Fa: Gastrointestinal - Pathology - 2B

Front 1

What are the potential complications of ulcers?

Back 1

- Hemorrhage
- Perforation

Front 2

Which ulcer complication is more common in gastric ulcers?

Back 2

Hemorrhage

Front 3

Which ulcer complication is more common in duodenal ulcers?

Back 3

- Perforation (anterior > posterior)
- Hemorrhage (posterior > anterior)

Front 4

If a patient with a gastric ulcer hemorrhages, what is the most likely source of the bleed?

Back 4

Most likely from lesser curvature → bleeding from L gastric artery

Front 5

If a patient with a duodenal ulcer hemorrhages, what is the most likely source of the bleed?

Back 5

Most likely from posterior wall of duodenum → bleeding from gastroduodenal artery

Front 6

Perforation as a consequence of a duodenal ulcer is most likely to occur where? Symptoms?

Back 6

- Anterior wall > Posterior wall
- May see free air under diaphragm on CXR
- Referred pain to shoulder

Front 7

What does this CXR show?

Back 7

Perforation of duodenal ulcer (anterior wall > posterior wall)
- Leads to free air under the diaphragm
- May cause referred pain to shoulder

Front 8

What are the potential consequences of malabsorption syndromes?

Back 8

- Diarrhea
- Steatorrhea
- Weight loss
- Weakness
- Vitamin and mineral deficiencies

Front 9

If your patient presents with diarrhea, steattorhea, weight loss, weakness, and vitamin/mineral deficiencies, what should you consider?

Back 9

Malabsorption Syndromes: "These Will Cause Devastating Absorption Problems"
- Tropical sprue
- Whipple disease
- Celiac sprue
- Disaccharidase deficiency
- Abetalipoproteinemia
- Pancreatic insufficiency

Front 10

Which malabsorption syndrome should you consider in a patient who recently visited the tropics? Cause? How should they be treated?

Back 10

Tropical Sprue
- Similar to celiac sprue (affects small bowel)
- Responds to antibiotics (cause is unknown)

Front 11

Which malabsorption syndrome should you consider in an older man who also presents with cardiac symptoms, arthralgias, and neurologic symptoms? Cause? Other?

Back 11

Whipple Disease
- Infection with Tropheryma whipplei (G+, PAS stain + for foamy macrophages in intestinal lamina propria and mesenteric nodes)

*Foamy Whipped cream in a CAN: cardiac sx, arthralgias, neuro sx)

Front 12

Which malabsorption syndrome should you consider in a patient of northern European descent? Cause? How should they be treated?

Back 12

Celiac sprue
- Autoimmune-mediated intolerance of gliadin (wheat) → malabsorption and steatorrhea
- Associated with HLA-DQ2 and HLA-DQ8
- Treat with gluten-free diet

Front 13

Which malabsorption syndrome should you consider in a patient intolerant of milk? Symptoms?

Back 13

Disaccharidase deficiency (lactase)
- Osmotic diarrhea
- May be self-limited follow an acute injury (eg, viral diarrhea)

Front 14

Which malabsorption syndrome should you consider in a young child with failure to thrive, steatorrhea, acanthocytosis, ataxia, and night blindness? Cause?

Back 14

Abetalipoproteinemia
- ↓ Synthesis of apolipoprotein B → inability to generate chylomicrons → ↓ secretion of cholesterol, VLDL into bloodstream → fat accumulation in enterocytes

Front 15

Which malabsorption syndrome should you consider in a patient with cystic fibrosis?

Back 15

Pancreatic insufficiency
- Causes malabsorption of fat and fat-soluble vitamins (A, D, E, and K)

Front 16

Which malabsorption syndrome should you consider in a patient with obstructing cancer?

Back 16

Pancreatic insufficiency
- Causes malabsorption of fat and fat-soluble vitamins (A, D, E, and K)

Front 17

Which malabsorption syndrome should you consider in a patient with chronic pancreatitis?

Back 17

Pancreatic insufficiency
- Causes malabsorption of fat and fat-soluble vitamins (A, D, E, and K)

Front 18

What are the signs/symptoms of malabsorption syndromes?

Back 18

- Diarrhea
- Steatorrhea
- Weight loss
- Weakness
- Vitamin and mineral deficiencies

Front 19

What are the characteristics of Tropical Sprue?

Back 19

Malabsorption syndrome
- Similar findings as celiac sprue (affects small bowel)
- Responds to antibiotics
- Cause is unknown, but seen in residents of or recent visitors to tropics

Front 20

What are the characteristics of Whipple disease?

Back 20

Malabsorption syndrome
- Infection with Tropheryma whipplei (G+)
- PAS positive for foamy macrophages in intestinal lamina propria
- Mesenteric nodes
- CAN: Cardiac symptoms, Arthralgias, and Neurologic symptoms common
- Most often occurs in older men

Front 21

What are the characteristics of Celiac Sprue?

Back 21

Malabsorption syndrome:
- Auto-immune mediated intolerance of gliadin (wheat) → malabsorption and steatorrhea
- Associated with HLA-DQ2, HLA-DQ8, and northern European descent
- Antibodies: anti-endomysial, anti-tissue transglutaminase, and anti-gliadin antibodies
- Blunting of villi and lymphocytes in lamina propria (picture)
- ↓ Mucosal absorption, primarily affects distal duodenum and/or proximal jejunum
- Diagnosis: serum levels of tissue transglutaminase antibodies
- Associated with dermatitis herpetiformis
- Moderately ↑ risk of malignancy (eg, T-cell lymphoma)
- Treat: gluten-free diet

Front 22

What are the characteristics of Disaccharidase Deficiency?

Back 22

Malabsorption syndrome:
- Most common is lactase deficiency → milk intolerance
- Normal-appearing villi
- Osmotic diarrhea
- Since lactase is located at tips of intestinal villi, self-limited lactase deficiency can occur following injury (eg, viral diarrhea)
- Diagnosis: lactose tolerance test (+) if administration of lactose produces symptoms and glucose rises <20 mg/dL

Front 23

What are the characteristics of abetalipoproteinemia?

Back 23

Malabsorption Syndrome:
- ↓ Synthesis of apolipoprotein B → inability to generate chylomicrons → ↓ secretion of cholesterol, VLDL into bloodstream → fat accumulation in enterocytes
- Presents in early childhood with failure to thrive, steatorrhea, acanthocytosis (RBCs with spiked membrane), ataxia, and night blindness

Front 24

What are the characteristics of Pancreatic Insufficiency?

Back 24

Malabsorption Syndrome
- Due to cystic fibrosis, obstructing cancer, and chronic pancreatitis
- Causes malabsorption of fat and fat-soluble vitamins (A, D, E, and K)
- ↑ Neutral fat in stool
- Diagnosis: D-xylose absorption test - normal urinary excretion in pancreatic insufficiency; ↓ excretion with intestinal mucosa defects or bacterial overgrowth

Front 25

Which type of malabsorption syndrome is caused by infection?

Back 25

- Tropical Sprue (treat with antibiotics) - cause is unknown
- Whipple Disease - infection with Tropheryma whipplei (G+)
- Self-limited lactase deficiency - following viral diarrhea

Front 26

Which type of malabsorption syndrome is characterized by foamy macrophages?

Back 26

Whipple Disease

Front 27

What is Celiac Sprue associated with?

Back 27

- HLA-DQ2, HLA-DQ8
- Northern European descent
- Dermatitis Herpetiformis (watery blisters, not caused by herpes)
- Increased risk of malignancy (eg, T-cell lymphoma)

Front 28

What antibodies cause Celiac Sprue?

Back 28

- Anti-endomysial antibody
- Anti-tissue transglutaminase antibody
- Anti-gliadin antibody

Front 29

What are the histologic findings in Celiac Sprue?

Back 29

- Blunting of villi
- Lymphocytes in lamina propria

Front 30

Which part of the GI tract has malabsorption in Celiac Sprue?

Back 30

Decreased mucosal absorption primarily affects distal duodenum and / or proximal jejunum

Front 31

How do you diagnose Celiac Disease?

Back 31

Presence of tissue transglutaminase antibodies in serum

Front 32

What kind of diarrhea occurs in disaccharidase deficiency (eg, lactase deficiency)?

Back 32

Osmotic diarrhea (too much water is drawn into the bowels)

Front 33

How do you diagnose a disacharidase deficiency (eg, lactase deficiency)?

Back 33

Lactose Tolerance Test is (+) for lactase deficiency, if:
- Administration of lactose produces symptoms AND
- Glucose rises <20 mg/dL

Front 34

What are the implications of a decreased ability to synthesize apolipoprotein B?

Back 34

Inability to generate chylomicrons → ↓ secretion of cholesterol, VLDL into bloodstream → fat accumulates in enterocytes

Abetalipoproteinemia (type of malabsorption disorder)

Front 35

How do you diagnose pancreatic insufficiency (malabsorption syndrome)?

Back 35

D-xylose absorption test:
- Normal urinary excretion in pancreatic insufficiency
- ↓ excretion with intestinal mucosa defects or bacterial overgrowth