitis is accompanied by perforation, it might present as...
46. if diverticulitis is accompanied by lower GI bleeding, it might present as...
47. describe the characteristics of blood flow from diverticulitis with GI bleeding.
48. diverticulitis with discomfort / pain upon defecation suggests...
49. in a case of diverticulitis, what sign would indicate an inflammatory bowel disease?
50. what would be involved in the PE for diverticulitis?
51. what might be the PE findings for diverticulitis that has led to perforation?
52. what is the imaging test used to diagnose diverticulitis?
53. what is an imaging test that might be dangerous to perform during an acute case of diverticulitis and why?
54. what are the conventional and naturopathic treatments for diverticulitis?

answers
1. an inflammatory bowel disease that results from ischemia of the mucosa and submucosa.
2. crohn's.
3. over 60, smokers, sedentary.
4. either decreased perfusion from insufficient cardiac output or occlusive disease such as atherosclerosis.
5. sudden onset lower left abdominal pain
rectal bleeding
fever / hypotension / tachycardia
peritoneal signs
[lower left, blood, fever, peritoneum] [i see you left perry's blood in the lower left freezer]
6. vague abdominal pain / tenderness
rectal bleeding
diarrhea
sparing of rectum
[vague, blood, diarrhea, spare] [i see you vaguely spared the bloody diarrhea]
7. diverticulitis, CA.
8. abdominal plain film, CT.

9. up to 50% of gastroenterologist visits are because of IBS.
10. any age, 70% females.
11. abnormal transit profiles
local histamine sensitization
food sensitivities
epigenetic effect (3-5%)
underlying emotional component.
12. part of the diagnosis of IBD by identifying symptoms that would be indicative of a more acute disorder:
onset after 50
severe diarrhea
nocturnal symptoms
unintentional weight loss
hematochezia
positive family history for organic GI diseases
[50, diarrhea, night, weight loss, blood, family] [HBS 50th anniversary: i had diarrhea that night, lost a lot of weight and blood, and called my family]
13. recurrent abdominal pain at least 3 days a month for 3 months in a row.
14. relief with defecation, onset associated with change in stool frequency, form, or appearance.
15. crampy abdominal pain
constipation, diarrhea, or alternating
increased mucous production
flatulence, nausea, anorexia
anxiety / depression / stress
[cramp, alternating, mucous, various, emotional]
16. may be asymptomatic, or increased bowel sounds and tenderness
17. only useful in excluding other conditions.
18. identifying typical symptoms, doing a complete PE, and excluding alarm features.
19. food hygiene and diet, stress reduction, fiber, probiotics, cell salts.

20. late teens.
21. obstruction from fecaliths, lymphoid hyperplasia, parasites.
22. a hard mass of feces formed from fecal debris and calcium.
23. 50% of cases have anorexia / weight loss with epigastric pain that is followed by RLQ pain.
24. nearly always follows onset of pain.
25. 48 hours, longer in elderly.
26. "irritative voiding symptoms", hematuria, pyuria.
27. hemiscrotum from migration of inflamed appendix or pus through patent processus vaginalis.
28. mcburney's point, rovsing sign, obturator / psoas sign, cough sign, Markle sign, rectal/vaginal tenderness.
[mburney, rovsing, obturator/psoas, cough, Markle, ass] [mr. burns's remarkable cough obstructed my roving ass]
29. WBC above 10,000
neutrophilia above 75%
30. abdominal CT, ultrasound.
31. pelvic inflammatory disease, acute gastroenteritis, pancreatitis, crohn's, cholecystitis, pyelonephritis, IBS.
32. volvulus, intussusception, acute gastroenteritis.

33a. outpouchings of the colon.
33b. 30%, 80%.
34. 90%
35. sigmoid colon.
36. low fiber diet
refined carbs
constipation
dehydration
corticosteroids
[fiber, refined, constipation, water, steroids] [divert the refined fiber-water; i have constipation on steroids right now]
37. if not asymptomatic, then LLQ pain, constipation, rectal bleeding if erosion.

38. inflammation of one or more diverticuli, leading to complications such as abscess, obstruction, fistula.
39. same as diverticula.
40. looks almost identical to appendicitis, except doesn't generally appear in children, and appears on the LLQ instead of RLQ.
41. LLQ pain- steady, severe, deep
fever
altered bowel habits
nausea/vomiting
dysuria, pyuria
[LLQ, fever, altered, nausea, pyuria] [look- a fever altered my nausea of pies via diversion!]
42. pneumaturia / recurrent UTI's.
43. fistulas with the vagina might result in feculent vaginal discharge.
44. severe, generalized abdominal pain.
45. back or lower extremity pain.
46. bright red or wine colored stool.
47. sudden onset, urge to defecate, massive flow, stopping spontaneous.
48. hemorrhoids or anal fissures.
49. history of weight loss, mucous in the stools.
50. checking abdomen for localized tenderness / rebound tenderness / guarding
vitals for hemodynamic stability, low grade fever
51. diffuse tenderness, absent bowel sounds, high grade fever.
52. sigmoidoscopy shows narrowing and inflammation.
53. barium xray, might cause perforation.
54. conventional: Cipro. naturopathic: hot vinegar pack, then treat like infection (similar to appendicitis treatment)