Disorders of Oral Cavity

July 24, 2018 11:23 AM

1. Diseases of the Oral Cavity and Throat

NECK
- Thyroglossal Cyst
- Cat Scratch LN
- Dermoid Cyst

ORAL CAVITY
Aphthous Ulcers Herpes Labialis Behcet Syndrome
Canker Sore Cold Sore

Description - Recurrent, painful on ulcer - Vesicle lesion caused by HSV1 - Canker sore + genital ulcer + uveitis
- T-cell mediated response - Immune complex vasculitis

Epidemiology - Stress induced - Recurs with fever, trauma,

sunshine, menstruation

Tongue
Glossitis Oral Candidiasis Leukoplakia Erythryoplakia

Descrip - Inflammation of tongue - White membranous lesions - Precancerous lesion - Precancerous lesion
tion - Beefy red tongue caused by Candida - White plaque that can't be - Red, velvety lesion due to
• papillary atrophy with mucosal - Can be scraped off scraped off angiogenesis
thinning - Lateral tongue
Epidem - Vitamin deficient - Immunocompromised, AIDS - Hairy Leukoplakia: EBV - High risk squamous cell
iology - Celiac sprue - Diabetes • Fluffy, on lateral tongue carcinoma
- Plummer Vinson Syndrome: middle age • May have curly white
women with membrane candida on
• Severe iron deficient anemia superimposed
• Esophageal web - Chronic tobacco use
• Beefy red atrophic tongue - Risk squamous cell carcinoma

Cancer Lesions
- Odontoma: harmatoma of odontogenic epithelium and odontoblastic tissue
○ Most common odontogenic tumor
Oral Squamous Cell Carcinoma Ameloblastoma Nasopharyngeal Carcinoma

Descrip - Cancer of the mouth, esophagus - Benign cancer of the odontogenic epithelium - Invasive cancer of the nose and pharynx
tion (squamous cell lining) • Slow growing, locally invasive
Epidem - 50-70 year old - EBV infection
iology - Tobacco, alcohol • African children, Chinese adults
- HPV 6, 16, 18

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 - HPV 6, 16, 18
- Betel nut and paan
Present - Cysts filled with thick motor oil fluid - Large epithelial cells with indistinct
ation - Dark tumor cells nests borders, big nuclei
• Crowded at periphery
• Loose in center

SALIAARY GLANDS
- Mumps: bilateral inflamed parotid glands
○ Orchitis, pancreatitis, aseptic meningitis
- Sialadenitis: unilateral inflamed parotid gland
○ Due to sialotithiasis (salivary stone) leading to Staph infection

Salivary Gland Cancer

- Usually benign, in parotid gland
- Tumor in smaller cells more likely malignant
- Painless mass/swelling
- May invade facial nerve CN VII → Bell's palsy
Pleomorphic Adenoma Warthin Tumor Mucoepidermoid Carcinoma Adenoid Cystic Carcinoma
Mixed Tumor Papillary Cystadenoma Lymphomatosum

Descrip - Benign mix of epithelial and mesenchyme - Benign - Malignant - Malignant

tion cells - Cystic tumor with lymphocytes, germinal - Mix of mucus, epidermoid, and - Tubular or cribriform pattern
• Cartilage tissue (LN tissue) intermediate cells - Small dark staining cells in cysts
• Epithelial tissue • Motor oil fluid
Epidem - Most common - Smokers - Most common malignant tumor
iology
Locatio - Parotid - Parotid - Parotid - Minor salivary glands
n - Submandibular, minor salivary glands
Notes - Large, painless mobile mass at angle of jaw - 10% malignant - Invade facial nerve → Bell's palsy - Invade perineural spaces, facial nerve →
- Slow growing - 10% bilateral Bell's palsy
- High rate of recurrence

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Disorders of Esophagus
July 26, 2018 3:33 PM

2. Disorders of the Esophagus

OVERVIEW
Congenital, Mechanical Hematemesis LES Disorders Carcinomas
- Tracheoesophageal fistula - Mallory Weiss - Achalasia - Squamous
- Esophageal webs - Esophageal Varices - GERD - Adenocarcinoma
- Esophageal rings - Barrett's esophagus
- Zenker's diverticulum

ESOPHAGUS

Congenital and Mechanical Disorders

Tracheoesophageal Fistula Esophageal Webs Esophageal Rings Zenker's Diverticulum

Descript - Connection between esophagus and - Thin protrusion of esophageal mucosa in upper - Concentric tissue plates protrude into - False diverticulum
ion trachea esophagus distal lumen - Out-pouch of pharyngeal mucosa due to acquired
• Blind proximal esophageal - Contain smooth muscle defect in muscular wall
atresia - UES at junction of esophagus and pharynx
• Distal esophagus connect to
trachea
Epidemi - Congenital - Plummer Vinson Syndrome: middle age
ology women with
• Severe iron deficient anemia
• Esophageal web
• Beefy red atrophic tongue
Present - Vomiting - Dysphagia - Dysphagia - Dysphagia
ation - Polyhydraminos: amniotic fluid not - Risk esophageal squamous cell carcinoma? - Obstruction
swallowed by fetus - Halitosis
- Abdominal distention: air enters
stomach
- Aspiration: food into lungs

Hematemesis
Esophageal Varices Mallory Weiss Syndrome Boerhaave Syndrome

Descrip - Dilated submucosal veins in lower esophagus - Longitudinal laceration of mucosa at - Esophageal wall ruptures
tion gastroesophageal junction
Epidem - Secondary to portal HTN - Severe vomiting erodes mucosal wall - Mallory Weiss Syndrome
iology • Distal esophagus → L gastric vein → • Acute alcohol (binge + vomit)
portal vein • Bulimia
• Chronic alcoholism
- Most common cause of death in cirrhosis
Present - Asymptomatic, risk rupture - Painful hematemesis - Pneumomediastinum: air enters mediastinum
ation - Painless hematemesis - Risk Boerhaave Syndrome • Upright chest X Ray: air along
mediastinum
- Subcutaneous emphysema: air under skin
• Neck area
• Crepitus: air bubble crackling under skin

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Lower Esophageal Sphincter Disorders
- HSV Esophageal ulcers: punched out ulcers
- CMV Esophagitis: deep ulcers in immunocomp
Achalasia GERD Barrett Esophagus

Description - Disordered esophageal motility + no relax - Reduced LES tone → acid reflux from stomach to - Lower esophageal epithelium metaplasia from
LES esophagus squamous → columnar with goblet cells
- Due to damaged ganglion cells in myenteric • Get basal layer hyperplasia
plexus
• No postganglionic inhibitory neurons
(NO, VIP) to relax
Epidemiology - Hirschsprung's Disease - Alcohol, tobacco - GERD
- Chagas disease Trypanosoma Cruzi - Obesity, fat rich diet - Response of esophageal stem cells to acidic stress
- Caffeine
- Sliding hiatal hernia: LES + stomach herniate into
hiatus
Presentation - Progressive dysphagia for solids and liquids - Heartburn - May lead to dysplasia and adenocarcinoma
- Putrid breath - Adult onset asthma and cough: acid irritate
- High LES pressure on esophageal airways
manometry - Damaged enamel of teeth
- Bird-beak sign on barium swallow study - Ulceration with stricture: damage mucosa, no stem
(lower esophagus dilates) cells → fibrosis
- Risk esophageal squamous cell carcinoma - Barrett esophagus

Notes - Treat with botulinum toxin, CaCB, nitrates

Esophageal Carcinomas
- Progressive dysphagia: solids → liquids
- Weight loss, pain, hematemesis
Squamous Cell Carcinoma Adenocarcinoma of Esophagus

Descrip - Malignant proliferation of squamous cells - Malignant proliferation of glands

tion • Glands not normally found in esophagus
Epidem - Most common world wide - Most common in America
iology - Risk Factors: irritation - Risk factors: chronic GERD, Barrett esophagus, obesity,
• Alcohol, tobacco smoking, achalasia
• Hot tea (china, Iran)
• Achalasia: food build up
• Esophageal web, Plummer Vinson: food build up
• Esophageal injury
Locatio - Upper 2/3 - Lower 1/3
n
Notes - May present with hoarse voice (recurrent laryngeal) or cough
(tracheal)

- LN spread:
○ Upper: cervical LN
○ Middle: mediastinal LN
○ Lower: celiac, gastric LN

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Disorders of Stomach
July 25, 2018 11:30 AM

3. Disorders of the Stomach - 1 ( case - 1)

4. Disorders of the Stomach - 2
5. Disorders of the Stomach - 3

OVERVIEW
Congenital Gastritis Hypertrophic Gastropathy Peptic Ulcer Disease Gastric Cancer
- Gastroschisis - Acute - Menetrier's disease - Duodenal - Intestinal adenocarcinoma
- Omphalocele - Chronic autoimmune - Gastric - Diffuse adenocarcinoma
- Pyloric stenosis - Chronic H Pylori - Gastrintestinal Stromal Tumor GIST
- MALT Lymphoma

CONGENITAL
Gastroschisis Omphalocele Pyloric Stenosis

Descrip - Anterior abdominal wall defect - Persistent herniation of bowel into - Hyperplasia smooth muscle of pyloric
tion exposes abdominal contents umbilical cord sphincter → gastric outlet block
Notes - Herniated intestines don't return to - Males > females
body cavity during development - Presents 2 weeks after birth
- Contents covered by peritoneum, • Projective nonbilious vomiting
amnion • Visible peristalsis
• Olive-like mass
- Treat with myotomy

GASTRITIS
- Burning of stomach by acid due to ↓ mucosal defense and ↑ acid production
- Mucosal defense:
○ Foveolar cells: produce mucin
○ Surface epithelium: make HCO3
○ Normal blood supply: provide nutrients, remove leaked acid

Acute Gastritis Chronic Gastritis - Autoimmune Chronic Gastritis - H. Pylori

Descript - Acidic damage to stomach mucosa - Autoimmune destroy gastric parietal cells in body, - H-pylori induced acute and chronic inflammation
ion • Superficial inflammation fundus = ↓ acid production • Urease: NH3 + H → NH4; basic
• Erosion, ulcer • Anti-IF • Protease, Cag A
• Anti-parietal cells • Inflammation
- Type IV hypersensitivity (T-Cells) - Antrum
Epidemi - Severe burn (Curling ulcer): hypovolemia - Associated with autoimmune conditions - Most common cause of gastritis
ology → mucosal ischemia, necrosis • Hashimoto thyroiditis
- NSAIDs: No PGE2 for gastric mucosa • Graves disease
- Alcohol: direct damage • DM type 1
- Chemotherapy: kill cells
- Cushing Ulcer: ↑ ICP stimulates vagus
PANS Ach = ↑ acid secretion in stomach
- Shock
Notes - Gross, hyperemic - Atrophy of mucosa with intestinal metaplasia - Epigastric abdominal pain
- Neutrophil infiltrate • Peyer's patches + goblet cells 1. Ulceration: peptic ulcer disease
• Risk gastric adenocarcinoma 2. Gastric adenocarcinoma: intestinal metaplasia
- Achlorhydria: ↑ gastrin, G cell hyperplasia 3. MALT lymphoma: Peyer patches, germinal center with
- Megaloblastic pernicious anemia: no IF marginal zone for infection
- Triple therapy resolves gastritis/ulcers and reverses intestinal
metaplasia
- Negative urea breath test, lack of stool antigen = no more H
Pylori

HYPERTROPHIC GASTROPATHY
Menetrier's disease

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 Menetrier's disease
Description - Hyperplasia of mucosa
- Giant gastric mucosal folds; look like brain gyri
Epidemiology - Middle age man
Notes - Excess mucous production
- Protein loss
• Edema, ascites
- Parietal cell atrophy, ↓ acid
- Pre-cancerous

PEPTIC ULCER DISEASE

- Peptic Ulcer Disease: Solitary mucosal ulcer in proximal duodenum > distal stomach
- H Pylori urease: urea → NH3
○ NH3 + H → NH4; damages gastric epithelium to decrease mucosal defence
Gastric Ulcer Duodenal Ulcer

Benign Malignant

Location - Lesser curve of antrum - Anterior duodenum > posterior duodenum

Epidemiol - H Pylori - H Pylori
ogy - NSAID - Zollinger Ellison Gastrinoma: ↑ gastrin = ↑ HCl secretion
- Bile reflux
Presentat - Epigastric pain worsens with meals - Epigastric pain improves with meals
ion • Increased acid secretion during meals • Duodenum increase HCO3 (CCK) to protect against incoming chyme
- Hypertrophic Brunner glands: secrete mucus
Rupture - Hemorrhage: rupture - Hemorrhage: posterior duodenum rupture
• Left gastric artery bleeding • Gastroduodenal artery bleeding
• "rigid board" abdomen • Acute pancreatitis
- Melena - Obstruct: pyloric channel
- Perforation: anterior duodenum
• Free air under diaphragm
• Referred pain to shoulder via phrenic nerve
Cancer - Can be caused gastric carcinoma - Never malignant
- Benign: small, punched out, sharply demarcated with radiating
folds of mucosa
- Malignant: large, irregular with heaped up margins

GASTRIC CARCINOMA
- Presents late
○ Weight loss, abdominal pain, anemia, early satiety
○ Acanthosis nigricans
○ Leser Trelat sign: pigmented skin lesions on skin
- Virchow's node: left supraclavicular LN
- Metastasize to liver

Gastric Adenocarcinoma Gastric Adenocarcinoma Gastrointestinal Stromal Tumours MALT Lymphoma

Intestinal Diffuse GIST

Descriptio - Malignant proliferation of surface - Malignant proliferation of surface epithelial cells - Mesenchyme tumor from interstitial cell - Peyer patches, germinal center with
n epithelial cells - Signet ring cells: Mucin filled infiltrate gastric wall of Cajal marginal zone for infection
- Large irregular ulcer with raised margins - Linitis plastica: leathery bottle; thick stomach wall • Submucosa
- Lesser curve of antrum • Desmoplasia: fibrous tissue in reaction to cancer invasion • Mesenchyme: spindle shaped
- Scarring and shrinkage

Epidemiol - More common - Mutate E-cadherin gene CDH1 - Mutate C-Kit Oncogene : CD117 - Chronic gastritis with H Pylori
ogy - Intestinal metaplasia • Tyrosine kinase
• H Pylori, autoimmune gastritis
- Nitrosamines in smoked foods, Japan
- Blood type A
Metastasi - Liver - Liver
s - Sister Mary Joseph nodule: periumbilical - Krukenberg tumor: mucinous metastasis to bilateral ovaries
spread

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Disorders of Small Intestine
July 25, 2018 11:30 AM

6. Disorders of the Small Bowel

OVERVIEW
Congenital Obstructive, Ischemic Malabsorption Infective Gastroenteritis Appendix
- Duodenal atresia - Volvulus - Celiac - E Coli EHEC - Acute appendicitis
- Meckel diverticulum - Intussusception - Tropical sprue - Clostridium difficile
- Small bowel ischemia - Whipple's Disease - Entamoeba histolytica
- Giardia lamblia
- Abetalipoproteinemia - Cryptosporidium
- Lactose intolerance - S Typhoid fever
- Campylobacteria

SMALL INTESTINE
- Irritable Bowel Syndrome: recurrent abdominal pain
○ Middle age women
○ with at least 2 of the following
▪ Related to defecation
▪ Change in stool frequency
▪ Change in form, consistency of stool
○ No structural abnormality

Congenital
Duodenal Atresia Meckel Diverticulum

Descript - Congenital failure of duodenum to - Out pouch of all 3 layers (True diverticulum)
ion canalize - Persistent vitelline duct
• Vitelline duct doesn't involute
- May contain gastric mucosa and/or pancreatic tissue
Epidemi - Associated with Down Syndrome - 2% of population
ology - 2 inches long
- Within 2 feet of ileocecal valve
Notes - Polyhydramnios - Asymptomatic
- Double bubble: Distended stomach - Bleeding: ectopic parietal cells secrete gastric acid,
and blind loop duodenum damaging surrounding tissue
- Bilious vomiting - Volvulus
- Intussusception
- Obstruction

Obstruction and Ischemia

- Currant jelly stools: mucosa and blood clot sloughed off
Volvulus Intussusception Acute Mesenteric Ischemia

Descript - Twisting of bowel along mesentery - Telescoping of proximal bowel segment into distal - Small bowel susceptible to ischemic injury
ion • Obstructs, disrupts blood supply with infarct segment • Nutrient absorption dependent on blood flow
- Lead point: peristalsis hooks onto something, drags it - Transmural infarct:
forward • SMA thrombosis/embolism
• Most common is Meckel diverticulum ○ Atrial fibrillation
- Obstructs, disrupts blood supply with infraction • Mesenteric vein thrombosis
- Non-occlusive mucosal infarct: hypotension secondary to heart failure
Epidemi - Infants, kids: midgut - Kids: lymphoid hyperplasia - Atherosclerosis
ology - Young adults: cecum • Adenovirus, rotavirus - Aortic aneurysm
- Elderly: Sigmoid • Peyer patches hypertrophy - Hypercoagulable states, OCP
- Adults: tumors - Cardiac vegetations emboli, aortic atheroma
Notes - Sigmoid: coffee-been sign on X-ray - May have sudden onset - Older patient with cardiac, valve disease + diffuse abdominal pain
- Current jelly stools
- Extreme pain is disproportionate to benign physical findings

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Malabsorption Disorders
- Small intestine villi contain enterokinase that activates trypsinogen → trypsin for peptide breakdown and absorption
- Damage to small intestine villi = malabsorption

Lactose Intolerance Celiac Disease Tropical Sprue Whipple Disease

Descript - Lactase deficiency - Autoimmune disease: gluten gliadin - Damage small bowel villi due to unknown - Tropheryma whipplei infection
ion • No lactose → galactose + glucose - Duodenum organism • Gram positive
• Flat villi - Jejunum, Ileum
• Crypt hyperplasia
• Intraepithelial lymphocytes
Epidemi - Asian, South American, and African - HLA DQ2, DQ8 - Tropical regions, Caribbean - Older men
ology - Congenital - Northern European - Occurs after infectious diarrhea
- Acquired after viral infection - Dermatitis herpetiform - Associated with megaloblastic anemia
• Damaged villi tips - Low bone density • Folate deficiency, B12 deficiency
Patholo - Bacteria ferment lactose - Inappropriate T cell and IgA response to gluten - Foamy macrophage: Macrophage incompletely
gy - Undigested lactose osmotically active - Tissue transglutaminase: deamidates gluten destroy organism
• APC eats deamidated gliadin - Foamy macrophage compress lacteal in lamina
• APC present to Helper T cell propria
• Helper T cell mediate damage - Chylomicrons can't enter lacteal to enter
lymphatics
Present - Bloating - Malabsorption, steatorrhea - Similar to celiac disease - Systemic damage
ation - Gas - Kids: abdominal distention, diarrhea, failure to • Cardiac symptoms
- Osmotic diarrhea thrive • Migratory arthralgia
- Acidic stool - Adults: chronic diarrhea, bloating • Neurologic symptoms
- Dermatitis herpetiformis: clusters of papules and - Malabsorption, steatorrhea
vesicles
• IgA deposits at tips of dermal papillae (end
of blood supply)
- Risk malignancy
• Small bowel carcinoma
• EATL: enterocyte associated T-cell
lymphoma
- Resolves with gluten-free diet
Notes - Lactose hydrogen breath test: - IgA against endomysium, tTG, gliadin - Responds to antibiotics - Macrophage PAS +
• Check IgG in IgA antibodies
- D xylose test: passively absorbed in small
intestine
• Mucosa defect, bacteria overgrowth = ↓
blood, urine levels
- Abetalipoproteinemia: AR defect apolipoprotein B-48 or B100
○ Apo B48: chylomicron formation = malabsorption
○ Apo B100: VLDL, LDL

Infective Gastroenteritis
- Enterocolitis: diarrhea disease
○ Secretory diarrhea: secretion that is isotonic with plasma and persists during fasting
○ Osmotic diarrhea: excessive osmotic forces exerted by luminal solutes that abate with fasting (lactase deficiency)
○ Exudative diarrhea: purulent, bloody stools that persists on fasting; stools are frequent but may be small or large volume
○ Malabsorption diarrhea: voluminous, bulky stools with increased osmolarity resulting from unabsorbed nutrients and excess fat (steatorrhea); it usually abates on fasting
- Dysentery: painful bloody diarrhea with mucus

E Coli EHEC Clostridium difficile Entamoeba histolytica Giardia Lamblia Cryptosporidium Typhoid Enteric Fever Campylobacteria jejuni

Bug - Gram negative bacteria - Gram positive rods - Protozoa - Flagellated protozoa - Cryptosporidium - Salmonella typhi - Gram negative curly rod
- E Coli O157:H7: Shiga - Clostridium difficile - Entamoeba histolytica - Gram negative rod
toxin
Epidemi - Kids eat contaminated - Broad spectrum antibiotics - Tropical contaminated - Most common diarrhea - Food, contaminated - Undercooked chicken
ology ground beef - Nosocomial water in AIDS water - Milk
- Chronic: dormant in
gall bladder
Present - Hemolytic uremic - Enterotoxin A: diarrhea - Bloody diarrhea - Malabsorptive - Unrelenting, watery - Watery diarrhea - Bloody diarrhea
ation syndrome - Enterotoxin B: - Flask-shaped ulcers diarrhea diarrhea - Bacteremia, fever - Crypt abscess, ulcer
pseudomembrane - Hepatic abscess - Rose spots - Guillen barre syndrome

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Carcinoid Tumor
Carcinoid Tumor

Description - Malignant proliferation of neuroendocrine cells

• Chromogranin +
- Submucosal polyp in gut
• Small bowel most common
Pathology - Secretes serotonin into portal circulation
• Liver MAO: 5HT → 5H1AA
• 5H1AA: excreted in urine
Presentation - If metastasize to liver, no 5HT metabolism → carcinoid syndrome
- Carcinoid syndrome: bronchospasm, diarrhea, flushing
• 5HT release triggered by alcohol, emotional stress
- Carcinoid heart disease: 5HT goes to heart, deposits on tricuspid valve
• Right sided valvular fibrosis
○ Tricuspid regurgitation
○ Pulmonary valve stenosis
- 5HT goes to lung
• Lung MAO: 5HT → 5H1AA
• Left heart not affected

APPENDIX
Acute appendicitis
Description - Acute inflammation of appendix
Epidemiology - Most common cause of acute abdomen pain
- Kids: lymphoid hyperplasia post infection
- Adult: fecalith
Clinical Features - Periumbilical pain → Right lower quadrant
• McBurney point
- Fever
- N+V
- Rupture → peritonitis with guarding and rebound tenderness
- Risk peri-appendiceal abscess
Treatment - Surgery

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Disorders of Large Intestine
July 29, 2018 3:37 PM

7. Disorders of the Large Bowel - 1 (Case- 2)

8. Disorders of the Large Bowel - 2 - Inflammatory Disorders
9. Disorders of the Large Bowel - 3

OVERVIEW
Structural Vascular Inflammatory Polyps Cancer
- Hirschsprung Disease - Angiodysplasia - Ulcerative colitis - Polyps - Colorectal carcinoma
- Diverticulosis - Ischemic colitis - Crohn's disease - Syndromes
- Hemorrhoids • Lynch HNPCC
• FAP

STRUCTURAL
Hirschsprung Disease Diverticulosis

Descript - Rectum, distal sigmoid colon no relax and no peristalsis - False diverticulum
ion - Neural crest ganglion cells no descend into ENS - Multiple outpouching of mucosa and submucosa through
• Submucosa Meissner plexus: blood flow, secretion muscularis propria
absorption - Arise where vasa recta traverse muscularis propria
• Myenteric Auerbach plexus: motility • Weak point in colon wall
- Sigmoid colon
Epidemi - Associated with Down Syndrome - Wall stress
ology - RET mutation - Constipation, straining, low fiber diet
- More common in Males - Risk increases with age
Clinical - Can't pass meconium → present at birth - Asymptomatic
Feature - DRE empty rectal vault - Painless red bleeding from anus
s - Bilious vomit - Diverticulitis: fecal material blocks
- Megacolon: dilation of bowel proximal to obstruction • Appendix-like pain but in LQ
- Risk rupture
Notes - Rectal suction biopsy: no ganglion cells - Inflammation, perforation → peritonitis
- Resect involved bowel - Do colonoscopy to confirm

VASCULAR
Angiodysplasia Ischemic Colitis Hemorrhoids

Descript - Tortuous dilation of mucosa, - Ischemic damage to colon - Variceal dilation of anal, perianal
ion submucosa vessels - Splenic flexure submucosa venous plexus
- Right colon: cecum, high • Distal end least blood flow
tension • Watershed area of SMA
Epidemi - Older adults - SMA atherosclerosis - 50+ year old
ology - Hypoperfusion - Chronic constipation
- Pregnant venous stasis
- Portal HTN
Present - Hematochezia - Postprandial pain: eating demands blood
ation supply
- Weight loss
- Infarct: pain, bloody diarrhea

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INFLAMMATORY DISORDERS
- Chronic, autoimmune inflammation of colon
- 30 year old female Caucasian of Jewish descent
- Intestinal manifestation: Malabsorption/malnutrition
- Extraintestinal presentation: rash, eye inflammation, oral ulcers, arthritis
○ Migratory Polyarthritis: most common, arthritis of large joints
○ Pyoderma gangrenosum: deep, necrotic skin ulcer
○ Spondylitis: inflamed spine arthritis
- Risk colorectal cancer

Crohn Disease Ulcerative Colitis

Cross section of villi

Description - Transmural inflammation with knife-like fissures - Mucosa, submucosa ulcers

Location - Mouth to anus - Rectum, extend to cecum
- Skip lesions - Continuous
- Terminal ileum most common
Gross - Cobblestone mucosa - Pseudo polyps: scar tissue from healing of ulcers
appearance - Creeping fat: inflammation → condensed fibrous tissue pulls fat around bowel - Lead pipe sign: loss of haustra
- Strictures: inflammation → dense fibrosis thickens wall, narrows lumen
Microscopic - Non-caseating granulomas - Crypt abscess with neutrophil infiltrate
Appearance - Lymphoid aggregates - Ulcers
- TH1 mediated - TH2 mediated
Presentation - Right lower quadrant pain - Left lower quadrant pain
- Non-bloody diarrhea - Bloody diarrhea
- ASCA: anti-Saccharomyces cervisiae antibodies - Primary sclerosing cholangitis
- Terminal ileum - P ANCA
• B12 deficiency: no absorption - Toxic megacolon: colon contractions stop
• Gall stones: no bile salt reabsorption • Dilation → rupture → perforate
- Calcium oxalate kidney stones: envelope/dumbbell shape
• Fat malabsorption
• Ca bind to fat instead of oxalate
• Oxalate get absorbed, filtered in kidney
- Fistula: transmural inflammation spread and connect to nearby structures
• Perianal
• Abdominal
• Enterovesical fistula: bowel attaches to bladder = UTI, pneumaturia
Treatment - Immunosuppressants - 5 ASA
- Anti-TNF-α drugs: Infliximab, adalimumab
Smoking - Worsens Crohn's - Improves ulcerative colitis

POLYPS
- Raised protrusion of colonic mucosa
- Hamartomatous polyp: benign solitary lesion in kids
○ Associated with juvenile polyposis, Peutz Jegher syndrome
- Mucosal polyp: tiny, insignificant polyp
- Inflammatory polyp: due to mucosal erosion in IBD
- Submucosa polyp:

Hyperplastic Polyps Adenoma Polyp Serrated Polyp

Description - Hyperplasia of glands - Neoplastic proliferation of glands - Premalignant polyp

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Description - Hyperplasia of glands - Neoplastic proliferation of glands - Premalignant polyp
• Exaggerated crypts • Tubular: most common, small and - Saw-tooth crypts
• Cystic dilation pedunculated on a stalk
• Goblet cells • Villous: malignant
• No dysplasia ○ Secretory: dehydration,
prerenal azotemia,
hyponatremia, hypokalemia,
metabolic acidosis
Epidemiology - Most common type - Second most common polyp
Notes - Left colon - Pre-malignant - CpG hypermethylation
- Benign - Malignant risk if > 2cm, sessile, and villous - Microsatellite instability
- Mutate BRAF

Polyposis Syndromes
- Juvenile Polyposis syndrome: AD, kids with multiple hamartomatous polyps in colon, stomach, small bowel
- Peutz Jegher Syndrome: AD, polyps throughout GI + mucocutaneous hyperpigmentation on lips, oral mucosa, genital skin
○ Risk colorectal, breast, gynecologic cancer

Lynch Syndrome Familial Adenomatous Polyposis FAP

Hereditary Nonpolyposis Colorectal Cancer

Descript - AD inherited mutation in DNA mismatch repair - AD mutate APC on chromosome 5 → thousands of
ion • MLH1 adenomatous polyps
- Microsatellite instability: repeating sequence of non-coding - Two hit hypothesis
DNA not copied during cell division - Onset after puberty (young)
- Proximal colon
Associat - Risk colorectal, ovarian, endometrial carcinoma - Gardner syndrome: FAP + fibromatosis + osteomas
ions • Fibromatosis: fibroblast proliferation in
retroperitoneal, locally destructive
• Osteoma: benign tumor of bone in skull
• Congenital hypertrophy of retinal pigment epithelium
• Impacted, supernumerary teeth
- Turcot Syndrome: FAP/Lynch + CNS Tumors
• Medulloblastoma
• Glial tumors

Adenoma-Carcinoma Sequence
Normal Colon at Risk Adenoma Carcinoma

- Lose APC - K Ras mutation - P53 mutation

- Less intracellular adhesion - Unregulated intracellular • Lose tumor suppressor
- Proliferation signalling - ↑ COX expression
- Lose tumor suppressor - Gain of function
- Aspirin: prevent adenoma → carcinoma

COLORECTAL CANCER
Colorectal Cancer
Description - Carcinoma from colon or rectal mucosa
Epidemiology - 3rd most common site of cancer
- 3rd most common cause of cancer death
- 60-70 year old
Risk factors - Chromosomal instability pathway → Adenoma-carcinoma sequence: APC mutation in FAP
- Microsatellite instability pathway: mutate mismatch repair genes MLH1 in Lynch Syndrome
- COX 2 overexpression
- IBD: chronic inflammation

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 - IBD: chronic inflammation
- Tobacco
- Processed meat, low fiber diet
Presentation - Rectosigmoid > ascending > descending
Right Side Bleeds Left Side Obstruct
- Raised lesion - Napkin-ring lesion
- Iron deficient anemia - Pencil-thin stool
- Vague pain - Colicky quadrant pain
- Blood-streaked stool
- Risk streptococcus bovis endocarditis
Diagnosis - Iron-deficient anemia in older males, post-menopausal females
- Screening:
• Colonoscopy: hyperplastic and adenoma polyps look the same
• Remove all polyps, examine under microscope
• Low risk patient: age 50
• Risk patient: age 40 or 10 years earlier than relative's presentation
- Barium enema: Apple-core lesion
- CEA tumor marker: for recurrence
TNM - Invasion limited to mucosa because no lymphatics
- Spread to regional LN
- Metastases to liver

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Disorders of Liver and Biliary Tract: Overview
July 31, 2018 10:47 AM

LIVER
- Hepatocytes are stable cells: can regenerate
- Liver disease: jaundice, portal HTN, distension

Markers of Liver Pathology

Description
↑ ALT - ALT: Alanine transaminase, cytosolic
- AST: Aspartate transaminase, mitochondria
• Mitochondria damaged by alcohol
- Increased in liver disease
- ↑ ALT > AST in most liver diseases
- ↑ AST > ALT: alcoholic liver disease
↑ GGT - GGP: γ glutamyl transferase
• ↑ GGT: blocked bile flow
- ALP: alkaline phosphate
- Made by bile duct epithelium
- ↑ ALP, GGT: liver cholestasis
↓ Albumin - Made by hepatocytes
- Long half life
- ↓ albumin: chronic liver disease
↑ Prothrombin Time - Coagulation factors made in liver
• Except Factor VIII
- Short half life
- Best index of severity of liver disorder
↓ BUN - Urea cycle in liver
- Cirrhosis, fulminant hepatitis
↑ NH3 - Metabolized in urea cycle in liver
- Cirrhosis
- Reye Syndrome
- Hepatic encephalopathy
Immune Function - Autoimmune hepatitis:
• Anti-smooth muscle antibody
• Antinuclear antibody ANA
- Primary biliary cirrhosis:
• Anti-mitochondrial antibody
• ↑ IgM

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 • ↑ IgM
AFP - α feta protein
- Tumor marker: Hepatocellular carcinoma

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Disorders of Liver and Biliary Tract
July 25, 2018 11:30 AM

3 and 4 -Disorders of the Liver and Biliary Tract - Cirrhosis and hepatitis
5 Disorders of liver and biliary tract - Liver pathology

Cirrhosis Other Liver Disorders Biliary Tract Disease Cancer

- Viral hepatitis - Autoimmune hepatitis - Primary sclerosing cholangitis - Hepatocellular adenoma
- Alcoholic Liver Disease - Neonatal hepatitis - Primary biliary cirrhosis - Hepatocellular carcinoma
- Non-alcoholic Liver Disease - Reye Syndrome - Secondary biliary cirrhosis - Fibrolamellar carcinoma
- Gene/metabolic disorders - Budd Chiari - Cholangiocarcinoma - Hepatoblastoma
• α1 antitrypsin deficiency - CHF
• Hemochromatosis
• Wilson's Disease
- Biliary Tract Disease

CIRRHOSIS
Cirrhosis Portal Hypertension

Descript - End stage liver damage - Increased blood flow through portal vein
ion - Regenerative nodules of hepatocyte • Pre-hepatic: portal, splenic vein blocked
- Bands of fibrosis • Intrahepatic: cirrhosis, tumors, Schistosoma
• TGF-β from stellate cells under endothelial cell, line sinusoid • Post-hepatic: venous congestion
Present - Portal HTN: - Ascites: fluid in peritoneal cavity
ation - Hepatic encephalopathy: ↑ NH4 ○ Due to hypoalbuminemia, increased hydrostatic pressure,
• No urea cycle: NH3 from gut bacteria, body accumulate hypovolemia reflex RAAS
• Mental status change, asterixis, eventual coma - Congestive splenomegaly, hypersplenism:
- Hyper Estrogen: ↑ estrogen ○ Venous congestion to spleen
• Gynecomastia, spider angiomas, palmar erythema ○ Spleen sequesters blood, more RBC destroyed = ↓
- Jaundice platelet count
- Decreased protein synthesis - Portosystemic shunts:
• Hypoalbuminemia with edema ○ Esophageal varices
• ↑ PT: no clotting factor synthesis ○ Caput Medusae
○ Hemorrhoids
- Hepatorenal syndrome: renal failure due to decreased blood
flow

Causes of Cirrhosis
Viral Hepatitis Alcoholic Liver Disease Non-Alcoholic Fatty Liver Disease

Description - Acute Hepatitis: parenchymal inflammation - Alcohol chemically injuries hepatocytes - Fatty infiltrate of hepatocytes
- Chronic Hepatis: 6+ months • Acetaldehyde damage mitochondria - Not related to alcohol

Epidemiology - Viral hepatitis - Most common cause of liver disease in West - Obesity; metabolic syndrome
- Dyslipidemia, diabetes type 2
Presentation - Inflammation in parenchyma → portal tract - Fatty Change: Fat accumulates in liver - Cellular ballooning → necrosis
- Piecemeal hepatocyte necrosis: fragmented • Heavy, greasy liver
necrosis • Resolves with abstinence
- Swelling - Alcoholic hepatitis
- Councilman bodies: apoptotic bodies • Hepatocyte swelling
• Mallory bodies: wavy eosinophilic
damaged cytokine filaments
• Necrosis, acute inflammation
• Jaundice
- Alcoholic Cirrhosis: final, irreversible
• Regenerative nodules of hepatocyte
• Bands of fibrosis
• Sclerosis around central veins
Lab - ALT > AST - AST > ALT - ALT > AST

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Lab - ALT > AST - AST > ALT - ALT > AST
- Hepatocyte damage: ↑ UCB - AST to ALT 2:1 - L is for lipids
- Ductules damage: ↑ CB

Cirrhosis Caused by Metabolism Problems

α 1 antitrypsin deficiency Hemochromatosis Wilson Disease
Hereditary and Secondary Hemochromatosis Hepatolenticular Disease

Descript - Misfolded gene aggregates in - Mutate HFE protein on enterocyte - Mutate hepatocyte copper transporting ATPase
ion hepatocellular ER - Abnormal iron sensing and increased iron absorption - No copper excretion into bile
- PAS + globules - Iron generates ROS → tissue damage • No copper incorporated into
- Brown pigment in hepatocytes ceruloplasmin
• Prussian blue • Ceruloplasmin: carries Cu in blood
• (differentiate from brown lipofuscin) - ROS → tissue damage
Epidemi - PiZZ allele very bad - Primary: AR mutate HFE gene - AR mutate ATP 7B gene on chrom 13
ology - Young patient with liver damage • Presents late adulthood - Present in childhood
dyspnea without history of smoking - Secondary: chronic transfusion (ex. β thalassemia)
• High RBC turnover release Fe = iron overload
Present - Panacinar emphysema: ↑ elastase - Iron overload - Copper overload
ation activity - Bronze triad: - Liver: Cirrhosis
- Liver injury: misfolded protein buildup • Cirrhosis - Brain: deposit in basal ganglia
• Bronze diabetes • Dementia, chorea, Parkinsonism
• Bronze skin - Fleischer ring: copper deposit on Descemet
- Dilated cardiomyopathy membrane of cornea
- Cardiac arrythmia - Hemolytic anemia
- Gonadal dysfunction - Renal disease: Fanconi Syndrome
- Risk hepatocellular carcinoma
Lab PAS + globules - ↑ ferritin - ↑ urinary copper
- ↓ TIBC - ↓ serum ceruloplasmin
- ↑ serum iron - ↑ Cu on liver biopsy
- ↑ % saturation
Treatm - Repeated phlebotomy - Penicillamine D: chelate copper
ent - Deferasirox - Trientine
- Deferoxamine - Oral Zinc
- Oral deferiprone

OTHER LIVER DISORDERS

- Congenital hepatic fibrosis: dense fibrous septa due to failure to involute during embryonic
○ Can lead to secondary biliary cirrhosis
○ Associated with childhood polycystic disease

Autoimmune Hepatitis Neonatal Hepatitis Reye Syndrome Budd Chiari Liver Abscess

Descript - Antibodies against liver - Hepatitis in neonates - Liver failure in kids with acute viral - Hepatic vein thrombosis - Entamoeba histolytica infection
ion - Anti-smooth muscle antibodies - Multinucleated giant cells infection that take aspirin - Centrilobular congestion and necrosis • Ameoba invades colonic
- Antinuclear antibodies • Aspirin metabolites inhibit • Nutmeg liver mucosa, submucosa
mitochondrial enzymes - Leads to congestive liver disease - Flask-shaped ulcer
• Less β oxidation - Trophozoites with phagocytosed RBC
Epidemi - Young women - Idiopathic - Young children post viral infection - Hypercoagulable states - Tropics
ology - May have other autoimmune - Infection • VZV • Anti-phospholipid syndrome - Men
disease - Biliary atresia • Influenza B • OCP
- α 1 antitrypsin deficiency - Polycythemia vera: ↑ viscosity
- Postpartum state
- Hepatocellular carcinoma invades
Present - Jaundice - Liver: micro vesicular fatty change - Congestive liver disease - Amebiasis: abrupt onset fever
ation - Hepatosplenomegaly - Brain: encephalopathy, convulsion, - Painful hepatomegaly - Progressive bloody diarrhea
- Mild fever coma - Liver abscess: anchovy paste
- Hypoglycemia
- Vomiting
Notes - Do NOT give to Kawasaki patient No JVD - Treat with metronidazole

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BILIARY TRACT
- May present with pruritus, jaundice, dark urine, light-colored stool, hepatosplenomegaly
- ↑ conjugated bilirubin, ↑ cholesterol, ↑ ALP

Primary Sclerosing Cholangitis Primary Biliary Cirrhosis Secondary Biliary Cirrhosis Cholangiocarcinoma

Descript - Onion skin fibrosis of intrahepatic and extrahepatic bile duct - Autoimmune disease destroy intralobular - Extrahepatic biliary obstruction - Cancer of the biliary tract
ion - Stricture and dilate bile ducts bile ducts - ↑ pressure in intrahepatic ducts = injury, - Adenocarcinoma
- Lymphocyte infiltrate and granulomas fibrosis, bile stasis
Epidemi - Ulcerative colitis - Middle age woman with autoimmune - Patient with unknown obstructive lesions - Clonorchis sinensis liver fluke
ology • Middle age man conditions, high cholesterol • Galls tone, biliary stricture, pancreatic - Primary sclerosing cholangitis
carcinoma
Present - May lead to secondary biliary cholangitis - Complicated by ascending cholangitis - Complicated by ascending cholangitis - Green liver
ation - Increase risk of cholangiocarcinoma, gall bladder cancer - Pruritis: NOT bile salts - Poor prognosis
- Xanthomas
- Hepatosplenomegaly
- Obstructive jaundice: late due to
destruction
Lab - P-ANCA - Anti-mitochondrial antibody: anti PDH
- ↑ IgM • No role in pathogenesis
- ERCP, MRI: beading of bile ducts - ↑ IgM

CANCER
- Hepatocytes: green because secrete bile
- Metastasis to Liver: most common cause of liver cancer
○ From GI malignancies, breast and lung cancer
○ Multiple nodules

Hepatic Adenoma Hepatocellular Carcinoma Cavernous Hemangioma Angiosarcoma Hepatoblastoma

Descript - Benign green tumor of hepatocytes - Malignant tumor of hepatocytes - Benign blood vessel malformation - Malignant tumor of endothelial cells - Malignant tumor of epithelial cells
ion - Subscapular - Can occur anywhere in body and mesenchyme
- Grows with estrogen exposure
Epidemi - Young woman on OCP - Asia - Age 30-50 - Arsenic: insecticide, alloy with lead - Most common liver tumor of
ology - Chronic HBV, HBC - Vinyl chloride: PVC pipes young childhood
- Cirrhosis
- Aflatoxins from Aspergillus
• P53 mutations
Present - Risk rupture, intraperitoneal - Detected late because masked - Asymptomatic - Factor 8
ation bleeding by cirrhosis - RUQ pain - CD31
- Risk Budd Chiari Syndrome
Notes - AFP tumor marker - Do not biopsy (risk hemorrhage) - Metastases easily because blood
- Hematogenous spread flow

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Disorders of Liver and Biliary Tract: Hepatitis
July 29, 2018 4:27 PM

3 and 4 -Disorders of the Liver and Biliary Tract Cirrhosis and hepatitis

HEPATITIS
- Hepatitis virus, EBV, CMV
- Acute Hepatitis: liver inflammation
○ Jaundice
○ Hyperbilirubinemia
- Chronic Hepatitis: Liver inflammation for 6+ months
○ Risk progression to cirrhosis
○ Inflammation involves portal tract
○ ALT levels <500

Viral Hepatitis
Hep A Hep B Hep C Hep D Hep E
Features - Picorna Virus - Ds DNA (incomplete), circular - Flavivirus - RNA circular - Calicivirus
Transmit - Fecal to oral - STD (Hep B >C) - STD - Hep B must be present - Fecal to oral
- Contaminated water - Blood - Blood, IV, transfusion - Superimpose Hep B: already - Contaminated water
- Eating Raw shellfish - Vaginal delivery - Vaginal delivery have Hep B (chronic) - Central Asia
- Day care centers - Usually chronic infection - Co-infect with Hep B
Clinical - Acute hepatitis - Acute hepatitis - Acute hepatitis - Superinfection more severe - Acute hepatitis
Features • Milder symptoms in • Serum sickness: fever, - Chronic Hepatitis: IgG not protective - Similar to Hep B - Pregnant woman: fulminant
children > adults arthralgia, rash • Most likely to lead to chronic hepatitis
- Chronic Hepatitis • → carcinoma • Massive liver necrosis
• → carcinoma • → cirrhosis

Extrahepati - Aplastic anemia - Mixed cryoglobulinemia

c Features - Membranoproliferative GN: - Risk B cell non-Hodgkin Lymphoma
immune complex - Autoimmune hemolytic anemia
- Polyarteritis nodosa - Membranous glomerulonephritis
- Leukocytoclasis vasculitis
- Sporadic porphyria cutanea tarda
- Lichen planus
- Risk diabetes
- Risk autoimmune hypothyroidism
Liver - Hepatocyte swelling - Granular eosinophilic ground glass - Lymphoid aggregates - Similar to Hep B - Patchy necrosis
Biopsy - Monocyte infiltrate appearance - Focal areas of macrovascular steatosis
- Councilman bodies: - Cytotoxic T cell mediate damage
apoptotic bodies
Treatment - INF-α - Ribavirin
- Tenofovir/Lamivudine - Sofosbuvir
- Simeprevir
- INF-α

Hepatitis B Serology
- HB S Ag: surface antigen
○ Anti HB S: body makes after infection resolves
- HB E Ag: extracellular core antigen, indicates current infection
○ Anti HB E: low transmissibility
- HB C Ag: core antigen covering nucleic acid
- Window period: time between virus cleared and time when body makes HBV S Ag

HBV DNA HB S Ag Anti HB S HB E Ag Anti HB E Anti Hb C

Acute + + - + - IgM
Window - - - - + IgM
Chronic + + - +/- +/- IgG
Carrier - + - +/- +/- IgG
Past, Recovered - - + - +/- IgG
Immunized - - + - - IgG

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Disorders of Liver and Biliary Tract: Jaundice
July 29, 2018 4:26 PM

1 and 2 -Disorders of the Liver and Biliary Tract - Jaundice and Gall Bladder

JAUNDICE
- Jaundice: Yellow discoloration of skin
- Scleral icterus: yellow sclera, earliest sign
- Serum bilirubin > 2.5 mg/dL
- Disturbance in bilirubin metabolism
• UCB: water insoluble
• CB: water soluble

↑ Unconjugated Bilirubin ↑ Conjugated Bilirubin ↑ Unconjugated and Conjugated Bilirubin

Location Pre-hepatic Post-hepatic Hepatic
Causes - Hemolytic Jaundice: - Bile duct obstruction - Viral hepatitis: inflammation
• Lots of RBC lyse → ↑ UCB levels overwhelm liver • Gall stone, pancreatic carcinoma, • Hepatocyte damage: ↑ UCB
• Insoluble, so stays in blood until liver can process cholangiocarcinoma, parasites, liver fluke • Ductules damage: ↑ CB
• Risk pigmented bilirubin gall stones • Bile (CB) can't enter gut, so overflows to blood • High blood ALT, AST
• Dark urine: urobilinogen • Damaged gall bladder = ↑ alkaline phosphatase
- Newborns • ↓ urine urobilinogen + pale stools
• Newborns have HbF, have to destroy = hemolysis - Dubin Johnson: AR
• Low UGT at birth, UCB build up • Defect bilirubin canaliculi transport protein
• Kernicterus: unconjugated bilirubin goes to brain • Bilirubin can't exit liver
• Treat with blue light phototherapy • Black liver
○ Makes UCB water soluble • Rotors: mild Dublin Johnson but no black liver
- Gilbert Syndrome: AR
• Mildly low UGT
• Jaundice during stress
Crigler Najjar:
• No UGT
• Kernicterus, fatal
Lab values

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Disorders of Gall Bladder
July 25, 2018 11:31 AM

06 Pathology of the Gall bladder

Congenital
- Biliary Atresia: extrahepatic biliary tree no forms or gets destroyed
○ Biliary obstruction within first 2 months of life
○ Early onset conjugated bilirubin jaundice → cirrhosis
○ Accounts for half of children liver transplant

Gall Stones
- Solid, round stones in gall bladder
- Due to supersaturation or decreased phospholipids, bile acids, or stasis
- Complications: biliary colic, cholecystitis, cholangitis, gallstone ileus, gall bladder cancer
Cholesterol Stones Pigmented Stones

Description - Yellow - UCB

- Radiolucent - Black: UCB, radiopaque (due to Ca salt)
- Brown: infection, radiolucent
• Bacteria convert CB → UCB
• Greasy: bacteria phospholipase release FA
Epidemiology - 40 year old - Black: Extravascular hemolysis
- Estrogen: ↑ HMG CoA reductase and lipoprotein • ↑ bilirubin synthesis
receptors = cholesterol synthesis • Excess UCB
• Females, obesity, multiple pregnancies, OCP • Insoluble, precipitate into stones
- Native Americans - Brown: Biliary tract infection
- Clofibrate • E Coli
- Crohn disease: terminal ileum, no bile salt • Ascaris lumbricoides: roundworm
reabsorption • Clonorchis sinesis: Chinese liver fluke
- Cirrhosis: no bile salt synthesis

Gall Stone Complications

- Biliary colic: gall bladder contract against stone in cystic duct
○ Episodic RUQ pain
- Choledocholithiasis: gall bladder stuck in common bile duct
○ Elevated ALP, GGT, conjugated bilirubin, and/or AST/ALT
Cholecystitis Gallstone Ileus Ascending Cholangitis Gall Bladder Carcinoma

Descriptio - Inflammation of gall bladder - Gallstone enters small bowel - Bacterial infection of biliary tree - Adenocarcinoma of glandular epithelium
n - Gall bladder wall thickens, shrinks - Blocks ileocecal valve lining gall bladder
• Rokitansky Aschoff sinus: Gall bladder
mucosa herniate into muscular wall
Etiology - Impacted gall in cystic duct - Cholecystitis → fistula formation between gall - Gall stone - Gall stones
- Gall bladder stasis bladder and duodenum - Gram negative enteric bacteria ascend from - Chronic cholecystitis →Porcelain gall bladder
- Hypo fusion duodenum to gall bladder
- Infection CMV
Presentati - Post-prandial RUQ pain, radiate to right scapula - RUQ pain - Charcot's Triad: - Cholecystitis in elderly woman
on - Fever, N+V - Small intestine obstruction • Sepsis (high fever, chills) - Poor prognosis
- Porcelain gall bladder: - Pneumobilia: air in biliary tree • Jaundice
• Chronic inflammation, fibrosis • RUQ pain
• Dystrophic calcification white outline on X
Ray
• Risk gall bladder carcinoma
- Cholescintigraphy: diagnose gall stones and
acute cholecystitis
• radiolabel stuff enters common bile duct
and duodenum, but not bladder

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Disorders of Pancreas
July 25, 2018 11:31 AM

07. Pathology of pancreas

Congenital
- Annular Pancreas: pancreas wraps around duodenum
- Ectopic pancreas
- Congenital cysts

Pancreatitis
- Inflammation and hemorrhage
- Epigastric abdominal pain radiates to back
Acute Chronic

Description - Pancreatic enzymes auto digest pancreatic parenchyma - Chronic inflammation → fibrosis, atrophy
• Premature activated trypsin activates other enzymes - Dystrophic calcification of pancreatic parenchyma
- Liquefactive hemorrhagic necrosis • Chain of lakes: dilated pancreatic ducts
- Fat necrosis of peripancreatic fat
Epidemiolo - Alcohol: contracts sphincter of Oddi, stimulates release of pancreatic - Alcohol
gy enzymes - Cystic fibrosis (kids)
- Gall stones
- Trauma: automobile accident in kids
- Hypercalcemia, hyperlipidemia
- Drugs
- Scorpion stings
- Mumps
- Ruptured posterior duodenal ulcer
Clinical - Acute epigastric pain radiating to the back - Pancreatic insufficiency:
features - Cullen's Sign, Grey Turner's sign: hemorrhage necrosis spread to • Malabsorption
periumbilical soft tissue, retroperitoneum • Steatorrhea
- Shock: due to peripancreatic hemorrhage, fluid sequestration • Vitamin ADEK deficiency
- Pancreatic pseudocyst: fibrous tissue surround liquefactive necrosis and - Secondary diabetes: destroyed islets
pancreatic enzymes - Pseudocyst
• Abdominal mass with persistent elevated amylase
• Rupture releases enzymes into abdomen, hemorrhage
- Pancreatic abscess: E Coli
- DIC, ARDS: pancreatic enzymes enter blood → alveoli
Lab - ↑ lipase: specific - Enzymes may or may not be elevated
- ↑ amylase
- Hypocalcaemia: Ca used for saponification in fat necrosis
Notes - Fat necrosis indicates poor prognosis - Risk pancreatic carcinoma

Cysts
- Serous cystadenoma

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 - Serous cystadenoma
- Mucinous cyst: slow-growing cyst in body or tail
- Intraductal papillary mucinous cyst: cyst in head of pancreas

Cancer
Pancreatic Adenocarcinoma Zollinger Ellison Gastrinoma

Descriptio - Adenocarcinoma of pancreatic ducts - Tumor of G cells in pancreas/duodenum

n • Disorganized glandular structure with cellular - ↑ gastrin: gastric acid hypersecretion
infiltration
Epidemiol - Elderly 70 year old - Associated with MEN 1
ogy - Jewish, African American
- Smoking
- Chronic pancreatitis
Clinical - Epigastric abdominal pain - Peptic ulcers
Features - Weight loss - Duodenal ulcers
- Head of pancreas: blocks common bile duct - Diarrhea
• Obstructive jaundice
• Pale stools
• Courvoisier sign: Palpable non-tender gall
bladder
- Body, tail of pancreas: secondary diabetes in elderly
patient
- Pancreatitis
- Trousseau syndrome: migratory thrombophlebitis
• Swelling, erythema, tenderness in extremities
• Tumor releases thrombogenic stuff
Lab - CA 19-9
Treatment - Whipple procedure: remove head, neck, proximal
duodenum, gall bladder
- Poor prognosis

GI - Path Page 23