Systems Pathology II - Exam 1 (Part 2)

What is an inflamed esophageal mucosa, where symptoms don't correlate well?

Esophagitis

What is pain in the inflamed esophageal mucosa? What is difficulty swallowing?

Pain = odynophagia

difficult swallowing = dysphagia

What is the most common cause of esophagitis & the MC GI complaint?

GERD (Gastroesophageal Reflux Disease)

NOTE: occurs in 25-40% of adults

What is 2 or more episodes of acid reflux per week, is idiopathic LES dysfunctions with a reflux of gastric juices leading to mucosal injury, with hyper OR hypo gastric secretions, leading to dysphagia, heartburn, our "sour brash" like taste?

GERD (Gastroesophageal Reflux Disease)

NOTE: the secretion isn't the problem, its the LES dysfunction

What are some risks of GERD (Gastroesophageal Reflux Disease) that can lead to pressure changes to the LES, therefore causing dysfunction?

Obesity, Alcohol, Smoking, Increased gastric volume, hiatal hernia, pregnancy, age >40

What is the #2 cause of esophagitis that is acute/self-limiting, often due to substances such as tobacco, alcohol, pill-induced, hot liquids, acidic foods, irradiation, or chemotherapy?

Chemical

What is the #3 cause of esophagitis that occurs in the debilitated or immunosuppressed, MC to develop following an ulcer, and includes microbes such as Candida Esophagitis (Fungal) or HSV/CMV (Viral)

Infectious

What condition is caused by an intense trauma to the esophagus such as an intense coughing or intense vomiting?

Esophageal Lacerations

What is a longitudinal and superficial incomplete tear of mucosa and submucosa at the Gastroesophageal junctions due to forceful vomiting from acute illness, intoxication, or bulimia, leading to Hematemesis (vomiting blood), indicating upper GI bleeds, but can heal quickly without surgical intervention?

Mallory-Weiss Tear (Mallory-Weiss Syndrome)

T/F: Lacerations of the esophagus are more commonly proximally located.

FALSE

Usually more distally located (closer to stomach)

If blood in vomit in esophagus lacerations is bright red, what location is the esophagus laceration? What if the blood is brownish/darker?

Bright Red = Upper GI

Brownish/Darker = Lower GI (mix w/ stomach acid & oxidizes)

What condition is a complete rupture at the lower thoracic esophagus with chest pain, shock, & subcutaneous emphysema?

Boerhaave's Syndrome

In Boerhaave's Syndrome, what is the crunching sound upon auscultation of the heart due to pneumomediastinum?

Hamman's Sign

What condition is when the stomach protrudes into the thorax/chest, widening the esophageal hiatus, is 90% of the time asymptomatic, but can mimic GERD or may perforate/hemorrhage?

Hiatal Hernia

What are the three main reasons as to why a Hiatal Hernia occurs?

1) Congenital

2) Acquired

3) Idiopathic

What type of Hiatal Hernia is when a separate portion of the stomach protrudes, and is prone to strangulation or obstruction?

Non-Axial (Rolling)

-- also known as Type 2

NOTE: GERD MC symptom with this type

What type of Hiatal Hernia is the MC type (95%) with a "bell-shaped" dilation?

Axial (Sliding)

-- also known as Type I

NOTE: know both names (axial & sliding)

____% of all adults have Hiatal Hernias, with majority of those (70%) being >____ years old

20%

>70 years

What are 2 differential diagnosis that can occur with Hiatal Hernia?

1) Angina pectoris

2) GERD

What condition is esophageal metaplasia, where normal stratified squamous epithelium undergoes a cylindrical muciparous metaplasia into columnar epithelium (glandular metaplasia, intestinal metaplasia) with intestinal goblet cells in the distal esophagus?

Barrett Esophagus

If an individual has GERD, there is a increased incidence and risk for Barrett Esophagus, and ____% of symptomatic GERD patients will progress to Barrett Esophagus, but it is also possible that Barrett's is developing while asymptomatic.

10%

What are some risk factors for Barrett Esophagus? How is it managed?

Caucasians, Males (x4), GERD, alcohol, obesity, family Hx, age 40-60, smoking

Managed via endoscopic survelliance

What is the characteristic features of Barrett esophagus during a scope?

Red, velvety mucosa (bands or "tongues")

What are 2 complications of Barrett Esophagus?

1) Esophageal adenocarcinoma (risk is proportional to amount of metaplasia/dysplasia change; more severe = more likely/faster risk of cancer)

2) Ulcerations & Strictures

How is Barrett Esophagus diagnosed? Treated?

Diagnosed = esophagoscopy & biopsy (regular surveillance)

Treatment = stop irritants (smoking, irritating foods, eating late), omeprazole (PPIs), laser ablation, surgery (Esophagectomy, risky - 10% mortality)

What is chronic esophagitis that is immunologically mediated far away from the GE junction showing cardinal histological feature of superficial "epithelial infiltration" by large number of eosinophils (circumferential rings w/in efsophagus)?

Eosinophilic Esophagitis

If an individual has Eosinophilic Esophagitis is occurring, what is often the triad of other presentations occurring along with this?

1) Atopic dermatitis (eczema)

2) Allergic rhinitis

3) Asthma

What symptoms can indicate Eosinophilic Esophagitis in a child? Adult symptoms? How is Eosinophilic Esophagitis treated?

Child = GERD-like

Adult = dysphagia & impaction of food

Treated = dietary restrictions, corticosteroids

T/F: Eosinophilic Esophagitis is 3x more likely to occur in males and is MC in developed countries

TRUE

What Esophageal tumor is the MC benign tumor from smooth muscle?

Esophageal Leiomyoma

___% of Esophageal Leiomyoma occur in the distal 1/3

___% of Esophageal Leiomyoma occur in the middle

___% of Esophageal Leiomyoma occur in the proximal

60%

30%

10%

What is the MC esophageal tumor WORLDWIDE, making up 90% of esophageal cancer cases and often seen in rural/underdeveloped areas and can lead to strictures, rigidity, hemorrhage, cardio-pulmonary invasion (possible fistula)?

Esophageal Squamous Cell Carcinoma

What are some risk factors of Esophageal Squamous Cell Carcinoma?

>45 year old, Males x4, African Americans x6, irritation (alcohol, tobacco, hot beverages, HPV x3, irradiation, nitrosamines), rural/underdeveloped/poverty, achalasia

NOTE: NOTHING TO DO WITH BARRETTS OR GERD

What are some symptoms of Esophageal Squamous Cell Carcinoma? What is the prognosis?

Dysphagia, Odynophagia, Cachexia

VERY poor prognosis due to lymphatic metastasis (5 years <10%; superficial tumor 5 year 75%)

What is the MC esophageal tumor in the US which is a esophageal mucus-secreting glandular metaplasia/dysplasia, and when advanced, demonstrates obstruction (dysphagia/odynophagia), vomiting, cachexia, fatigue, and weakness, due to risks similar to GERD and follows Barrett's esophagus?

Esophageal Adenocarcinoma

NOTE: healthy lifestyle decreases risk (ex: eat fruit/veggies)

What is the prognosis of Esophageal Adenocarcinomo?

Poor (<25% over 5 years)

- due to early lymphatic invasion

Esophageal Adenocarcinoma is diffuse, flat or raised, with possible ulceration and is more common in what location?

Distal esophagus

T/F: Gastric/Stomach pathologies are a common cause of mortality

FALSE

- Morbidity (suffering with)

What is the MC infection in the stomach?

Helicobacter pylori (H. pylori)

What characteristic vomitus occurs due to the presence of coagulated blood in the vomit?

Coffee Ground (Hematemesis; Coffee Ground Emesis)

What does black or tarry stool indicate? What is this called?

Blood in upper GI tract, esophagus, stomach, SI gets digested and goes through the GI tract

- black color & strong odor caused by hemoglobin in blood being altered by digestive enzymes & intestinal bacteria

Called Melena (Melaena)

What is inflammation of the gastric mucosa that may be asymptomatic?

Gastritis

What type of Gastritis is sudden onset, transient (short period) with invasion of neutrophils that may have possible erosion/ulceration?

Acute Gastritis

What is a version of Acute Gastritis where there is more severe damage done really quick, such as possible erosion, ulceration, and hemorrhage?

Acute Erosive Hemorrhagic Gastritis

What may cause or be risks of Acute Gastritis?

NSAIDs

Alcohol/smoking

Physical Trauma

Irradiation/Chemotherapy

Systemic infection

Allergies

Spicy/Irritating foods

Severe stress (trauma/burns/surgery)

Ingestion of corrosive substance

What are some symptoms of Acute Gastritis (Note: related to cause)?

Epigastric pain

Nausea/vomiting/anorexia

Fever/Headache

Hemorrhage

Hematemesis (Alcoholics)

Melena

How is Acute Gastritis Treated?

Dose-dependent w/ NSAIDs (Salicylism)

- Self-limiting (1-2 days)

- Meds that decrease gastric acidity = PPIs, H2 receptor antagonists

T/F: Acute Gastritis is self-limiting, lasting about 1-2 days, but it will never completely regenerate the gastric mucosa to what it was prior.

FALSE

- Complete regeneration of the gastric mucosa

What type of Acute gastric ulceration is small, shallow ulcerations in the stomach (duodenum = peptic) leading to nausea, vomiting, "coffee-ground" hematemesis that occurs due to severe physiologic stress (shock, sepsis, trauma, burns), High doses of NSAIDS, or Intracranial disease (vagal nerve)? How long does this take to heal?

Stress-Related Mucosal Disease

Heal in few days/weeks

What are the 3 types of Acute Gastric Ulcers that are related to the Stress-Related Mucosal Disease?

1) Stress Ulcers

2) Curling Ulcers

3) Cushing Ulcers

What type of gastritis is less intense but prolonged with atrophy of gastric mucosa, decreasing secretion of gastric acid output, leading to nausea and upper abdominal discomfort, but hematemesis is RARE?

Chronic Gastritis

What are 3 multifactorial causes of Chronic Gastritis and which is the MC?

1) H. Pylori (MC)

2) Increased age

3) Other stressors

What are two consequences of Chronic Gastritis?

1) Peptic ulcer disease (PUD)

2) Gastric adenocarcinoma (5x risk)

What is an organism that synthesizes urease, which produces ammonia that damages the gastric mucosa and neutralize acid pH which allows it to further live in the stomach, is a curved gram (-) rod, and is the most common precursor of gastritis and peptic ulcers?

Helicobacter Pylori Infection

NOTE: remember that it can also damage the LES as a consequence

What is H. Pylori a risk factor for? (3) How is it treated?

1) Gastric Adenocarcinoma (MC than MALT)

2) MALT lymphoma

3) Peptic Ulcer Disease

Treated via Omeprazole, Clarithromycin, and Amoxicillin

___ - ___% of all cases of chronic gastritis are positive for H. pylori infection (H. Pylori Gastritis), with it most commonly be asymptomatic, and can be due to poor childhood sanitation/hygiene?

70-90%

Patients with H. pylori infection have __________ resting and meal-stimulated gastrin-levels and _______ gastric mucus production and duodenal mucosal bicarbonate secretion, all of which favor ulcer formation?

Increased

Decreased

What gastritis is when antibodies attack parietal cells, happening more often in elderly (60) or females (3x) leading to chronic gastritis which leads to gastric atrophy, complicating erythropoiesis and demonstrate features of anemia?

Autoimmune Gastritis (Autoimmune atrophic gastritis)

What do parietal cells secrete?

HCL & Intrinsic factor

What is HCL super important for the absorption of? IF?

HCl = Iron

IF = Vit B12

What is the condition that develops as a consequence to intrinsic factor (IF) loss in autoimmune gastritis?

Pernicious Anemia

T/F: H pylori-associated atrophic gastritis usually involves both the antrum and the oxygenic mucosa of the gastric corpus and fundus, while autoimmune gastritis essentially is restricted to the gastric corpus and fundus?

TRUE

What condition is an open sore or raw area in the lining of the stomach or the intestine with nausea/vomiting, heartburn, weight loss, bloating, cachexia, fatigue (iron-deficiency anemia), epigastric pain (gnawing/burning, night or 1-3 hours postprandial, relived by alkaline substances), and is diagnosed via an upper endoscopy?

Peptic Ulcer Disease

What type of peptic ulcer disease has peptic ulcers that appear in the stomach? In the first part of the small intestine?

Gastric Ulcer

Duodenal ulcer

What is the MC cause of Peptic Ulcer Disease and what percent of cases of PUD does this make up?

H. Pylori (70-90% of cases)

NOTE: anything that increases acidity is ulcerogenic, NSAIDs can also since they decrease bicarbonate

Additional risks = old age, alcohol, corticosteroids, smoking, stress

____ - ____% of everyone with H. pylori has peptic ulcer disease?

5-10%

What is a rare condition that is a tumor of the pancreas where cells of the pancreas begin producing Gastrin, which causes the parietal cells in the stomach to produce more HCl, increasing the acidity level?

Zollinger-Ellison

T/F: If epigastric pain is worse (greater) with meals its a duodenal ulcer, but if pain decreases (gets better) with meals its gastric ulcers

FALSE

Greater w/ meals = Gastric

Decreased w/ meals = Duodenal

What are 3 shared features of gastric & duodenal ulcers?

1) Eating influences pain

2) Relieved by alkaline substances (or vomiting)

3) Worse at night

SUMMARY Gastric vs Duodenal Ulcer

Gastric

- junction between antrum and acid secretory mucosa (can happen n fundus but rare)

- H. pylori 70%

- gastritis (shallow/deep ulcer)

- inflammatory cells

- can cause hematemesis or melena

- vomiting occurs

- pain starts & aggravated after a meal (1-2 hours; weight loss)

- High risk of malignancy

Duodenal Ulcer

- 95% in first part of duodenum

- MC type of ulcer

- H pylori almost 100%

- Usually small <1cm

- Sharply demarcated lesion

- Eosinophils specially on the base of the ulcer

- Can cause melena or hematoschezia

- Pain starts after 3-5 hours after meal

- Pain relieved by food & increase in intensity during night (weight gain)

What is a mass projectecting from mucosa, with chornic gastritis a risk and in 5% of all endoscopies?

Polyp

What is the removal of a polyp?

Polypectomy

Which of the 3 types of polyps occur in 75% of cases, is inflammatory or regenerative, <2 cm, age 50-60, H. pylori, and has 1-3% malignant transformation?

Hyperplastic Polyps

Which of the 3 types of polyps occur due to long term PPI use or FAP and make up 15%?

Fundic Gland Polyp

Which of the 3 types of polyps make up 10%, have dysplastic (pre-cancerous lesions), with risks being males (3x) & increased in age?

Gastric Adenomas

1/3 of Gastric adenomas can become what?

Gastric adenocarcinomas

What cancer has symptoms such as gastritis, altered bowels, nausea/anorexia, weight loss, hemorrhage, and anemia when its advanced, and has a 5 year survivability when caught early (90%) but when advanced <20%?

Stomach Cancer

____% of stomach cancer are adenocarcinomas & ____% are lymphomas & carcinoid tumors; both from dysplastic adenomas?

90%

10%

What are some risk factors for Stomach Cancer?

1) MC males (2x) age 55

2) Chronic inflammation

3) Japan (20x)

What is the characteristic histology finding of stomach cancer?

Signet ring cells

What is a congenital (MC) or acquired condition of fibrous scar tissue where hypertrophy of pyloric muscle causes narrowing of the pyloric sphincter, leading to hyperperistalsis & projectile vomiting (NOT bile stained), dehydration, irritability, small/infrequent stool, failure to gain weight, and is diagnosed shortly after birth?

Pyloric Stenosis

What are some risk factors of Pyloric Stenosis?

Risk: Family history; Caucasians, males (4x), Turner syndrome

What is the treatment for Pyloric stenosis, where the surgeon only cuts through the outer layer of the thickened pylorus muscle, allowing the inner lining to bulge out, opening a channel for food to pass through the small intestine, and is often done using minimally invasive surgery?

Pyloromyotomy

What is a distinctive palpable feature of Pyloric Stenosis?

Palpable epigastric olive-shaped mass